Qual Life Res DOI 10.1007/s11136-014-0659-y

Psychosocial determinants of quality of life in parents of obese children seeking inpatient treatment Petra Warschburger • Daniela Ku¨hne

Accepted: 20 February 2014 Ó Springer International Publishing Switzerland 2014

Abstract Purpose To examine and identify predictors of parental health-related quality of life (HRQoL) in a sample of obese and very obese children participating in an inpatient program for treating obesity. Methods Data are part of a prospective multicenter randomized-controlled intervention trial. Parents (n = 463) of obese and very obese children (7–13 years) completed standardized questionnaires assessing their own and their child’s HRQoL, psychosocial functioning, demographics and parental weight-specific self-efficacy on the child’s admission to an inpatient pediatric weight management program. Weight and height of the children were measured by trained personnel; parental weight was assessed via self-report. Results Parents reported lower mental HRQoL compared to healthy adults and even lower than reference values for acute or chronic illness. With respect to physical HRQoL, parents of obese children reported higher scores than both groups. Effect sizes were small to medium. Overweight parents reported a lower physical HRQoL. Mental HRQoL was higher for married parents with a higher educational level and a higher self-efficacy and for those whose children depicted fewer behavioral problems and reported a higher HRQoL. Hierarchical regression analyses revealed that weight-specific self-efficacy explained 3 % of variance in mental HRQoL in addition to the demographic and child psychosocial variables. Parental self-efficacy also partially mediated the association between the child’s HRQoL and parental mental HRQoL.

P. Warschburger (&)
D. Ku¨hne Counseling Psychology, University of Potsdam, Karl-Liebknecht-Str. 24-25, 14476 Potsdam, Germany e-mail: [email protected]

Conclusion Childhood obesity is associated with reduced parental HRQoL. Interventions for obesity in children should consider the parents’ psychosocial situation as well. Enhancing parental self-efficacy may be a promising approach. Keywords Health-related quality of life
Obesity
Parents
Children
Self-efficacy

Introduction A chronic disease in childhood or adolescence always affects the whole family and of course the parents in particular: Profound empirical evidence indicating a higher psychological strain among parents of chronically ill children in comparison with healthy children can be found in the literature [e.g., 1–3]. However, most research focuses on life-threatening or life-shortening diseases (such as cancer or cystic fibrosis) and on diseases which require intensive daily therapeutic management such as asthma, diabetes or atopic dermatitis. Though parents of obese children are affected by their child’s disease in many ways as well, little is known about their psychosocial situation. A comprehensive change in lifestyle in terms of nutrition and physical activity behavior is pivotal to obesity treatment [4]. Nutrition and exercise patterns in children are learned from and shaped by their parents. This means that parents not only provide food, but also prepare it and shape the framework for the child’s nutrition (e.g., through table rules). Additionally, they also influence the child’s preferences through regular presentation of food. Treatment guidelines therefore suggest behavioral changes involving the whole family [5]. It is important to understand the psychosocial consequences for parents raising an obese child, as family factors

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are known to have potentially adverse influences on the child’s adjustment [e.g., 6] as well as on treatment efficacy [7]. McConley et al. [8] reported that maternal depression is associated with a higher body mass index (BMI) of their children and that this association is mediated by parenting quality. In addition, parents have to perceive obesity as a health threat in order to seek treatment [9]. Despite the major role parents play in obesity management, there is little research addressing their psychosocial situation. Research into family characteristics has focused on family (e.g., cohesion and parenting styles) and parental functioning [10]. In general, the empirical picture is quite controversial: Whereas some studies reported higher rates of anxiety and depression among mothers of obese children in clinical [e.g., 11–14] as well as nonclinical samples [15], others did not [e.g., 16, 17]. One explanation for these inconsistencies may lie in the diverse sample characteristics: Gibson et al. [18] found no overall effect of higher depression scores on the overweight group, but by trend among treatment seekers. All these studies focused on parental psychopathology instead of health-related quality of life (HRQoL), which is considered to reflect a broader array of functional impairments in daily life associated with a chronic disease. Yet, to our knowledge, only two studies have examined parental HRQoL in parents of obese children. In a nonclinical sample of 360 parents of normal weight, overweight and obese girls (age 9–12 years) in Brazil, Melo et al. [19] found no differences in parents’ HRQoL (assessed with the SF-36). However, the study is limited in several ways. First, the authors defined ‘normal weight’ as 5th–85th BMI percentile (therefore including underweight children). Second, since 60 % of the obese children (n = 62) showed only a mild form (up to 10 % over 95th %) of obesity, the study may underestimate the influence of the child’s weight. Third, the authors did not assess the weight status of the parents. Since obesity in adults is associated with a compromised HRQoL [e.g., 20], this influence has to be considered in the analyses. Parental weight was controlled for in the study by Modi et al. [21]. Examining the HRQoL of 120 mostly obese parents of treatment-seeking youths (aged 5–18 years), these parents reported lower scores than the healthy control group, similar scores to obese adults not seeking treatment, and higher HRQoL scores than treatment-seeking obese adults. Regression analysis revealed lower socioeconomic status (SES) and higher BMI as predictors for a more compromised mental as well as physical HRQoL. A higher age was associated with a higher mental HRQoL score. Children’s variables (age, gender, weight and HRQoL) did not explain additional variance. Parental and children’s HRQoL were significantly correlated. Given the importance of self-efficacy (SE) to treatment outcomes in other pediatric populations, it is surprising that

