Eat Weight Disord (2015) 20:473–481
DOI 10.1007/s40519-015-0208-x
ORIGINAL ARTICLE
Quality of life as a mediator in the association between body mass
index and negative emotionality in overweight and obese
non-clinical sample
Alessandra Pokrajac-Bulian1 • Miljana Kukić1 • Nina Bašić-Marković2
Received: 18 February 2015 / Accepted: 21 July 2015 / Published online: 2 September 2015
Ó Springer International Publishing Switzerland 2015
Abstract
Purpose The present study investigates the differences in
physical health-related quality of life (HRQoL) among
overweight and obese people, as well as the correlates of
HRQoL in this population and the association between
BMI, depression, anxiety, and potential mediating effects
of HRQoL.
Methods The research was conducted on a sample of
overweight and obese adults who visited their primary care
physician. A total of 143 women and 130 men were
enrolled in the study, 43 % of the subjects were over-
weight, and 57 % of the subjects were obese. The subjects
ranged in age between 21 and 60 years. Depression and
anxiety were assessed using the Hospital Anxiety and
Depression Scale, and HRQoL was evaluated using the
Medical Outcome Study Short-Form 36.
Results The analysis of variance results showed that
women in comparison to men have lower physical HRQoL
(e.g. worst physical functioning, more bodily pain), and
that severely obese patients have lower physical HRQoL in
comparison to overweight ones. The regression analysis
results indicated that some of the aspects of physical
HRQoL (e.g. physical functioning, role limitations) medi-
ate the relationship between BMI and depression only in
This research is a part of the project ‘Biopsychosocial aspects of
obesity’ (number: 13.04.1.3.07) supported by grant from University
of Rijeka, Croatia.
& Alessandra Pokrajac-Bulian
pokrajac@ffri.hr
1
Department of Psychology, Faculty of Humanities and Social
Sciences, University of Rijeka, Sveučilišna avenija 4,
51000 Rijeka, Croatia
2
Familiy medicine practice, Srdoči 65d, 51000 Rijeka, Croatia
women. The higher level of body mass decreased the
physical HRQoL, which became a potential risk factor for
the development of depressive symptoms.
Conclusions The results from the present study show that
a different pattern of functioning exists between men and
women. It is important to identify the factors that can
effectively motivate and stimulate obese people to change
their lifestyle and to consider the differences in psycho-
logical functioning between women and men.
Keywords Health-related quality of life
Depression

Anxiety
BMI
Introduction
According to the recent statistics, the overweight frequency
among adults in Croatia is approximately 38 %, and an
additional 20 % of men and women are obese [1]. It is well
documented that excess weight increases the risk for many
diseases and metabolic abnormalities, such as type 2 dia-
betes, coronary heart disease, certain malignancies,
hypertension and dyslipidaemia [2]. In severely obese
people, an array of psychological problems can range from
negative body image and lowered self-esteem to eating
disorders and clinical depression [3]. Obesity has negative
effects on the activities of daily living [4] and subjective
health status, especially its physical aspect [5].
The results of studies on the general population samples
do not clearly support the assumption that obese people, as
a group, have more psychological problems than non-obese
people do. Although several studies have shown that BMI
is significantly associated with mood, anxiety, and per-
sonality disorders [6, 7], other studies have suggested that
there is no significant association between BMI and scores
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on standard psychological tests [8] or that obese people
have better mental health than non-obese people [9]. In
Western societies where obesity is stigmatised, being obese
increases the risk of anxiety and depression and the pos-
sibility to understand the nature of the association between
these two conditions is important for prevention and
treatment [6, 10].
Results from prospective studies have shown that obe-
sity is associated with future incidence of depression, and
cross-sectional studies suggested significant positive asso-
ciation between obesity and depression, particularly in
females [7]. Several reviews have found that depression is
more common among persons with extreme obesity; when
the BMI is higher than 40 kg/m2, the likelihood of expe-
riencing a major depression episode may increase by five
times [9]. Additionally, several studies have demonstrated
that obese women experience more psychological prob-
lems than men [7, 11, 12].
One of the reasons obese persons may have a higher risk
for depression and other affective disturbances might be
their impaired health-related quality of life (HRQoL) [13].
