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The Patient’s View on Quality of Life

The Patient’s View on Quality of Life

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The Patient’s View on Quality of Lifeand Eating Disorders
Simone de la Rie, MA
1
*Greta Noordenbos, PhD
2
Marianne Donker, PhD
3
Eric van Furth, PhD
1
ABSTRACT
Objective:
This study investigated thepersonal views of eating disorder (ED)patients on their quality of life (QOL).
Method:
The views of 146 current EDpatients and 146 former ED patients ontheir QOL were studied using a self-reportquestionnaire. Patients were requested toname the most important aspects of their lifeand they subsequently rated themselves onthese aspects. Qualitative analysis clustereditems into meaningfulcategories.
Results:
A sense of belonging was men-tioned most often (93.0%) by the partici-pants. Work or education, health and well-being were also mentioned frequently. Fur-thermore, participants stated a sense ofself, disease-specific psychopathology, lifeskills, leisure activities, a sense of purpose,financial situation, living condition, andpets. Current ED patients more frequentlymentioned disease-specific psychopathol-ogy than former ED patients. Current EDpatients reported poor QOL on most do-mains, particularly on self-image and well-being. Former ED patients reported betterQOL than current ED patients, but ratingswere just above average.
Conclusion:
The views on QOL of EDpatients broadens the scope of relevantdomains of QOL. The assessment of theseviews may be a useful adjunct to the useof standardized QOL measures.
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2006by Wiley Periodicals, Inc.
Keywords:
eating disorders; quality oflife; patient outcomes
(Int J Eat Disord 2007; 40:13–20)
Introduction
The quality of life (QOL) of patients with an eating disorder (ED) was reported to be poor.
1–10
Padierna et al.
6
showed that after 2 years of treatment andfollow-up, ED patients were still more dysfunc-tional in all areas of life than women of the generalpopulation although their perception of their QOLhad improved. De la Rie et al.
1
also showed that EDpatients, even after symptoms are no longer mani-fest, still report a poorer QOL than a normal refer-ence group.The QOL for EDs in most of these studies wasassessed using general health-related QOL mea-sures, such as the Short Form-36 (SF-36)
1–8
or theNottingham Health Profile.
9
 Although the use of a generic health-related QOL measure helps to pro-vide insight into the QOL of a patient group in com-parison to other patient groups or a normal refer-ence group, it has several limitations. In their study on EDs and emotional and physical well-being, Dollet al.
3
found that an EDhistory of students is accom-panied by health-related QOL impairment in emo-tional well-being. However, anorexia nervosa (AN)participants reported fewer limitations on the SF-36,although they reported several severe comorbid psy-chiatric symptoms. Doll et al.
3
suggest that the SF-36 is insensitive to emotional distress, particularly in AN patients. In a study on QOL of inpatients with AN Gonzalez-Pinto et al.
4
found global deteriorationin the perception of health-related QOL, especially in mental health and vitality of the SF-36. Purging behaviors and comorbidity were found to predictpoor QOL of AN patients. Mond et al.
2
found thatalthough ED patients participating in an EDs Day Program reported poorer QOL than normal controls,restrictive AN patients tended to report better QOLthan other patient groups, after adjusting for levelsof general psychological distress. Mond et al.
2
com-pared two general health-related QOL-measures,namely the SF-12 and the WHOQOL-BREF. Thefound differences between the SF-12 and the WHO-
1
Centre for Eating Disorders Ursula, Leidschendam,The Netherlands
2
University of Leiden, Department of Clinical and HealthPsychology, Leiden, The Netherlands
3
Erasmus MC, Department of Public Health, University MedicalCentre Rotterdam, Rotterdam, The NetherlandsAccepted 4 July 2006
*Correspondence to:
Simone de la Rie, Centre for Eating DisordersUrsula, P.O. Box 422, 2260 AK Leidschendam, The Netherlands.E-mail: s.delarie@centrumeetstoornissen.nlPublished online 29 August 2006 in Wiley InterScience(www.interscience.wiley.com). DOI: 10.1002/eat.20338
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2006 Wiley Periodicals, Inc.
International Journal of Eating Disorders 40:1 13–20 2007—
DOI 10.1002/eat
13
REGULAR ARTICLE
 