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this variable has not been evaluated for its contribution to HRQOL in parents of children who are obese. Consistent with the Transactional Stress and Coping Model by Thompson and Gustafson [22], we supposed illness parameters and demographic parameters (such as the child’s age or the socioeconomic status) to be correlates of parental adjustment. In line with this conceptual model child’s psychological adjustment and parental cognitive processes (e.g., self-efficacy) should contribute to the parental QoL. Selfefficacy is defined as the individual belief that one can successfully overcome problems in achieving goals or completing tasks [23]. People with a strong sense of selfefficacy will invest more time and effort to achieve their goals, will recover more quickly from setbacks, will be more committed to their goals and view problems as challenges not as insurmountable threat. SE can therefore be viewed as a health-promoting cognition. There is evidence linking parental SE to parental well-being and child’s adjustment [3]. Whereas there is strong support for the role of parental SE in the field of conduct disorders, very little is known about its influence on psychosocial functioning of parents of a chronically ill child. Research focusing on asthma or diabetes has found that parents’ SE influences the mental health of the parents [24–28]. Silver and colleagues [29] showed that significantly higher parenting stress was experienced by mothers who reported a low SE and a high functional impairment of their child. Thus, parental SE may be associated with their HRQoL. Summing up, the parental HRQoL has rarely been investigated up to now. Since the majority of children in Germany are treated within an inpatient setting [30], we decided to focus on this group. The aims of our study were to (1) examine the HRQoL of parents of obese children in an inpatient program for treatment for obesity and compare it with norm values and (2) investigate the impact of demographic factors, parent’s BMI, children’s behavioral problems, child’s HRQoL and parental self-efficacy on parental HRQoL. We hypothesized that (1) parents of obese and very obese children would report significantly lower mental and physical HRQoL, as measured by the SF12, compared to normative values, and (2) HRQoL would be lower for overweight compared to normal weight parents and for parents with a lower level of education compared to those with a higher level of education, whereas (3) HRQoL would not differ significantly by child sex, age, weight status, but should be lower for those parents whose children experience more behavioral problems and a lower HRQoL; (4) weight-specific self-efficacy would account for a significant proportion of the variance in HRQoL when controlling for parent and child demographic variables and child HRQoL. We further assumed that (5) parental weight-specific self-efficacy mediates the relationship between child and parent mental HRQoL.

