Published online April 3, 2006
PEDIATRICS Vol. 117 No. 4 April 2006, pp. 1155-1161 (doi:10.1542/peds.2005-1141)
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Health-Related Quality of Life and Depressive Symptoms in Adolescents With Extreme Obesity Presenting for Bariatric Surgery

Meg H. Zeller, PhDa, Helmut R. Roehrig, PhDa, Avani C. Modi, PhDa, Stephen R. Daniels, MD, PhDb and Thomas H. Inge, MD, PhDc

a Division of Behavioral Medicine and Clinical Psychology
b Division of Cardiology
c Department of Pediatric Surgery, College of Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. We sought to document health-related quality of life (HRQoL) impairment and depressive symptomatology in adolescents with extreme obesity considering surgical weight loss.

STUDY DESIGN. A retrospective review of clinical data was conducted for 33 consecutive extremely obese adolescents presenting for evaluation at a bariatric surgery program for adolescents. Adolescents completed the PedsQL and the Beck Depression Inventory. Mothers completed the parent-proxy PedsQL and the Child Behavior Checklist.

RESULTS. HRQoL scores from both informants were markedly impaired relative to published norms on healthy youth. Moderate agreement was found for self-reported and parent-proxy HRQoL. Approximately 30% of youth met criteria for clinically significant depressive symptoms when based on self-report and 45% of youth when based on mother report. Only 21% of youth were currently engaged in some form of psychological treatment (eg, medication or therapy).

CONCLUSIONS. The day-to-day life of adolescents with extreme obesity seeking bariatric surgery is globally and severely impaired. However, only some of these adolescents demonstrate clinically significant levels of depressive symptomatology. These data will be critical to the development of more informed patient selection criteria and more efficacious treatment paradigms for this vulnerable pediatric subgroup.

Key Words: obesity • pediatric • psychosocial • bariatric • weight loss surgery

Abbreviations: HRQoL—health-related quality of life • BDI—Beck Depression Inventory • DSM—Diagnostic and Statistical Manual of Mental Disorders

The epidemic of pediatric obesity and the substantial increase in the degree of overweight1 has made adolescents with extreme obesity (body mass index [BMI] ≥40 kg/m2) a growing subpopulation for which there is increasing concern. In adult populations, bariatric surgery has become a viable intervention option for extreme obesity, and surgical weight loss procedures are now being critically evaluated for adolescents.2,3 Given that adolescence is often marked by significant emotional, cognitive, and interpersonal growth, the fluidity of this developmental period may present unique challenges for the adolescent bariatric patient. However, there is a critical gap in our understanding of the psychosocial functioning of adolescents pursuing bariatric surgery.

The measurement of health-related quality of life (HRQoL) is one method used to assess global psychosocial functioning. HRQoL is a multidimensional construct that assesses the individual's subjective evaluation of his/her physical, emotional, social, and, for youth, school functioning.4 We know that adult extreme obesity is associated with impaired HRQoL,5–8 with the greatest impairment in those seeking bariatric surgery,9,10 as well as depression.11 Furthermore, poor HRQoL has been found to be a stronger predictor of depressive symptoms than BMI in extremely obese adults.12 Given that adults report improved psychosocial status postbariatric surgery,13 it is hypothesized that adolescents who are extremely obese are at considerable psychosocial risk without intervention.

