Short –Term Weight Management Programs Improve the Quality of Life of Attendees of the Dietetic Centers in the West Bank

Short –Term Weight Management Programs Improve the Quality of Life of Attendees of the Dietetic Centers in the West Bank | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Short –Term Weight Management Programs Improve the Quality of Life of Attendees of the Dietetic Centers in the West Bank Umaymah Abu-Alwafa, Mohammad Al Tamimi, Manal Badrasawi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4365276/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Obesity is a primary health issue. This study aimed at assessing health related quality of life (HRQOL) among overweight/obese adults. Participants were referred to Nutri Health centers in the West Bank for weight management programs during the period between 1 of May 2019 to 30 November 2020. A total of 466 participants were involved in the study. Body composition, anthropometric measurements, socio-demographic data, and HRQOL were determined at baseline and after 3 months. The results showed a significant decline in the mean weight of participants from 93.9 ± 17.2Kg to 83.9 ± 15.7 kg. More than half (51.3%) of participants had weight reduction more than 10%. Participants reported significant improvement in all components of (36-SF) HRQOL after 3 months compared to baseline scores. Moreover, participants with ≥ 10% loss of baseline weight had a greater improvement in the overall HRQOL scores by 14.6 ± 17.6 (mean ± SD) compared to 9.7 ± 15.0 for those who lost < 10% baseline body weight. Moreover, the Role limitation due to physical health achieved the highest score after 3 months by (mean ± SD) of 93.0 ± 20.7 compared to baseline score of 80.8 ± 32.2. The highest improvement was reported in Physical functioning with 18.9 ± 27.3 and 10.9 ± 27.3 for participants who lost ≥ 10% and < 10%, respectively. In conclusion, weight management programs seemed to be not only effective to induce weight loss but also to improve HRQOL. The mechanism behind this improvement should be investigated in light of decreased levels of inflammation and changes in gut microbiota. Obesity Weight management quality of life 36-SF HRQOL. Figures Figure 1 Background Obesity has become a global primary health issue worldwide, due to its complications and further economic and social impacts. By definition, obesity is an abnormal accumulation of excess fat that impairs health ( 1 ), however, according to Word Health Organization overweight adult is defined as a person having body mass index (BMI) 25-25.99 kg /m² while BMI ≥ 30 kg/m² is classified as obese ( 2 ). Globally, the prevalence rate of obesity has tripled in 1975 with more than 1.9 billion adults classified as overweight in 2016, of whom over 650 million adults were obese. In addition, more than 38.2 million children under the age of 5 years were obese in 2019 ( 1 ). In another word, about one-third of the world's population is classified as overweight or obese ( 3 ). Furthermore, a recent study has projected that the prevalence of adult obesity will continue to increase and by 2030 one out of two adults will have obesity and 1out of 4 will have severe obesity in the USA ( 4 ). Obesity is a multifactorial metabolic disorder where environmental factors and genetic predisposition interact to manifest its features and complexity. It is recognized as an illness and an aggravator of many other preventable chronic diseases such as cardiovascular diseases, certain types of cancer, diabetes type 2 and all-cause mortality. In addition, obesity is found to be associated with other diseases including: asthma, infertility, cataracts, sleep apnea, gallstones, and others ( 5 – 7 ). Being obese or overweight or even underweight is not only considered as a predisposing factor for many chronic diseases but also has a major influence on Quality of life (HRQOL). HRQOL, a multidimensional concept, can't be expressed simply with terms like wellbeing, or life satisfaction. HRQOL is a reflection of social, emotional, physical, mental, and environmental aspects of life ( 8 ). However, health related quality of life (HRQOL) is an individual perception about health and how health affects the ability to function in life ( 9 ). Recently, a huge advance has been established in the main three modalities to manage obesity :lifestyle intervention, pharmacotherapy and weight loss operations including bariatric surgery ( 10 ). Reduction in weight, particularly more than 5% of body weight, is related to decreased risk of incidence of obesity-comorbidities and has been established to improve health of obese patients, however, this finding is not significantly clear according to quality of life of obese. In general, excess weight could have a great influence on daily activity, emotional status, and acceptance of self-image ( 11 ). This was well demonstrated in the literature, moreover, there is much evidence of the association