Empirical studies have consistently indicated that increases
in weight are associated with deterioration in HRQoL,
particularly physical health. In addition to the fact that
excessive BMI primarily affects an individual’s physical
well-being, numerous studies have shown that different
domains of physical HRQoL are differently affected by
increased BMI. Yancy et al. [14], for example, showed that
men with BMI of C25 kg/m2, compared with individuals
of normal weight, had significantly lower scores on the
Bodily Pain Subscale. Those with BMI C35 kg/m2 had
lower scores on the Physical Functioning Subscale, and
those with BMI C40 kg/m2 had lower scores on the Role
Limitations due to Physical Problems. Jagielski et al. [15]
have found that with increasing BMI, there were more
problems in physical functioning, mobility, self-care and
performing usual activities, reduced ability to work and
overall quality of life.
Several studies have indicated gender differences
between relative weight and physical health. Laaksonen
et al. [16] have demonstrated that lower levels of BMI in
women may be associated with impaired physical well-
being in contrast to men. They have shown that in women,
physical health gradually deteriorated with increasing BMI,
even among those in the normal weight range. In men,
physical health deteriorated only among those who had
BMI levels exceeding 27 kg/m2, and poor physical health
was associated only with obesity.
Wadden and Sarwer [13] have suggested that because
obesity is a chronic state, decreases in the quality of life are
likely to be long-term impairments and therefore could
render obese persons more vulnerable to affective
disturbances.
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Eat Weight Disord (2015) 20:473–481
Depressive and anxiety symptoms are not necessarily
entirely harmful and may have several positive effects.
Herpertz et al. [17] have demonstrated that depressive and
anxiety symptoms, as indicators of psychological stress
with regard to obesity, appeared to be positive predictors of
weight loss after obesity surgery. These authors stressed
that the presence or the absence of emotional problems
might not be predictive of weight loss; more importantly,
the severity of emotional problems might be predictive of
weight loss. Severe depression and anxiety may have many
negative effects and interfere with a person’s ability to
function in everyday life. For instance, because of the
symptoms of depression, such as apathy, sadness, sleeping
problems and lack of energy, the affected persons may
have difficulties fulfilling their responsibilities and suc-
cessfully performing their work. Additionally, they may
have difficulties regarding social interactions; e.g. they
may avoid others and withdraw from the community,
commonly feel lonely, and often report the overuse of
alcohol as ‘‘self-medication’’ [18]. Similar to obesity,
depression significantly increases health care costs [19].
Therefore, in addition to monitoring the physical health of
obese individuals, it is important to monitor the patients’
emotional status.
The present study aims to exam the differences in
physical health functioning among overweight and obese
people given their level of nutrition. It also aims to better
understand the multidimensional correlates of HRQoL in
the adult overweight and obese population. Specifically, we
examined the association between body mass index,
depression and anxiety as well as the potential mediating
effects of physical health functioning on this association.
Because of the expected gender differences and influence
of age to negative affect and physical health, the analyses
were separately done for men and women and the effects of
age were controlled.
Method
Participants
The research was conducted on a sample of overweight and
obese adults who visited their primary care physician
during the 6-month study period. Overall, 273 persons
(n = 143 women and n = 130 men) were enrolled in the
study. The inclusion criterion of the study was BMI major
than 25. The body mass index (BMI) of participants ranged
from 25 kg/m2 to 49 kg/m2 (M = 31.17, SD = 5.07), and
age ranged between 21 and 60 years (M = 46.68,
SD = 10.62). Of the subjects, 43 % were overweight and
57 % were obese; 2.5 % completed elementary school,
9.6 % vocational and 57.9 % high school, and 30 % were
Eat Weight Disord (2015) 20:473–481 475

undergraduate or graduate; 72.1 %, were married, 4.3 % Statistical analysis

divorced or widowed, and 23.6 % single.
All of the analyses were conducted using SPSS version 15.
A two-way analysis of variance was used to test the dif-
Measures
ferences among three groups of patients with different BMI
categories (overweight, obesity class I, class II and class
Depression and anxiety were assessed using the Hospital
III) in quality-of-life scores between men and women. For
Anxiety and Depression Scale (HADS) [20], one of the
correlation analyses involving HRQoL, BMI, and psycho-
most widely used instruments for detecting depression and
logical measures, we used Pearson correlation coefficients.
anxiety, with well-established validity and reliability. The
Finally, to evaluate whether different aspects of physical
HADS is a 14-item self-report questionnaire: 7 items assess
quality of life mediate between BMI, anxiety and depres-
anxiety (HADS-A) and 7 items assess depression (HADS-
sion, we used the regression analysis.
