The results of this study challenge the possible assumed relationship between Hispanic ethnicity and health-related quality of life among children. In our study, both overall HRQoL and physical health were inversely related to having been diagnosed with diabetes, having a family history of diabetes, and having hyperglycemia symptoms. However, while being overweight was inversely related to overall HRQoL it did not have an independent significant relationship with physical functioning in this cross-sectional sample. There is a paucity of literature addressing QoL issues among overweight children and adolescents. Ravens-Siebere et al. [12
] used the KINDL®
questionnaire to assess QoL among obese German children. An impaired QoL on all subscales, with the exception of the physical functioning was observed, similar to the results reported in this study. Hesketh et al. [13
], using data from Child Health Questionnaire (CHQ), reported that increased frequency of diabetes symptoms was associated with poor QoL on physical and psychosocial functioning scales. On the other hand, Wagner and colleagues [14
] failed to observe any relationship between body mass index and any of the scales measuring KINDL®
HRQoL among children with type 1 diabetes mellitus. Wagner et al's study population had access to a supportive network and an experienced multidisciplinary team of health care professionals managing their diabetes, which may explain the absence of any association with psychosocial outcomes. Our results suggest that overweight does not directly influence physical functioning but may have an indirect effect via self-esteem domain and/or hyperglycemia symptoms. Efforts should be made for early psychosocial intervention and early detection and control of hyperglycemia via timely primary care for maintaining better physical health among children.
Speaking Spanish was significantly related to HRQoL in complex ways. Those who mostly spoke Spanish at home rated their children health poorer on overall, emotional, self-esteem, friends, and school subscales as compared to those who reported speaking mostly English (p < 0.001). However, they rated their children health better on physical health and family subscales. Interestingly, Hispanic ethnicity was not significantly related to physical health, emotional well-being, or school subscales when language ability was controlled. This suggests that Hispanic ethnicity does not directly determine poor physical health among children. However, because of small numbers the role of chance cannot be ruled out. Hence, overall KINDL® score may be more relevant for this finding. The results of our study suggest that efforts should be made to overcome language barriers that may face Spanish-speaking children or their parents.
Although we cannot infer causality because of the cross-sectional design of our study, it seems likely that hyperglycemia symptoms lead to poor HRQoL. The West Texas population is not typical of the U.S. population and thus results may not be generalizable. However, our findings may be relevant to other regions where the region is largely rural, many areas are medically underserved, and many children are not as conversant in English as they are in Spanish. The low response rate of approximately 55% can potentially result in self-selection bias if parents concerned with their child's health were more likely to participate in the survey. However, the rate of participation was comparable to other population-based health surveys [15
]. Similarly, since this was a telephone survey, exclusion of subjects without telephone may induce a potential bias in the study. This seems unlikely though since less than 5% of households in Texas are without telephone service [16
]. In this study parents'/guardians acted as proxy for children and may not have reported their child's health accurately. It is difficult to determine the direction of bias this may have caused in this cross-sectional study.
The impact of hyperglycemic symptoms and language barriers on the health of children in the United States is potentially quite large. The increasing prevalence of childhood obesity has been recognized, but this fact understates the true magnitude of the problem. At least among rural and Spanish-speaking children, hyperglycemia symptoms are much more common and have more direct impact on health.