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Development of a Brief Measure to Assess

Quality of Life in Obesity


Ronette L. Kolotkin,* Ross D. Crosby, Karl D. Kosloski, and G. Rhys Williams

Abstract
KOLOTKIN, RONETTE L., ROSS D. CROSBY,
KARL D. KOSLOSKI, AND G. RHYS WILLIAMS. Development of a brief measure to assess quality of life in
obesity. Obes Res. 2001;9:102111.
Objective: Obesity researchers have a growing interest in
measuring the impact of weight and weight reduction on
quality of life. The Impact of Weight on Quality of Life
questionnaire (IWQOL) was the first self-report instrument
specifically developed to assess the effect of obesity on
quality of life. Although the IWQOL has demonstrated
excellent psychometric properties, its length (74 items)
makes it somewhat cumbersome as an outcome measure in
clinical research. This report describes the development of a
31-item version of the IWQOL (IWQOL-Lite).
Research Methods and Procedures: IWQOLs from 996
obese patients and controls were used to develop the
IWQOL-Lite. Psychometric properties of the IWQOL-Lite
were examined in a separate cross-validation sample of 991
patients and controls.
Results: Confirmatory factor analysis provided strong support for the adequacy of the scale structure. The five identified scales of the IWQOL-Lite (Physical Function, SelfEsteem, Sexual Life, Public Distress, and Work) and the
total IWQOL-Lite score demonstrated excellent psychometric properties. The reliability of the IWQOL-Lite scales
ranged from 0.90 to 0.94 and was 0.96 for the total score.
Correlations between the IWQOL-Lite and collateral measures supported the construct validity of the IWQOL-Lite.
Changes in IWQOL-Lite scales over time correlated significantly with changes in weight, supporting its sensitivity to
change. Significant differences in IWQOL-Lite scale and

Submitted for publication June 20, 2000.


Accepted for publication in final form December 11, 2000.
*Department of Psychiatry, Duke University Medical Center, Durham, North Carolina;
Neuropsychiatric Research Institute, Fargo, North Dakota; Department of Neuroscience,
University of North Dakota, Fargo, North Dakota; Department of Gerontology, University
of Nebraska, Omaha, Nebraska; and Knoll Pharmaceutical Company, Mount Olive, New
Jersey.
Address correspondence to Ronette L. Kolotkin, Ph.D., 1004 Norwood Avenue, Durham,
NC 27707. E-mail: kolot001@mc.duke.edu
Copyright 2001 NAASO

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OBESITY RESEARCH Vol. 9 No. 2 February 2001

total scores were found among groups differing in body


mass index, supporting the utility of the IWQOL-Lite across
the body mass index spectrum.
Discussion: The IWQOL-Lite appears to be a psychometrically sound and clinically sensitive brief measure of quality of life in obese persons.
Key words: health-related quality of life, HRQOL,
Impact of Weight on Quality of Life questionnaire,
IWQOL, assessment

Introduction
In 1947, the World Health Organization defined health as
not merely the absence of disease, but complete physical
function, social function, role function, mental health, and
general heath perceptions (1). In recent years, the terms
quality of life and, more specifically, health-related quality
of life (HRQOL) have been used to refer to the physical,
psychological, and social domains of health, seen as distinct
areas that are influenced by a persons experiences, beliefs,
expectation, and perceptions (2). With increasing frequency, clinical researchers are choosing measures of
HRQOL as primary and secondary outcomes in clinical
trials (3). As new anti-obesity drugs are developed, there is
an increasing need to measure HRQOL in obese persons
participating in clinical trials for the treatment of obesity.
It is well known that obesity may impact important aspects of HRQOL, such as physical health, emotional wellbeing, and psychosocial functioning (4 7). HRQOL has
been found to vary directly with the severity of obesity
among individuals seeking weight-loss treatment, with the
most obese individuals having the poorest quality of life (8)
and obese persons reporting pain showing the greatest impairments (9). Obese persons seeking treatment have been
shown to be significantly more physically impaired than
those who are not trying to lose weight (10). Furthermore,
increases in weight have been associated with deteriorated
physical, but not emotional, well-being (11,12), and weight
loss has been associated with improved physical rather than
mental components of HRQOL (12). HRQOL has been
shown to improve after treatment (1315).

Development of a Brief Measure, Kolotkin et al.