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Methods Study design and sample The data are part of a prospective longitudinal randomizedcontrolled trial (empowerment of parents of obese children, EPOC). The EPOC study was established to assess the impact of a supplementary behavioral parent training on the long-term course of children’s weight loss within an inpatient program for treatment for obesity. The clinical sample included obese children aged 7–13 years and their parents. We excluded parents with inadequate German language skills and parents or children with psychiatric disorders. Overall, 523 children and their parents were included in the study. Parents filled in several self-report measures at home. As information on parental quality of life was not available for 60 parents, the current sample consisted of n = 463 parents and their children. The protocol was approved by the Ethical Committee of the University of Potsdam. Procedure Measures Demographics Parents completed a questionnaire that assessed the child’s age and gender as well as the parents’ age, marital status and degree of education completed. All continuous variables were later dichotomized into the categories ‘in a relationship’ versus ‘single parent’ for marital status and ‘more than 10 years in school’ versus ‘less than or 10 years in school.’ Going to school more than 10 years usually enables at least to visit a university of applied sciences. Child and parent age were dichotomized by median split into ‘younger’ (\11.6 and 40.55 years, respectively) and ‘older’ (C11.6 and 40.55 years, respectively). Weight status Children were weighed in light underwear on a balance beam scale. Height was measured with a wallmounted stadiometer. On that basis, gender- and age-specific weight-for-height z-scores (BMI in standard deviation scores, BMI-SDS) according to Kromeyer-Hauschild et al. [31] were calculated. Children were then categorized as ‘obese’ ([97th %) or ‘very obese’ ([99.5 %). Since the data were assessed on the child’s admission to the rehabilitation clinic, we could only collect parents’ height and weight as self-reported. Based on their BMI, parents were classified into one of the following categories: underweight or normal weight (BMI B 25), overweight (25 \ BMI B 30) or obese (BMI [ 30). Parental quality of life Parental quality of life was measured with the German version of the Short-Form Health Questionnaire 12 (SF-12 [32], the short-form of the SF-36). It consists of 12 items, assessing physical (PHS) and mental health (MHS). For each dimension, summary

scores were calculated with high values representing a better physical or mental health status. The SF-12 has been validated in large samples from different European countries and showed very high correlations with the established SF-36 for PHS (.94–.96) as well as for MHS (.94– .97) [33]. Reference values are reported by Bullinger and Kirchberger [32]. Parental weight-specific self-efficacy Parents’ self-efficacy was assessed by means of an instrument we designed consisting of 27 items (SW-ADI, unpublished). This instrument for the measurement of self-efficacy is specific to weight management. It assesses the degree to which parents are convinced that they can change their child’s diet and physical activity when facing obstacles (e.g., child’s resistance, lack of support from the family and necessary changes to their own behavior). Parents answered the questions on a six-point Likert rating scale ranging from ‘very uncertain’ to ‘very certain’ with high values representing a higher self-efficacy. The items compose four scales and a total sum score. For this study, the total score was used. The reliability was high with Cronbach’s a = .95. For further analyses, parental selfefficacy was dichotomized by median split. Child’s quality of life Children’s HRQoL was assessed by proxy report. Parents were asked to fill in the proxy form of the KINDL-R, a HRQoL questionnaire [34]. It consists originally of 24 items representing 6 dimensions. For the present study, parents reported only on four subscales: ‘mental quality of life,’ ‘self-esteem,’ ‘family’ and ‘friends’ of their child. Parents answered the items on a five-point Likert scale ranging from ‘never’ to ‘always.’ The KINDL-R shows satisfactory reliability with an internal consistency ranging from a = .74 to a = .81. Convergent and discriminant validity were also satisfactory. The answers were aggregated to a global score representing the child’s overall HRQoL, with higher scores indicating a better HRQoL. In the current sample, Cronbach’s a reached .85. For further analyses, we dichotomized the scores by median split into ‘high scores’ and ‘low scores.’ Behavioral problems In order to assess the behavioral problems experienced by the children, we used the Strengths and Difficulties Questionnaire (SDQ; [35]). Twenty-five items compose the five subscales ‘emotional symptoms,’ ‘conduct problems,’ ‘hyperactivity/inattention,’ ‘peer problems’ and ‘prosocial behavior.’ Parents were asked to rate their child’s behavior on a three-point Likert scale (‘not true,’ ‘somewhat true’ and ‘certainly true’). Scores for each subscale as well as an overall score of the child’s emotional or behavioral problems were calculated. The SDQ scores were then categorized into ‘inconspicuous’ (up to 80th %), ‘borderline’ (80th– 90th %) or ‘conspicuous’ ([90th %). The SDQ proved to

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be a reliable, valid and sensitive behavioral screening instrument [35, 36]. In the current study, as ranged from .66 to .75 for the subscales; the reliability was high for the total problem score, with a = .85.

Baron and Kenny [37] and then calculated Sobel’s test [38] to check for significance.

