The primary purpose of this study was to investigate the associations between quality of life and weight status in young Chinese children. The main finding of this study, based on quantitative and qualitative analyses, was that abnormal weight children such as obese, overweight or underweight children are more likely to suffer from impaired quality of life compared to normal weight children. Our quantitative findings are particularly supported by previous studies, which show that obese children generally suffer from greatly impaired physical health and social disadvantages [1
], as well as difficulties in school performance compared to healthy weight children [35
]. National Institute for Health Care Management (NIHCM) Foundation has stressed that obesity is associated with poorer academic performance beginning as early as kindergarten [36
]. Conversely, normal-weight children have been found to have higher school functioning and social functioning scores than all three types of abnormal-weight children, and better physical health than underweight and obese children [37
], findings that correspond to those of the current study.
One of the strengths of this study is that we used mixed methods, a new approach in this literature. This allowed us to draw conclusions based both on the mothers’ perceptions of their children’s quality of life from the quantitative data and the mothers’, teachers’ and the children’s comments from the case studies. The key limitation of many mixed-method studies is that there is a loss of information when qualitative data are quantified [38
]. However, in the current study we retained the qualitative data in its original form and did not convert it for purposes of quantitative statistical analysis. Our findings from the quantitative and qualitative data were quite similar, with some exceptions. Quantitative analyses showed no statistically significant difference in the Physical Functioning scores of normal weight and overweight children, but the case study data provided examples of physical problems experienced by the overweight children, such as the Case 2 girl, whose mother and teacher comment: “… to have difficulties with playing actively”; “.. she is unable to play certain activities in the school…”
Moreover, the quantitative data showed that the abnormal-weight children encountered a certain degree of interruptions to their School Performance and Social Functioning but not to their Emotion Functioning. However, the findings from the case studies indicated that the obese children were deeply worried and unhappy. As one child stated, “I am sad because my mother is feeling sad…”, “I am scared the house will catch fire because my parents are not at home…” and “I am afraid of my teacher dislikes me because I work slowly… and I am afraid there is a ghost because the flat is too dark…and the teacher punished me because I left the classroom without telling her.” It is necessary to pursue further the children’s stories on the socio-emotional aspect of health when assessing young children’s health-related quality of life. Data from the case studies on the association of young children overweight or obesity with lower levels of emotional functioning may too spare to draw conclusion. Most importantly, future studies should investigate further the extent of causality between a young child’s weight and the contextual quality of life measures.
This study demonstrates that overweight and obesity of young children in Hong Kong are associated with the issue of multiple childcare arrangement arrangements. Based on the parent survey data in this study, 40% of primary caregivers were relatives or childcare providers; of the 10 case studies, only two mothers were full-time workers and the child was also cared for either by grandparents, in-house maids or older siblings. In this respect, the total sample was more representative of Hong Kong families in general than were the subset of families described in the case studies. According to the Hong Kong Government, there are approximately 273,609 foreign domestic helpers employed as childcare providers for young families in Hong Kong [39
]. Reliance on multiple caregivers and on childcare outside the home is especially evident among more affluent “Westernised” and educated parents who are likely both to be working full time [40
]. In the current study, the low quality of life experienced by some children may be attributable in part to disruptions associated with childcare arrangements, parenting difficulties, or/and special familial circumstances.
Increasing evidence shows that paediatric obesity is linked to family socio-demographics. Our study in Hong Kong showed that obese children come from situations of social disadvantage, with poor housing and newly immigrated families with cross-boundary marriages (e.g., bridegrooms are Hong Kong residents and brides are from mainland China) [41
]; the majority of these families reported receiving social welfare benefits [42
]. This is to support previous studies that obese children generally suffer from physical and social disadvantages associated with poor quality of life [43
], and obesity has also been framed as a consequence of poor lifestyle choices and increased consumption of low-cost, energy-dense/nutrient-poor foods. Jenkin et al. [9
] stressed that obesity policies must address broader determinants of health, such as social inequalities.
However, more recent research findings reveal that the relationship between socio-economic characteristics and obesity in children may not follow consistent trends according to age and gender or over time [45
] because QoL is context specific, and what impacts one group of children's QoL within a particular context may not impact another group in a different situation [47
]. A large heterogeneous sample should be recruited to investigate which food-intake behaviours or child food consumption practices contributing to excess weight gain are specific to or more prevalent in certain SES groups. Future studies should also investigate the relative importance of socio-cultural attitudes and beliefs of parenting regarding obesity versus the physical, psycho-social, economic, and policy environments of children and their families.
One of the limitations of this study is that the findings cannot be generalised beyond the Hong Kong setting. Furthermore, this sample was based on voluntary preschool community participation, and because we did not recruit in clinical settings, the results likely under represent the experiences of abnormal-weight children who have an even poorer quality of life than the study sample. Nevertheless, the present study reveals similar findings to those of the Hong Kong government’s needs assessment of children under five years of age in Hong Kong [48
], which demonstrated that the majority of children in this age group are given insufficient attention by their parents when both parents work. These parents spend a small amount of time with their children, who generally experience considerable stress. Furthermore, in families from low socio-economic backgrounds, single-parent families and new immigrant families, parents experience more problems in parenting.
This special obesity-link phenomenon is supported by Garasky et al. [49
], who note positive associations between a range of family stressors and children’s problems with being overweight or obese, such as lack of cognitive stimulation and emotional support in the household among younger children and financial strain in households among older children. One issue that should be considered is how public policies that reduce family stressors may, in turn, help reduce childhood obesity because of an improved quality of life.