Overweight and health-related quality of life in adolescents of Florianópolis, Southern Brazil

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1 Rev Súde Públic 2009;43(2) Nádi Kunkel Wlter Ferreir de Oliveir Mrco Aurélio Peres Overweight nd helth-relted qulity of life in dolescents of Florinópolis, Southern Brzil ABSTRACT OBJECTIVE: To ssess helth- relted qulity of life nd its ssocition to excess weight in dolescents. METHODS: Cross-sectionl study including 467 dolescents ged 15 to 18 yers enrolled in public school in Florinopolis, Southern Brzil, nd their prents, conducted in Overweight nd obesity were defined ccording to the body mss index. The combintion of overweight nd obesity ws defined s excess body weight. Helth-relted qulity of life ws ssessed using the Peditric Qulity of life Inventory (PedsQL) 4.0 for dolescents nd their prents. Descriptive sttistics nd undjusted nd djusted logistic regression nlyses were performed. RESULTS: The response rte ws 99.4% mong dolescents nd 53.4% mong their prents. The prevlence of overweight ws 12.2% nd obesity ws 3.6%. The group of dolescents with excess weight hd lower helth-relted qulity of life when compred with those who were not excess weight, except for the emotionl domin in the dolescents, nd the psychosocil helth domin for the prents. After djusting, dolescents with excess weight were 3.54 (95% CI 1.4;6.47) folds more likely to hve low qulity of life thn those with no excess weight. Femle dolescents hd lower qulity of life scores. CONCLUSIONS: Helth-relted qulity of life ws significntly lower in dolescents with excess weight excess. Public helth ctions directed to weight control in dolescents nd instruments for qulity of life mesures re mjor instruments for better thorough understnding of this importnt public helth problem. DESCRIPTORS: Adolescent. Overweight. Obesity. Qulity of Life. Questionnires, utiliztion. Adolescent Helth. Cross-Sectionl Studies. INTRODUCTION Progrm de Pós-Grdução em Súde Públic. Centro de Ciêncis d Súde Universidde Federl de Snt Ctrin. Florinópolis, SC, Brsil Correspondence: Nádi Kunkel Centro de Ciêncis d Súde, Progrm de Pós-Grdução em Súde Públic Universidde Federl de Snt Ctrin Cmpos Universitário Trindde Florinópolis, SC, Brsil E-mil: ndikunkel@gmil.com Received: 21/11/2007 Revised: 11/9/2008 Approved: 29/9/2008 Obesity is public helth concern worldwide ffecting children, dolescents, dults, nd the elderly. 19 In Brzil the prevlence of excess body weight (overweight plus obesity) in dolescents incresed from 2.6% to 11.8% in boys nd from 5.8% to 15.3% in girls between 1975 nd Bsed on the sme clssifiction criteri, the Fmily Budget Survey (POF) conducted by the Brzilin Institute of Geogrphy nd Sttistics (IBGE) in found prevlence of 23.6% nd 17.1% of overweight nd 3.3% nd 2,9% of obesity in sme-ge mle nd femle dolescents, respectively, in urbn res of southern Brzil. A 2003 study including school dolescents in the city of Florinópolis reported 12% prevlence of overweight. 5 Brzilin Institute of Geogrphy nd Sttistics. Household Budget Survey Análise d disponibilidde domicilir de limentos e do estdo nutricionl no Brsil. Rio de Jneiro; 2004 [cited 2006 Jun 14]. Avilble from: condicodevid/pof/2003medids/pof2003medids.pdf

2 2 Overweight nd qulity of life Kunkel N et l It is estimted tht 50% of obese children will become obese dults. 14 In ddition, they re very likely to develop other relted conditions such s dibetes mellitus, crdiovsculr diseses, therosclerosis, rteril hypertension, orthopedic nd joint disorders, skin diseses, nd higher surgicl risk, mong other complictions. 2 Incresed prevlence of excess body weight during childhood nd dolescence hs stirred renewed interest in the study of psychosocil outcomes of these conditions t this ge group becuse they my hve mjor psychosocil consequences. 20 A criticl time point for the development of obesity is erly dolescence, 8 life phse when dolescents hve constnt concern bout their body weight, envisging n idel of beuty, imposed by the len, slender body type. Non-cceptnce of one s own body cn mke dolescents feel socilly mrginlized. 