International Journal of Obesity (2002) 26, 417–424

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PAPER
Impact of overweight and obesity on health-related
quality of life — a Swedish population study
U Larsson1, J Karlsson2 and M Sullivan2*
1
The Nordic School of Public Health, Göteborg, Sweden; and 2Health Care Research Unit, Institute of Internal Medicine,
Sahlgrenska University Hospital, Göteborg, Sweden

OBJECTIVE: To investigate the impact of overweight and obesity on health-related quality-of-life (HRQL) in the general
population in western Sweden.
DESIGN: Cross-sectional survey.
SUBJECTS: A total of 5633 men and women aged 16 – 64 y born in Sweden.
MAIN OUTCOME MEASURES: Scale and summary component scores of the SF-36 Health Survey.
RESULTS: Obese men aged 16 – 34 y rated their HRQL lower than normal-weight men did on all four physical health scales of
the SF-36 and on two of the four mental health scales. Obese women in the same age group rated their health worse than
normal-weight women on three of the physical health scales. Thus, in younger men and women the analysis indicated a clearer
negative association between obesity and physical health than between obesity and mental health. Obese women aged 35 –
64 y rated their health worse on all scales than normal-weight women did, while obese men in this age group rated their health
worse on only two SF-36 subscales — physical functioning and general health perception. The massively obese men and women
suffered from a poor level of HRQL.
CONCLUSION: Not only does the level of obesity affect HRQL, the impact of overweight and obesity also differs by age and sex.
The importance of aspects of both physical and mental health should be fully recognised.
International Journal of Obesity (2002) 26, 417 – 424. DOI: 10.1038=sj=ijo=0801919

Keywords: health-related quality of life; SF-36; overweight; general population; epidemiology

Introduction relevant to the patients. This is especially useful in clinical

Health-related quality-of-life (HRQL) has gained increasing
interest as an outcome measure in clinical medicine and
public health settings. It is particularly useful in studies on
chronic diseases where the realistic goal of care is to make life
as comfortable as possible.1 There is consensus on a mini-
mum set of core concepts to be included in the assessment of
HRQL: physical functioning, mental health, social function-
ing, role functioning and general health perceptions.1,2
There are in principle two paths to follow when choosing
an instrument to assess HRQL, the specific and the generic,
or a combination of the two. A disease-specific instrument is
that are of the disease or the health state that are most
*Correspondence: M Sullivan, Health Care Research Unit, Sahlgrenska
University Hospital, SE-413 45 Göteborg, Sweden.
E-mail: healthcare.research@medicine.gu.se
Received 25 October 2000; revised 31 August 2001;
accepted 16 October 2001
studies where a detailed assessment of the patients’ HRQL is
necessary to fully evaluate a specific therapeutic interven-
tion. On the other hand, a generic instrument is used to
measure people’s perceived HRQL across a wide range of
diseases, complaints and health states and across different
sociodemographic groups. It is thus possible to assess the
relative burden of different conditions and also interpret that
burden in health economic terms.
Our knowledge about the impact of obesity on HRQL is
increasing due to the recent development of standardised
questionnaires with high reliability and validity. One
attempt to assess HRQL in the obese is the ongoing Swedish
Obese Subjects (SOS) study, where more than 6000 severely
obese persons have been recruited to take part in a combined
registry and intervention study.3 HRQL is measured with a
battery of instruments comprising established generic mea-
sures, an eating questionnaire and a study-specific module
on obesity-related problems. The instruments were chosen to
cover a broad spectrum of health impairments related to
 Quality of life in the overweight population
U Larsson et al
418
obesity. An initial study showed that the obese rated their
health and psychosocial functioning lower than a reference
group. This study also displayed the consequences of weight
reduction on HRQL. Compared to traditionally treated con-
trols, the obese subjects who underwent weight-reduction
surgery showed a markedly improved HRQL 2 y after sur-
gery.4 These results also suggest that obesity causally affects
the level of the HRQL. This reasoning is in line with modern
thinking on the association between obesity and psycho-
pathology, where the latter now is seen as a consequence
rather than a cause.5
Studies on the relationship between obesity and HRQL
usually include obese persons seeking treatment, ie
patients.6,7 However, there are reasons to believe that obese
people who seek treatment differ in respect to HRQL from
those who do not seek treatment. For example, it has been
shown that obese patients report more symptoms of certain
psychopathologies and more binge eating than obese people
who are not in treatment.8 Therefore, it is uncertain if results
from HRQL studies with patient samples are generalisable to
all obese persons. So far, four general population surveys
using the same psychometrically sound HRQL instrument,
SF-36, have examined the association between HRQL and
obesity.9 – 12 The purpose of the present paper is to further
study the impact of overweight and obesity on HRQL in
persons from the general population. Using a random
sample from the general population, stratified by age and
sex, and the generic HRQL instrument, SF-36 Health Survey,
the present paper addressed the following questions:

Does the impact of overweight and obesity on HRQL
among persons in the general population vary with age
and sex?

Are both physical and mental aspects of HRQL affected?

Is HRQL related to the level of obesity?

What is the impact of body mass index (BMI) on HRQL
after adjusting for age, sex, education, physical activity
and sick leave=disability pension?
Methods
Design
A cross-sectional survey was conducted in western Sweden to
aid in the planning and organisation of health promotion
activities and to support health policy decision-making. A
16-page questionnaire was mailed to a random sample
(n ¼ 12 295), aged 16 y or older, during the spring of 1997.
Statistics Sweden, which is the public authority responsible
for the national civil registers, performed the fieldwork. If
the questionnaire was not returned within 2 weeks, a remin-
der was sent. In total three reminders were provided. The
fieldwork took about 10 weeks.
The questionnaire contained questions on HRQL (SF-36),
allergy, smoking and exercise, personal economy, psychoso-
cial and physical working conditions, social network and
social support, demography, weight and height, and socio-
International Journal of Obesity
economic status including sick leave and disability pension.
In addition to the questionnaire, information on age, sex,
education, income, marital status, residence, nationality and
country of birth was available from the civil registers used for
selecting the subjects.
The sample was stratified by the 25 municipalities in the
area. During the data collection procedure, it was possible to
identify and eliminate 204 subjects included in the registers
but not in the target population. The majority of these
persons were not able to answer the questions because of
physical or mental illness (72%) or for other reasons, eg
residing abroad. A total of 214 respondents returned the
questionnaire with the identification label ripped off,
making it impossible to add the registry information to
this person’s record. Of the 12 091 persons in the target
population receiving the questionnaire, 8751 (72%) returned
it, including those with the identification label ripped off.
The item non-response, ie returning the questionnaire with-
out completing all questions, was small. In accordance with
the SF-36 scoring procedure, imputation was applied for this
subgroup of questions.13
Measures
Health-related quality of life, HRQL. HRQL was assessed
with the generic and standardised SF-36 Health Survey. The
SF-36 taps eight health concepts (scales) representing multi-
ple operational definitions of health, including function and
dysfunction, distress and well-being, and favourable and
unfavourable self-ratings of one’s general health status.14
The physical functioning (PF) scale measures the ability to
perform activities of daily living but also strenuous activities
(10 items). Role-physical (RP) reflects the extent that physi-
cal health has a limiting effect on work or other activities
(four items). Bodily pain (BP) concerns the amount of pain
felt and whether it interferes with normal activities (two
items). General health (GH) measures perceived general
health status (five items). Vitality (VT) includes items on
energy, tiredness, etc (four items). Social functioning (SF)
concerns how social activities are affected by physical health
or emotional problems (two items). Role-emotional (RE)
reflects the extent that work or other activities are limited
by emotional problems (three items). Mental health (MH)
measures emotional well-being (five items). All scale scores
range from 0 to 100, with 100 representing optimal physical
functioning and well-being. The first four scales (PF, RP, BP,
GH) are here referred to as the physical part of the HRQL,
while the latter four scales (VT, SF, RE, MH) are referred to as
the mental part of the HRQL concept.
To reduce the number of outcome measures, two sum-
mary components have been extracted from the eight origi-
nal scales.13 The physical component summary (PCS) score
and the mental component summary (MCS) score together
account for 80 – 85% of the variance in the eight scales.13
They are standardised through norm-based scoring to a
normal distribution with a mean of 50 and a standard