D) over the last 2 weeks. The items focus on the psycho-
logical and cognitive symptoms of these two disorders and
they have a 4-point Likert-type format (values 0 through
Results
3). In each subscale, the responses result in a total score
ranging from 0 to 21, with higher scores indicating higher
We examined the differences in health-related quality of
levels of distress. A score between 8 and 10 is considered
life among three groups of patients of both sex: overweight,
as ‘‘a possible case’’, and a score of 11 or more is con-
those with obesity class I, and those with obesity class II
sidered as a case of depression or anxiety. In this sample,
and III. Participants with obesity class II and III were
Cronbach’s alpha coefficient for the HADS-A was 0.83,
grouped together because of the small number of subjects
and Cronbach’s alpha coefficient for the HADS-D was .70.
in these categories. Hereinafter referred, we will use the
Physical health functioning was measured using the
term severely obese for a description of this category of
Medical Outcome Study Short-Form 36 (SF-36) [21]. It is a
patients.
well-validated, widely used generic health-related quality-
The main effect of the sex of the patients was significant
of-life measure, and as such, it allows measurements and
(Table 1); women in comparison to men had worst physi-
comparisons of QoL across various diseases. This 36-item
cal functioning, more role limitations due to physical
self-report questionnaire assesses health status within eight
problems, more bodily pain, and lower composite score
domains of functioning: four domains reflect physical
reflecting worst physical health. There was a significant
health (physical functioning, role limitations due to phys-
main effect of BMI on composite score reflecting physical
ical problems, bodily pain, and general health) and four
health, and physical functioning. Employing the Scheffe
domains reflect mental health. The scores in each subscale
post hoc test, we found that severely obese patients sig-
range from 0 to 100, with higher scores representing better
nificantly differ from overweight patients and from the
quality of life. Additionally, the results from these eight
group of obese in class I. There was a significant main
subscales can be compressed into two composite scores
effect of BMI on bodily pain. Employing the Scheffe post
that describe physical and mental health. In this study, the
hoc test, significant differences were found between over-
physical component summary (PCS) score was used to
weight and severely obese. Severely obese patients feel
measure physical health functioning. Cronbach’s alpha
more bodily pain in comparison to overweight one. There
coefficient for the PCS was 0.94 in this sample.
was no significant interaction between sex and BMI of
Body mass index (BMI) was calculated as weight (kg)
patients.
divided by height squared (m2).
Regarding the level of anxiety and depression, 50.9 %
of the patients did not express anxiety symptoms, 25.1 %
Procedure of the patients showed signs of possible anxiety, and 24 %
of the patients had anxiety symptoms (14 % women and
The study data were collected during the subjects’ visit to 10 % man). In terms of depressive symptoms, 56.8 % of
their primary care physician. All of the subjects were asked the patients were not depressed, 25.3 % of the patients had
if they want to participate in a study that aims to examine possible depression, and 17.9 % of the patients were
the quality of life. Those who agreed signed an informed depressed (11.9 % women and 6 % man).