In each of the above studies, the researchers measured


HRQOL using the SF-36, a generic quality-of-life measure
that assesses physical functioning, role limitations due to
physical health, bodily pain, general health, vitality, social
functioning, role limitations due to emotional problems, and
mental health (16). Whereas generic instruments allow for
comparisons of quality of life across various disease states
and provide insight into improvements in general health,
disease-specific instruments are designed to focus on the
domains, characteristics, and complaints most relevant to a
particular disease. Disease-specific measures are clinically
sensible in that patients and clinicians intuitively find the
items directly relevant; their increased potential for responsiveness is particularly compelling in the clinical trial (3).
Disease-specific instruments are usually more sensitive to
changes in quality of life that result from treatment (17). In
clinical trials in which specific therapeutic interventions for
specific diseases are being evaluated, it is generally recommended that disease-specific instruments be used in addition to generic measures (2,3). The Impact of Weight on
Quality of Life questionnaire (IWQOL) is one such diseasespecific instrument (18,19).
The IWQOL was the first instrument specifically developed to assess quality of life in obesity (18,19).) The
IWQOL was developed in a clinical setting for moderate to
severe obesity, and measures those aspects of quality of life
that were identified by obese persons in treatment to be of
greatest concern. Eight areas of functioning are assessed by
the IWQOL: health, social/interpersonal, work, mobility,
self-esteem, sexual life, activities of daily living, and comfort with food.
Since the initial development of the IWQOL, several other
quality-of-life instruments for obesity have been in development. Mathias et al. (20) developed a 55-item HRQOL measure containing global domains (general health, comparative
health), obesity-specific domains (overweight distress, depression, self-regard, and physical appearance), and an obesityspecific health state preference. Sullivan et al. (21) developed
an HRQOL measure (assessing general health perceptions,
mental well-being, mood disorders, social interaction, and obesity-specific symptoms) that was derived largely from existing
instruments (General Health Rating Index, Mood Adjective
checklist, Hospital Anxiety and Depression scale, Sickness
Impact profile, and an eight-item obesity-specific module developed from a cancer survivors study questionnaire) and is
being used in the Swedish Obese Subjects intervention trial on
morbidly obese participants. An 11-item instrument that assesses physical state, vitality/desire to do things, relations with
other people, and psychological state (Obesity-Specific Quality
of Life questionnaire) was developed in France using a large
community-based sample (22). Another instrument, the Obesity-Related Well-Being scale (ORWELL 97), was developed
to examine the occurrence of physical and psychosocial symptoms as well as the subjective relevance of these symptoms in

obese patients. (23). The ORWELL 97 consists of 18 items and


2 factors: Factor 1 measures psychological status and social
adjustment; Factor 2 measures physical symptoms and impairment. The Obesity Adjustment Survey (24) measures the psychological distress of individuals who are morbidly obese.
The IWQOL has been shown to be a reliable and valid
instrument for measuring posttreatment changes in HRQOL
(18,19). However, researchers designing clinical trials have
commented unfavorably on the length of the IWQOL (74
items), citing the potential for response burden to research
subjects. As new anti-obesity compounds are developed,
there is an increasing need for brief, psychometrically sound
measures of HRQOL in obese persons undergoing clinical
trials for the treatment of obesity.
This report describes the development and psychometric
properties of a brief version of the IWQOL (IWQOL-Lite)
that is more convenient for use as an outcome measure in
obesity research and even more psychometrically sound and
clinically sensitive than the original IWQOL.

Research Methods and Procedures


Subjects
Baseline data from the original 74-item IWQOL were
accumulated from 1987 individuals who had previously
taken the IWQOL in a variety of settings. These individuals included 211 obese subjects from an open-label
study of phentermine-fenfluramine, 834 subjects who
participated in an intensive, day treatment program for
weight loss and lifestyle change, 668 subjects who were
participants in outpatient weight reduction studies or
weight control programs, 51 subjects who were undergoing gastric bypass surgery for obesity, and 223 community subjects including employees and friends of local
businesses. One-year data were also available for 160
subjects from the open-label study of phentermine-fenfluramine who completed at least 1 year in the treatment
program. Information on gender, age, and body mass
index (BMI) is presented in Table 1. From Table 1, we
can see that age and BMI varied depending on group
membership. Mean age varied from 37 in the community
sample to 52 in the day treatment program. Mean BMI
varied from 27 in the community sample to 51 in the
gastric bypass sample. Information on race was available
on 1538 subjects (77% of the sample), with the following
racial breakdown: 71% white, 16% Hispanic, 10% African American, 1.4% Asian, 1.6% Other.
Collateral Measures
BMI data were available for 1907 (96%) of the subjects
at baseline. In addition, data from the Rosenberg SelfEsteem scale (25), the Beck Depression Inventory (BDI)
OBESITY RESEARCH Vol. 9 No. 2 February 2001

103

Development of a Brief Measure, Kolotkin et al.

