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Abstract
KOLOTKIN, RONETTE L., ROSS D. CROSBY,
KARL D. KOSLOSKI, AND G. RHYS WILLIAMS. Development of a brief measure to assess quality of life in
obesity. Obes Res. 2001;9:102111.
Objective: Obesity researchers have a growing interest in
measuring the impact of weight and weight reduction on
quality of life. The Impact of Weight on Quality of Life
questionnaire (IWQOL) was the first self-report instrument
specifically developed to assess the effect of obesity on
quality of life. Although the IWQOL has demonstrated
excellent psychometric properties, its length (74 items)
makes it somewhat cumbersome as an outcome measure in
clinical research. This report describes the development of a
31-item version of the IWQOL (IWQOL-Lite).
Research Methods and Procedures: IWQOLs from 996
obese patients and controls were used to develop the
IWQOL-Lite. Psychometric properties of the IWQOL-Lite
were examined in a separate cross-validation sample of 991
patients and controls.
Results: Confirmatory factor analysis provided strong support for the adequacy of the scale structure. The five identified scales of the IWQOL-Lite (Physical Function, SelfEsteem, Sexual Life, Public Distress, and Work) and the
total IWQOL-Lite score demonstrated excellent psychometric properties. The reliability of the IWQOL-Lite scales
ranged from 0.90 to 0.94 and was 0.96 for the total score.
Correlations between the IWQOL-Lite and collateral measures supported the construct validity of the IWQOL-Lite.
Changes in IWQOL-Lite scales over time correlated significantly with changes in weight, supporting its sensitivity to
change. Significant differences in IWQOL-Lite scale and
102
Introduction
In 1947, the World Health Organization defined health as
not merely the absence of disease, but complete physical
function, social function, role function, mental health, and
general heath perceptions (1). In recent years, the terms
quality of life and, more specifically, health-related quality
of life (HRQOL) have been used to refer to the physical,
psychological, and social domains of health, seen as distinct
areas that are influenced by a persons experiences, beliefs,
expectation, and perceptions (2). With increasing frequency, clinical researchers are choosing measures of
HRQOL as primary and secondary outcomes in clinical
trials (3). As new anti-obesity drugs are developed, there is
an increasing need to measure HRQOL in obese persons
participating in clinical trials for the treatment of obesity.
It is well known that obesity may impact important aspects of HRQOL, such as physical health, emotional wellbeing, and psychosocial functioning (4 7). HRQOL has
been found to vary directly with the severity of obesity
among individuals seeking weight-loss treatment, with the
most obese individuals having the poorest quality of life (8)
and obese persons reporting pain showing the greatest impairments (9). Obese persons seeking treatment have been
shown to be significantly more physically impaired than
those who are not trying to lose weight (10). Furthermore,
increases in weight have been associated with deteriorated
physical, but not emotional, well-being (11,12), and weight
loss has been associated with improved physical rather than
mental components of HRQOL (12). HRQOL has been
shown to improve after treatment (1315).
103
Group
Open-label phen-fen
Obese
211
Day treatment
Obese
834
Weight-reduction studies/programs
Obese
668
Gastric bypass
Obese
51
Community
223
Employees/friends
Total
1987
Gender
32
179
322
512
91
577
11
40
159
64
615
1372
males
females
males
females
males
females
males
females
males
females
males
females
Age
BMI
47.8 10.3
44.4 9.3
52.1 14.3
50.2 17.6
47.4 9.4
43.9 11.3
46.6 4.5
38.5 9.7
37.2 11.4
39.0 14.1
47.3 14.1
45.9 14.3
42.0 8.7
40.7 7.1
41.7 11.1
37.0 9.1
35.5 6.2
35.0 6.1
50.6 10.0
51.0 12.9
27.7 3.6
26.5 10.1
37.2 10.8
36.6 9.4
Physical
Function
SelfEsteem
Sexual
Life
Public
Distress
Work
Total
0.84
0.84
0.84
0.84
0.80
0.84
0.76
0.66
0.61
0.61
0.44
0.43
0.44
0.44
0.46
0.45
0.48
0.47
0.45
0.32
0.31
0.40
0.50
0.49
0.47
0.48
0.48
0.49
0.46
0.42
0.39
0.36
0.32
0.61
0.61
0.64
0.63
0.56
0.62
0.63
0.48
0.38
0.43
0.38
0.54
0.51
0.55
0.53
0.57
0.61
0.44
0.47
0.43
0.39
0.37
0.75
0.74
0.75
0.76
0.73
0.77
0.71
0.64
0.55
0.54
0.48
0.47
0.47
0.48
0.41
0.41
0.44
0.50
0.84
0.86
0.84
0.78
0.74
0.73
0.73
0.53
0.54
0.52
0.54
0.48
0.50
0.54
0.51
0.49
0.54
0.44
0.56
0.52
0.56
0.48
0.51
0.55
0.47
0.49
0.42
0.51
0.69
0.69
0.71
0.63
0.63
0.63
0.69
0.41
0.51
0.57
0.51
0.48
0.56
0.54
0.60
0.80
0.79
0.77
0.83
0.33
0.37
0.49
0.45
0.41
0.48
0.49
0.49
0.55
0.63
0.68
0.67
0.42
0.66
0.67
0.65
0.48
0.55
0.48
0.52
0.47
0.61
0.35
0.41
0.43
0.38
0.37
0.62
0.83
0.87
0.83
0.64
0.41
0.47
0.48
0.47
0.44
0.57
0.70
0.73
0.69
0.62
0.58
0.55
0.57
0.50
0.53
0.54
0.47
0.49
0.46
0.50
0.49
0.41
0.49
0.45
0.49
0.47
0.78
0.79
0.85
0.72
0.67
0.66
0.66
0.61
Correlations between each item and its designated scale are in bold type. Also in bold type are correlations between each item and total score.