consent to participate in the study. The subjects were We aimed to verify the relationship between psycho-
requested to complete the self-assessment questionnaires, logical characteristics, the quality of life, and BMI. For
and research personnel obtained the height and weight for this purpose, we conducted a correlation analysis. A
each participant. The Institutional Review Board consent correlation matrix (Tables 2 and 3) was separately com-
was obtained for this study. puted on the results of men and of women because of the

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Table 1 Scores of health-related quality of life by obesity classes for men and women
Overweight n = 50 (1) Class I obesity n = 61 (2) CClass II obesity n = 18 (3) Fa
M W M W M W Sex BMI Sex 9 BMI

Physical functioning
M 84.40 80.37 79.34 72.95 71.94 63.06 4.82* 7.83** 0.21
SD 20.64 21.61 22.50 24.79 21.84 18.11
Role limitations due to physical problems
M 77.45 74.24 71.72 67.44 73.61 48.39 4.11* 2.32 1.36
SD 35.09 39.70 41.70 40.65 40.65 43.75
Bodily pain
M 81.50 73.96 77.05 67.16 71.94 58.83 9.59** 4.36* 0.22
SD 20.22 25.75 26.27 25.90 22.60 24.26
General health
M 59.31 59.55 57.95 58.64 53.89 50.47 0.10 2.24 0.18
SD 18.55 18.50 19.86 20.50 21.73 23.08
QoL—physical component
M 77.57 73.47 72.58 68.00 67.96 57.07 5.35* 6.40** 0.46
SD 17.18 20.86 22.45 23.41 20.69 19.94
* p \ 0.05; ** p \ 0.01
a
Degrees of freedom for sex (1,266), for BMI (2,266), for sex 9 BMI (2,266)

Table 2 Zero-order and first-order correlation among all measured variables for men (N = 130)
BMI HRQoL—physical component Physical functioning Role limitations Bodily pain General health

BMI
Zero-order – -0.15 -0.21* 0.00 -0.12 -0.08
First-order -0.15 -0.22* 0.01 -0.14 -0.09
Anxiety
Zero-order 0.05 -0.55** -0.49** -0.42** -0.40** -0.48**
First-order 0.05 -0.51** -0.43** -0.37** -0.39** -0.46**
Depression
Zero-order -0.11 -0.45** -0.38** -0.38** -0.37** -0.42**
First-order -0.11 -0.42** -0.33** -0.34** -0.36** -0.40**
* p \ 0.05; ** p \ 0.01

expected gender differences in the correlation of the
examined variables. As this study included participants in
a wide range of age (21–60 years old), we considered the
necessity to include age as a control variable in the cor-
relation analysis. The average age of the respondents in
our sample was 46.68 years. Due to changes in men, and
especially in women that occur around the fifties, it is
necessary to control the age because of the possibility of
interfering with the interpretation of results. Factors
closely related with physical and mental quality of life
are menopause and andropause symptoms that are not
measured in the study. Recent studies suggest that
women become increasingly vulnerable during the
menopausal transition to declines in physical and role
function and increases in depressive symptoms [22].
These biological shifts may determine age-related phys-
ical changes (e.g. increased BMI) during mid-life, and for
this reason we controlled the respondents age. Beside a
zero-order correlation, a first-order partial correlation
was computed to explore the relationship between mea-
sured variables, controlling for the effects of age. If the
age affects BMI and different domains of physical quality
of life, anxiety and depression, the partial correlation
between mentioned variables should be lessened or no
longer significant.
In men, the BMI results are unrelated to different
aspects of physical functioning, anxiety, and depression
when controlling for age (Table 2). We found only a low,
although significant, correlation between BMI and physical
functioning (r = -0.22; p \ .05).

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Table 3 Zero-order and first-order correlation among all measured variables for women (N = 143)
BMI HRQoL—physical component Physical functioning
BMI
Zero-order – -0.32** -0.30**
First-order -0.25** -0.25**
Anxiety
Zero-order 0.17* -0.54** -0.47**
First-order 0.12 -0.49** -0.43**
Depression
Zero-order 0.24** -0.56** -0.48**
First-order 0.22** -0.52** -0.46**
* p \ 0.05; ** p \ 0.01
In women, the first-order correlations between BMI and
physical component (PC) of QoL, physical functioning,
role limitation due to physical problems, and depression
were found to be statistically significant, indicating that a
relationship between those variables exists above and
beyond the effects of age, but the relationship is lessened
after controlling the age. These correlations ranged from
r = 0.22 (p \ .01) between BMI and depression, to
r = -0.25 (p \ 0.01) between BMI and PC of QoL and
physical functioning (Table 3). Higher BMI levels in
women were associated with lower physical functioning,
more role limitations because of physical problems, and
more depression. The lower perceived physical QoL in all
of the domains is related to higher levels of anxiety and
depression in women. The results of the female sample also
revealed that when controlling the effects of age, the
relationship between BMI, bodily pain, general health, and
anxiety is no longer significant. It means that age is the
determinant of more bodily pain, lower general health, and
more anxiety. Apparently, age affects both BMI and dif-
ferent domains of physical quality of life, anxiety and
depression and is closely related to them.