Table 1. Study demographics


Study

Group

Open-label phen-fen

Obese

211

Day treatment

Obese

834

Weight-reduction studies/programs

Obese

668

Gastric bypass

Obese

51

Community

223

Employees/friends
Total

1987

(26), and the SCL-90-R (27) were available at baseline and


after 1 year for 160 subjects in the open-label study of
phentermine-fenfluramine.
Procedures and Statistical Analyses
Item Selection and Scale Construction. The sample of
1987 individuals was divided into two groups through
random assignment: the development sample (N 996) and
the cross-validation sample (N 991). The development
sample and the cross-validation sample were not statistically
different in terms of age, BMI, gender, or race (p 0.25).
The development sample provided data on which decisions
about item selection and scale construction were based.
Selection of items and construction of scales in the
development sample was accomplished by compiling data
on each of the 74 original IWQOL items. Data included
inter-item correlations, frequency distributions, coefficients
for scales and total score, item-to-scale correlations for
scales and total score, baseline correlations with collateral
measures, exploratory factor analysis, and 1-year change
correlations between items and collateral measures. Items
were selected if they were adequately distributed across item
responses (never true to always true), maximized
coefficients, maximized item-to-scale correlations, and
correlated significantly with relevant collateral measures,
both cross-sectionally and longitudinally. Initially, we
deleted items from the original 74 if they correlated poorly
with the scale score, correlated poorly with the total score,
or correlated poorly with BMI. Changes in items at the 1year follow-up were then correlated with changes in BMI at
the same follow-up. Additional items were deleted if they
did not correlate well with changes in BMI. Exploratory
factor analyses were then performed on the reduced set of
items. Factor loadings were examined, and additional items
were deleted if they did not load adequately on the derived
104

Gender

OBESITY RESEARCH Vol. 9 No. 2 February 2001

32
179
322
512
91
577
11
40
159
64
615
1372

males
females
males
females
males
females
males
females
males
females
males
females

Age

BMI

47.8 10.3
44.4 9.3
52.1 14.3
50.2 17.6
47.4 9.4
43.9 11.3
46.6 4.5
38.5 9.7
37.2 11.4
39.0 14.1
47.3 14.1
45.9 14.3

42.0 8.7
40.7 7.1
41.7 11.1
37.0 9.1
35.5 6.2
35.0 6.1
50.6 10.0
51.0 12.9
27.7 3.6
26.5 10.1
37.2 10.8
36.6 9.4

factors. This process was repeated until an acceptable and


interpretable factor structure was obtained. Assignment of
items to scales was therefore based both on exploratory
factor analysis and on the original scale composition. All
decisions about item selection were finalized before
analyzing any data in the cross-validation sample.
Psychometric Evaluation. Psychometric evaluation was
based entirely on the cross-validation sample. Using the
cross-validation sample, a two-way ANOVA (gender by
BMI classification; 25, 25 to 29.9, 30 to 34.9, 35 to 39.9,
and 40) was performed for each of the newly developed
scales and total score. An coefficient of 0.01 was used to
control for multiple comparisons. Post hoc tests for
comparisons between BMI groups were performed using
Tukeys honestly significant difference procedure (28) based
on an coefficient of 0.01.
A series of confirmatory factor analyses was performed
on the cross-validation sample to evaluate the
hypothesized scale structure using EQS software
(Multivariate Software Inc., Encino, CA) (29). Details of
confirmatory factor analyses are presented in Appendix 1.
The sensitivity of the IWQOL-Lite was evaluated on
the cross-validation sample using two different
methods. First, effect sizes were calculated between
adjacent BMI groups (25 vs. 25 to 29.9, 25.9 to 29.9
vs. 30 to 34.9, 30 to 34.9 vs. 35 to 39.9, etc.) and
between extreme BMI groups (25 vs. 40). Effect
sizes were calculated as the difference between group
means (after adjusting for age and gender) divided by
the SD for the entire sample. For example, the effect
size comparing 25 with 40 would be calculated as
the adjusted mean for 25 minus the adjusted mean
for 40. That quantity is then divided by the SD for
the entire group. Next, effect sizes were calculated in
the 1-year longitudinal sample (N 160) for three

Development of a Brief Measure, Kolotkin et al.