between impairment of physical and mental aspects of HRQOL and elevated BMI ( 12 ). On another hand, improvement in domains of HRQOL related to weight loss was established in many randomized controlled trials ( 13 – 15 ). In addition, many lifestyle interventions for weight management such as dietary intervention accompanied with physical activity may help in the improvement of HRQOL of obese and overweight individuals ( 14 , 16 , 17 ). For obese attending weight management programs in the West Bank, no data are available about their HRQOL and further changes in the HRQOL as a consequence of their weight management. This study aims to assess the effect of weight management programs applied in dietetic centers in the West Bank on overweight/obese individuals' quality of life before and after weight loss. Methods The current study has followed a quasi-experimental study design and was conducted to determine the impacts of weight loss on quality of life using a validated and reliable questionnaire. The study was conducted among adult participants who attended Nutri Health, a specialized dietetic center located in the West Bank, to participate in weight management programs. Participants were eligible to enroll in the study if their ages were over 18-year-old and if their BMI was > 25 kg /m², as verified by an objective measurement taken by trained dieticians in registered centers. The study was conducted between 1st of May 2019 and 30th of November 2020. All eligible participants who visited Nutri Health centers of Ramallah, Jenin, Tulkarm, Nablus and Hebron during the period of the study were invited to take part. The study included all participants who met the eligible criteria, completed assessment and had complete data required for analysis at baseline and after 3-month follow up. Trained data collection dieticians assisted participants in completing the quality-of-life questionnaire properly, and conducted all assessments of nutritional status at baseline and after 3 months. Participants were freely adopting any dietary programme recommended by the dieticians. Compliance with the programme, weight monitoring and follow-ups were conducted weekly. Quality of life Questionnaires were administered to the participants at baseline and at the end of 3 months follow-up assessment. Assessment Weight and height measurements were recorded at baseline and after three months. The measurement was done according to the standard anthropometric techniques. Body weight was measured to nearest 0.1 kg by using an electronic scale while height was determined to the nearest 0.5 cm at the head level by using a tape measure fixed to the wall. Body mass index was calculated as body weight in kilogram divided by height squared in meter (kg/m²). BMI was classified according to WHO classification: less than 18.5 = underweight, 18.5-24.99 = normal weight, 25-29.99 = overweight, 30-34.99 = obese class I, 35-39.99 = obese class II and ≥ 40 as obese class III ( 2 ). The body composition was done by using bioelectronics impedance (BIA), a Korean brand model of Mediagate BOCA X1®. Anthropometric and body composition were repeated twice and then averaged. The Arabic version of self-administered 36-SF health questionnaire was used to assess participants HRQOL ( 18 ). The 36-SF HRQOL is considered a superior and relatively simple instrument to assess HRQOL and can be used to a general or specific population. The validity and reliability of this questionnaire were established in the past ( 18 – 20 ). It is composed of 36 items that assess the following eight HRQOL domains or scales: Physical functioning, General health, Role limitation due to physical health, Energy/Fatigue, Body pain, Emotional wellbeing, Role limitation due to emotional problems and Social functioning. Responses to each question within the domain were added up to achieve scores ranging from 0-100, where 0 indicates the worst health status and 100 indicates the best health status. Weight management programs All participants were subjected to three-month intensive weight-reducing programs. The dietary plans and physical activity instructions were tailored according to the participants preference and obesity degree. All participants were in good physical health to perform a regular physical activity of 45 minutes a day for 4 days a week. They have received a dietary plan of 4 meals per day: breakfast, lunch, snack, and dinner. The caloric restriction diet contained 800–1500 Kcal /day and 1000–1800 Kcal/day for females and males, respectively. Total energy requirement was calculated by using the Harris-Benedict equation for each participant. Participants were subjected to iso-caloric dietary plans throughout three months. Statistical Analysis Analysis Statistical package for social science (SPSS) for windows version 20 for statistical analysis was used. All statistical values were considered significant at P value < 0.05. The data were cleaned, before the