To explore the mediational effects of the PC of HRQoL
and its four subscales in relation between BMI as a predictor
and the negative affect as criterion, we conducted a series of
regression analyses. We evaluated the mediating effects of
the PC of QoL and its subscales on the relationship of BMI to
the anxiety and depression subscale scores using the Baron
and Kenny approach. The component of QoL is considered
to be a mediator if: (1) the initial variable (BMI) is signifi-
cantly associated with the outcome (anxiety or depression),
(2) the initial variable (BMI) is significantly associated with
the mediator (different aspect of physical QoL), and (3) the
mediator is significantly associated with the outcome (anxi-
ety or depression) after controlling for the effects of the
initial variable (BMI). Baron and Kenny [23] discussed a
fourth condition concerning the reduction of the initial and
outcome variables relationship for evidence of partial or
477
Role limitations Bodily pain General health
-0.30** -0.20* -0.21*
-0.23** -0.11 -0.15
-0.39** -0.39** -0.56**
-0.34** -0.32** -0.54**
-0.45** -0.35** -0.54**
-0.40** -0.29** -0.51**
complete mediation. Specifically, if a test for the partial
relationship between the initial variable and the outcome
variable is non-significant, this finding might suggest that the
mediator is a complete (or near-complete) mediator of the
effect of the initial variable on the outcome variable.
Because of the specificity related to gender, which is
described in the introduction, the analysis of mediation
effects was separately calculated for men and women. In
addition, to exclude the effects of age on the variables in the
analyses, a simple linear regression was used. Instead of the
original variables, all of the mediation analyses were per-
formed with the residuals from the above-mentioned model.
In a sample of men, the first two conditions for the use of
mediation analysis were not satisfied: the correlation
between predictor and criteria, and the correlation between
predictor and mediators. The Baron and Kenny approach
was not met; that is, there was no relationship to be medi-
ated. The PC of quality of life, as any of its components,
does not mediate between BMI and anxiety or depression in
men. In a sample of women, we found the same situation for
anxiety. The PC of quality of life, as any of its components,
does not mediate between BMI and anxiety.
In women, the PC of QoL mediates between BMI and
symptoms of depression (Table 4). There was statistically
significant relationship between the BMI and depression
(b = 0.21, p \ 0.01). After controlling for the PC, the
magnitude of this association decreased and was no longer
statistically significant, indicating that the PC of QoL
completely mediated the relationship between BMI and
depressive symptoms in women (b = 0.10). Women with
higher BMI levels have a greater likelihood of decreasing
their physical quality of life, which in turn has a direct effect
on the development of depressive symptoms. This mediation
ratio also applies to the physical functioning and role limi-
tations due to physical problems (Table 4). After controlling
for the physical functioning, the magnitude of the associa-
tion between BMI and depression decreased (b = 0.10 \ b
= 0.21) and was no longer statistically significant, indicating
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Table 4 Results of regression analyses—evaluation of mediational women in comparison to men, in the domains reflecting PC
effects of different subscales of physical quality of life in the rela- of quality of life, which is consistent with the literature [13,
tionship between BMI and depressive symptoms in women, when
14, 24–26] but also in physical functioning, role limitations
controlling for the effects of age
due to physical problems, and bodily pain. Obese women
Predictor/Outcome R R2 Beta report worse physical functioning than men do, especially
1. Regression analysis 0.25 0.06 because of the experience of fatigue and sleepiness [27].
BMI/Physical component -0.25** The prevalence of most common forms of pain is higher
2. Regression analysis 0.21 0.04 among women then men. They report greater pain with a
BMI/Depression 0.21* long-term duration, [28], and display enhanced sensitivity
3. Regression analysis 0.53 0.28
to most forms of pain [29]. Stone et al. [30] found that
BMI, 0.10
obese individuals report more daily pain compared to
overweight persons, and the obesity–pain association was
Physical component/Depression -0.50**
stronger for women than for men. Various comorbidities
1. Regression analysis 0.24 0.06
and functional limitations associated with obesity can
BMI/Physical functioning -0.24**
adversely affect physical quality of life. Obese women in
2. Regression analysis 0.21 0.04
our sample have more difficulties in physical functioning;
BMI/Depression 0.21*
the pain that they feel is very high, and they have many
3. Regression analysis 0.46 0.21
difficulties in performing their daily tasks, professional and
BMI, 0.10
family roles.