Table 2. Item-to-scale correlations

Physical Function ( 0.94)


Picking up objects
Tying shoes
Getting up from chairs
Using stairs
Dressing
Mobility
Crossing legs
Feel short of breath
Painful stiff joints
Swollen ankles/legs
Worried about health
Self-Esteem ( 0.93)
Self-conscious
Self-esteem not what it could be
Unsure of self
Do not like myself
Afraid of rejection
Avoid looking in mirrors
Embarrassed in public
Sexual Life ( 0.91)
Do not enjoy sexual activity
Little sexual desire
Difficulty with sexual performance
Avoid sexual encounters
Public distress ( 0.90)
Experience ridicule
Fitting in public seats
Fitting through aisles
Worry about finding chairs
Experience discrimination
Work ( 0.90)
Trouble accomplishing things
Less productive than could be
Do not receive recognition
Afraid to go on interviews

Physical
Function

SelfEsteem

Sexual
Life

Public
Distress

Work

Total

0.84
0.84
0.84
0.84
0.80
0.84
0.76
0.66
0.61
0.61
0.44

0.43
0.44
0.44
0.46
0.45
0.48
0.47
0.45
0.32
0.31
0.40

0.50
0.49
0.47
0.48
0.48
0.49
0.46
0.42
0.39
0.36
0.32

0.61
0.61
0.64
0.63
0.56
0.62
0.63
0.48
0.38
0.43
0.38

0.54
0.51
0.55
0.53
0.57
0.61
0.44
0.47
0.43
0.39
0.37

0.75
0.74
0.75
0.76
0.73
0.77
0.71
0.64
0.55
0.54
0.48

0.47
0.47
0.48
0.41
0.41
0.44
0.50

0.84
0.86
0.84
0.78
0.74
0.73
0.73

0.53
0.54
0.52
0.54
0.48
0.50
0.54

0.51
0.49
0.54
0.44
0.56
0.52
0.56

0.48
0.51
0.55
0.47
0.49
0.42
0.51

0.69
0.69
0.71
0.63
0.63
0.63
0.69

0.41
0.51
0.57
0.51

0.48
0.56
0.54
0.60

0.80
0.79
0.77
0.83

0.33
0.37
0.49
0.45

0.41
0.48
0.49
0.49

0.55
0.63
0.68
0.67

0.42
0.66
0.67
0.65
0.48

0.55
0.48
0.52
0.47
0.61

0.35
0.41
0.43
0.38
0.37

0.62
0.83
0.87
0.83
0.64

0.41
0.47
0.48
0.47
0.44

0.57
0.70
0.73
0.69
0.62

0.58
0.55
0.57
0.50

0.53
0.54
0.47
0.49

0.46
0.50
0.49
0.41

0.49
0.45
0.49
0.47

0.78
0.79
0.85
0.72

0.67
0.66
0.66
0.61

Correlations between each item and its designated scale are in bold type. Also in bold type are correlations between each item and total score.
All correlations are corrected for overlap.

groups: those subjects losing 10% of baseline BMI,


those subjects losing 10% to 20% of their baseline
BMI, and those subjects losing 20% of their baseline
BMI. Effect sizes were calculated as the difference
between IWQOL-Lite scores at baseline and at 1 year

(after adjusting for age and gender) divided by the SD


at baseline (30). Effect sizes were calculated rather
than Guyatts responsiveness statistic because there
were not sufficient cases with stable weight over the 1year period (97% lost at least 10 pounds and 89% lost
OBESITY RESEARCH Vol. 9 No. 2 February 2001

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Development of a Brief Measure, Kolotkin et al.

at least 20 pounds, leaving only five subjects who lost


10 pounds.)

Results

0.94; Self-Esteem, 0.93; Sexual Life, 0.91; Public Distress, 0.90; and Work, 0.90, with the overall coefficient
equaling 0.96.
Table 2 presents correlations between each item and its
designated scale in bold type (corrected for the influence of
that item), and the correlations between each item and the
other scales in normal type. Correlations between each item
and its designated scale were all significant at p 0.001.
For each item, the item-to-scale correlation was higher for
the designated scale (indicated in bold) than for any other
scale. In addition, for all but one item (Worried about
health), that correlation was higher than the corrected
item-to-total score correlation. Finally, for all items, the
item-to-total score correlation is higher than all item-toscale correlations except the designated scale. This pattern
of results suggests excellent reliability and distinct separation of scales.

