Impaired Health-related Quality of Life in Caregivers of Youth Seeking Obesity Treatment

An expert committee convened by the American Medical Association in 2007 recommended that the term overweight be used to characterize children with a body mass index (BMI) between the 85th and 94th percentile and the term obesity to characterize children with a BMI ≥ 95th percentile (Barlow, 2007). As such, ∼17.1% of youth age 2–19 years and 32.2% of adults were considered obese (i.e., BMI ≥ 30) in the US from 2003 to 2004 (Ogden et al., 2006). Ethnic minorities tend to be at higher risk for obesity with 20.0% of African-American and 19.2% of Mexican-American youth classified as obese, compared to 16.3% of Caucasian youth (Ogden et al., 2006). Medical comorbidities typically associated with adult obesity (e.g., type 2 diabetes and cardiovascular disease) are becoming increasingly prevalent in pediatric obesity (Dietz, 1998). In addition, children and adults with obesity are at increased risk for poor psychosocial functioning, such as low self-esteem (Friedman et al., 2005; Stern et al., 2007; Thompson et al., 2007) and poor health-related quality of life (HRQOL) (Fontaine, Bartlett, & Barofsky, 2000; Hughes, Farewell, Harris, & Reilly, 2007; Schwimmer, Burwinkle, & Varni, 2003; Zeller & Modi, 2006). Often youth with obesity live within an “obesigenic” family environment, which is a commonly used term in the obesity literature to characterize families engaging in high caloric intake and low physical activity (Krahnstoever Davison, Francis, & Birch, 2005). Since caregivers initiate both medical and psychosocial services for their youth (Janicke, Finney, & Riley, 2001; Seid, Varni, & Kurtin, 2000), understanding caregiver functioning may be important to developing interventions for pediatric obesity. For example, caregiver obesity status has been identified as a strong predictor in the development and persistence of pediatric obesity (Agras, Hammer, McNicholas, & Kraemer, 2004; Krahnstoever Davison et al., 2005; Whitaker, Wright, Pepe, Seidel, & Dietz, 1997). In addition, compared to nonoverweight peers, youth presenting for obesity treatment are more likely to have a caregiver with obesity (Zeller et al., 2007). Given that a significant portion of caregivers of youth with obesity are obese themselves, they may be experiencing some degree of psychosocial maladjustment. Although psychosocial impairments in adults with obesity have been documented, few studies have examined this population in the context of caring for their child with obesity. Two groups of investigators, Epstein and colleagues and Zeller and colleagues, have reported that a large percentage of mothers of youth seeking obesity treatment (28–50%) experience psychological distress at rates higher than instrument norms (Epstein, Klein, & Wisniewski, 1994; Epstein, Myers, & Anderson, 1996) or demographically matched mothers of nonoverweight youth (Zeller & Daniels, 2004; Zeller et al., 2007). In addition, caregiver distress has been linked to lower HRQOL in this population by both parent proxy and self-report (Janicke et al., 2007). HRQOL is a global, multidimensional construct that captures individual perspectives of physical, psychological, and social functioning (Schipper, Clinch, & Olweny, 1996) and has increasingly been recognized as an important patient-reported outcome (U.S. Food and Drug Administration, 2006). Several factors impact the HRQOL of children and adults with obesity, such as health (e.g., degree of overweight) (Fontaine et al., 2000; Friedlander, Larkin, Rosen, Palermo, & Redline, 2003), psychosocial (e.g., depressive symptoms) (Fabricatore, Wadden, Sarwer, & Faith, 2005; Janicke et al., 2007; Zeller & Modi, 2006), and sociodemographic factors [e.g., gender, socioeconomic status (SES)] (Kolotkin, Head, Hamilton, & Tse, 1995; Zeller & Modi, 2006). For example, increased weight status in youth has been associated with lower HRQOL in community-based samples (Friedlander et al., 2003) and treatment-seeking samples (Zeller & Modi, 2006; Zeller, Roehrig, Modi, Daniels, & Inge, 2006). Furthermore, predictors of HRQOL may vary between community- and treatment-seeking samples, such that psychosocial factors have greater impact on HRQOL in community samples and functional limitations better predict HRQOL in treatment-seeking samples (Arif & Rohrer, 2006; Swallen, Reither, Haas, & Meier, 2005; Williams, Wake, Hesketh, Maher, & Waters, 2005). Similar trends have been found in adults (Fontaine et al., 2000; Kolotkin, Crosby, & Williams, 2002; Ware, Snow, Kosinski, & Gandek, 1993). In pediatric populations, HRQOL is often assessed via complementary measures, parent-proxy and self-report HRQOL (Eiser & Morse, 2001; Quittner, Davis, & Modi, 2003). However, discrepancies have been identified between parent-proxy and self-report, such that lower HRQOL tends to be reported across all domains in parent-proxy reports versus self-report (Ingerski, Janicke, & Silverstein, 2007; Schwimmer et al., 2003). Caregiver functioning has been implicated as a contributing factor to the lack of convergence and respondent bias (Janicke et al., 2007; Quittner et al., 2003). Prior developmental literature suggests that mothers meeting criteria for depression and/or anxiety have been found to have cognitive biases [i.e., the depression-distortion hypothesis; (Beck, 1967)] that lead to overestimated reporting of internalizing (e.g., depression, anxiety) and externalizing symptoms (e.g., aggression) in their children (Chilcoat & Breslau, 1997). Within the pediatric asthma literature, an inverse association between caregiver negative affect and lower parent-proxy HRQOL was detected (Price, Bratton, & Klinnert, 2002). These data suggest that caregiver depression and negative affect influence parent-proxy reporting of child functioning. Since caregivers of youth with obesity are likely to be obese themselves and exhibit physical and psychosocial impairments (Agras et al., 2004; Janicke et al., 2007; Zeller et al., 2007), HRQOL offers a broader approach to understanding caregiver functioning in pediatric obesity. Thus, it is plausible that caregiver HRQOL influences parent-proxy HRQOL, and in turn, the relation between parent-proxy and child self-report HRQOL. To our knowledge, one study has demonstrated that caregiver HRQOL moderates the link between parent-proxy and self-report HRQOL in youth with congenital heart disease (CHD) (Goldbeck & Melches, 2005). At present, no studies have directly examined HRQOL in both caregivers and their youth with obesity. The primary study aims were to (a) document the HRQOL of caregivers of youth seeking obesity treatment and compare their scores to three previously published samples, (b) identify sociodemographic (i.e., marital status, ethnicity, and SES) and anthropometric (i.e., age, BMI) predictors of caregiver HRQOL, and (c) examine caregiver HRQOL as a moderator of the relation between parent-proxy and youth self-report HRQOL, covarying caregiver weight status. This covariate was included due to the high likelihood of caregiver obesity status in this population (Zeller et al., 2007). The authors hypothesized that (a) caregiver HRQOL scores would be lower than normative scores from a “healthy” US sample and similar to adult obese samples, (b) caregiver and child BMI and SES would account for significant variance in caregiver HRQOL, and (c) the association between parent-proxy and youth self-report HRQOL would be weaker with lower caregiver HRQOL.