Three studies to date have examined HRQoL in obese adolescents presenting for behavioral weight management, a noninvasive intervention, and found significant impairment across HRQoL domains.14,15 However, these studies have not specified range of weight status,14 used well-validated measures,16 or specifically examined the subgroup of extremely obese adolescents.15 On the basis of the adult literature, it is likely that adolescents with extreme obesity and seeking surgical intervention will report greater impairments in HRQoL relative to published data.14,15 Several studies have also documented that some treatment-seeking obese adolescents report significant depressive symptoms compared with community-based obese or nonobese control groups17,18 and instrument normative samples.19–21 Whether adolescents with extreme levels of obesity presenting for bariatric surgery report similar or greater levels of depressive symptoms than the above populations is unknown. Thus, the aims of this study were to document HRQoL and depressive symptoms in this unique adolescent patient population considering surgical weight loss.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Participants
A retrospective review of clinical data was conducted for 33 consecutive extremely obese adolescents presenting for a surgical evaluation at the Comprehensive Weight Management Center22 at Cincinnati Children's Hospital Medical Center between April 2004 and February 2005. Surgical candidacy was based on adolescent patient selection guidelines as described previously.2,3,22 These indications include (1) failure of ≥6 months of organized, medically supervised weight loss attempts, (2) BMI ≥40 kg/m2 in the presence of a severe obesity-related comorbidity (eg, type 2 diabetes, obstructive sleep apnea syndrome, or pseudotumor cerebri), and (3) BMI ≥50 kg/m2 in the presence of less severe comorbidities (eg, hypertension, dyslipidemia, or gastroesophageal reflux disease). Patients were required to have a physician referral through primary care or subspecialty clinics.

Inclusion criteria for the present study included patients 13 to 18 years of age having no physical impairment unrelated to obesity (eg, spinal anomaly) or developmental disability. Of the 36 potential participants, 3 patients did not meet study entrance criteria because of a significant non–obesity-related physical disability, developmental delay, or missing data. Data were collected as part of the family's comprehensive intake clinic visit that included physiological, anthropometric, and psychological assessment. Approval for retrospective analysis of these clinical data was obtained from the institutional review board of Cincinnati Children's Hospital Medical Center.

Procedures
Data were abstracted from the medical charts of the participants. These data included demographic information (eg, race/ethnicity, gender, age, and type of insurance), school status, psychological history, psychosocial self-report and mother-report measures, and adolescent weight and height measurements. The presence of the following obesity-related medical comorbidities was determined by clinical evaluation, which included history, physical examination, and appropriate laboratory testing for sleep apnea, type 2 diabetes, hyperinsulinemia, hypertension, dyslipidemia, and polycystic ovary syndrome. Weight and height data were used to calculate BMI (kg/m2). Given that BMI increases with age as children mature, standardized z score BMI was calculated using age- (to the nearest month) and gender-specific median, SD, and power of the Box-Cox transformation (LMS method; details regarding the calculation of zBMI using the LMS method are available at www.cdc.gov/nchs/about/major/hanes/growthcharts/datafiles.htm) based on national norms from the Centers for Disease Control and Prevention.23 A summary of demographic, school, and weight status of the 33 adolescent participants is presented in Table 1.


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  		TABLE 1 Demographic Information of Youth With Extreme Obesity (n = 33)

 
Measures of Psychosocial Status
PedsQL
The PedsQL is a reliable and valid generic HRQoL measure, which contains general items that are applicable to a wide variety of pediatric populations and includes both an adolescent self-report and parent-proxy version for ages 13 to 18.24 The measure consists of 4 core scales, including physical, emotional, social, and school functioning, as well as 2 broad domain scores (physical and psychosocial functioning) and a total score. Scaled scores are standardized and range from 0 to 100, with higher scores representing better quality of life.

Beck Depression Inventory-II
The Beck Depression Inventory (BDI)-II25 is a 21-item questionnaire that measures specific symptoms of depression for individuals ≥14 years of age. The BDI has well-established psychometric properties25,26 and has been found to be a reliable and valid screening tool for depressive symptoms in adolescents. This instrument has been recommended by clinicians and obesity researchers27,28 because of the unbiased nature of items regarding obesity status. For the present study, the total raw score was used, with higher scores reflecting more depressive symptoms. A raw score of ≥17 is a conservative marker for depression recommended for clinical settings.25

Child Behavior Checklist
The Revised Child Behavior Checklist29 provides parent descriptions of child and adolescent (aged 6–18 years) psychological problems and competencies in a standardized t score (mean: 50; SD: 10). t scores are interpreted with reference to national age norms, with standardization samples consistently matching US population percentages of racial/ethnic groups. This measure includes Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented scales, which were constructed by having clinicians (eg, psychologists and psychiatrists) rate the consistency of items with DSM-IV30 diagnostic categories for youth. For the present study, the DSM-oriented Affective Problems scale was used, which is consistent with dysthymic and major depressive disorders. Interpretive guidelines define affective t scores ranging from 41 to 65 in the "normal" range, scores in the 65 to 69 range "at risk," and scores of ≥70 in the clinical range, indicating a need for additional assessment and potential intervention.

