Health-related quality of life among adolescents with eating disorders
Introduction
Eating disorders (EDs) are costly to treat [1], have high mortality rates [2], [3], and are associated with impaired health-related quality of life (HRQoL). Measures of HRQoL assess an individual's subjective evaluation of his or her health and its impact on functioning in various domains, such as performance at work or physical activity. Compared to measures that focus only on symptomatology, an assessment of quality of life (QoL) may consider a broader range of factors that influence a person's well-being, such as adequacy of housing or quality of social relationships. Both QoL and HRQoL have become increasingly popular areas of mental health research, with such measurement covering areas that might be overlooked by measures that simply assess symptoms (e.g., see [4]). Assessing HRQoL has important implications for clinical practice as well, as it represents a major goal of treatment in addition to symptom reduction (e.g., [5], [6], [7]).
Several recent studies have found that ED sufferers report poorer HRQoL than healthy comparison groups, recovered ED patients, or those suffering from physical health problems such as angina (see [8], for a review). Quality of life in adults with EDs varies with body mass index (BMI), showing a curvilinear relationship with QoL generally poorer at extremes of BMI (e.g., [9]). Gender may also moderate this relationship, with poorer QoL seen in obese women compared to obese males [10], and some limited findings also reported in ED samples (e.g., [11]). Mental health domains have been found to be more affected by the presence of ED symptoms than physical health domains (e.g., [12]). In addition, ED symptoms may be differentially related to HRQoL. In a large community sample of young adult females, for example, Mond, Hay, Rodgers, Owen, and Mitchell [13] found that extreme dietary restriction for purposes of weight control was the best predictor of functional impairment among disordered eating behaviors. A similar study by Latner et al. [14] looked at the contribution of ED symptoms to impaired functioning in a sample of females (both clinical and non-clinical). In addition to finding some associations with ED behaviors (such as dietary restriction, laxative use, and binge eating), functional impairment was also affected by extreme levels of concern (often referred to as “overvaluation”) with weight and shape. This recent work has highlighted the importance of assessing not only behavioral features of an ED, but also those of a cognitive, or attitudinal, nature.
The majority of information available on HRQoL among ED patients is based on studies of adults, with younger samples seldom being assessed. In adolescents, the finding that obesity is frequently associated with poorer HRQoL appears well-established (e.g., [15], [16]), but less is known about HRQoL and EDs among adolescents. Some studies have found associations between ED behaviors and impaired HRQoL [17], [18]. Herpertz-Dahlmann and colleagues [19] provide data on 1895 individuals aged 11–17 selected from a nationally representative sample of German families. Alongside other self-report measures, participants completed brief measures of ED symptoms (the SCOFF; [20]) and HRQoL (the KINDL-R; [21]). Associations were found between ED symptoms and general psychopathology, as well as poorer HRQoL in adolescents with self-reported disordered eating.
There is also some evidence that adolescents with EDs (including sub-threshold forms) show greater functional impairment than healthy controls (e.g., [22]). Thus it may be the case that ED behaviors and attitudes are associated with poorer HRQoL in adolescents, although few studies in this area have been conducted on clinical samples, despite the fact that EDs typically begin during adolescence [23]. Studies on HRQoL among individuals with EDs have typically grouped younger patients and adults together, but there is good reason to study adolescents as a distinct group [24]. Differences have been found between younger and older non-ED populations, with young adolescents generally reporting less impaired HRQoL compared to older adolescents and adults (e.g., [25], [26]). In addition, adolescents' perception of their HRQoL may be different from their adult counterparts, and the effects of an ED during a time of dramatic change, such as adolescence, may differ from the impact of an ED on adults. Information obtained on younger samples may also give clues as to the developmental trajectory of EDs, and what factors are important in an adolescent's perception of his or her HRQoL. Furthermore, as in the treatment of adult EDs, where assessment of HRQoL is an emerging area, more information about HRQoL can help to provide an index of how ED symptoms impact functioning and determine if subjective improvements in quality of life accompany improvements in symptoms [4], [6].
As the presence of any disordered eating has been suggested to negatively impact HRQoL ([19], [27]; see also [28]), the purpose of the present study was to examine the subjective impact of the presence or absence of various ED behaviors and attitudes on HRQoL among a clinical sample of eating disordered adolescents. Based on previous research (e.g., [9]; see also [8]), the variables of BMI and gender will be controlled for in these analyses.
Section snippets
Participants and procedure
Sixty-seven adolescents (n = 57 female; 85.1%; age range = 11–18 years) seeking outpatient treatment at multiple sites (University of North Dakota, ND; The Center for Balanced Living, OH; University of South Florida, FL; and The University of Chicago, IL) between 2000 and 2004 were included in this study. The majority of sites treat primarily adult patients, but all were referred for disordered eating and completed self-report assessment measures at baseline. This study was approved by Institutional
HRQoL impairment
Scores were lower across the entire sample for the MCS than the PCS (mean difference = 19.66, Z = − 5.653, p < .001) (see Table 1). Table 2 presents data for SF-36 composite scores according to the presence and absence of eating disorder behaviors (note: only two individuals indicated use of diuretics for the purposes of weight/shape control, so this variable is not reported). The number of individuals endorsing those behaviors is also shown.
Results from these analyses suggest that the presence of all
Discussion
The purpose of the current study was to examine the impact of different ED symptoms on quality of life in a clinical sample of adolescents with EDs, an area that has received limited research attention. The adolescent group as a whole had greater deficits in the mental health component of HRQoL than the physical health component. Similar findings have been reported in the literature on adults [12], suggesting that ED behaviors affect mental health HRQoL more so than physical health HRQoL across
Declarations and potential conflicts of interest
Parts of this manuscript were presented at the Academy for Eating Disorders International Conference on Eating Disorders, Seattle, WA, 15–17 May, 2008.
RDC serves as a statistical consultant to Health Outcomes Solutions.
DLG receives honoraria from the Training Institute for Child and Adolescent Eating Disorders, LLC, and royalties from Guilford Press and from Routledge.
Drs. Hoste and Celio Doyle receive honoraria from the Training Institute for Child and Adolescent Eating Disorders.
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