analysis, from missing data of primary outcomes like weight, height and quality of life data at baseline and after 3-month follow up. Participants who had missed data of primary outcomes were excluded from the final analysis. Variables of quality-of-life domains at baseline and after three months were calculated, then the descriptive statistics such as mean and standard deviation were calculated. By using means, standard deviations analysis, one-way ANOVA and independent sample T-test, the socio-demographic variables were compared with different SF-36 domains at baseline and after 3 months. Changes of each domain score were calculated by the mean difference between scores of domains after 3 months and scores at baseline. Furthermore, paired sample t-test was used to test the significance of changes in various HRQOL parameters (as individual domain scores and total HRQOL score) from baseline to the end of 3-month follow up. Mean change scores of weights and HRQOL scores were calculated from baseline to 3-month follow up. Moreover, analysis of changes in HRQOL after 3 months related to changes in weight was conducted by independent sample T-test after categorizing the participants according to their percentage of weight loss into two main groups (participants lost less than 10% of their initial weight and participants > 10% of their initial weight). Results At baseline Six hundred and ten subjects were invited to participate in the study while 516 subjects completed the assessment. Thirty-two subjects were excluded from the final analysis due to missing data in the primary outcome (HRQOL data and weight changes) and 18 participants also were excluded due to they didn’t have weight loss or had weight gain instead after three months. Thus, the data of a total of 466 participants were included in the final analysis. The mean age of participants was 33±10 years, ranging from 18-68 years old. As shown in Table 1, the majority of participants were females (82.6%), married (63.5), with bachelor degree (57.5%), unemployed (59%) and living in the city (55.6%). Above quarter of the participants had a monthly average income between 1500-3000 NIS (New Israeli shekel). Table 2: A-C, showed the baseline quality of life of the participants according to their socio demographic characteristics. The total score of quality of life at baseline according to sociodemographic variables indicated that there was a significant difference between male and female in overall quality of life score, P<0.05. Males had a mean score of (70±17) in total QOL score while females had a mean score of total QOL of (65±18). According to age categories, there was a significant difference between participants with different age categories in means of scores of total QOL,(P50 years (46±21). According to marital status, single participants had significantly higher scores in overall QOL score among other participants (69±16) while the lowest scores were for widowed or separated participants (58±20). According to living locations, cities had a significant highest score in the mean of total QOL score ompared with camps or towns p<0.05. Employed participants had significantly higher scores than unemployed participants in total score of QOL (P<0.05); participants who earned an average monthly income over 5000 ILS had a significantly higher score as compared to other participants who earned less. According to the educational level, participants who attained higher education had significantly higher scores in as compared to the other groups with( P<0.05) Moreover, the sample had a mean±(SD) weight of 93.9±17.2 kg, and BMI of 35.4±5.7kg/m². BMI ranged from 25.02 to 58.87kg/m² with about 76 participants (16.3%) were overweight and the rest were obese. Among those who completed the study the mean of body weight declined significantly after three months compared to baseline weight. Participants reported a decline of mean ±SD of weight from 93.9±17.2kg to 83.9±15.7 kg over three months. Two hundred and twenty-seven participants (49.8%) had a reduction < 10% of their weight while 229 subjects (50.2%) had a reduction ≥ 10% of their weight after 3 months. Moreover, BMI declined as a mean and SD from 35.38±5.7 to 31.6±5.4. Fig 1 shows distribution (%) changes in BMI categories after three months of joining the weight management programs. Results of analysis of mean scores of HRQOL domains after 3 months compared to baseline scores shows that participants reported a significant improvement in mean scores of all quality-of-life components after 3 months of joining weight management programs compared to baseline scores (P<0.05). Table 3 summarized the mean scores of all components of HRQOL scales and overall quality of life score. The relationship between weight reduction and change of HRQOL are shown in Table 4, where the results show the higher percent of weight loss is associated with significantly greater improvements in total quality of life and all quality