All correlations are corrected for overlap.
105
Results
0.94; Self-Esteem, 0.93; Sexual Life, 0.91; Public Distress, 0.90; and Work, 0.90, with the overall coefficient
equaling 0.96.
Table 2 presents correlations between each item and its
designated scale in bold type (corrected for the influence of
that item), and the correlations between each item and the
other scales in normal type. Correlations between each item
and its designated scale were all significant at p 0.001.
For each item, the item-to-scale correlation was higher for
the designated scale (indicated in bold) than for any other
scale. In addition, for all but one item (Worried about
health), that correlation was higher than the corrected
item-to-total score correlation. Finally, for all items, the
item-to-total score correlation is higher than all item-toscale correlations except the designated scale. This pattern
of results suggests excellent reliability and distinct separation of scales.
Analysis of the development sample led to the specification of a 31-item instrument (IWQOL-Lite) consisting of
five scales: Physical Function (11 items), Self-Esteem (7
items), Sexual Life (4 items), Public Distress (5 items), and
Work (4 items). The correlation between the new 31-item
instrument (IWQOL-Lite) and the longer 74-item instrument (IWQOL) was 0.97. A description of the IWQOL-Lite
items and scales follows.
As in the original IWQOL, all items are rated by the research subject as always true, usually true, sometimes
true, rarely true, or never true; always true responses
were given a score of 5, never true responses were given a
score of 1. Scale scores are obtained by adding item scores, and
the total score is obtained by adding scale scores. Higher scores
indicate poorer quality of life. All items except for four begin
with the phrase because of my weight. The 11-item Physical
Function scale is concerned with mobility and day-to-day
physical functioning (e.g., Because of my weight, I have
difficulty getting up from chairs.). Seven of the 11 items on
the Physical Function scale were originally on the Mobility
scale of the longer IWQOL, and 4 were from the Health scale.
The seven-item Self-Esteem scale assesses self-esteem concerns related to weight (e.g., Because of my weight, I dont
like myself.). Five of the seven items were on the original
Self-Esteem scale of the IWQOL, and two were from the
Social/Interpersonal scale. The four-item Sexual Life scale
assesses sexual limitations related to obesity (e.g., Because of
my weight, I have little or no sexual desire.). All of the items
on the IWQOL-Lite Sexual Life scale were on the original
IWQOL Sexual Life scale. Three of the five items on the
Public Distress scale pertain to fitting in public places (e.g.,
Because of my weight, I worry about finding chairs that are
strong enough to hold my weight.) and were on the Activities
of Daily Living scale of the IWQOL. Two of the items on the
Public Distress scale pertain to negative reactions from others
(e.g., Because of my weight, I experience ridicule, teasing, or
unwanted attention.) and were on the Social/Interpersonal
scale of the IWQOL. The four items on the Work scale are
concerned with work performance as it relates to weight (e.g.,
Because of my weight, I have trouble getting things accomplished or meeting my responsibilities.). All of the items on
the Work scale were on the Work scale of the 74-item
IWQOL.
All results reported below are based on the crossvalidation sample.
106
Interscale Correlations
Interscale correlations ranged from 0.46 (Sexual Life and
Public Distress) to 0.70 (Physical Function and Public Distress). Uncorrected correlations with total scale score ranged
from 0.74 (Sexual Life) to 0.89 (Physical Function),
whereas corrected correlations ranged from 0.66 (Sexual
Life) to 0.73 (Public Distress). The equivalence of correlations between individual scales and total score corrected for
overlap suggests that scales contribute comparably to the
total score.
107
Discussion
This report describes the development and validation of a
brief version of the IWQOL (IWQOL-Lite) that consists of
108
Scale
Physical
Function
Self-Esteem
Sexual Life
Public Distress
Work
Total Score
0.62
1.20
0.81
0.43
0.20
0.28
0.09
0.46
0.65
0.36
0.47
0.19
0.65
0.95
0.73
0.62
0.44
1.12
0.73
0.46
0.50
0.26
0.79
109
Acknowledgments
This study was supported by a research grant from Knoll
Pharmaceutical Company. We thank the following individuals for their assistance: Kathleen Meter and Colleen Mc
Kendrick, research assistants, for their role in data compilation; Stan Heshka, Jim Hill, George Cowan, Cynthia Buffington, Gil Hartley, and Duncan Adams for sharing their
data; and Jim Mitchell for his suggestion of the name
IWQOL-Lite.
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Appendix 1
A series of confirmatory factor analyses was performed
on the cross-validation sample to evaluate the hypothesized
scale structure using EQS software (29). Three models were
compared. The first model (Model 1) was a single-factor
model in which all 31 items were considered to be indicators of a single global factor. The second model (Model 2)
was a correlated-factors model in which items were assigned to one of the five hypothesized scales. This model
specified no a priori relationship among scales, but rather
allowed the correlation among scales to vary freely according to the data. The final model (Model 3) was a secondorder model in which items were assigned to scales, and
scales were considered to be part of a higher order construct,
presumably HRQOL. The adequacy of the models was
evaluated using the 2 goodness of fit test, the Normed Fit
Index (NFI), the Tucker-Lewis Index (TLI), the Comparative Fit Index (CFI), and the Standardized Root Mean Residual (SRMR). Evidence of an adequate model fit was
considered if coefficients (NFI, TLI, and CFI) of 0.90 and
111