Statistical and Data Analyses
Frequencies of medical comorbidities and psychiatric treatment use were calculated. Descriptive analyses, including means and SDs, were calculated for self-reported and parent-proxy HRQoL and depressive symptom scores. z tests were conducted to compare HRQoL scores between the present sample and the instrument normative data of healthy youth.24 Student t tests were used to examine gender differences in psychosocial functioning, which were exploratory in nature. Furthermore, multivariate analyses of variance were conducted to explore whether the presence of a medical comorbidity affected HRQoL scores. Because of the high number of multivariate analyses of variance conducted, a Bonferonni correction was applied to these analyses ({alpha} = .05/6 = .008). Pearson correlation coefficients were also calculated between the total number of medical comorbidities and HRQoL scales. Intraclass correlations and paired t tests were used to determine the convergence of parent and child reports of HRQoL. An intraclass correlation of ≥0.80 suggests excellent agreement, between 0.61 and 0.80 suggests moderate agreement, and between 0.41 and 0.60 suggests fair agreement.31 Analyses were performed using SPSS 11.5 statistical software (SPSS Inc, Chicago, IL).


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Medical Comorbidities
Because of eligibility criteria for surgical evaluation, participants presented with ≥1 obesity-related medical comorbidity diagnosed by either the referring physician or determined during our clinical assessment. Ninety-one percent (n = 30) of patients presented with hyperinsulinemia, 70% (n = 23) with sleep apnea, 76% (n = 25) with dyslipidemia, 36% (n = 12) with hypertension, 12% (n = 4) with polycystic ovary disease, and 12% (n = 4) with diabetes.

Psychological History
Overall, 52% (n = 17) reported use of psychological services (eg, therapy) in their lifetime. Of those, the majority sought assistance for mood and anxiety disorders (n = 13 [76%]), whereas the remaining primary or additional concerns included attention-deficit/hyperactivity disorder (n = 3 [18%]), learning problems (n = 1 [6%]), family issues (n = 1 [6%]), and disordered eating (n = 1 [6%]). Overall, 36% (n = 12) reported use of pharmacological interventions in their lifetime. Specifically, 8 (24%) reported using antidepressants, and 4 (12%) reported using stimulant medications. At the time of their presentation for surgical evaluation, 7 (21%) of the participating adolescents reported that they were currently being treated with antidepressant medications, and, of those, 3 were also participating in psychotherapy.

HRQoL
Both self-reported and parent-proxy HRQoL scores were markedly impaired and significantly lower relative to published norms on healthy youth (see Table 2). For example, the mean score for total self-reported HRQoL was 54.9 for extremely obese adolescents compared with 83.0 for healthy adolescents. Similarly, the mean score for total parent-proxy HRQoL was 48.4 for extremely obese adolescents compared with 87.6 for healthy adolescents. Mean HRQoL scores for adolescent self-report and parent-proxy are presented in Fig 1 for both adolescent bariatric candidates and the healthy normative sample.