Results Statistical analyses

Sample demographics

Data were analyzed with the Statistical Package for the Social Sciences (SPSS, version 20). In all analyses, the p value was set at 0.05 to be considered significant, except when multiple analyses were carried out. We then adapted the a-value with Bonferroni correction. Descriptive statistics were calculated including means, standard deviations and clinical cut-off values when appropriate. All psychometric scales were standardized to a range from 0 to 100. In all analyses, we referred to the corresponding data of the person who filled in the questionnaire (mother and father). In case of missing data or joint completion of the questionnaire, we referred to the maternal data based on plausibility considerations. All analyses were also run excluding these cases. Since this did not change the results, we decided to include all parents. We tested the hypotheses as follows: One-sample t tests were conducted to analyze differences in HRQoL between parents of obese children, healthy adults and adults suffering from acute or chronic illnesses with reference values (see hypothesis 1) given in the manual [32]. Cohen’s d was determined as a measure of the clinical significance of the results. To test hypothesis 2 and 3 (for within-samples differences), multivariate analyses of variance (MANOVA) with PHS and MHS as dependent variables were applied. Since the independent variables showed no significant correlations with each other, we did not include them as covariates in further analyses. MANOVAs were carried out to compare parents with different ages (dichotomized), education levels, marital status and weight status (categorized). As child variables, sex, age, BMI (categorized) and psychosocial variables (KINDL-dichotomized and SDQ-categorized) were examined in MANOVAs. MANOVAs were also run to analyze the impact of parental self-efficacy (dichotomized) on parental HRQoL. Hierarchical multiple regression analyses were carried out for PHS and MHS separately to test hypothesis 4. In a first step, children’s and parents’ demographic variables were included, followed by children’s psychosocial variables in a second and parents’ self-efficacy in a third step. We checked for multicollinearity by using the tolerance statistic (all values were [.5) and VIF (all values were \10). Autocorrelation was ruled out according to the results of the Durbin–Watson’s test (dw = 1.94 and 2.17, respectively). To test hypothesis 5, we conducted a mediation analysis using the approach of

The children were on average 11 years old (range 7–13, SD 1.29), and girls and boys were included in equal proportions. Forty-two percent of the children were classified as very obese. The mean age of the parents was 40.6 years, and mostly mothers filled in the questionnaire. Thirty-one percent of the respondents were single parents, and the remaining 69 % lived in a relationship. Two-thirds of the parents were overweight or obese. Nearly 60 % of our sample attended school for more than 10 years. A detailed sample description is depicted in Table 1.

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Parental quality of life Parents reported a slightly higher mean PHS than MHS (M = 49.85 vs. M = 48.21, t(462) = 2.89, p = 0.004,

Table 1 Characteristics of parents and their children Parents (n = 463) Sex

Children (n = 463)

76.7 % mothers

52.1 % female

8.2 % fathers

47.9 % male

12.7 % both 2.4 % missing Age

M = 40.59 (SD 5.71) years

Education

40.4 % B 10 years in school

M = 11.27 (SD 1.30) years

59.6 % [ 10 years in school Employment status (mothers/ fathers)

71.3/85 % full or part time 7/11.4 % unemployed 2.8/2.1 % retired 1.5/19.9 % others

Marital status

69.0 % in a relationship 31.0 % single parent

Weight status

Mean BMI = 29.20 (SD 6.95, range 17.13–59.06) kg/m2

Mean BMISDS = 2.56 (SD .38, range 1.89–3.98)

32.6 % under-/normal weight

58.1 % obese ([97th %)

28.3 % overweight

41.9 % extremely obese ([99.5 %)

39.1 % obese

Qual Life Res

d = .18). Also, in comparison with healthy adults and with adults facing an acute or chronic illness, parents of obese children reported a significantly lower MHS [t(462) = -8.71, p \ 0.001, d = .48 and t(462) = -6.55, p \ 0.001, d = .33]. 22.70 % (11.80 %) of the parents scored 1 SD (2SD) below the average of the representative sample. In contrast, their PHS was slightly higher compared with healthy and acute or chronically ill adults [t(462) = 2.18, p = 0.03, d = .09; t(462) = 9.40, p \ 0.001, d = .36]. 9.20 % (3.20 %) of the parents scored 1SD (2SD) below the

** d= 0.36

60 ** d= 0.33 *** d= 0.48

* d= 0.09

50 40 30 20

52.24 51.24 48.21 (8.10) (8.80) (9.96)

49.85 49.03 46.32 (8.08) (9.40) (10.10)

MHS

PHS

10 0 Parents of obese children Reference values for healthy adults Reference values for adults with acute or chronic illness