of life subscales after 3 months(P<0.05) with exception in Role limitation due to physical health, Role limitations due to emotional problems and Pain scales. Participants who lost more than 10% percent of their weight had a greater improvement in overall quality of life and all of its scales with mean± SD of 14.6±17.6 in overall quality of life score. The highest number of change or improvement as absolute change (baseline score subtracted from follow up score) was in Physical functioning in group 2 (participants who lost more than 10% of their weight) with a mean of 18.9±27.3 compared with participants who lost less than 10% of their weight with a mean of 10.9±23.8. Finally, a comparison of HRQOL change based on participants' socio-demographic characteristics shows that males had greater improvements in several HRQOL scales after weight reduction than females with an exception in changes in Role of limitation due to the emotional problems scale. Physical functioning and Energy/Fatigue significantly have improved in males more than females (with p=0.014, 0.040 respectively). On the other hand, according to marital status significantly the greatest number of improvements in HRQOL was in participants who were widowed or separated, so according to the marital status of participants the significant improvement in the number of HRQOL scales was in overall HRQOL, Social, and Pain HRQOL subscales(P<0.05) with mean± SD of 16.8±22.7, 15.4±24 and 26.9±31.7 respectively. In addition, according to the employment status of participants, unemployed participants had a greater improvement in the number of HRQOL scores that was significantly (P<0.05) in Role limitation due to physical health and General health subscales than employed participants. Moreover, participants who earned an average monthly income between 3000-5000 had a significantly (p = 0.047) greater improvement in Physical functioning than other participants. Participants who live in towns had significantly (p=0.041) greater improvements in the total HRQOL and Role limitations due to physical health than others who live in cities or camps. Finally, improvements in the Emotional concept of HRQOL were significantly higher among participants who had primary education with (P=0.032) than others. Discussion The current study was conducted to evaluate the impact of weight reduction programs on HRQOL among overweight/obese adults after 3 months of weight management. In general, the results showed a decline in weight after three months of dietary management however more than half of participants had a reduction of more than 10% of their initial body weight with a mean loss of about 10 Kg during three months. Compared to a previous studies of weight management programs based on a combination of dietary management and physical activity in a previous study a baseline to 6 month-weight loss was about 9.4% in participants who completed intensive lifestyle approaches which have included low caloric eating and 30 mints of daily walking ( 21 ). Also, the current finding is in line with another study that showed a mean weight loss of about 9.3% of initial body weight after 14 weeks of a low caloric diet program combined with physical activity ( 22 ). In addition, most obese participants have a mean loss of 5–10% of their initial body weight after 12–18 months of lifestyle modification ( 16 , 23 ). Moreover, a modest weight loss of about 6–7% was achieved either by calorie-restricted diet or increased physical activity in obese postmenopausal women after 16 weeks of intervention ( 24 ). In contrast, an average weight loss was 20% of initial body weight and a significant reduction in fat mass was in 63.7% of ninety two participants following 3 months of a very-low-calorie ketogenic diet with more than 24.2% of participants reached a weight loss of more than 20% of initial body weight ( 25 ). An explanation to why participants may differ in their weight loss degree was the adherence. Many studies showed an association between weight loss and adherence regardless of dietary intervention; however, many participants find it difficult to adhere to a weight loss diet due to limitation of food intake ( 26 ). Additionally, adherence to daily calorie restriction declined after about 4 weeks (one month) and continued to decrease ( 27 ). Moreover, concerning HRQOL participants have reported a significant improvement in mean scores of all HRQOL components compared to baseline scores after weight reduction. This finding is consistent with many previous studies that showed a linear relationship between weight change and HRQOL ( 13 – 15 , 28 ). Moreover, current findings showed that higher percentage of weight loss was associated with significantly greater numbers of improvement and changes in the quality of life and all HRQOL subscales after 3 months. Greater improvement with exceptions in Role limitation due to physical health, Role limitations due to emotional problems and