Overweight–obesity is an endemic disease in developed countries. They are the most frequent metabolic disorders in the western world. The World Health Organization believes that it constitutes a serious public health problem and has labelled it as the pandemic of the XXI century.1 According to the last national survey conducted in Spain, the Encuesta Nacional de Salud de España 2011–2012, the prevalence of overweight in the 2–17 year old population is of 18.26%, and the prevalence of obesity of 9.56%. The figures specific to the Autonomous Community of Navarra for this age group show a prevalence of overweight and obesity of 15.79% and 7.81%, respectively.2

The aetiology of obesity has been subject to numerous studies. Nowadays, it would be more accurate to speak of “obesities” than of “obesity”, as there is evidence that it can be due to endogenous or exogenous causes; be a primary disease or develop secondary to another condition; or be a monogenic or polygenic trait.3 The literature has described numerous clinical and metabolic complications associated with excess body fat, both in the short and the long term: insulin resistance, hypercholesterolaemia, type 2 diabetes mellitus, metabolic syndrome, polycystic ovary syndrome, or cardiovascular disease.4,5 Excess body fat is also associated with behavioural and psychosocial complications: eating disorders, anxiety, depression, dependence, passivity, poor academic performance, social isolation, real or perceived discrimination, and low self-esteem.6–8

The concept of health encompasses more than the absence of disease. In children and adolescents, the concept of health has certain characteristics, as stated by Starfield: “The measurement of health in children should consider their capacity to fully participate in physical, social, and psychosocial activities and functions adequate to their age.”9 The concept of health-related quality of life (HRQoL) entered the healthcare field in the 1970s, and stemmed from the belief that patient wellbeing and how patients experience their disease and the medical care they receive are important factors to consider during treatment and followup.10,11 Adolescence is a key stage in the development of an individual's personality and traits, and it is a very vulnerable period during which individuals are particularly susceptible to beneficial and deleterious environmental factors. As noted above, overweight and obesity have a significant impact on overall HRQoL and on self-esteem, physical wellbeing, and emotional wellbeing in particular.

There are studies about the impact of overweight–obesity on the HRQoL of adolescents, but so far none have been conducted in Spain. Our hypothesis was that overweight and obesity may have physical and psychosocial consequences that are detrimental to the HRQoL of adolescents. The aim of this study was to analyse the scores obtained by adolescents 12–16 years of age for different aspects of HRQoL and assess whether there are differences associated with sociodemographic characteristics or weight status.

Of the 99 adolescents that were asked to participate in the study, 7 declined. Of the 92 adolescents that agreed to participate, 3 were withdrawn because they did not answer the required minimum number of questions. The final sample included 89 adolescents of both sexes, 12–16 years of age. Of all participants, 54 were classified as having normal weight, and 35 as having overweight–obesity. Table 2 shows the sociodemographic characteristics of the participants.

We found significant differences between the weight status groups in the compliance with the dietary recommendations. Of all participants with overweight–obesity, 45.7% were in compliance, compared to 1.9% of participants with normal weight (P<.001).

The multivariate analysis of the scores of the domains and subdomains by weight status and adjusted for sex, age and socioeconomic status revealed that adolescents with overweight–obesity had less resilience (P=.003), less family involvement (P=.017), less capacity for physical activity (P=.04) and more peer influences (P=.024) (Fig. 1).

Figure 1.

Box plots and error plots for the domain and subdomain scores of the CHIP-AE questionnaire for which the multivariate analysis found significant differences according to weight status.

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Furthermore, the multivariate analysis showed that the scores obtained by girls were significantly lower than those of boys in the satisfaction (P=.001) and resilience (P=.001) domains, and in the self-esteem (P<.001) and physical activity (P<.001) subdomains (Fig. 2).

Figure 2.

Box plots for the domain and subdomain scores of the CHIP-AE questionnaire for which the multivariate analysis found significant differences according to sex.