Analysis of the development sample led to the specification of a 31-item instrument (IWQOL-Lite) consisting of
five scales: Physical Function (11 items), Self-Esteem (7
items), Sexual Life (4 items), Public Distress (5 items), and
Work (4 items). The correlation between the new 31-item
instrument (IWQOL-Lite) and the longer 74-item instrument (IWQOL) was 0.97. A description of the IWQOL-Lite
items and scales follows.
As in the original IWQOL, all items are rated by the research subject as always true, usually true, sometimes
true, rarely true, or never true; always true responses
were given a score of 5, never true responses were given a
score of 1. Scale scores are obtained by adding item scores, and
the total score is obtained by adding scale scores. Higher scores
indicate poorer quality of life. All items except for four begin
with the phrase because of my weight. The 11-item Physical
Function scale is concerned with mobility and day-to-day
physical functioning (e.g., Because of my weight, I have
difficulty getting up from chairs.). Seven of the 11 items on
the Physical Function scale were originally on the Mobility
scale of the longer IWQOL, and 4 were from the Health scale.
The seven-item Self-Esteem scale assesses self-esteem concerns related to weight (e.g., Because of my weight, I dont
like myself.). Five of the seven items were on the original
Self-Esteem scale of the IWQOL, and two were from the
Social/Interpersonal scale. The four-item Sexual Life scale
assesses sexual limitations related to obesity (e.g., Because of
my weight, I have little or no sexual desire.). All of the items
on the IWQOL-Lite Sexual Life scale were on the original
IWQOL Sexual Life scale. Three of the five items on the
Public Distress scale pertain to fitting in public places (e.g.,
Because of my weight, I worry about finding chairs that are
strong enough to hold my weight.) and were on the Activities
of Daily Living scale of the IWQOL. Two of the items on the
Public Distress scale pertain to negative reactions from others
(e.g., Because of my weight, I experience ridicule, teasing, or
unwanted attention.) and were on the Social/Interpersonal
scale of the IWQOL. The four items on the Work scale are
concerned with work performance as it relates to weight (e.g.,
Because of my weight, I have trouble getting things accomplished or meeting my responsibilities.). All of the items on
the Work scale were on the Work scale of the 74-item
IWQOL.
All results reported below are based on the crossvalidation sample.

IWQOL-Lite Scores by Gender and BMI


The results of the two-way ANOVAs are shown in Figure
1. (Means and SDs for each group are available from the
authors on request.) The main effect for BMI group was
significant for all scales and for the total score (p 0.001),
with higher scores associated with increasing BMI. Post hoc
tests revealed that all groups were significantly different
(p 0.01) from each other with the exception of the
following: 25 vs. 25 to 29.9 for all five scales and the total
score; 25 to 29.9 vs. 30 to 34.9 for Work; and 30 to 34.9 vs.
35 to 39.9 for Self-Esteem, Sexual Life, and Work. In
addition, the main effect for gender was significant for
Sexual Life, with females reporting more problems than
males. Finally, both the main effect for gender and the BMI
group-by-gender were significant for Self-Esteem and total
score. In both cases, females overall reported more problems, with the greater disparity between genders occurring
for the lower BMI groups.

Reliability and Separation of Scales


Reliability coefficients (Cronbach coefficients) for
the individual scales were as follows: Physical Function,

Baseline Correlations with BMI


All five scales and the total IWQOL-Lite score correlated
significantly (p 0.001) with BMI at baseline. Individual

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OBESITY RESEARCH Vol. 9 No. 2 February 2001

Interscale Correlations
Interscale correlations ranged from 0.46 (Sexual Life and
Public Distress) to 0.70 (Physical Function and Public Distress). Uncorrected correlations with total scale score ranged
from 0.74 (Sexual Life) to 0.89 (Physical Function),
whereas corrected correlations ranged from 0.66 (Sexual
Life) to 0.73 (Public Distress). The equivalence of correlations between individual scales and total score corrected for
overlap suggests that scales contribute comparably to the
total score.

Development of a Brief Measure, Kolotkin et al.