deviation of 10. The Swedish version of the SF-36 has been
shown to possess sound psychometric properties in different
groups of people and is now widely used.15 – 17
Selected variables. Background variables analysed included
BMI, sex, age, education level, physical activity in leisure
time and sick leave more than 6 months or disability pen-
sion. BMI (kg=m2) was calculated from questionnaire data
and classified according to standards proposed by WHO.18
Data on sex, age and educational level was obtained from the
civil registers.
Subjects
The analysis was restricted to the age group 16 – 64 y. Respon-
dents over 64 were excluded since physical health status
declines with increased age and thus interferes with the
study purpose to evaluate the effect of obesity on HRQL.
Non-response rates were also higher among the elderly. This
subsample of the target sample comprised 9410 subjects and
6618 (70%) returned the questionnaire. The prevalence of
overweight and obesity in this group is given in Table 1.
Reference values for the Swedish population are also given.
Compared with a Swedish nationwide interview survey
(personal interview, self-reported weight and height) on
living conditions 1996=1997, the prevalence of overweight
(BMI 25.0 – 29.9 kg=m2) differed between 0.1 and 1.2 percen-
tage points for men and women and the two age groups from
our sample. The prevalence of obesity and massive obesity
differed slightly more between the two studies.
Analysis of data showed that the prevalence of overweight
and obesity is larger in people born outside of Sweden and
also that they suffer from lower levels of HRQL (data avail-
able from the authors upon request). Thus, to eliminate
potentially confounding results due to ethnicity, individuals
born outside of Sweden were excluded (n ¼ 881). Under-
weight persons were also excluded (n ¼ 104), leaving 5633
subjects in the study with valid values on sex, age and BMI.
Quality of life in the overweight population
U Larsson et al
419
Statistical methods
Different technigues were applied to adjust for non-response
and selection bias.19 Since auxiliary information (distribu-
tion of persons over strata categorised by sex, age and
municipality) was available from the registers at the popula-
tion level, it was possible to adjust not only for non-response
bias but also for selection bias. Different techniques were
adopted to eliminate and minimise the influence of con-
founders. After excluding persons born outside of Sweden
and underweight persons, the remaining subjects were stra-
tified into two age strata, following the practice used in the
Swedish SF-36 manual.13 That resulted in 1084 men and
1027 women in age stratum 16 – 34 y and 1711 men and
1811 women in age stratum 35 – 64 y. Dichotomising age in
this manner was considered relevant based on the perfor-
mance of physical health scales in relation to age in the
normative database. When testing for differences between
means, age was standardised in the 16 – 34 y group and age
and education was standardised in the 35 – 64 y group. Edu-
cation was not standardised in the younger group since
many were still too young to continue their education on
higher levels. The z-test was used to assess differences
between groups. One-way analysis of variance (ANOVA)
with contrasts was applied to test for a linear trend in the
SF-36 scale and summary component scores across the three
BMI categories (normal-weight, overweight and obesity).20
In this test, data was not standardised for age (16 – 34 y) or
age and education (35 – 64 y). Also, since the two role-func-
tioning scales (RP, RE) deviate substantially from the assump-
tion of normality, ANOVA analyses were not performed on
these two scales.
Fourteen men and 16 women were massively obese
(BMI 40.0 kg=m2) in the ages 16 – 64 y (mean age 44 y).
To be able to compare the HRQL in this small group with
those of normal-weight (BMI 18.5 – 25.0 kg=m2), the
method of matching was used.21 Matching was carried
out taking into account the potentially confounding factors
sex, age and educational level.22 A group of 924 normal-
weight individuals was selected and stratified into 14 strata

Table 1 Estimated prevalence of BMI categories by sex and age; random sample

Men (%) Women (%)

16 – 34 y 35 – 64 y 16 – 34 y 35 – 64 y

2 a a a a
Classification BMI (kg=m ) (n ¼ 1209) ULF (n ¼ 2020) ULF (n ¼ 1204) ULF (n ¼ 2185) ULF

Underweight < 18.5 1.6 0.8 4.4 1.8

Normal-weight 18.5 – 24.9 67.5 71.3b 42.1 43.7b 73.3 81.6b 59.5 62.1b
Overweight 25.0 – 29.9 25.4 25.3 47.1 47.6 15.9 14.7 29.8 29.9
Obesity 30.0 – 40.0 5.3 3.4c 9.3 8.7c 5.7 3.7c 8.5 8.0c
Massive obesity > 40.0 0.2 0.7 0.7 0.4
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
a
Adopted from ULF, Swedish nationwide interview survey on living conditions 1996=97 (Johansson S-E, unpublished data,
Statistics Sweden).
b
Underweight þ normal-weight.
c
Obesity þ massive obesity.