Pain scales, was reported with subjects losing more than 10% of their initial weight compared to those who lost less than 10% of their weight. Such results are consistent in many studies ( 16 , 22 , 29 – 31 ); in which a greater acute weight loss intervention with a mean loss of an average weight loss of 10% was associated with improved HRQOL. The highest improvement in HRQOL in our study was in Physical functioning domain after three months of weight reducing-program and this was consistent with previous results from a study showed that loss of about 15 Ibs (~ 7.5 kg) or more was associated with 0.89 point improvement in Physical component score ( 32 ) also after 3 and 6 months of reduced caloric diet ( 33 ). In addition, most of the previous studies reported improvement in the physical aspect of 36-SF more frequently than mental /psychological or emotional aspect ( 15 ). However, the results of other clinical studies varied according to the type of intervention and HRQOL measurement tools but, most of them demonstrated greater improvement in HRQOL within the group of greater weight loss independently of the type of intervention ( 34 ). One potential explanation of the improvement in Physical functioning, Social and Vitality (Energy/Fatigue) subscales after weight loss is that adiposity induces inflammation, hypertension and insulin resistance which in turn impair cardiac, atrial and skeletal muscle elasticity and functioning leading to a decrease in physical functioning and performance ( 35 ). In addition, at baseline participants with higher BMI showed lower scores in 36-SF concepts. Especially, in physical and emotional domains. Many previous studies showed the similar trends of the negative association between BMI and HRQOL however, participants with higher BMI had significantly reduced physical Quality of Life and there was an inverse linear relationship (as the level of BMI became higher the scores in physical component became lower) across different BMI categories even in absence of chronic diseases ( 12 , 14 ). Impairment in HRQOL was particularly in the physical aspect, pain and vitality (energy/fatigue) where the lowest score was in obese class III participants. This is in agreement with previous studies showed that dimensions of mobility and pain are the largest components negatively affected by obesity ( 36 , 37 ), while physical functioning and vitality were the lowest scores in male outpatient with BMI > 35 ( 38 ). Regarding to the mental aspect of quality of life some studies showed a weak association between BMI and the mental aspect of HRQOL, in contrast, a meta-analysis has shown that impairment was mainly in obese class III participants and that was less obvious in other classes ( 12 ). This finding is not surprising as obesity and its complications result in numerous emotional and mental problems that interfere with social life and relationships with others, in addition to a decrease in self-esteem. However, many biological studies explained this result by bi-direction causal–relationship of mental conditions such as anxiety, depression and mood disorders ( 39 ). With regard to pain and physical functioning impairment, increasing in weight and BMI have contributed negatively to the mechanical load on joints and have shown an impact on physical functioning of obese interfering with their daily activities. Many obese have recognized that obesity was a great limitation in their physical performance( 11 ). Nevertheless, to address the relationship between obesity and impairment in HRQOL few studies have investigated the underlying mechanism. The general explanation was that obesity will lead to low -grade inflammation that underlines the biological, physiological and psychological etiology of impaired HRQOL ( 5 ). It is not surprising that improvements in HRQOL may differ according to gender, age, socio-demographic and socioeconomic status. However, in this study, levels of improvement in HRQOL after weight reduction were greater in males than females except in Role of limitation due to emotional problems. Moreover, in this study, single, employed, living in cities, earned an average income of more than 5000 ILS and had a higher educational level participants have reported higher HRQOL. This finding is in agreement with a previous study that showed a significantly lower HRQOL was reported in un-employed, low income, less educated and chronic conditions participants ( 40 ). Moreover, understanding the relationship between HRQOL and socioeconomic, socio-demographic status is a complicated process due to the fact that different aspects of socioeconomic-demographic status affect the health and HRQOL either separately or by overlapping at different levels of life ( 41 ). Limitations : The study was conducted during COVID-19 pandemic and collecting data wasn’t easy. This also confined the follow-up period to be short. Another limitation was that male patients normally don’t attend