20 Studies on helth-relted qulity of life (HRQL) in obese individuls hve become incresingly common. Most hve investigted dults but those few focusing on dolescents hve showed strong consistent ssocition between low HRQL nd obesity. 9,11,21 Further studies re needed in this popultion in Brzil. A serch conducted in Medline, Lilcs, nd Scielo dtbse in July 2006 did not find ny Brzilin study investigting weight nd HRQL issues in dolescents. To test the hypothesis tht HRQL is lower mong dolescents with excess body weight compred to their peers with non-excess body weight, the objective of the present study ws to ssess qulity of life of dolescents nd its ssocition with excess body weight. METHODS A cross-sectionl nlyticl study ws crried out in students ttending public high school in the city of Florinópolis, southern Brzil, in The smple size ws estimted considering 1:4 rtio of exposed/nonexposed (excess body weight/non-excess body weight) nd negtive HRQL of 15% in non-exposed nd 30% in exposed. To tht it ws dded 20% to compenste losses nd refusls. The smple hd 80% power t 95% level of confidence. Smple selection ws proportionl to the number of students enrolled in ech grde. A systemtic smpling ws crried out in ech clss. The inclusion criteri were: being under the ge of 18 nd enrolled in the study school. There were excluded pregnnt dolescents nd those with physicl disbilities tht prevented or ffected nthropometric mesures. Of bout 2,400 students enrolled in the high school progrm, 470 were drwn to prticipte in the study. The outcome ws HRQL mesured using the Peditric Qulity of Life Inventory (PedsQL) 4.0, vlidted in Brzil. This questionnire hs module formt designed to ssess HRQL of children nd dolescents ged between two nd 18 yers. 15 It ws conceived to mesure scores of physicl, mentl, nd socil helth dimensions s described by the World Helth Orgniztion nd tking into considertion their school functioning s well. 16 A self-dministered PedsQL for dolescents ged between 13 nd 18 yers ws used. It comprised 23 items divided into four domins: physicl, emotionl, socil nd school functioning. Tble 1 describes the items of ech domin. This instrument consists of two prllel questionnires, one for dolescents nd one for prents. This ltter ws designed to ssess prents perception of their children HRQL. Qulity of life ws mesured through psychometric nlysis using five-point Likert scle: 0 = never ws problem; 1 = lmost never; 2 = sometimes; 3 = frequently; 4 = lwys). Items were scored, nd linerly converted into 0 to 100 scle (0 = 100; 1 = 75; 2 = 50; 3 = 25; nd 4 = 0). All items were then summed up nd divided by the number of questions nswered. The higher the score, the better the qulity of life. 16 Besides the PedsQL scle, prtil physicl (physicl helth subscle) nd psychosocil helth (men emotionl, socil, nd school subscles) scles were mesured. 15 Excess body weight (overweight plus obesity) ws mesured using the body mss index (BMI = weight [kg] / height [m 2 ]) by gender nd ge. The clssifiction criterion pplied for the dignosis of overweight nd obesity ws bsed on the BMI cutoff 25 kg/m 2 for dults (Cole et l 3 ). Weight ws mesured using digitl scle (Tnit) with 150-kg cpcity nd 0.2-kg precision tht ws regulrly checked. Mesures were tken with subjects in the stnding position wering light clothing nd preferbly brefoot. When subject did not gree to be brefoot, there were subtrcted from the weight mesured 500 g of footwer for mles nd 250 g for femles. All dt were collected by skilled nutritionist with experience in nthropometric mesures. Height ws self-referred by dolescentes 6,7 becuse the pilot study showed tht dolescents hd difficulty referring their weight but not their height. There were collected independent nd control vribles using self-dministered complementry questionnires: gender, ge, self-referred skin color, living sitution (with whom they lived). The following vribles were investigted mong prents: fmily hed schooling, child morbidity, fmily socioeconomic condition (per cpit income in reis in the month prior to the interview). Kltchoin DA. Confibilidde d versão brsileir do questionário genérico de qulidde de vid pediátric versão 4.0 (pedsql 4.0) [doctorte thesis]. São Pulo: Universidde Federl de São Pulo; 2007.

