Self-perception: Does Obesity Inuence Quality of Life

The number of obese and overweight people around the world rapidly grows and takes on epidemic proportions. The aim of this research is to determine the inuence of body weight on quality of life and to investigate our patients' consciousness about their body weight and its impact on their quality of life. Methods : The cross-sectional study was conducted by interviewing 1067 respondents, using the WHOQOL-BREF questionnaire. Results : Out of 1067 patients, 684 were females. 65.5 % of patients had BMI ≥ 25 kg/m 2 . 21.7% of 699 patients who had BMI ≥ 25 kg/m 2 think that their increased body weight doesn’t affect their health, 27.9 % of respondents think that their overweight is unrelated to physical activity, 41.8 % of respondents have no problems purchasing the clothes due to their weight and 31.6 % of respondents with BMI ≥ 25 kg/m 2 think that it doesn’t affect their quality of life. Conclusion : Quality of life is signicantly better in respondents with BMI <25 kg/m 2 . The alarming result is that slightly less than half of respondents think that overweight doesn’t affect their health and don’t understand the seriousness of the problem.

Namely, we have proven that the quality of life is higher at those with a normal body weight and that obesity at our respondents affects all aspects of quality of life. What has been proven in our study is that more than a half of obese respondents are not aware of their problem, which is a problem given the number of patients and deaths from cardiovascular disease, and obesity is known to be one of the leading risk factors for cardiovascular disease and death eventually. We wanted to draw the attention to this problem, both the publicly and professionally.

Background
Obesity has become one of the leading causes of mortality even though it is preventable through the vision of public health. More than 1.9 people worldwide were overweight and at least 650 million were obese in 2016. The prevalence of obesity and overweight was highest in the World Health Organization (WHO) Regions of the Americas (62% of overweight in both genders, and 26% of obese) and lowest in the WHO Region of South East Asia (14% of overweight in both genders and 3% of obese). In the WHO Regions of Europe, the Eastern Mediterranean and the Americas over 50% of women were overweight. For all three of these regions, roughly half of overweight women were obese (23% in Europe, 24% in the Eastern Mediterranean, 29% in the Americas). In all WHO regions women were more likely to be obese than men [1][2].
Obesity is associated with numerous chronic conditions such as hyperlipidemia, non-insulin-dependent diabetes, hypertension and coronary artery disease [1][2] and contributes to higher morbidity and mortality [3][4].
Less is known about the impact of obesity on status and health-related life quality (HRQoL) [2,[4][5].
HRQoL is an important health outcome used to measure how health conditions affect an individual's subjective assessment of physical, social and psychological well-being [5]. Numerous published studies indicate that obesity impairs HRQoL and that higher obesity degrees are associated with greater impairment [2].
The discussion about the potential dangers of extreme underweight has received disproportionate attention in cultures where obesity and overweight are far more prevalent [6]. The number of obese and overweight people in developed and developing countries around the world rapidly grows and takes epidemic proportions due to the imbalance between diet and physical activity [7]. It remains controversial whether or not obesity is associated with impaired mental HRQoL. Studies in Asian countries reported that excess weight was related to worse physical but not mental HRQoL, while being underweight correlated with worse overall HRQoL [5].
Body mass index (BMI), a measure showing the status of nutrition in adults, is the most commonly used tool for the correlation of risk of developing health problems with the body weight. It's de ned as the ratio of weight in kilograms and the person's square of height in meters (kg/m 2 ). Values of recommended BMI are the same for both genders [8]. Cardiovascular risk is signi cantly lower in BMI <25 kg/m 2 compared to the higher values of BMI [9]. The risk of mortality of all causes, cardiovascular diseases, cancer or other diseases, is higher through the range of moderate and severe obesity for men and women in all age groups [10]. Insulin resistance, elevated blood parameters of lipid metabolism and sympathetic nervous system disorders are considered to be associated with obesity [11]. Numerous epidemiological studies in different countries worldwide have shown that, related to socio-economic conditions and diet, there is a direct correlation between the concentration of blood cholesterol and mortality caused by coronary heart disease [12]. Obesity is also a signi cant factor for the development of insulin resistance [13].
Previous research works examined the impact of body weight on quality of life, but in the available literature we found very little data related to the consciousness and self-perception of patients when it comes to overweight.
The aim of this research is to determine the in uence of body weight on quality of life and to investigate our patients' consciousness about their body weight and its impact on their quality of life.