Physical functioning/Depression -0.42**
Our assumption was that there are gender differences in
1. Regression analysis 0.23 0.05
quality of life and we therefore did analyses separately for
BMI/Role limitations -0.23**
men and women. There are a few reasons for analysing
2. Regression analysis 0.21 0.04
men and women separately. First, this is a usual way to
BMI/Depression 0.21* adjust for the possible confounding effect of sex differ-
3. Regression analysis 0.42 0.18 ences on the relationship between obesity and quality of
BMI, 0.14 life. Second, there are large differences in the distribution
Role limitations/depression -0.37** of risks factors related to obesity between men and women
The results of 2nd and 3rd regression analysis are signed with bold for some variables (cardiovascular risks, or major depres-
* p \ 0.05; ** p \ 0.01 sion risk), such that subjects of both sex cannot be con-
sidered as belonging to a single population for statistical
that the physical functioning completely mediated the rela- analysis [31].
tionship between BMI and depressive symptoms in women. For women, there is a low but significant correlation
Women with higher BMI levels have a greater likelihood of between BMI and some of the measured aspects of phys-
decreasing their physical functioning, which in turn has a ical quality of life, such as physical functioning, role lim-
direct effect on the development of depressive symptoms. itations due to physical problems and PC of HRQoL, when
After controlling for the role limitation due to physical controlling for age. It is likely that because of their weight,
problems, the magnitude of the association between BMI they have lower physical functioning; their weight might
and depression also decreased (b = 0.14 \ b = 0.21) and interfere with performing gender roles, such as taking care
was no longer statistically significant, indicating the com- of the household and managing the family. Other authors
plete mediation between BMI and depressive symptoms in have obtained similar results and the encumbrance on
women. Women with higher BMI levels have a greater physical quality of life appeared to affect women more than
likelihood of increasing their role limitations due to physical men [31]. A higher BMI level was associated with lower
problems, which in turn has a direct effect on the develop- PC, physical functioning [32], and role limitations [33]. In
ment of depressive symptoms. part, this phenomenon can be attributed to the higher
prevalence of concurrent somatic diseases and psy-
chopathological disturbances in morbidly obese women,
Discussion compared to those with lower degrees of obesity. When
controlling for age in men, the only relation we found was
In the present research, we explored the differences in between BMI and physical functioning. A higher BMI
physical health functioning in a community sample of level appeared to affect the physical functioning, functional
overweight and obese individuals. The results supported impairment and physical discomfort.
the hypothesis of the existence of gender differences in Another objective in this study was to examine the
quality of life. The major decrease was observed for association between body mass index, depression and

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Eat Weight Disord (2015) 20:473–481
anxiety as well as the potential mediating effects of phys-
ical health functioning on this association. The results
indicated that some aspects of the physical aspects of
HRQoL (PC of QoL, physical functioning and role limi-
tations) mediate the relationship between BMI and level of
depression, but only in women. In our research, a higher
level of body mass index decreased the quality of life, a
different physical aspect of health, which became a
potential risk factor for the development of depressive
symptoms. This pattern is consistent with previous research
indicating that women, compared to men, perceived their
weight as a barrier in their physical quality of life and
developed a higher rate of depression [34]. In men, this
condition does not apply; men do not see their weight as a
factor that diminishes or worsens their quality of life. They
do not associate their weight to poorer quality of life (e.g.
general health, the experience of pain, or life roles).
Fabricatore et al. [35] in a research on extremely obese
participants (81 % women) also found that impairments in
HRQoL were common. More than 40 % of participants
scored in the impaired ranges of physical functioning,
physical role limitations, and bodily pain. The impairments
in HRQoL were related, significantly and more strongly, to
symptoms of depression than were related to BMI.
Jagielski et al. [15] found that the association between
quality of life and BMI remains stable after controlling for
comorbid health problems, and the authors conclude that
obesity independently, negatively affects quality of life.
Kolotkin et al. [36] found that HRQOL was more impaired
for those with higher BMIs, and women in treatment
groups. Recently, Buscemi et al. [37] demonstrate that just
a modest amount of weight loss can improve physical and
psychological quality of life.