3 Rev Súde Públic 2009;43(2) 3 The questionnires were pre-stndrdized nd pre-tested in 25 students (nd one of their prents mother or fther or gurdin) ttending 10 th grde of secondry public school. After due djustments, pilot study comprising 130 students of two public stte schools in the city of Florinópolis ws crried out to test the study procedures nd stndrdize nthropometric mesures. Insted of self-referred weight it ws opted for mesuring it since most dolescents did not know their weight. Subjects filled out the study questionnires in the clssroom. At tht time questionnires were lso hnded to their prents nd they were sked to return them on the next dy. The questionnires were then coded nd reviewed nd dt ws entered using Epi Dt progrm. Dt nlysis ws performed using SPSS for Windows version Those dolescents who completed less thn 50% of the HRQL instrument were excluded from the nlysis. It ws set cutoff of one stndrd devition below the men score of non-excess body weight subjects nd low HRQL ws then dichotomized. 11 Descriptive sttistics were used to summrize ll vribles studied nd the ssocitions between outcome nd explortory vribles were tested using the chi-squre test nd ANOVA. Additionlly, pired comprison of norml weight, overweight, nd obesity groups ws performed using the Mnn-Whitney U test. Those vribles with p-vlue 0.20 were selected nd included in the multiple model. Nonconditionl logistic regression nlysis ws crried out strtified by gender. The vribles were included in the model in n scending order by their sttisticl significnce in the chi-squre test. Odds rtio (OR) ws the mesure of effect used to estimte the likelihood of dolescents with excess body weight to hve different HRQL thn those with non-excess body weight. Crude nd djusted ORs were estimted nd vribles with p<0.05 fter djustment were considered significntly ssocited. Simple liner correltion nlysis ws crried out between totl PedsQL scores reported by dolescents nd BMI vlues for the entire smple nd strtified by gender. The study ws pproved by the Reserch Ethics Committee of Universidde Federl de Snt Ctrin nd complied with ethicl principles. RESULTS A totl of 467 dolescents (99.4% of the smple) prticipted in the study. Two dolescents were excluded due to physicl disbilities tht prevented nthropometric mesurements nd one ws excluded from the nlysis becuse he did not complete t lest 50% of PedsQL. All their prents received the questionnire nd 251 completed it (46.3% response rte). Men totl HRQL score reported by dolescents whose prents nswered the questionnire ws (stndrd devition [SD]: 12.00) while men score mong those whose prents did not complete the questionnire ws (SD: 11.66), difference tht ws not sttisticlly significnt (p>0.05). There were 34 (13.6%) dolescents Tble 1. Description of PedsQL 4.0 instrument items in ech domin. Physicl domin Emotionl domin 1 item for ech one of the following subjects Difficulty to wlk more thn block Feeling fer Difficulty to run Feeling sd or depressed Difficulty to engge in sports ctivities Feeling ngry Difficulty to lift weight Difficulty to sleep Difficulty to bth by himself/herself Self-concern Difficulty to help with household tsks Pin Lck of energy Socil domin School domin 1 item for ech one of the following topics Problem or difficulty to interct with peers Attention difficulty Problem or difficulty to mke friends Memory difficulties Problems with peer tesing Difficulty to follow clssroom ctivities Difficulty to do the sme things other dolescents do 2 items on resons for missing school Difficulty to follow sme-ge dolescents Source: Adpted from Kltchoin DA. Confibilidde d versão brsileir do questionário genérico de qulidde de vid pediátric versão 4.0 (pedsql 4.0) [doctorte thesis]. São Pulo: Universidde Federl de São Pulo; 2007.