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The research has been designed as cross-sectional and was conducted by interviewing respondents using the two questionnaires. The rst questionnaire included basic information about the patient: age, gender, work and marital status, body weight and height, BMI, self-assessment of the body weight's impact on the health and quality of life. The second questionnaire evaluated the quality of life (WHOQoL-BREF). We have conducted the pilot study on 232 respondents with the purpose of the questionnaire validation, and based on those answers the questionnaire was updated.
Interviewing was conducted during one month of September 2019 n 10 outpatient clinics of Health Care Center Mostar. All the patients who visited the outpatient clinic in that period were interviewed, regardless of the reason for the visit. Patients with severe mental illnesses (severe depression, schizophrenia, mental retardation or impaired development), cancer (within 5 years of illness development), impaired cognition, pregnant women, handicapped patients and people who did not want to participate were excluded from the study. Overall, 1300 questionnaires were distributed, and 1067 were valid for analysis. The response rate was 82.08 %.
Respondents were divided into categories by gender, age in decades (from 30 to 70 and more), education degree (elementary, high school, college and faculty), marital status (married or other) and working status (employed, unemployed/employment bureau, retired). Results were observed in all individual groups.
Respondents were provided with an informational sheet to be familiarized with the research aims to which they have given their consent. The researcher lled the socio-demographic data (age, gender, education degree, working and marital status) based on patient's statement. Further, anthropometric measurements, height and weight, were performed and BMI was calculated. Respondents were categorized by BMI into the following groups: BMI <18.5 kg/m 2 , BMI 18.5 -24.9 kg/m 2 , BMI 25 -29.9 kg/m 2 , BMI 30 -34.9 kg/m 2 and BMI >35 kg/m 2 (14).
To evaluate the quality of life, the World Health Organization WHOQoL-BREF questionnaire, consisting of 26 questions with structured responses on a Likert scale of ve points, was used. The questionnaire was self-administered, based on the perception of the last two weeks. Of the 26 questions, 24 questions comprise the physical, psychological, social and environmental domains and the other two assess the perception of quality of life and patient's health [15][16]. The physical domain includes the questions related to daily activities such as pain and discomfort, energy and fatigue, sleep and rest, dependence on the medications, work and mobility. The psychological domain consists of questions regarding the positive and negative feelings, meaning of life, self-esteem, body image, physical appearance, personal beliefs and ability to concentrate. The domain of social relationship is related to personal relationships, social support and sexual activity. The environmental domain investigates the physical security and safety, nancial resources, physical and home environment, availability of health and social care, leisure activities, opportunities for new information and skills acquisition as well as opportunities for recreation and transport and participation in those.

Statistical analysis
The collected data were analyzed in Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA, USA) and SPSS for Windows (version 17.0., SPSS Inc. Chicago, Illinois, USA). Descriptive analyses were performed including absolute frequencies, relative frequencies (percentages, %), means (M) and standard deviations (SD). Cronbach's alpha (internal consistency index) was used to estimate the reliability of the WHOQoL-BREF (Cronbach's alpha values of 0.70 and over were deemed acceptable). Pearson's correlation coe cient was used to investigate the correlation between BMI and QoL domains. Independent t-test and ANOVA were used to investigate the difference ih QoL regarding participants' socio-demographic characteristics. Original scores of QoL domains were used for statistical analyses.
The level of signi cance was set at p <0.05. P values that cannot be expressed up to three decimal places are shown as p <0.001.

Participant characteristics
Out of 1067 patients, 383 were males and 684 females. Most of the patients were older than 50 years, had a high school degree and were married and retired ( Table 2). BMI ≥25 kg/m 2 was found in 65.5 % of patients. Only 8 patients had a BMI <18 kg/m 2 so they were merged with patients with a normal BMI for the purpose of the analysis. BMI in range 18.5-24.9 kg/m 2 was found in 360 patients (BMI <25 kg/m 2 overall 368 patients), 426 patients wre overweight (BMI 25-29.9 kg/m 2 ), BMI 30-34.9 kg/m 2 had been determined in 213 patients, and BMI >35 kg/m 2 in 60 patients.
The impact of body weight on the perception of … ... health: Out of 699 respondents with BMI ≥25 kg/m 2 , 21.7% think that their excessive weight does not affect their health, 22% that it has mild impact on their health, 35.9 % that it has moderate impact, and 20.3% think that it has high impact on their health.
... physical activity: 27.9% respondents think that their overweight is unrelated to the physical activity, 24.7% that it has a weak correlation, 32 % moderate correlation, and 15.3% of them think that overweight has a strong impact on their physical activity.
... choice when buying clothes: 41.8% of respondents do not have problems due to their overweight when buying clothes, 37.8% sometimes have a problem, 12.6% usually have a problem, while 7.9% of respondents always have a problem when buying clothes due to their excessive weight.
... quality of life: 31.6% of respondents with BMI ≥25 kg/m 2 think that overweight does not affect the quality of life, 26.5% think that it has a mild impact on quality of life, 29.2% think that it has a moderate impact, while 12.7% think that overweight has a high impact on quality of life.
Comparison of the quality of life in two BMI groups (BMI <25 kg/m 2 and BMI ≥25 kg/m 2 ) Signi cant difference regarding the BMI has been found in all domains of the WHOQoL-Bref questionnaire as well as in the assessment of the quality of life and satisfaction with health (Table 3).
Signi cantly, respondents with BMI <25 kg/m 2 , assess their quality of life as better and are more satis ed with their physical and mental health, social relations and environment than respondents with BMI ≥25 kg/m 2 .
A signi cant negative correlation in the group with BMI <25 kg/m 2 has been found between BMI and psychological health (Table 3). In subgroups of respondents with BMI ≥25 kg/m 2 , a signi cant negative correlation has been found between BMI and all four domains of quality of life (physical and psychological health, social relations and environment), as well as between BMI and assessment of quality of life and satisfaction with health. A negative sign of the correlation coe cient indicates that an increase in body weight has a negative impact on all domains of quality of life.