Fig. 1 Parental MHS and PHS compared to reference values. Given are means (SD) and effect sizes (d); *p \ .05; **p \ .001. MHS mental health score, PHS physical health score. Reference values as cited in Bullinger and Kirchberger [32]

Table 2 Results for univariate analyses for differences in parental MHS and PHS

average of the representative sample. PHS and MHS were correlated with a slightly significant degree (r = 0.09, p = 0.048) (Fig. 1). Differences in parental quality of life To explore the differences in parental HRQoL, MANOVAs with parental and child variables as factors were conducted. Parental and child demographic variables were taken into consideration first. HRQoL did not differ by education level and parental age, but differences were found for marital status and parental BMI. Univariate analyses showed that weight status influenced both PHS and MHS (see Table 2) and post hoc tests revealed that obese parents reported significantly higher HRQoL than overweight parents (PHS: M = 48.45 vs. M = 51.61, p = 0.006; d = .42; MHS: M = 47.89 vs. M = 50.25, p = 0.006, d = .40) and significantly lower PHS than normal- or underweight parents (PHS: M = 52.55, p = 0.01, d = .33; MHS: M = 44.07 p = n.s., d = .23). Marital status was only associated with MHS (see Table 2): Parents living in a relationship reported a significantly higher MHS than single parents did (relationship: M = 48.85; single: M = 45.61, d = .31). Children’s age, sex and weight status were not associated with parental HRQoL, but we found a negative correlation between the child’s BMI-SDS and parental PHS (r = -0.11, p = 0.02). Differences due to children’s emotional and behavioral problems and children’s quality of life were found as well [SDQ: F(4; 836) = 9.76, p \ 0.001, g2 = .045; KINDL: F(2; 459) = 17.26, p \ 0.001, g2 = .07]. Univariate analyses showed that only parental MHS differed according to children’s quality of life and emotional and behavioral problems: Parents of children with high HRQoL showed F value

p value

g2

Parental physical health (PHS) Parent Weight status

F(2; 365) = 5.22

.01*

.03

Marital status

F(1; 382) = .01

.93

.00

Weight-specific self-efficacy

F(1; 455) = 3.22

.07

.01

F(2; 418) = 2.45

.09

.01

F(1; 460) = .87

.35

.00

Child Emotional and behavioral problems Quality of life Parental mental health (MHS) Parent

PHS physical health score, MHS mental health score * p \ 0.05; ** p \ 0.01; *** p \ 0.00

Weight status

F(2; 365) = 4.86

.01*

.03

Marital status

F(1; 382) = 8.58

.01*

.02

Weight-specific self-efficacy

F(1; 455) = 13.38

.00***

.03

Child Emotional and behavioral problems

F(2; 418) = 18.29

.00***

.08

Quality of life

F(1; 460) = 34.40

.00***

.07

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Qual Life Res SDQ Inconspicuous

SDQ Borderline

SDQ Conspicuos

High QoL

Low QoL

60 *** d= 0.64

*** d= 0.55

** d= 0.39

50

40

30 51.00 (7.93)

48.83 (9.28)

20

50.77 44,9 (8.65) 45.52 (10.53) (10.94)

50.95 (7.06)

50.06 (8.44)

49.10 (8.29)

50.20 (8.30)

49.50 (7.87)

10

0 MHS

PHS

Fig. 2 Parental HRQoL by child’s SDQ and KINDL scores. Given are means (SD) and effect sizes (d); **p \ .01; ***p \ .001. MHS mental health score, PHS physical health score, SDQ psychosocial functioning, KINDL quality of life

significantly higher MHS themselves than parents of children with low HRQoL (M = 50.77 vs. M = 45.42, p \ 0.001, d = .55). For emotional and behavioral problems, parents of children with inconspicuous scores reported the highest MHS (M = 51.00 vs. M = 48.83, d = .64, vs. M = 44.90, d = .39). Significant differences were found for inconspicuous versus conspicuous scores (p \ 0.001) and borderline versus conspicuous scores (p = 0.009). Mean scores and significant differences in parental HRQoL according to children’s well-being are shown in Fig. 2. Significant differences were also found for the degree of self-efficacy: Parents with a higher degree of self-efficacy exhibited a higher level of MHS than parents with a lower degree of self-efficacy (M = 49.98 vs. M = 46.6, d = .34). No differences were found for PHS. Prediction of parental quality of life Physical health The multivariate linear regression explained only 4.7 % of variance in PHS (see Table 3). Of the parents’ demographic variables (Step 1), only parental BMI proved to be a significant predictor, with a higher BMI associated with lower PHS. Children’s behavioral problems and HRQoL and parental self-efficacy did not add significant incremental variance (both R2 changes = .001, n.s.). Mental health The multivariate regression analysis explained 20 % of the variance in MHS (see Table 4). Parents of children with a