4 4 Overweight nd qulity of life Kunkel N et l Tble 2. Frequencies of demogrphic nd nutritionl vribles ccording to sex mong high school dolescents. Florinópolis, Southern Brzil, Vrible Totl (N = 467) N (%) of subjects Mles (N= 173) Femles (N=294) p-vlue Age (yers) 0.532* (40.0) 69 (39.9) 118 (40.0) (35.1) 56 (32.4) 108 (36.7) (19.9) 39 (22.5) 54 (18.4) (4.9) 9 (5.2) 14 (4.8) Nutritionl sttus 0.291* Non-excess body weight 393 (84.2) 138 (79.8) 255 (86.7) Overweight 57 (12.2) 31 (17.9) 26 (8.8) Obese 17 (3.6) 4 (2.3) 13 (4.4) Skin color White/ yellow 333 (71.5) 132 (76.3) 201 (68.6) Indin/ blck/ mixed 133 (28.5) 41 (23.7) 92 (31.4) Living sitution With both prents 321 (68.7) 121 (69.9) 200 (68.0) With mother only 114 (24.4) 41 (23.7) 73 (24.8) With fther only 12 (2.6) 4 (2.3) 8 (2.7) Other 20 (4.3) 7 (4.0) 13 (4.4) * p-vlue of liner trend with excess body weight mong those whose prents completed the questionnire nd 40 (18.5%) mong those whose prents did not complete it, difference tht ws lso not significnt (p= 0.18). Demogrphic nd nutritionl chrcteristics of dolescents re presented in Tble 2. Men ge ws 15.9 yers (SD: 0.89) nd femles were 63.0% of the smple studied. The prevlence of overweight nd obesity ws 12.2% nd 3.6%, respectively. Mle dolescents hd higher prevlence of overweight thn femles (17.9% nd 8.8%, respectively) while obesity ws higher mong femles (4.4% versus 2.3%), but these differences were not sttisticlly significnt. There were no significnt differences between mles nd femles by ge, skin color, nd living condition. As for prentl schooling, 2.8% of fmily heds were illiterte, 10.0% hd t lest four yers of schooling, 28.3% t lest eight yers, nd 56.6% nine yers or more. Men per cpit income ws R$ HRQL 100,00 Femles r=-0,256 p<0,01 HRQL 100,00 Mles r=-0,067 p=0,378 HRQL 100,00 Entire smple r= p< ,00 80,00 80,00 60,00 60,00 60,00 40,00 40,00 40,00 20,00 30,00 40,00 BMI HRQL: Helth-Relted Qulity of Life BMI: Body mss index 20,00 30,00 40,00 BMI 20,00 30,00 40,00 BMI Figure. Correltion between helth-relted qulity of life nd body mss index by sex mong high school dolescents. Florinópolis, Southern Brzil, 2007.