International Journal of Obesity

 Quality of life in the overweight population
U Larsson et al
420
according to the above mentioned criteria (sex, age and
education).
To further investigate the relationship between HRQL and
obesity, multiple regression analysis was used without classi-
fying BMI or age. In the total sample the PCS and MCS scores
were used as dependent variables and BMI, age, sex, physical
activity and sick leave=disability pension were incorporated
as independent variables. Since sex, physical activity and sick
leave=disability pension are not continuous variables, they
were represented with dummy variables. Regarding physical
activity, subjects were divided into two groups: whether they
were sedentary in leisure time (n ¼ 635) or not (n ¼ 4998).
Among the 5633 subjects in the study, 283 had been on sick
leave for more than 6 months or received disability pensions.
To test for interaction effects between the main variables,
10 first-order (11) and 10 second-order (111) interaction
terms were constructed. Age intervals were set to 10 y instead
of 1 y in order to facilitate interpretation. Partial F-tests
were used to test the significance of coefficients of the
independent variables.
Results
The mean BMI was slightly less in the younger age group
than in the older. In the age stratum 16 – 34 y mean BMI was
24.1 kg=m2 for men and 23.0 kg=m2 for women. In the age
stratum 35 – 64 y mean BMI was 25.9 kg=m2 for men and
24.7 kg=m2 for women.
Age stratum 16 – 34 y
Mean scores for the eight scales and the two summary
components of SF-36 are displayed in Tables 2 and 3, for
normal-weight, overweight and obese persons. As shown in
Table 2, overweight men and women, aged 16 – 34 y rated
their health worse than normal-weight men and women.
This was particularly true for PF, GH and the PCS. Compared
with the normal-weight persons, obese men and women
suffered from lower levels of HRQL on all of the physical
health scales, although the difference was not significant for
women on RP. Obese men also scored lower on VT and SF.

Table 2 Mean SF-36 scale and summary scores (standard error) by sex and BMI category; standardised for age; 16 – 34 y

BMI

Linear trend b
18.5 – 24.9
(kg=m2) 25.0 – 29.9 (kg=m2) 30.0 – 39.9 (kg=m2) F P-value

Men
n 720 – 735a 275 – 284a 55 – 58a
Physical functioning (PF) 97.7 (0.3) 95.8** (0.8) 94.4** (1.5) 13.9 0.000
Role-physical (RP) 91.1 (0.9) 89.5 (1.8) 83.2** (3.7) NA NA
Bodily pain (BP) 85.1 (0.8) 82.6 (1.4) 78.2* (3.6) 7.0 0.008
General health (GH) 84.0 (0.6) 80.0*** (1.2) 73.5*** (2.5) 29.3 0.000
Vitality (VT) 69.9 (0.7) 67.8 (1.2) 61.0*** (2.9) 10.5 0.001
Social functioning (SF) 91.0 (0.6) 91.6 (1.1) 84.4** (2.9) 4.9 0.027
Role-emotional (RE) 89.4 (1.0) 87.9 (1.7) 82.8 (4.2) NA NA
Mental health (MH) 81.3 (0.6) 80.9 (1.1) 79.4 (2.1) 0.6 0.450
Physical component (PCS) 55.1 (0.2) 53.8** (0.5) 51.9*** (0.9) 18.2 0.000
Mental component (MCS) 52.5 (0.4) 52.4 (0.6) 50.0* (1.4) 3.1 0.076

Women
a a a
n 764 – 778 161 – 166 66 – 69
Physical functioning (PF) 95.9 (0.4) 91.5*** (1.4) 90.8*** (1.9) 22.4 0.000
Role-physical (RP) 85.8 (1.2) 84.4 (2.5) 79.4 (4.0) NA NA
Bodily pain (BP) 80.8 (0.9) 77.6 (1.9) 72.5** (3.2) 10.5 0.001
General health (GH) 80.6 (0.7) 76.0** (1.7) 73.0*** (2.5) 14.2 0.000
Vitality (VT) 63.4 (0.8) 62.0 (1.7) 60.5 (2.7) 1.7 0.187
Social functioning (SF) 85.8 (0.7) 88.0 (1.4) 84.2 (2.8) 0.0 0.895
Role-emotional (RE) 82.3 (1.1) 85.1 (2.1) 82.5 (4.5) NA NA
Mental health (MH) 77.2 (0.6) 76.1 (1.4) 76.8 (2.4) 0.1 0.776
Physical component (PCS) 54.0 (0.3) 52.2** (0.7) 50.0*** (1.0) 22.9 0.000
Mental component (MCS) 49.8 (0.4) 50.6 (0.8) 50.5 (1.6) 1.5 0.224