Comparison of quality of life in respondents of four BMI groups
Signi cant difference regarding the BMI has been found in all domains of WHOQoL-Bref questionnaire (physical and psychological health, social relations and environment), as well as in the assessment of quality of life and satisfaction with health (Table 3).
Analyzing the correlation in subgroups of respondents with BMI ≥25 kg/m 2 , signi cant negative correlation has been determined only in respondents with BMI >35 kg/m 2 between BMI and quality of life and BMI and psychological health ( Table 3).
Quality of life in respondents with BMI ≥25kg/m 2 -differences by socio-demographic characteristics Analyzing the quality of life in respondents with BMI ≥25 kg/m 2 , we have found a signi cant difference regarding the gender in psychological health (better rates are determined in women). Regarding the age, education degree and working status, there is a signi cant difference in all four domains of quality of life (physical and psychological health, social relations and environment) as well as in assessment of quality of life and satisfaction with health (younger respondents are more satis ed, with a higher education degree and work for those who are employed). Regarding marital status, we have not found a signi cant difference only in satisfaction with health (married respondents are more satis ed) ( Table 4).

Discussion
In the investigated sample, 34.5% of respondents had a normal body weight, which is not a departure from the results published in the Report of the health condition of the population in the Federation of Bosnia and Herzegovina from 2018 [17]. Unlike our results, the Swiss state that 76.3% of young men in their sample have a normal body weight [3]. In Japan there are 75.7% of those with normal body weight [5], Turks 35.8% [2], Americans (Pennsylvania) 42% of women and 53% of men [18], and Serbs 46.6% of men and 22.1% of women [19]. Such differences are the result of dietary habits and culture and differences in lifestyle associated with risky behavior.
More than a fth of our respondents are not aware of the problem with their obesity, which is better than the results published by Muda et al. [20]. They found that 66.7% of their respondents (housewives) assessed their health as very good or good, and more than half said that obesity symbolizes happiness.
This difference may be a result of a different sample. Tchicaya et al. suggest a signi cant improvement in both physical and mental health in subjects reporting weight loss compared to those who did not lose weight [21]. More than 31% of respondents think that overweight does not affect the quality of life. However, Yan et al. proved that compared to normal-weight persons, obese men and women had a higher prevalence of most chronic diseases. Underweight individuals, especially men, also had more comorbidities, although not signi cantly [2][3]22]. Similarly, Kunzova et al. have found that being male, besides the increasing age, was the main determinant for poor metabolic health regardless of the obesity status [23]. Our results show that respondents with BMI <25 kg/m 2 assess the quality of life as better, they are more satis ed with health in general and are more satis ed with their physical and psychological health, social relations and environment.
As it has been shown in the research of Dinc et al. we found the poorer quality of life in all domains for respondents with BMI >35 kg/m 2 [2]. They state that obesity may have an independent impact on HRQOL in a representative sample of the population with high obesity [2].
The proportion of respondents with the highest education degree is largest in the subgroup of respondents with normal BMI. In researches conducted in Japan and Turkey, most of the respondents with the highest education level had BMI <25 kg/m 2 [13,16]. We can assume that people with a higher degree of education are more aware of the consequences of risky behavior and are more receptive to healthier dietary habits and physical activity.
In the investigated sample, we had more obese respondents who were married, unlike Wu et al. who state that a greater number of his subjects with central obesity were not married. The author himself explains this result with a greater number of elderly subjects who are prone to central obesity [22]. Numerous studies show that married respondents enjoy better health than those who were never married [24]. The study conducted in nine European countries showed interesting results indicating that average, never married respondents had a lower BMI than married respondents. In our research, we have not found statistically a signi cant difference between married and others (not married, widowed). Married respondents reported stronger preferences for regional/unprocessed and organic/fair trade food and paid less attention to the dietary convenience or dietary fat and body weight. Men who were married exercised less. Despite the differences in behavior, only attention to dietary fat and body weight predicted BMI differently for married men and men who have never been married. It can be concluded that despite more favorable eating-related behavior, married individuals had higher BMI values than respondents who have never been married, but those differences were small. The relation between BMI and marital status cannot be fully described by a single explanation. Obesity interventions could bene t from considering speci c weight-related behavior in married individuals versus individuals who have never been married [24].
Respondents with normal BMI assessed their quality of life better compared to those with high BMI in all categories. The results of our research are one more con rmation of correlation of BMI and quality of life [2,[16][17][18]20]. In the group of obese respondents, the worst results were found in those with the highest BMI values, in the assessment of the quality of life and psychological domain. Vasiljevic

Conclusion
Although it is widely held opinion that overweight people are also happier, the results of our research did not support this position. There is a strong negative correlation between BMI and quality of life in all domains. The alarming result of our research is that nearly half of our respondents do not understand the problem of obesity and do not see an increased BMI as a problem. This is what should be the goal for health professionals -to explain the impact of obesity on the development of various diseases and to raise the awareness on this problem.