5 Rev Súde Públic 2009;43(2) 5 Tble 3 shows significnt difference between excess nd non-excess weight groups in ll HRQL domins except the emotionl one. As for prents perception, totl nd physicl score significntly vried between the groups studied. The pired comprison nlysis using the Mnn-Whitney U test showed tht the difference between non-excess body weight nd overweight group ws not significnt. However, the comprison between non-excess body weight nd obesity group reveled significnt difference in ll domins (p<0.05 for the emotionl domin nd p<0.01 for ll others). The comprison between overweight nd obesity groups showed significnt difference in the totl nd physicl helth domins (p<0.01), psychosocil nd school (p<0.05) but not significnt in ll others. According to the prents perception, there ws no significnt difference in the pired comprison of ll domins. Men totl PedsQL scores of dolescents nd their prents/gurdins for the entire smple, non-excess, nd excess body weight subjects were compred by gender, ge, skin color, nd living sitution (Tble 4). Femle dolescents hd significntly lower HRQL thn mles. And mong prents, child s mixed nd blck skin color ws ssocited to low qulity of life. After dichotomizing HRQL scores (cutoff vlue: 65.43) into low nd dequte, it ws found 13.0% of low HRQL in the non-excess body weight nd 29.3% in the excess body weight group. Tble 5 presents ORs strtified by gender nd djusted for ge, skin color, nd living sitution. Femle dolescents with excess body weight were significntly more likely to report low HRQL thn those with non-excess body weight in ll domins, except the emotionl one. As for the prents perception, significnt difference ws seen in the totl physicl nd socil score. With respect to mle dolescents, this difference remined significnt only for the totl scle score in the self-report nd for the physicl domin in their prents perception. BMI vlues hd negtive correltion with totl PedsQL scores reported by dolescents (Figure). Higher correltion ws seen mong femle dolescents (r = in femles nd r = 0,067 in mles). Only the correltion coefficient between BMI nd HRQL in the entire smple nd mong femle dolescents ws sttisticlly significnt (p<0.01). DISCUSSION The present study findings indicte significnt ssocition between excess body weight nd low HRQL in school dolescents under 18 in the city of Florinópolis. HRQL scores mesured using PedsQL were higher in non-excess body weight, followed by overweight nd obese dolescents. It suggests positive ssocition between severity of excess body weight nd low qulity of life. Adolescents with excess body weight hd lower HRQL not only in the totl scle score but lso in the physicl, psychosocil, socil, nd school domins compred to their peers with non-excess body weight, which suggests this condition hs globl impct on the dolescent s dily life. Aprt from the emotionl domin, the study findings re consistent with those of recent Americn studies using the sme instrument. They reported obese children nd dolescents under tretment hd lower HRQL in ll domins (physicl, emotionl, socil, nd school) compred to their peers with norml weight. 11,21 Similr scores were described Tble 3. Mens nd stndrd devitions of totl nd PedsQL subscle scores reported by dolescents nd their prents by nutritionl sttus of high school dolescents. Florinópolis, Southern Brzil, Vrible Men (SD) Non-excess body weight Overweight Obese Excess body weight p-vlue Adolescent (N=467) Totl scle score (11.0) (14.3) (14.9) <0.001 Physicl helth (13.7) (17.6) (22.5) <0.001 Helth psychosocil (11.5) (14.4) (12.9) Emotionl (17.8) (18.4) (18.3) Socil (12.6) (17.3) (13.8) School (15.3) (17.7) (13.6) Prents (N=251) Totl scle score (12.4) (16.9) (18.0) Physicl helth (16.2) (21.9) (19.7) Psychosocil helth (12.8) (15.4) (17.4) Emotionl (18.5) (21.2) (21.4) Socil (13.5) (13.8) (20.2) School (16.1) (21.3) (17.9) ANOVA