*P  0.10. compared with the normal-weight group (18.5 – 24.9 kg=m2).

**P  0.05. compared with the normal-weight group (18.5 – 24.9 kg=m2).
***P  0.01. compared with the normal-weight group (18.5 – 24.9 kg=m2).
a
The number of individuals for different scales=components differ due to non-response.
b
Analysis of variance (ANOVA) test for linear trend by the use of a contrast.
NA ¼ not applicable.

International Journal of Obesity

 Quality of life in the overweight population
U Larsson et al
421
Table 3 Mean SF-36 scale and summary scores (standard error) by sex and BMI category; standardised for age; 35 – 64 y

BMI

b
Linear trend
18.5 – 24.9
(kg=m2) 25.0 – 29.9 (kg=m2) 30.0 – 39.9 (kg=m2) F P-value

Men
n 698 – 733a 785 – 804a 137 – 148a
Physical functioning (PF) 92.3 (0.6) 88.8*** (0.6) 87.0*** (1.4) 32.7 0.000
Role-physical (RP) 85.5 (1.2) 81.8** (1.2) 89.3 (2.5) NA NA
Bodily pain (BP) 77.4 (0.9) 74.4** (0.9) 78.6 (2.2) 1.4 0.239
General health (GH) 76.7 (0.7) 73.6*** (0.7) 73.3* (1.8) 10.6 0.001
Vitality (VT) 69.8 (0.8) 68.0 (0.8) 69.7 (1.9) 0.8 0.373
Social functioning (SF) 89.7 (0.7) 88.9 (0.7) 89.4 (1.9) 0.3 0.617
Role-emotional (RE) 90.9 (1.0) 88.1** (1.0) 88.9 (2.4) NA NA
Mental health (MH) 82.3 (0.7) 81.3 (0.6) 81.6 (1.6) 0.7 0.397
Physical component (PCS) 51.3 (0.3) 49.8*** (0.3) 50.6 (0.8) 8.9 0.003
Mental component (MCS) 54.0 (0.4) 53.6 (0.3) 54.1 (0.9) 0.0 0.914

Women
a a a
n 1070 – 1101 516 – 544 136 – 145
Physical functioning (PF) 89.4 (0.5) 84.4*** (0.8) 79.3*** (2.0) 94.9 0.000
Role-physical (RP) 82.2 (1.1) 76.8*** (1.7) 71.1*** (3.7) NA NA
Bodily pain (BP) 74.2 (0.8) 69.1*** (1.2) 59.7*** (2.8) 44.6 0.000
General health (GH) 76.4 (0.7) 70.9*** (1.0) 59.9*** (2.3) 83.5 0.000
Vitality (VT) 66.6 (0.7) 62.0*** (1.1) 55.1*** (2.3) 24.6 0.000
Social functioning (SF) 87.1 (0.7) 85.2 (1.0) 78.9*** (2.3) 12.1 0.001
Role-emotional (RE) 87.8 (0.9) 86.4 (1.4) 81.8* (3.1) NA NA
Mental health (MH) 80.4 (0.6) 79.7 (0.8) 73.0*** (2.1) 3.7 0.055
Physical component (PCS) 50.5 (0.3) 47.8*** (0.5) 44.8*** (1.2) 75.2 0.000
Mental component (MCS) 52.9 (0.3) 52.9 (0.5) 50.1** (1.2) 0.1 0.755
2
*P  0.10. compared with the normal-weight group (18.5 – 24.9 kg=m ).
2
**P  0.05. compared with the normal-weight group (18.5 – 24.9 kg=m ).
***P  0.01. compared with the normal-weight group (18.5 – 24.9 kg=m2).
a
The number of individuals for different scales=components differ due to non-response.
b
Analysis of variance (ANOVA) test for linear trend by the use of a contrast.
NA ¼ not applicable.