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higher BMI-SDS and those that are married reported a higher HRQoL. Children’s behavioral problems and HRQoL added significant variance to the model (R2 change = 13 %, p \ 0.001): behavioral problems reduced and child HRQoL increased parental HRQoL. Parental self-efficacy (Step 3) accounted for a small, but significant amount of variance in MHS (R2 change = 3.1 %, p = 0.001). Higher weight-specific self-efficacy predicted higher parental mental HRQoL. Mediation analysis We further tested whether self-efficacy mediated the relationship between children’s and parental MHS. We found a significant positive relationship between child’s HRQoL and parental mental HRQoL (b = .26) as well as between parental MHS and their self-efficacy (b = 0.27). Regression analyses showed that the effect of children’s quality of life on parental HRQoL was partially mediated by parental self-efficacy for MHS (Sobel’s test t = 3.45, p \ 0.001). Coefficients are shown in Fig. 3.

Discussion Parents play a major role in the weight management of their obese child. Their own well-being, therefore, is important for their child’s health and psychological adjustment. However, up to now little information has been available about their psychosocial situation. The aim of the current study was to examine the HRQoL of parents of obese children and its influencing factors.

Qual Life Res Table 3 Hierarchical regression for parental PHS, R2 = .047, * p \ .05

b

Independent variables

t

Step 1: Demographics

R2

DR2

.03

.03

95 % CI

Child’s sex

.05

.90

-.94; 2.53

Child’s age

.05

.82

-.39; .96

-.08

1.30

-3.99; .83

Parents’ age

.01

.10

-.14; .16

Parental BMI

-.12*

Child’s BMI-SDS

-2.10

-.26; -.01

Educational status

.02

.30

-1.49; 2.02

Marital status

.00

.01

Step 2: Child’s variables

-1.82; 1.83 .04

Child’s sex

.06

Child’s age

.01

.98

-.87; 2.60

.06

.95

-.36; 1.02

-.07

-1.24

-3.93; .90

Parents’ age

.02

.03

Parental BMI

-.12*

-2.06

-.26; -.01

Educational status Marital status

.01 -.01

.22 -.08

-1.56; 1.95 -1.90; 1.75

Child’s BMI-SDS

Child’s quality of life Child’s behavioral problems

.01

.06

-.09

-1.24

Step 3: Parents’ variables

-.15; .15

-.10; .10 -.30; .07 .05

.01

Child’s sex

.07

1.15

-.72; 2.77

Child’s age

.05

.93

-.36; 1.01 -4.04; .79

Child’s BMI-SDS

-.08

-1.32

Parents’ age

.01

.12

-114; .16

Parental BMI

-.11*

-1.95

-.25; .00

Significant predictors are printed in bold

Educational status

.01

.22

-1.56; 1.95

Marital status

-.01

-.12

-1.94; 1.71

PHS physical health score, BMISDS body mass index in standard deviation scores

Child’s quality of life

-.01

-.11

-.10; .09

Child’s behavioral problems

-.08

-1.09

-.29; .08

.08

1.41

-.02; .10

* p \ 0.05

Parental weight-specific self-efficacy

Compared with healthy and acute or chronically ill adults, parents of obese children exhibited a lower level of mental health with medium effect sizes. This observation is in accordance with the result obtained by Modi et al. [21] in a sample of parents of obese children. Both studies contradict the results of Melo et al. [19] who did not find different HRQoL scores due to children’s weight status in a nonclinical sample. It seems that a lower HRQoL can only be observed in a group of highly affected children and their parents. In contrast to Modi et al. [21], our sample did not report a lower PHS although there were a high percentage of overweight parents as well. The factors influencing parental HRQoL were analyzed in the next step. With respect to sociodemographic factors, we found the following pattern: In line with other results [21], higher parental weight was associated with lower parental HRQoL (MHS and PHS). Parental age and educational level were not associated with HRQoL, but marital status was: Single parents reported a lower MHS. As the