6 6 Overweight nd qulity of life Kunkel N et l Tble 4. Mens nd stndrd devitions of totl nd PedsQL subscle scores reported by dolescents nd their prents ccording to socioeconomic nd demogrphic vribles by nutritionl sttus of high school dolescents. Florinópolis, Southern Brzil, Men (SD) Vrible Totl Non-excess body weight Excess body weight Totl scle score dolescents (N= 467) Gender Mle (10.62)** (9.57)** (3.71)** Femle (12.01) (11.19) (5.13) Age (yers) (11.35) (10.80) (3.94) (12.26) (10.74) (6.63) (11.88) (11.78) (2.58) (13.42) (12.55) (6.74) Skin color White/ Yellow (11.65) (11.32) (3.17) Indin/ Blck/ Mixed (12.47) (10.23) (18.14) Living sitution With both prents (11.47) (10.78) (14.75) With mother only (12.17) (11.01) (15.55) With fther only (11.79) (8.49) (14.57) Other (16.20) (15.44) (23.96) Totl scle score prents (N= 251) Gender Mle (10.78)** (9.57)** (15.03)** Femle (13.56) (12.77) (17.24) Age (yers) (12.90) (11.59) (18.40) (12.90) (12.28) (17.29) (13.58) (12.85) (16.19) (16.68) (16.71) ( - ) Skin color White/ Yellow (12.68)** (12.39) (14.52)* Indin/ Blck/ Mixed (14.18) (12.34) (18.47) Living sitution With both prents (12.60) (12.17) (15.58) With mother only (15.04) (13.64) (19.50) With fther only (3.87) (3.92) ( - ) Other (10.43) (9.7) ( - ) * p<0.05 ** p<0.01 non-significnt in study with children nd dolescents dignosed with cncer. 11 The non-significnt difference in the emotionl domin my be ssocited to the fct tht dolescence is stge of mjor chnges, conflicts, nd lck of selfconfidence, which mkes dolescents more vulnerble to socil nd culturl contrdictions involving body imge-relted emotionl issues. The dolescents prents studied reported slightly higher HRQL compred to tht self-perceived by excess nd non-excess body weight subjects. Totl nd physicl domin scores obtined from prents were lso significntly lower mong those with excess body weight. This finding contrsts with tht found in clinicl studies of obese dolescents reporting prentl perception of

7 Rev Súde Públic 2009;43(2) 7 Tble 5. Odds rtio nd 95% confidence intervl of low helth-relted qulity of life mong excess nd non-excess body weight mle nd femle high school dolescents. Florinópolis, Southern Brzil, 2007 Adjusted OR (95% CI) Vrible Mle Femle Adolescent (N=467) Totl scle score 2,94 (1,12-7,73) 4,59 (2,16-9,74) Physicl helth 1.87 (0.73;4.79) 3.08 (1.42;6.68) Psychosocil helth 1.52 (0.64;3.63) 3.14 (1.49;6.59) Emotionl 1.33 (0.54;3.26) 2.32 (0.98;5.52) Socil 1.59 (0.65;3.91) 3.33 (1.45;7.62) School 1.45 (0.61;3.47) 2.32 (1.08;4.98) Prents (N=251) Totl scle score 4.83 (0.88;26.5) 2.59 (1,23;5,44) Physicl helth 5.73 (1.2;27.43) 2.78 (1.31;5.93) Psychosocil helth 2.23 (0.42;11.8) 2.04 (0.99;4.23) Emotionl 1.41 (0.29;6.89) 2.01 (0.99;4.11) Socil 1.84 (0.36;9.40) 2.28 (1.09;4.77) School 0.67 (0.10;4.38) 1.89 (0.92;3.88) Adjusted by ge, skin color, nd living sitution. their children s HRQL to be lower thn tht reported by the dolescents. 11,21 These Americn studies found significntly lower scores in ll domins for obese dolescents ccording to their prents perception. 11,21 However, the results of the present study re consistent with those of nother study with schoolchildren where prents reported higher HRQL scores. 18 The differences found between clinicl nd school smples suggest tht prents hve greter concern, cre, nd interest regrding their children s dily life routine nd behviors s they strt clinicl tretment. In the present study, men totl scle score of obese subjects ws similr to tht reported by Zeller & Modi 21 nd Schwimmer et l 11 in United Sttes studies with clinicl smples. Willims et l 18 reported contrsting results in popultion-bsed study with elementry schoolchildren in Victori, Austrli. Compred to studies with clinicl smples, they found smller differences between overweight nd obese children nd those with norml weight. An dequte comprison is not possible s there re no Brzilin studies with clinicl smples. But the predominnce of femle dolescents in the smple studied tht showed significntly lower HRQL thn mles my explin lower totl scores found. When men totl HRQL scores self-reported by dolescents nd perceived by their prents were strtified by gender, significnt difference ws seen. Qulity of life of femle dolescents compred to tht of mles ws lower mong both excess weight nd non-excess weight groups. These results re expected since mny