A test for linear trend was used to see if the magnitude of
obesity was related to HRQL. For men and women, the
results of the ANOVA tests for a linear trend strengthened
the impression of a negative association between obesity and
HRQL. The association was more pronounced for the physi-
cal than mental health aspects. Thus, in 16 – 34- y old men
and women, the magnitude of obesity appeared to be related
to impaired physical health status. For many of the scales,
the decline in SF-36 scores was slightly larger in comparison
between overweight and obese men than between over-
weight women and obese women.
GH and PCS. Overweight women rated their physical health
(PF, RP, BP, GH) and VT lower than the normal-weight
women. In contrast, obese women rated both their physical
and mental health lower than the normal-weight women
did. In particular, large differences between obese and over-
weight women were seen in BP and GH. The evidence for a
linear trend, and thus for a correspondence between the
magnitude of obesity and HRQL, was strong on all scales
except for MH. In sum, the negative impact of obesity on
HRQL was stronger in women than in men.

The massively obese

Age stratum 35 – 64 y
Results regarding the older age group, 35 – 64 y, are shown in
Table 3. Overweight men scored lower on the four physical
scales (PF, RP, BP, GH) and the mental scale RE than the
normal-weight men. In contrast, the obese men scored
higher than the overweight men on all scales but PF and
GH. Consequently, linear trends were found only for PF and
The massively obese (14 men and 16 women) were compared
with a sex, education and age-matched sample of normal-
weight persons. Table 4 shows that the massively obese men
and women reported poorer physical and mental HRQL
status compared to the reference group. The massively
obese persons had the poorest levels of HRQL of all groups
in Tables 2 – 4.

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 Quality of life in the overweight population
U Larsson et al
422
Table 4 Mean SF-36 scale and summary scores (standard error); men and women mostly have a negative affect on physical
matched by sex, age and education; 16 – 64 y health, but not on mental health. Among the middle-aged
18.5 – 24.9 (35 – 64 y), however, obese women reported impairments on
2 2
(kg=m )  40.0 (kg=m ) all of the eight physical and mental scales, while obese men
a
(n ¼ 924 – 956) (n ¼ 30) reported impairments on only two of the physical scales:
Physical functioning (PF) 92.8 (0.4) 69.6 (5.4)*** physical functioning and general health perceptions.
Role-physical (RP) 85.0 (1.0) 67.4 (9.9)* The relationship between obesity and mental health has
Bodily pain (BP) 77.0 (0.8) 59.8 (6.4)*** been a subject of considerable debate for decades. In a
General health (GH) 77.4 (0.6) 55.0 (4.4)*** review, Friedman and Brownell conclude that obesity is not
Vitality (VT) 66.5 (0.7) 54.3 (4.4)***
Social functioning (SF) 87.2 (0.7) 68.5 (6.3)*** associated with increased psychopathology in the general
Role-emotional (RE) 86.1 (1.0) 74.5 (6.5)* population.23 However, they suggest that increased risk for
Mental health (MH) 79.8 (0.6) 69.4 (4.4)** developing psychopathology may be present for particular
Physical component (PCS) 52.0 (0.3) 42.6 (2.3)***
groups in the obese population. This hypothesis was con-
Mental component (MCS) 51.9 (0.3) 47.9 (2.2)*
firmed in a recent population study that investigated the
*P  0.10. compared with the normal-weight group (18.5 – 24.9 kg=m2). relationship between HRQL and obesity using the SF-36 and
**P  0.05. compared with the normal-weight group (18.5 – 24.9 kg=m2). questions on chronic illness.12 Consistent with our results,
***P  0.01. compared with the normal-weight group (18.5 – 24.9 kg=m2).
a
The number of individuals for different scales=components differ due to non-
they conclude that overweight and obesity have a greater
response. impact on physical than mental health. Further, the pre-
sence of obesity in conjunction with other chronic illnesses
was associated with a significant deterioration in both phy-
Regression analysis sical and mental health, while obese persons with no con-
Regression analysis, used to uncover the association between current conditions reported only a slight deterioration in
HRQL and BMI adjusted for age, sex, physical activity and physical health. After adjusting for the number of comorbid
sick leave=disability pension, confirmed the negative associa- conditions, an independent association between obesity and
tion between PCS and BMI (Table 5). Age, a sedentary leisure impacts on physical but not mental health was established.
time and sick leave=disability pension were negatively Doll et al suggested that poor emotional well-being among
related to PCS. In the total sample, women scored 1.6 units the obese may be due to comorbidity rather than obesity per
lower than men on average. The model explained 24% of the se.12 In the present study, concomitant conditions were not
variance in PCS. Interaction effects suggested that physical controlled for and it is possible that the poorer HRQL among
health (PCS) was more impaired in women than men at middle-aged women is attributable to a higher prevalence of
increasing BMI levels (data not shown). With MCS as depen- comorbidities. On the other hand, our results indicate that
dent variable, the coefficient for BMI was not significant, gender and age are also important determinants of HRQL in
suggesting no relationship between mental health and the obese population. As would be expected, a sedentary
weight. Being a woman, having a sedentary leisure time leisure time and long-term sick leave or disability pension
and being on sick leave or disability pension contributed further substantially contribute to lower physical health.13
negatively, while age was positively related to MCS. How- In a general population study of 45 – 49 y old women,
ever, the proportion of explained variance was low (5%). Brown et al found that the obese (BMI 30 – 39.9 kg=m2) had
lower scores on all of the eight SF-36-scales than their
normal-weight counterparts (BMI 20.0 – 24.9 kg=m2).9 How-
Discussion ever, the effect of obesity on the mental health scales was
In this paper we report the impact of overweight and obesity slightly weaker than in the present study. In a study of obese
on HRQL in a general Swedish population. Our results subjects seeking treatment (mean age 45 y, mean BMI
suggest that overweight and obesity in young (16 – 34 y) 38 kg=m2), it was found that women suffered from poorer