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The multiple linear regression analysis showed that as the age of participants increased, they obtained lower scores in the risks domain (P<.001) and in the home health and safety (P=.037), individual risk (P=.001) and peer influences (P<.001) subdomains (Fig. 3).

Figure 3.

Box plots for the domain and subdomain scores of the CHIP-AE questionnaires for which the multivariate analysis found significant differences according to age.

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Several authors have assessed the psychosocial consequences of overweight and obesity in adolescents, but there are few studies on the impact of excess weight in their HRQoL. We must nevertheless take into account that psychosocial aspects are, in fact, part of HRQoL.

The works of Mirza et al. and Sjoberg et al. show that excess weight in adolescence leads to body dissatisfaction, low self-esteem and a higher incidence of depression, which are more pronounced in female adolescents.20,21 The study by Al-Akour et al. conducted in Jordan as well as the study by Beer et al. conducted in the Netherlands showed an association between the presence of overweight–obesity and lower scores in every aspect of HRQoL.22,23 Keating et al. specifically analysed the consequences of excess weigh on physical aspects and observed that overweight and obese patients obtained significantly lower scores compared to patients with normal weight.24 According to the review by Griffiths et al., as BMI increases, self-esteem and HRQoL decrease.25,26 The results that we present here are consistent with all of the above.

Still, weight status in not the sole determinant of HRQoL. The differences in perception between the sexes have a considerable impact on its consequences on HRQoL. Several studies have reported that the influence of body image, social acceptance and mood impairment is stronger in female than in male adolescents, which makes girls more vulnerable to psychosocial disorders.20,24,27,28 These differences were also observed in our study, as girls reported lower satisfaction, self-esteem, resiliency and physical capacity than boys.

Excess weight often elicits teasing from peers. The increased influence of the environment combined with perceived teasing and bullying lead to greater insecurity, lower self-esteem and emotional wellbeing, and more difficult interpersonal relationships.29,30 As children grow they become more aware of their environment and of interpersonal differences; self-criticism increases and negative self-perceptions and self-dissatisfaction develop, negatively affecting HRQoL. The decrease in self-esteem leads to increased peer influence and a reduced perceived social acceptance. These aspects may lead to a more introverted character that, as our results demonstrate, may reduce family involvement. The reduced interaction with the family may delay finding the help that the adolescent needs.29,31,32

To date, there are no other published studies of this nature conducted on the adolescent population in Spain. A European multicentre study on the impact of overweight on the HRQoL of participants 8–18 years of age included a representative sample of 714 individuals from Spain; the study concluded that overweight and obesity have deleterious effects on HRQoL, especially on physical comfort and self-perception.33

The anthropometric measurements were taken at the hospital by trained staff, as opposed to self-reported. None of the participants had IBM values at the border between normal weight and overweight–obesity, which guarantees that the groups were separated correctly.

The main limitation of this study is its cross-sectional design, which can establish correlation but not causality. Furthermore, we used a convenience sample because those participants could then be considered for health-promoting interventions, but this means that the sample may not be representative of the adolescent population of Navarra. There may also be a selection bias, as the adolescents with overweight–obesity that seek care in the endocrinology department may have a greater awareness of the repercussions of their disease. One of the main biases to consider is the observer bias: since participants are aware of being questioned, they give more favourable responses in regards to their health status. However, this potential confounding factor would not invalidate the results of this study, since were it not at play, the differences found in the study would be even greater.

Overweight–obesity has a detrimental effect on the HRQoL of adolescents, but it must be taken into account that sex and age have a significant impact on the decrease of HRQoL.

The stronger influence of body image and social acceptance in women makes them more vulnerable to psychosocial disorders. These negative perceptions already occur in female adolescents and have an influence on the development of their personality and behaviour.

We believe that in order to offer patients personalised and multidisciplinary care it is crucial that we know the subjective perception and impact of their health status, and to assess the emotional and psychosocial features related to health from the perspective of the paediatric patient.

The authors have no conflicts of interest to declare.