studies hve shown tht femle dolescents hve greter concern with their body imge. 4,10 Brnco et l, 1 in study conducted in São Pulo investigting body perception nd stisfction mong dolescents nd their ssocition with nutritionl sttus, reported body imge disstisfction ws more prevlent mong overweight nd obese dolescents, especilly mong femles, s well s greter disstisfction mong eutrophic dolescents. Prents perception lso reveled significnt difference in men totl scle score by skin color. Prents perceived non-white children s hving lower HRQL thn white ones. This finding my indicte greter sensitivity to discrimintion by the prents tht is projected onto their children. However, it cnnot be properly inferred s it is out of the scope of the present study. HRQL is intended to ssess overll physicl nd psychosocil functioning. 13,15 Although not designed to explore ll domins tht my be prticulrly ssocited to obesity, this instrument cn provide n overll picture of how obese people perceive their helth nd well-being. HRQL ssesses mjor spects of helth tht re not covered by conventionl physiologicl nd clinicl dimensions. The present study hs some limittions. There my hve been errors regrding self-referred height, most likely overestimting it nd therefore underestimting overweight nd obesity. In ddition, it ws not checked when height ws lst mesured nd how it ws mesured. But studies hve shown tht self-referred weight nd height in dolescents re vlid mesures. 6,7 In ddition, morbid conditions nd socioeconomic conditions were not controlled for s this informtion ws not properly provided by prents/gurdins. The clssroom ws

8 8 Overweight nd qulity of life Kunkel N et l not the most dequte environment for the instrument dministrtion s it ws noisy nd my hve disturbed dolescents concentrtion. Also, being close to their peers my hve mde dolescents embrrssed. A comprison between schooling of Florinópolis popultion in 1996 nd tht of fmily heds of the dolescents studied showed similrities. IBGE dt b showed tht, in 1996, 39.6% of dults ged 20 to 59 yers hd t lest eight yers of schooling compred to 38.3% in the present study. Men per cpit income ws R$ , which is lower thn R$ seen in Florinópolis in b It suggests tht the study popultion hd lower socioeconomic condition tht the verge popultion living in Florinópolis, thus preventing further extrpoltion of results citywide. Despite these limittions, the study generted relevnt findings nd corroborted other interntionl studies: excess body weight significntly ffects the qulity of life of dolescents, especilly girls. The instrument dministered proved to be esy to use nd provided consistent results. The study findings stress the importnce of ssessing HRQL before, during, nd fter obesity mngement. This mesure cn be used s prmeter to ssess effectiveness of obesity mngement. It cn lso help understnd the consequences of obesity in dolescents nd support public policies trgeting this specific popultion s well. The instrument dministered to prents is useful tool to evlute nd promote fmily involvement. Rvens-Sieberer et l 12 clim tht interventions trgeting obese children nd their fmilies would require better understnding of life spects tht re most ffected by obesity. HRQL ssessment cn help helth providers better understnd these spects. These uthors 12 conclude tht HRQL evlution of obese children is mjor tool for ssessing tretment success. It is recommended to further investigte HRQL in popultion-bsed nd clinicl smples of dolescents nd in other ge groups nd to ssess depression in this popultion s well. ACKNOWLEDGEMENTS To the school dministrtion nd stff of Instituto Estdul de Educção, Florinópolis, Brzil, for their support. To Prof. Dr Eleonor d Orsi nd Dr Frncisco de Assis Vsconcelos, of Universidde Federl de Snt Ctrin, for their suggestions. Brzilin Ministry of Helth. Bnco de Ddos do Sistem Único de Súde (DATASUS) [internet]. [cited 2007 Aug 12]. Avilble from: tbnet.dtsus.gov.br/cgi/deftohtm.exe?ibge/cnv/estsc.def. b Brzilin Institute of Geogrphy nd Sttistics Popultion Census. Rio de Jneiro; 2001.

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