Table 5 Regression models with physical component summary (PCS) and mental component summary (MCS) of the SF-36 as dependent variables;
16 – 64 y

Coefficients for independent variables and standard error (s.e.)

Dependent variable n Intercept BMI Agea Sex Physical activity Sick r2

PCS 5267 63.5*** (0.76) 7 0.23*** (0.03) 7 1.17*** (0.09) 7 1.62*** (0.22) 7 2.59*** (0.35) 7 15.78*** (0.54) 0.24
MCS 5267 49.0*** (0.95) 0.02 (0.04) 1.11*** (0.11) 7 1.46*** (0.27) 7 3.12*** (0.43) 7 6.26*** (0.68) 0.05

*P < 0.05; **P < 0.01; ***P < 0.001.

a
Age is measured by 10 y.
Coding of dummy variables — sex: men ¼ 0, women ¼ 1; physical activity in leisure time: non-sedentary ¼ 0, sedentary ¼ 1; sick ¼ sick leave > 6 months or disability
pension: no ¼ 0, yes ¼ 1.

International Journal of Obesity


psychosocial health than did men.24 It is generally believed
that young women are particularly vulnerable to psychoso-
cial distress due to their obesity since societal pressures
against obesity are especially focused during adolescence
and young adulthood, particularly among women. The
reason why our study did not indicate any such detrimental
effects in young women may be that mental health in
general, as measured by the SF-36, is not heavily influenced
by specific weight-related distress, such as body image dis-
paragement. In line with this, Wadden et al found that
adolescent obese girls were more dissatisfied with their
weight than their non-obese peers, but did not display
greater anxiety or depression.25
An earlier population study of the impact of obesity on
HRQL failed to demonstrate negative psychosocial conse-
quences.10 A possible explanation for this may be that the
study sample was not stratified by sex or age. Thus, the
effects of gender and age may have confounded the results.
The general finding that women report more problems and
poorer well-being than men is well known from other
epidemiological studies.26 In another population study
(20 – 59 y), Han et al concluded that overweight subjects
did not suffer from more non-physical problems, such as
poor social functioning, adverse mental health, or role
limitations due to emotional problems, than other sub-
jects.11 One possible reason why these results diverge from
ours might be that Han et al did not distinguish between the
overweight and obese and thus mixed the impact of over-
weight with that of obesity on HRQL.
Our regression analysis provided further evidence for the
strong relationship between physical health (PCS), and BMI
even after adjusting for age, sex, physical activity and sick
leave=disability pension. The independent variables were
chosen from those shown in previous research to be related
to HRQL.13,27 The conclusion that BMI is less related to
mental health (MCS) was confirmed. Age was negatively
associated with physical health (PCS) and positively related
to mental health (MCS). These results, however, may be due
in part to a scoring artefact, where MCS is artificially inflated
by low physical health scale scores.28 Conclusions about
mental health in the obese should therefore be drawn with
caution. A fairly good proportion of explained variance,
24%, in the PCS regression model is noteworthy. All inde-
pendent variables contributed substantially: age, being a
woman, having sedentary leisure time and being on long-
term sick leave or disability pension contributed negatively.
Since the inclusion of interaction terms did not increase the
percentage of variance explained combined with the diffi-
culties in interpreting such results, the interaction models
were not shown.
An important question is whether the obese in the general
population differ from obese patients regarding HRQL. No
studies have yet investigated this question; however, some
light may be shed on this subject by comparing our popula-
tion data with patient data from Fontaine et al.6 The mas-
sively obese (BMI  40 kg=m2) patients reported lower HRQL
Quality of life in the overweight population
U Larsson et al
423