Figure 1. IWQOL-Lite Scores by BMI and gender.


OBESITY RESEARCH Vol. 9 No. 2 February 2001

107

Development of a Brief Measure, Kolotkin et al.

correlations were: Physical Function, 0.61; Self-Esteem,


0.34; Sexual Life, 0.30; Public Distress, 0.68; Work, 0.35;
and Total Score, 0.59.

Table 3. One-year change effect sizes in IWQOL-Lite


scores by percent BMI loss group
% BMI loss

One-Year Change Correlations


We examined correlations between changes in IWQOL
scores and changes in collateral measures (BMI, Rosenberg
Self-Esteem scale, BDI, SCL-90-R Global Severity Index
[GSI]) for the 160 patients from the open-label phentermine-fenfluramine study who had data available both at
baseline and 1 year. At this point in treatment, patients had
lost on average 18% of their body weight. Changes in all
five scales and the total IWQOL-Lite were significantly
(p 0.01) correlated with changes in BMI, with Physical
Function and total score correlating most highly. Four of the
five scales (all except Public Distress) and the total score
correlated with changes in the Rosenberg Self-Esteem scale,
and, as would be expected, the correlation was highest for
Self-Esteem. All five scales and the total score correlated
significantly with changes in BDI and GSI, with the correlation highest in both cases with the total score.
Confirmatory Factor Analysis
Results from confirmatory factor analysis provided
strong support for both the proposed scale structure of the
IWQOL-Lite and for the existence of a higher order factor,
presumably HRQOL. Appendix 1 provides details of the
confirmatory factor analyses.
Sensitivity
Cohen (31) describes an effect size of 0.20 as small, 0.50
as medium, and 0.80 as large. The average effect size across
adjacent groups (e.g., 25 vs. 25 to 29.9, 25 to 29.9 vs. 30
to 34.9, etc.) was 0.44 for the total score, 0.44 for Physical
Function, 0.34 for Self-Esteem, 0.28 for Sexual Life, 0.44
for Public Distress, and 0.25 for Work. The effect size
contrasting the extreme groups (i.e., 25 vs. 40 ) was
1.76 for the total score, 1.70 for Physical Function, 1.34 for
Self-Esteem, 1.07 for Sexual Life, 1.76 for Public Distress,
and 0.97 for Work. These results demonstrate that groups
differing in BMI also differed in IWQOL-Lite scores.
We hypothesized that those groups experiencing greater
BMI loss would exhibit greater changes (i.e., larger effect
sizes) in IWQOL-Lite measures. These results are presented
in Table 3. The results again clearly support the sensitivity
of the IWQOL-Lite. With the exception of the Work scale,
even modest losses in BMI (10%) were associated with
decreases in IWQOL-Lite scores ranging from 0.20 to
0.50 SD.

Discussion
This report describes the development and validation of a
brief version of the IWQOL (IWQOL-Lite) that consists of
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OBESITY RESEARCH Vol. 9 No. 2 February 2001

Scale
Physical
Function
Self-Esteem
Sexual Life
Public Distress
Work
Total Score

<10% 10 to 20% >21% Overall


(n 25) (n 77) (n 58) (n 160)
0.50

0.62

1.20

0.81

0.43
0.20
0.28
0.09
0.46

0.65
0.36
0.47
0.19
0.65

0.95
0.73
0.62
0.44
1.12

0.73
0.46
0.50
0.26
0.79

31 items and five scales: Physical Function (11 items),


Self-Esteem (7 items), Sexual Life (4 items), Public Distress
(5 items), and Work (4 items). The IWQOL-Lite was created partly in response to feedback from clinical researchers
who felt that a 74-item instrument created a response burden
for their subjects in clinical trials. In addition, the original
IWQOL had been developed and tested on a homogeneous
sample of patients from one treatment center who had
similar racial and socioeconomic characteristics; consequently, this original questionnaire may not have had widespread generalization to other samples. In contrast to the
development of the original IWQOL, the development of
the new IWQOL-Lite used multiple data sources, including
subjects from a controlled, nonpharmaceutical trial, subjects
from an open-label pharmaceutical trial, participants at a
day treatment program, subjects in outpatient weight-reduction treatment, patients undergoing gastric bypass surgery,
and individuals from the community. The sample was racially diverse and contained a large number of males as well
as females. One notable strength of this study is the use of
separate samples to develop and validate the IWQOL-Lite.
The use of separate samples minimizes the possibility of
capitalizing on chance relationships among the variables
that may occur in a single sample. The strong psychometric
properties of the IWQOL-Lite found in the cross-validation
sample provide strong evidence that this new instrument
performs consistently across samples.
Another strength of the present study is the use of confirmatory factor analysis. Unlike exploratory factor analysis, which calculates factor loadings based on the actual
data, confirmatory factor analysis compares the actual data
to an a priori model of how the data should look.
Thus, confirmatory factor analysis is hypothesis driven. The
results of the confirmatory factor analyses provide
strong support for the proposed scale structure of the
IWQOL-Lite and the existence of a higher order factor,
presumably HRQOL.