In our study, we did not get the results that indicate
physical component of HRQoL and its different aspects as
mediators between BMI and anxiety. We found that older
female respondents were more anxious, but this is not the
case for men. Female ageing is synonymous of a decline in
physical attractiveness, and it is not surprising that middle-
aged women experience anxiety about ageing [38]. Gender
differences in HRQoL could be also related to the higher
prevalence of psychopathology among women [39, 40] or
to a greater cultural drive for thinness experienced by the
female sex in Western societies [41, 42]. The presence of
depressed mood, which is the most common psychological
problem observed in obese women [43], can increase
subjective distress induced by disease-related physical
symptoms and functional impairment [39]. These are dif-
ferent health treats associated with obesity and they have
an influence on the perception of stress in obese people. On
the other hand, obese people are exposed to the negative
effects of stigmatisation and discrimination related to
weight. Because of high frequency of stigmatisation and
479
poor coping strategies, the probability to develop depres-
sive mood as consequence becomes higher [15, 44]. Mur-
phy et al. [44] concluded that depression among obese
subjects in a community sample tends to be more severe in
comparison to non-obese, and gaining weight is important
factor that contributes to the severity of the depressive
symptoms. According to our results, a portion of the
variance of depressive symptoms in women could be
explained by BMI. Women are likely to be more aware of
the connection between obesity and health, in contrast to
men in whom this aspect of life is not of primary
importance.
The results in the present study show a different pattern
of functioning between men and women. In women, the
quality of life is significantly weakened because of
increasing body weight, which in turn produces symptoms
of depression. In men, this association does not exist. Preiss
et al. [45] analysed results obtained in 20 studies, and in
more than half found that gender was significantly asso-
ciated with the relationship between obesity and depres-
sion, such that being female conferred risk of comorbid
obesity and depression. Obese women experienced a
greater impairment of HRQL than their male counterparts
did. This confirms previous reports in clinic-based samples,
and in population studies. Knowledge of gender differences
allows us to better plan therapeutic interventions for men
and women with high BMI levels. It is important to iden-
tify the factors that can effectively motivate and stimulate
obese people to modify their lifestyles and regimens. This
research emphasised the importance of assessing the dif-
ferences in the psychological functioning of women and
men to promote effective weight loss treatment.
In this study, we did not include information about the
presence of eating disorders in a sample of obese patients,
which can potentially be one of the limitations. However,
research on the relationship between binge eating disorder
with quality of life is not consistent and we have decided to
focus on depression and anxiety as criteria. Some studies
analysed association between BED and HRQOL impair-
ment and found that this association can be mediated by
higher BMI, and a greater prevalence of mental disorders
[42, 43]. After adjustment for these potential confounders,
binge eating was only marginally associated with some
domains of HRQL, without any impact on physical scales.
Kolotkin et al. [46] suggested that factors such as BMI,
psychological symptoms, and demographic variables
explained the association between BED and quality of life.
Because earlier studies did not control for pertinent vari-
ables, the implication that the presence of BED itself
accounts for the observed differences in quality of life may
not be correct, Kolotkin et al. [46] concluded. Preiss et al.
[45] in their article wrote that the results of research on
BED might reflect an influence of binge eating that is
123
480
specific to an obese (non-surgical) treatment-seeking pop-
ulation. On the other hand, in our research, we had a
community non-clinical obese sample. There are several
other limitations to our study. One limitation is related to
the sample size. Therefore, it is necessary to conduct
additional research with larger samples and to include
information concerning co-morbidity, which is lacking in
this research. Specifically, general practitioners collected
the data; however, the information related to the reason for
the visit to the physician was not recorded. We can only
speculate that the potential reason for visiting the primary
care physician was related to some of co-morbidity of
obesity. In conclusion, these findings are of clinical
importance, indicating that the impairment of the quality of
life in obese must be of high importance in planning
treatment with these individuals.
Compliance with ethical standards
Conflict of interest On behalf of all authors, the corresponding
author states that there is no conflict of interest.
Ethical approval This study was approved by Ethical committee of
Faculty of Humanities and Social Sciences in Rijeka, Croatia.
Informed consent Informed consent was obtained from all indi-
vidual participants included in the study.
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