than in our study, particularly on PF, RP, BP and VT. Com-
parisons of this kind are, however, difficult to interpret due
to differences between studies, eg magnitude of obesity,
sociodemographic status and cultural context. Still, the
comparison suggests that massively obese persons seeking
treatment report poorer HRQL. This observation is consis-
tent with differences in health status found between out-
patients with rheumatoid arthritis and women with
rheumatoid arthritis in the population.29
The prevalence rates in the present investigation give the
impression that the population of western Sweden is fairly
slim compared to many European countries and the US.30,31
In order to determine if our sample was representative, we
compared our prevalence rates with those obtained in the
Swedish nationwide survey on living conditions. The differ-
ence between the two investigations was found to be very
small. This fact in itself indicates the validity of the measure-
ment of BMI in the two studies. The validity of self-reported
height and weight has been confirmed in several studies.32 – 34
The bias resulting from self-report was in general small, and
values of self-reported weight and height were highly corre-
lated with true values. Weight underestimates were particu-
larly prevalent among overweight and obese subjects,
especially women and the elderly. One study found self-
report to underestimate BMI by 0.7 units among women
(20 – 84 y) and by 0.4 units among men (16 – 84 y) compared
to objective methods.33 The prevalence of obesity was under-
estimated by 1.7 percentage units among women and by 4.2
percentage units among men. Although the possibility that
subjects were misclassified into BMI classes cannot be
entirely negated, this would have at most marginal influence
on the HRQL results in this study.
Generic instruments have the advantage of enabling
HRQL comparisons across different diseases and sociodemo-
graphic groups. A disadvantage, however, is that they may
not cover all essential health aspects pertinent to one parti-
cular disease. It was shown in our study that SF-36 had a high
degree of responsiveness to obesity, in the sense that it
managed to discriminate between people in different cate-
gories of overweight and obesity. Our results also stressed
the importance of using a multidimensional instrument
embracing different health aspects that do not necessarily
correlate.
To reduce bias related to potential confounding factors,
sociodemographic variables such as ethnicity, age, sex and
education were controlled for. However, it has also been
shown that obesity is associated with diseases like diabetes
mellitus, hypertension, coronary heart disease, respiratory
disease and osteoarthritis.35 In the present study we did not
control for comorbidity or discriminate between the effect of
obesity on HRQL and obesity-related comorbidity on HRQL.
We did confirm, however, that persons on long-term sick-
leave or receiving disability pension for any reason had
profoundly poorer physical and mental health.
Our analyses showed that the impact on HRQL of over-
weight and obesity, with or without concomitant ailments,
International Journal of Obesity
 Quality of life in the overweight population
U Larsson et al
424
differs between the young and the middle-aged, and between
men and women. Longitudinal population studies with
stratified samples would be of considerable value to learn
more about the causal pathways between obesity and HRQL,
and to what extent certain groups in society suffer.
Acknowledgements
The authors are indebted to the county council of Västra
Götalandsregionen for permission to use the data. We grate-
fully acknowledge helpful comments on the manuscript
from Charles Taft. We also extend our thanks to Helen A
Doll, IJO referee of this paper, for challenging and construc-
tive criticism. This article was made possible by support from
the Medical Faculty, Göteborg University.
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