Development of a Brief Measure, Kolotkin et al.

The five identified scales of the IWQOL-Lite and the


total IWQOL-Lite score demonstrated excellent psychometric properties. Internal consistency reliabilities ranged from
0.90 to 0.94 for the five scales and equaled 0.96 for the total
score. Furthermore, correlations between the IWQOL-Lite
and collateral measures were found to support the validity
of this new, brief instrument. To begin with, the IWQOLLite total score had a strong and fairly linear relationship
with BMI at baseline. This finding is consistent with previous reports that the impact of obesity on HRQOL varies
directly with severity of obesity (8). Changes in the
IWQOL-Lite total score at the 1-year follow-up were also
related strongly to changes in BMI at this same 1-year
follow-up, consistent with other studies that reported improved HRQOL associated with weight reduction (1315).
The concordance between the total IWQOL-Lite change
score and other measures of similar constructs provides
solid evidence for the construct validity of the IWQOL-Lite
total score. The particularly strong correlation between
Physical Function and BMI at follow-up (0.45) is also
consistent with the findings of other researchers who observed that BMI changes were associated more with the
physical dimensions of HRQOL rather than the psychological dimensions (11,12). As expected, scores on the SelfEsteem scale of the IWQOL-Lite at the 1-year follow-up
were associated strongly with scores on the Rosenberg
Self-Esteem scale, providing support for the construct validity of this scale. BDI scores and GSI scores also changed
in the expected direction after subjects lost 18% of their
weight (i.e., indicating improved quality of life).
The IWQOL-Lite demonstrated the ability to differentiate
between adjacent overweight and obese groups for all scales
and the total IWQOL-Lite score. The average effect size of
the IWQOL-Lite total score between adjacent BMI groups
was nearly a half SD (0.44). This delineation was even more
pronounced for the extreme BMI groups (effect size of 1.76
for the total score). In the longitudinal analysis, the
IWQOL-Lite exhibited larger effect sizes for those groups
experiencing greater decreases in BMI at 1 year. For the
Physical Function scale and the IWQOL-Lite total score,
even modest losses in BMI (10%) were associated with
medium effect sizes (about a one-half SD decrease). With
the exception of the Work scale, the other scales demonstrated small to moderate effect sizes in the group of subjects who lost 10% of their weight. These results clearly
support the sensitivity of the IWQOL-Lite instrument.
When exploring gender differences, we found that women
experienced the effects of their weight more profoundly than
did men in the areas of Sexual Life, Self-Esteem, and total
score. In each case, females overall reported more problems
than males, with the greatest disparity between genders occurring in the lower BMI groups (BMI between 25 and 35). This
finding is consistent with what is generally known about gender differences and body image (32).