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  		TABLE 2 Generic HRQoL Scale for Adolescents With Extreme Obesity and Healthy Youth

 

Figure 1
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  		FIGURE 1 Self-reported and parent-proxy HRQoL scores for adolescents with extreme obesity and healthy youth. a Adapted from published data on norms for healthy children.24

 
Exploratory analyses indicated no significant gender differences in HRQoL with 1 exception. Females were found to have lower social functioning than males for both self- (t[31]: 2.1; P < .05; female mean: 48.3, male mean: 63.3) and parent report (t[31]: 3.3; P < .01; female mean: 31.2; male mean: 57.3). The presence or absence of a medical comorbidity was unrelated to HRQoL scores. For example, no significant differences were found in HRQoL for patients with hypertension as compared with those without, with Wilk's {lambda} = .90 (F4,26 = 0.75; P = .57). Furthermore, the total number of medical comorbidities was not associated with HRQoL scores, with correlations ranging from 0.03 to 0.17. Moderate agreement was found for self-reported and parent-proxy physical functioning (r1 = 0.59; P < .01), emotional functioning (r1 = 0.78; P < .00001), social functioning (r1 = 0.72; P < .001), school functioning (r1 = 0.81; P < .00001), psychosocial functioning (r1 = 0.79; P < .00001), and total HRQoL (r1 = 0.77; P < .00001).

Depressive Symptoms
The mean total raw score of depressive symptoms as self-reported by adolescents on the BDI was in the mild range (mean: 14.6; SD: 12.4) based on instrument normative guidelines. Approximately 52% (n = 17) of the sample reported a minimal level of depressive symptoms, 21% (n = 7) reported mild levels, 12% (n = 4) reported moderate levels, and 15% (n = 5) reported severe levels of depressive symptoms. Approximately 30% (n = 10) of adolescents exhibited depressive symptoms within a clinical range (raw scores: ≥17). No significant gender differences were found.

Mother report on the Child Behavior Checklist revealed a mean affective t score within the at-risk range (mean: 67.3; SD: 8.8) based on instrument normative guidelines. Forty-five percent of adolescents (n = 15) scored within the clinical range, whereas a smaller percentage scored in the at-risk (n = 9 [27%]) and normal (n = 9 [27%]) range of depressive symptoms. No significant gender differences were found.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Recent publications have focused on the best practice guidelines for bariatric surgery in youth2,3; however, no empirical studies have documented the psychosocial status of this new, growing, clinical population. These are the first data to document marked impairments in HRQoL across all domains, including physical functioning, emotional well-being, social relations, and school functioning. When compared with previous reports citing HRQoL in youth with chronic diseases (eg, diabetes32, migraine headaches33, and asthma34), the level of impairment characterizing extremely obese youth seems to be worse. Furthermore, patients from the current study exhibited lower scores on all of the HRQoL domains compared with those with less extreme levels of obesity,15 suggesting that those with extreme obesity are more vulnerable to impairments in daily functioning. One could speculate that the severity of HRQoL impairments in the extremely obese adolescent is because of the visible nature of extreme obesity, the social stigma attached to it, and the cumulative impact of medical comorbidities.

Approximately half (52%) of the adolescents endorsed minimal symptoms of depression, whereas approximately one third reported clinical levels. However, this proportion with clinical levels of depressive symptoms increased substantially when based on the mother's report (45%). There is solid pediatric literature documenting that some obese adolescents who seek weight management treatment present with depressive and/or internalizing symptoms.17–20 Depressive symptoms, even at levels below a clinical cutoff, are of concern.35 Although only 21% of the current sample was receiving treatment for their depressive symptoms at the time of surgical evaluation, the overall use rate of psychological or psychiatric services is notably high (52%). Knowing that depressive symptoms are associated with poor adherence to treatment of obesity in adolescents,36,37 it is clear that depressive symptomatology should be routinely assessed and closely managed, especially in this clinical population, who are at increased risk of morbidity/mortality.