these weight management centers, this explained the high percent of female participants in the study. Recommendations : For practitioners, it is recommended to focus on a dietary programme that suits the patient and has the ability to reduce 10% of total body weight rather than adopting strict regimen. HRQOL should be an important derive to lose weight and should be part of the weight management outcomes. Conclusion In conclusion the implementation of various weight reducing programs including a combination of moderate exercise and a caloric restriction diet, has been proven to induce weight loss. Moreover, HRQOL has significantly improved as body weight is reduced after three months of weight management. In addition, the levels of HRQOL improvement were positively associated with the level of weight loss. With physical functioning being the most improved subscale, partly and presumably due to decreased level of inflammation due to shifts in gut microbiota. Relationships between weight loss, HRQOL and microbiota composition should be investigated. Finally, gender, socio-demographic, and socioeconomic factors played a major role in HRQOL at baseline and the level of improvement after 3 months of weight management. Declarations Ethics approval and consent to participate The study protocol was approved by the Internal Review Board for Research Ethics at An-Najah National University on 31 st March 2019. In addition, data collection was performed in accordance with the Declaration of Helsinki. The eligible participants were given informed consent before the onset of the study. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request Competing interests The authors declare that they have no competing interests Funding This work has no source of fund Authors' contributions MA and MB shared the study design, interpreting the results and finalized the manuscript writing, UA, collected data and wrote the first draft. All authors reviewed and approved the final draft. Acknowledgements The authors would like to thank An-najah University and NurtiHealth center for their cooperation and support during the data collection. References Organization WH. World Health Organization obesity and overweight fact sheet. 2016. 2019. Organization WH. Physical status: The use of and interpretation of anthropometry. Report of a WHO Expert Committee: World Health Organization; 1995. Chooi YC, Ding C, Magkos F. The epidemiology of obesity. 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Tables Table 1: Socio-demographic characteristics of participants, presented as number and %. Parameter N % Gender Male 81 17.4 Female 385 82.6 Material status Single 157 33.7 Married 296 63.5 Other 13 2.8 Current employment status Employed 191 41 Unemployed 275 59 Education level Primary school (less than 10 years) 27 5.8 Secondary school 156 33.5 Bachelor or equivalent 268 57.5 Higher education (Master or doctoral) 15 3.2 Area of living Town 186 39.9 City 259 55.6 Camps 21 4.5 Monthly average income Less than 1500 101 21.7 1500-3000 130 27.9 3000-5000 80 17.2 >5000 39 8.4 No data 116 24.9 Table 2:A Quality of Life of participants according to gender and age groups at baseline QOL Total 466 Male 81 Female 385 P-value 18-39 years 40-50 years 50-51 years P value Physical functioning 71±28 71±27 71±28 .93 75±26 58±28 57±25 .000** Role limitation due to physical health 81±32 83±27 80±33 .44 83±30 75±35 76±37 .014* Role limitation due to emotional problems 65±44 75±41 62±44 .015* 65±43 61±44 70±46 .624 Energy/fatigue 51±19 55±21 51±18 .063 53±19 49±15 46±21 .054 Emotional well –being 56±20 63±23 55±19 .001** 56±20 59±19 56±20 .793 Social functioning 70±23 73±23 69±23 .146 70±27 70±21 68±23 .969 Pain 65±26 71±24 64±26 .022* 68±25 61±23 52±30 .001** General health 65±21 68±21 64±20 .123 67±20 60±21 55±20 .000** Total QOL 66±18 70±17 65±18 .013* 67±18 61±17 60±18 .008** Significant at p value <0.05, *:p<.05,**:p<.01 by using the independent samples T-test. Table 2: B Quality of Life of participants according to gender and age groups at baseline Marital status Living place QOL/socio-demographic factor Single (157) Married (296) Others (13) P-value Town (186) City (259) Camps (21) P-Value Physical functioning 78±24 67±29 65±28 .000** 69±27 73±28 61±32 .124 Role limitation due to physical health 84±30 79±33 71±39 .180 76±36 84±29 85±27 .050* Role limitation due to emotional problems 62±44 66±44 56±44 .497 62±44 66±43 71±43 .484 Energy/fatigue 55±18 50±18 40±19 .001** 49±18 53±19 51±18 .099 Emotional well –being 57±21 56±19 52±27 .752 55±20 58±20 50±21 .081 Social functioning 71±24 69±23 66±25 .709 68±23 71±23 67±26 .291 Pain 72±23 63±26 49±28 .000** 62±26 68±25 63±31 .096 General health 68±19 63±21 60±20 .029* 62±22 67±19 64±22 .095 Total QOL 69±16 64±18 58±20 .011* 63±19 67±17 64±18 .033* Significant at P<0.05, *:p<.05,**:p<.01 by using one -way ANOVA test. Table 2: C Quality of Life of participants accoding to gender and age groups at