QOL-BREF. They concluded that using only oneinstrument can be misleading.Several more specific instruments have beendeveloped to assess the QOL of patients with mental disorder.
11–13
In a small study of 46 formerED patients from an outpatient clinic, Danzlet al.
10
assessed the QOL with one of such instru-ments, namely the Lancashire Quality of Life Pro-file. In this study, a positive change in the eating behavior of former patients from an outpatientclinic was associated with a better QOL on severaldomains: leisure time, financial situation, and per-ception of mental health. These changes wereassociated with changes in family life. The Lanca-shire Quality of Life Profile includes objective indi-cators of the QOL (i.e. leisure activities or presenceof a significant other) as well as subjective ratingsof satisfaction with several life domains, such as work, leisure, financial situation, living conditions,relationships with significant others, health, andgeneral satisfaction with life. Recently, a diseasespecific health-related QOL instrument has beendeveloped by Engel et al.
14
Domains and items of the instrument were elicited by a panel of expertson EDs. Firstly, areas affected by the ED were iden-tified, including the following domains: physical,psychological, financial, social, work/school, andlegal. Secondly, the experts listed relevant areas of functioning on these domains. Thirdly, items wereelicited. The EDQOL showed to have good psycho-metric properties. Whereas objective measures to assess QOL in-clude information on the presence/absence of, forinstance, a job or relatives, or information onincome and living condition, subjective measuresassess the QOL based on personal ratings on sev-eral fixed domains. In a disease-specific instru-ment such as the EDQOL, the fixed domains referto domains that are known to be affected by theED. Nonetheless, the relative importance of lifedomains to the perception of the QOL of EDpatients or their personal views on what (do-mains) they feel to contribute to their QOL are as yet undetermined. Therefore, it seems importantto assess the personal views on QOL of ED pa-tients.The current study explored the personal viewsof current and former ED patients on their QOL.It examined differences between AN, bulimia nervosa (BN), and ED not otherwise specified(EDNOS) patients as well as between purging andnonpurging ED patients. It aimed to investigate whether the use of an individualized measure— with individually chosen instead of xeddomains—would contribute to the assessment of QOL of ED patients.
Method
Participants
The study sample consisted of current ED patients andformer ED patients recruited from the community in theNetherlands. They volunteered to participate in thestudy. Informed consent was assured. Participants wererecruited from different parts of the country using vari-ous methods. The majority of the sample was recruitedthrough articles and advertisements in newspapers, andin a women’s magazine, leaflets (33%), and the magazineand website of the Dutch patient organization for EDs(27%). A smaller part of the sample was recruited directly at specialized ED centers (10%). The remaining part of the sample (
6
30%) was recruited through diverse chan-nels, for example patients that were in treatment in a specialized ED center applied to participate in the study  when reading about it on the website of the patient orga-nization.
 Assignment of Diagnosis
Participants were included in the study upon meeting a life time self-reported diagnosis for a DSM-IV ED.
15
Lifetime diagnosis for a DSM-IV ED was based on the diag-nostic items of the self-report Eating Disorder Examina-tion Questionnaire (EDE-Q), information on body massindex (BMI: weight in kilogram/height in meter
2
) andmenstrual status. Participants filled out the EDE-Q, andanswered questions about weight, height, and menstrualstatus for what they perceived as the period they sufferedmost from their ED (worst period). If they met the criteria for a DSM-IV ED for that period, they were included inthe study. To ensure they did suffer from an ED during that period, participants were asked if a clinician men-tioned a diagnosis to them and if so what they were told.If no clinician ever mentioned a diagnosis, the research-ers carefully examined all answers on the EDE-Q, espe-cially reported restrictive eating behaviors, binging andpurging behaviors, reported weight and height as well a preoccupation with weight or shape, before including theparticipants in the study. After positive screening for a life time diagnosis for a DSM-IV ED, the EDE-Q was administered again, but now to assess current ED pathology. The EDE-Q is a self-reportquestionnaire developed by Fairburn and Wilson.
16
It in-cludes 36 questions on eating behavior in the past 28 days.The questionnaire consists of diagnostic items and foursubscales: Restraint, Eating Concern, Shape Concern,and Weight Concern. Diagnostic items include questions
DE LA RIE ET AL.
14
International Journal of Eating Disorders 40:1 13–20 2007 
 —DOI 10.1002/eat
 