Although this study successfully developed a new, brief


measure of obesity-related quality of life and subsequently
validated this instrument, there are some limitations in this
study. One limitation is that subjects completed the original,
74-item IWQOL, rather than the newer 31-item version.
This study, therefore, assumes that subjects would have
responded similarly to items if they had taken the 31-item
questionnaire. Additional psychometric data on subjects
completing the 31-item IWQOL-Lite are currently being
collected. Another limitation is that no statistically significant differences were observed on the IWQOL-Lite between the group with BMIs of 25 and the group with
BMIs of 25 to 29.9. However, there were consistent trends
suggesting lower quality of life in the higher BMI group.
The failure to detect significant differences between these
groups could have been due to smaller differences between
BMI groups at lower BMI levels or reduced power due to
small sample sizes for the group with BMIs of 25. A
further limitation is that we did not obtain testretest data on
the IWQOL-Lite. Finally, the IWQOL-Lite does not specifically ask individuals to assess the relevance of each item to
themselves. Rather, the original IWQOL items were developed in a clinical setting based on complaints from moderately to severely obese patients. Thus, the issue of importance of the items has been addressed for moderately to
severely obese persons as a group but not on an individual
basis. Most measures of symptoms (e.g., SCL-90, BDI) do
not assess the importance of those specific symptoms to the
individual. Therefore, this approach is by no means unique
to HRQOL. In addition, the researchers who developed the
ORWELL 97 did not find any relation between relevance
and BMI (23).
On the basis of the above findings, we believe that the
IWQOL-Lite is a convenient, clinically sensitive, and valid
instrument with strong psychometric properties. We recommend the use of the IWQOL-Lite instead of the 74-item
IWQOL for the following reasons: the IWQOL-Lite was
developed on a heterogeneous sample of subjects, separate
development and cross-validation samples were used, the
scales were based on hypothesis-driven confirmatory factor
analyses, and psychometrically unsound items and scales
have been omitted. Although other obesity-specific
HRQOL instruments have been developed since the creation of the original IWQOL, the IWQOL-Lite is the only
instrument to be cross-validated in a separate sample and to
have the scale structure verified with confirmatory factor
analysis. In our opinion, the IWQOL-Lite would make a
useful addition to the assessment protocol of clinical trials
for obesity.
Future research is being planned concerning the interpretation and application of the IWQOL-Lite in different samples. Our goals are to establish separate norms for men and
women and for adolescents, to determine the psychometric
properties of the IWQOL-Lite in other languages and culOBESITY RESEARCH Vol. 9 No. 2 February 2001

109

Development of a Brief Measure, Kolotkin et al.

tures, to determine clinically meaningful changes in


IWQOL-Lite scores, and to collect testretest data.

Acknowledgments
This study was supported by a research grant from Knoll
Pharmaceutical Company. We thank the following individuals for their assistance: Kathleen Meter and Colleen Mc
Kendrick, research assistants, for their role in data compilation; Stan Heshka, Jim Hill, George Cowan, Cynthia Buffington, Gil Hartley, and Duncan Adams for sharing their
data; and Jim Mitchell for his suggestion of the name
IWQOL-Lite.
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Appendix 1
A series of confirmatory factor analyses was performed
on the cross-validation sample to evaluate the hypothesized
scale structure using EQS software (29). Three models were
compared. The first model (Model 1) was a single-factor
model in which all 31 items were considered to be indicators of a single global factor. The second model (Model 2)
was a correlated-factors model in which items were assigned to one of the five hypothesized scales. This model
specified no a priori relationship among scales, but rather
allowed the correlation among scales to vary freely according to the data. The final model (Model 3) was a secondorder model in which items were assigned to scales, and
scales were considered to be part of a higher order construct,
presumably HRQOL. The adequacy of the models was
evaluated using the 2 goodness of fit test, the Normed Fit
Index (NFI), the Tucker-Lewis Index (TLI), the Comparative Fit Index (CFI), and the Standardized Root Mean Residual (SRMR). Evidence of an adequate model fit was
considered if coefficients (NFI, TLI, and CFI) of 0.90 and

an SRMR of 0.05 were observed (33). It was anticipated


that Model 1 would not provide an adequate fit of the data
due to the lack of scale specification, Model 2 would
provide a test of the adequacy of the item-to-scale assignment, without specifying the relationship among scales, and
Model 3 would evaluate the extent to which scales can be
considered part of a more global construct. The extent to
which the correlation among the five scales could be accounted for by the higher-order construct was evaluated
using the target coefficient described by Marsh and Hocevar
(34), calculated as the ratio of Model 2 to Model 3 2.
As anticipated, the fit indices for Model 1 (single-factor
model) indicated that this model did not adequately characterize the data (2 [434] 9678, NFI 0.60, TLI 0.59,
CFI 0.61, SRMR 0.07). Model 2 (correlated-factors
model) resulted in an acceptable fit (2 [424] 2139,
NFI 0.91, TLI 0.92, CFI 0.93, SRMR 0.05). The
fit of Model 3 (second-order model) was also adequate (2
[429] 2316, NFI 0.91, TLI 0.92, CFI 0.93,
SRMR 0.05. The target coefficient of Marsh and Hocevar
(34) indicated that 92% of the covariation among scales
could be accounted for by the second-order factor. In summary, the confirmatory factor analysis provides strong support both for the proposed scale structure and for the existence of a higher-order factor, presumably HRQOL.

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