same association can be found in the general population [39], this result was not unexpected. Further, we found no influences of children’s age, sex or weight status (‘obese’ and ‘very obese’) on parental HRQoL, but only a minor correlation between children’s BMI and parental PHS. We also analyzed influences of the child’s behavioral problems. Differences were found only in parental MHS, but not PHS. Higher conspicuity of the child was associated with a lower parental MHS with medium effect sizes, stressing the clinical importance of the results. This is in accordance with other studies reporting reduced quality of life in parents of mentally ill children [40, 41]. As hypothesized, we found that parental self-efficacy influenced parental MHS: Parents with higher self-efficacy showed higher MHS. A study with parents of children suffering from cerebral palsy found comparable evidence: High self-efficacy was associated with a higher HRQoL for the parents [42]. These results suggest that the parental cognitive belief that they are able to cope with the

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Qual Life Res Table 4 Hierarchical regression for parental MHS, R2 = .201***, *** p \ .001, ** p \ .01, * p \ .05

b

Independent variables

t

Step 1: Demographics

R2

DR2

.04

.04

95 % CI

Child’s sex

-.01

-.25

-2.50; 1.94

Child’s age

-.01

-.16

-.93; .79

Child’s BMI-SDS

.15*

.95; 7.77

2.57

Parents’ age

-.02

-.30

Parental BMI

-.05

-.78

Parents’ educational status

.05

.85

Parents’ marital status

.12*

2.21

Step 2: Child’s variables

-.22; .16 -.23; .10 -1.27; 3.21 .028; 4.95 .17

Child’s sex

.00

Child’s age Child’s BMI-SDS

.13***

.08

-1.99; 2.16

.06

1.02

-.40; 1.25

.18**

3.20

1.81; 7.57 -.22; .14

Parents’ age

-.02

-.43

Parental BMI

-.04

-.76

-.21; .09

.04 .10

.81 1.94

-1.23; 2.96

Parents’ educational status Parents’ marital status Child’s quality of life

.26***

Child’s behavioral problems

-.14*

-.03; 4.33 .10; .33

3.57 -2.04

Step 3: Parents’ variables

-.45; -.01 .20

.03**

Child’s sex

.03

.51

-1.52; 2.59

Child’s age

.05

.98

-.41; 1.21

Child’s BMI-SDS

.16**

3.03

1.54; 7.22

Parents’ age

-.01

-.22

-.20; .16

Parental BMI

-.03

-.51

Significant predictors are printed in bold

Parents’ educational status

.04

.83

-1.19; 2.93

Parents’ marital status

.10

1.87

-.10; 4.19

MHS mental health score, BMISDS body mass index in standard deviation scores

Child’s quality of life

* p \ 0.05; ** p \ 0.01

-.12

Parental weight-specific self-efficacy

requirements of the child’s weight management is positively associated with their HRQoL. Regression analyses further confirmed our findings. In summary, only parental BMI predicted parents’ PHS, whereas parental MHS was predicted by the child’s weight, parental marital status, child’s quality of life and behavioral problems, as well as by parental self-efficacy (16 % of the variance was explained by children’s well-being and by parental selfefficacy). Children’s psychosocial well-being was found to be the strongest predictor of parental HRQoL, which is in accordance with the literature [see 43]. To our knowledge, only Modi et al. [21] have included children’s HRQoL, but did not analyze the influence of children’s HRQoL on parental HRQoL. It seems that it is not the degree of the child’s overweight itself that burdens parents of obese children, but its emotional well-being. Many studies have showed that obese children and adolescents, especially in a clinical context, suffer from enhanced strains [cf. 44]. This would explain why Melo et al. [19] did not find an

123

.23**

Child’s behavioral problems

.18**

-.19; .11

3.21

.07; .30

-1.70

-.40; .03

3.43

.05; .19

influence of children’s weight on parental HRQoL. The current study as well only found a comparatively small effect, with 4 % of variance explained. On the other hand, we only included parents of children undergoing inpatient treatment, which may lead to an underestimation of the weight influence. In addition, parental self-efficacy proved to be a relevant predictor beyond the child’s psychosocial well-being. Mediation analysis revealed that self-efficacy is a partial mediator of the influence of children’s HRQoL on parental MHS, underscoring the relevance of parental beliefs in their management abilities. This observation is in line with reports from other chronic diseases [28, 29] and underscores the important role of self-efficacy. Several topics should be mentioned that limited our results. First, we excluded heavily burdened parents and children at the start of our study due to the defined inclusion and exclusion criteria of the clinical trial. Therefore, a bias toward a higher parental HRQoL could be the case. However, this allows us to state that severe mental disorders on