based on DSM-IV criteria for EDs relating to feeling of fat-ness, fear of gaining weight, bulimic episodes, dietary re-striction, compensatory behavior (for instance self-inducedvomiting or laxative misuse), importance of shape or weight for self-esteem, and abstinence from weight con-trol behavior. The diagnostic items are rated on a 6 pointscale and address the past 28 days, where appropriate re-spondents are requested to provide a frequency count. Sothat all criteria for an ED could be assessed according tothe DSM-IV, additional questions were asked about weight,height, to calculate BMI, and menstrual status. An algo-rithm reliably assigned DSM-IV diagnosis for an ED or nocurrent diagnosis for an ED. The four subscales containquestions regarding distorted cognitions about eating,dieting, weight, shape or eating behavior, and provideinsight into the nature and severity of the ED. In a recentstudy by Mond et al.,
17
the validity of the EDE-Q in com-parison to the EDE interview in screening for EDs in a community-based sample was investigated. The EDE-Qhas good concurrent validity and acceptable criterion va-lidity and can therefore be used for assessment of EDs in a community-based sample.
QOL Measure 
To assess the patient’s view on QOL a procedure de-rived from the Schedule for the Evaluation of IndividualQuality of Life (SEIQOL) was used.
18,19
The SEIQOL is a semi-structured interview that assesses an individual’sQOL in three steps. In this study, the questions were ad-ministered written.First the participants were asked to nominate the fiveareas of their life (cues) that are most important to them.These five areas are referred to as domains (and not cues)in this study. Secondly, participants rated their currentlevel of functioning on each domain. They were asked torate their QOL on a VAS scale from 0 to 100 for all fiveaspects, subsequently. A higher score indicates a betterQOL. The third assessment step of the original SEIQOLprocedure involves quantifying the relative importance(weight) of each domain to their perception of the overallQOL. A weighting disk is used, consisting of five disksthat are rotated around a central point to form a piechart. The disks are labeled with the five domains andare adjusted by the participants until the proportion of each domain on the pie chart then accurately reflects therelative importance they attach to these domains. By multiplying each weight with the relevant level of func-tioning a 
\
SEIQOL Index score
"
is calculated. These fivescores are summed. In our study, the third step was sim-plified in comparison to the SEIQOL procedure. Partici-pants were asked to rank the five domains from one tofive with the most important domain on number onedown to the least important domain at five to assess therelative importance of the domains mentioned. An Index score was not calculated.
 Analysis
Both quantitative and qualitative analysis were carriedout to investigate the patient’s own view on their QOL.Qualitative analysis was carried out by careful examina-tion of all aspects mentioned by the participants. Allthese aspects were saved and then coded by the research-ers. Subsequently, these coded items were clustered intomeaningful categories based on their content. This pro-cess was facilitated by means of KWALITAN, a softwareprogram that enables clustering of relevant items inmeaningful categories.
20
 A 
2
test was used to investigatethe differences between current and former ED patientsand between diagnostic subgroups on the frequency of the domains mentioned. A 
2
test was also used to inves-tigate the differences between current and former EDpatients on the ranking of the domains. Some domains were mentioned with a low frequency. Consequently, theranking of the different diagnostic subgroups was notcompared. Mean scores of the ratings on the domains were calculated for current ED patients and former EDpatients.
-tests were used to investigate the differencesbetween current ED patients and former ED patients ontheir ratings for the QOL and the differences betweenpurging (use of laxatives, diuretics or vomiting twice a  week) and nonpurging ED patients (use of laxatives, diu-retics or vomiting less than twice a week or no purging behavior at all). Again because of the low frequency with which several domains were mentioned, the differencesbetween diagnostic subgroups were not analyzed.
Results
Of the 292 participants, 146 (50.0%) met DSM-IV criteria for an ED in the present: 44 (30.1%) met cri-teria for AN, 43 (29.5%) for BN, and 59 (40.4%) forEDNOS. EDNOS patients met (sub)threshold crite-ria for AN or BN. The remaining 146 (50.0%) partic-ipants did not meet criteria for an ED in the presentand were designated as former ED patients. Themajority of the sample received a formal diagnosisof an ED by a clinician (81.7%). Only 17.4% did notreceive a diagnosis of an ED by a clinician. Twenty-four participants did not meet criteria for an ED inthe present. Careful examination of their responseson the EDE-Q regarding the worst period they suf-fered from an ED and information on their weightand height showed they did suffer from ED pathol-ogy in the past and they were therefore included inthe study.Participants were predominantly women with a mean age of 28.6 years (SD 8.8). The median age was 27.0 years. The mean duration of illness was
THE PATIENT’S VIEW AND QUALITY OF LIFE
International Journal of Eating Disorders 40:1 13–20 2007 
 —DOI 10.1002/eat
15

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