Our exploratory analyses examining potential gender differences in HRQoL add to existing research suggesting that obese adolescent girls may be at particular risk in the social domain. For example, relative to average-weight peers, obese adolescents, and to a greater extent obese adolescent females, are less likely to be nominated by their peers as a friend38 and more likely to report higher rates of peer victimization that is "relational" (eg, damage or control of friendships) in nature. The obesity literature is currently lacking in prospective and longitudinal studies that document the psychosocial trajectory of obese youth. However, the broader developmental literature would suggest that adolescents who are extremely obese, and females in particular, are at considerable risk of continued and mounting psychosocial impairment and poor developmental adaptation.39

There are several limitations that are important to note and have implications for the directions of future research. This selective sample of adolescents was highly motivated to achieve weight loss through surgical intervention, which may have been driven by their level of psychosocial distress. Whether the present psychosocial difficulties also characterize adolescents with extreme obesity who are not currently in treatment or seeking other methods of weight loss remains unknown. Furthermore, within the context of evaluation for bariatric surgery, do adolescent patients and their caregivers overreport or underreport psychosocial symptoms if they perceive this to be important to their surgical candidacy? Given this question, gathering information from multiple informants (eg, adolescent and parents) may enable clinicians to more accurately assess psychosocial functioning. For example, in the present study, adolescents and their mothers had good agreement regarding HRQoL impairments. In contrast, mothers reported higher levels of depressive symptoms compared with adolescent self-report, which may be attributed to underreporting or overreporting of symptoms or potentially the mother's own distress. We have shown previously that maternal psychological distress is a predictor of depressive symptoms in treatment-seeking adolescents with obesity.19 Future research should assess parental and family functioning to understand the potentially modifiable barriers (eg, social support for lifestyle change) within the family context.

Previous research has documented the impact of medical comorbidities on HRQoL in less extreme levels of obesity in youth, and these data suggest that youth with obstructive sleep apnea have poorer, generic HRQoL.15 Given the high levels of medical comorbidities in the obese adolescent population,40–45 including those that are silent (eg, hyperinsulinemia and hypertension), and those that impact daily functioning (eg, asthma and joint pain), one could hypothesize that these conditions have a cumulative and negative impact on HRQoL. Exploratory analyses in the present study were limited by the use of only confirmed medical conditions, and, thus, this area warrants additional attention.

It is also important to note that generic measures of HRQoL may lack specificity and sensitivity, and, thus, disease-specific measures are better suited for medical populations with comorbidities.46 Furthermore, a weight-related HRQoL measure8 developed for adult obese populations has been shown to be more sensitive to change in weight after bariatric surgery than a generic HRQoL measure (eg, Short Form 36).47 A weight-specific measure has been developed recently for adolescents48 and is likely to enhance clinical decision making and care of the adolescent seeking bariatric surgery.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The present study documents the impaired psychosocial status of a pediatric subgroup choosing an aggressive mode of weight loss. Surgical weight loss procedures are increasingly being considered as 1 type of clinical intervention for adolescents with extreme obesity. As a result, prospective and controlled longitudinal studies are needed to document the psychosocial changes associated with surgical weight loss, the psychosocial factors that are predictive of optimal surgical outcomes and long-term maintenance of weight loss, and include a comparison group of similarly obese adolescents not undergoing weight loss surgery. These data will be critical to the development of more informed patient selection criteria and more efficacious treatment paradigms.


   ACKNOWLEDGMENTS
 
This work was funded by National Institutes of Health grant K23 DK60031 (to Dr Zeller) and National Institutes of Health postdoctoral training grant T32 DK063929 (to Dr Modi). Additional resources were provided by the Cincinnati Children's Hospital Medical Center-General Clinical Research Center, which is supported in part by Public Health Service grant M01 RR 08084 from the General Clinical Research Centers Program, National Center for Research Resources/National Institutes of Health.


   FOOTNOTES
 
Accepted Aug 17, 2005.

Address correspondence to Meg Zeller, PhD, Division of Behavioral Medicine and Clinical Psychology, MLD-3015, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229. E-mail: meg.zeller{at}cchmc.org

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
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 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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A. C. Modi, S. M. Guilfoyle, and M. H. Zeller
Impaired Health-related Quality of Life in Caregivers of Youth Seeking Obesity Treatment
J. Pediatr. Psychol., March 1, 2009; 34(2): 147 - 155.
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