Qual Life Res Fig. 3 Mediation analysis. ***p \ .001

the parents’ side cannot explain their HRQoL in the current study. Second, due to organizational and time-related constraints, we could only assess parental weight status via selfreport. Self-report is considered a valid approach in epidemiological studies [cf. 45], but in our preselected sample (we did expect a high proportion of overweight parents), this may have led to an underestimation of the weight status. On the other side, the self-reported weight status seems to be more closely related to the psychosocial situation then objective measurements [46], and data point to valid information given by the parents. Third, due to the clinical setting, we cannot make a statement on the situation of parents of obese children in general. We assume that the burdens are lower in general populations [cf. 2, 19], and there is evidence that treatment-seeking populations show greater psychological stress [cf. 47, 48], so there may be an overestimation of the psychological burden imposed by the child’s weight-related problems. In addition, the children participating in the study were often very obese, which may also limit the generalizability of our results. Fourth, it has to be considered that the child’s psychosocial situation was assessed via parental report. While selfreported data on HRQoL is available for children older than 9 years, this limits the sample size considerably. As there are only parental data for the SDQ, we used parent reports in general due to content consistency. Fifth, the current study did report the relationship between children’s weight status and parental quality of life in a cross-sectional design. Therefore, we cannot draw any causal conclusion. However, there is empirical support that raising a child with a chronic disease may lead to adverse psychological consequences for the parents [1–3, 49]. In our study, we used a generic measure instead of an obesity-specific HRQoL instrument. While a generic measure of HRQOL allows us to compare different diagnostic groups, it may be less sensitive for detecting obesity-specific problems. Future studies should include obesity-specific assessment for the parental QoL. The strengths of our study are the sample size and the broad assessment of psychosocial influencing variables. In summary, the current study is the first to examine parental HRQoL in parents of children in an inpatient program for treatment of obesity. The results stress that parents of treatment-seeking obese children suffer from a reduced HRQoL. Apart from the child’s weight status, mostly the

child’s HRQoL and parental weight-specific self-efficacy seem to be relevant here. Our findings call for a greater consideration of parental psychosocial well-being when developing interventions for obese children. Several interventions target parenting skills [see [50] for an overview], but to our knowledge the focus of these interventions is mainly on weight-related parenting skills (e.g., monitoring and positive reinforcement). A reduced HRQoL of the parents could be hindering the implementation of learned strategies and thus endanger the success of the program. Strengthening parental self-efficacy could help to enhance the application of learned strategies via enhancing parental HRQoL. Furthermore, it has been shown that pediatric weight loss programs can improve child’s HRQoL [51]. Since child’s HRQoL predicts parental HRQoL, we assume that successful weight loss of the child will have a positive effect on parental HRQoL. Besides targeting the HRQoL of the parents directly and discussing the burdens associated with caring for an obese child, it seems reasonable to strengthen parental weight-specific self-efficacy, which might have a positive effect on parental HRQoL. The integration of strategies to increase parental HRQoL (such as giving emotional support and expressing sympathy for their situation) may therefore increase the likelihood that parents are willing and able to implement the necessary modifications in their own behavior (such as monitoring the child’s eating behavior and giving emotional support) to facilitate their child’s weight loss attempts. Acknowledgments This study was supported by a DFG (German Research Foundation) Grant (WA 1143/3-1; 4-1: 4-2). Special thanks to Dr. Kro¨ller for statistical discussions and Patricia Kulla for critical proofreading. We greatly appreciate the support of our cooperation clinics: Kinder-Reha-Klinik ‘Am Nicolausholz’ Bad Ko¨sen, Charlottenhall Vorsorge und Rehabilitationsklinik fu¨r Kinder und Jugendliche Bad Salzungen, Fachklinik Prinzregent Luitpold Scheidegg, Edelsteinklinik Bruchweiler, Spessart-Klinik Bad Orb, Viktoriastift Bad Kreuznach, Kinder- und Jugendklinik Gesundheitspark Bad Gottleuba, Auguste-Viktoria-Klinik Bad Lippspringe, AHG Klinik fu¨r Kinder und Jugendliche Beelitz-Heilsta¨tten.

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