baseline Employment status Average monthly salary QOL Employed (191 ) Unemployed (275) P value 5000 (39) P value Physical functioning 74±26 69±29 .098 69±29 75±26 67±28 75±27 .143 Role limitation due to physical health 85±27 78±35 .014*¹ 82±32 84±28 79±32 83±33 .717 Role limitation due to emotional problems 67±43 63±44 .408 62±45 63±43 70±44 68±46 .592 Energy/fatigue 53±18 50±19 .124 51±19 55±18 50±19 53±21 .327 Emotional well –being 59±21 54±19 .013*¹ 52±19 57±19 59±20 63±22 .021*² Social functioning 71±22 69±24 .195 68±23 72±22 69±26 74±20 .451 Pain 67±25 64±27 .141 67±25 66±25 62±27 71±25 .337 General health 67±20 63±21 .050*¹ 65±18 65±19 66±20 68±25 .870 Total QOL 68±16 64±19 .014*¹ 65±16 67±16 65±19 69±19 .439 *:p<05 ,¹:by using independent sample T test ,,²:by using one way ANOVA. Table 3: Changes in QOL at baseline and after three months presented as mean ±SD Quality of life domain At baseline After 3 months P-value Total QOL 66±18 77±13 <0 .00 1 ** Physical functioning 71±28 86±22 <0 .00 1 ** Role limitation due to physical health 81±32 93±21 <0 .00 1 ** Role limitation due to emotional problems 65±44 80±37 <0 .00 1 ** Energy/fatigue 51±19 64±18 <0 .00 1 ** Emotional well –being 56±20 64±19 <0 .00 1 ** Social functioning 70±23 78±19 <0 .00 1 ** Pain 65±26 77±20 <0 .00 1 ** General health 65±21 77±16 <0 .00 1 ** Significant at P<0.05, **:p<.001 by using paired samples T-test Table 4: Relationship between reduction in weight and changes in quality of life Scale of change Group 1 (< 10%weight reduction Group 2(≥ 10%weight reduction P-value Change in Physical functioning 10.9±23.8 18.9±27.3 0 .001** Change in Role limitation due to physical health 10.4±28.9 14.7±35.5 0 .158 Change in Role limitation due to emotional problem 14.3±39.6 18.5±43.3 0 .293 Change Energy/fatigue 9.2±18.4 15.8±21.3 <0 .00 1 ** Change in Emotional well-being 6.4±14.5 9.3±16.3 0 .050* Change in Social functioning 6.3±20.1 10.1±20.8 0 .047* Change in Pain 10.8±23.7 14.4±25.6 0 .109 Change in General health 9.3±18.3 15.4±20.2 0 .001** Change in Total QOL 9.7±15.0 14.6±17.4 0 .002** Significant at P<0.05, **: p<.001 by using paired samples T-test Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4365276","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":298615475,"identity":"0a86d4f0-a40c-4345-9c2a-b5c4703e4348","order_by":0,"name":"Umaymah Abu-Alwafa","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Umaymah","middleName":"","lastName":"Abu-Alwafa","suffix":""},{"id":298615482,"identity":"82613a48-616c-4763-9b2b-225c384e993c","order_by":1,"name":"Mohammad Al Tamimi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIie3NsQrCMBCA4ZNAupx7xYJPINQlOOmrWAQnEUEQQcGCUJeiz+JS15OATuIquHRyUnAqHURsOwlCQzfB/EPCwX0cgE73m5UoeRAYo/TrJIOtNJTtMt4pRtJD2aaa1F0WyscssOpLjMLYag3AWARmHhHEbaL9BYUsbxs+dkeA+7GCQEJ4RgITkTmu2RcKYjyIXinBa+WJc8et3VQEbdp5GeFVRJlcQQWROKTjKiVcVC08OB72Rs1cclhuwkl0aYuTvFbu/tRZG3JzziPAPoeSD8Bz17+LC+7rdDrdX/QGpjhMBMyKuRMAAAAASUVORK5CYII=","orcid":"","institution":"An-Najah National University","correspondingAuthor":true,"prefix":"","firstName":"Mohammad","middleName":"Al","lastName":"Tamimi","suffix":""},{"id":298615486,"identity":"621065a3-c2e9-4245-ae09-8a7a1f263d51","order_by":2,"name":"Manal Badrasawi","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Manal","middleName":"","lastName":"Badrasawi","suffix":""}],"badges":[],"createdAt":"2024-05-03 16:54:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4365276/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4365276/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56396368,"identity":"d1d04e9d-a9cf-4440-a225-cf89ead23206","added_by":"auto","created_at":"2024-05-13 15:44:15","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":375993,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution (%) of BMI categories after 3 months of joining weight management programs. A clear shift in the classes of obesity (II and III) towards normal weight and overweight.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4365276/v1/f9f3bd57c55395a531bf6568.jpeg"},{"id":56399051,"identity":"6fb6deac-ea0f-4296-9dc8-14a7438b78cb","added_by":"auto","created_at":"2024-05-13 16:00:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1111243,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4365276/v1/b06bb250-92fe-4880-a073-ee2e81b74d65.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short –Term Weight Management Programs Improve the Quality of Life of Attendees of the Dietetic Centers in the West Bank","fulltext":[{"header":"Background","content":"\u003cp\u003eObesity has become a global primary health issue worldwide, due to its complications and further economic and social impacts. By definition, obesity is an abnormal accumulation of excess fat that impairs health (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), however, according to Word Health Organization overweight adult is defined as a person having body mass index (BMI) 25-25.99 kg /m\u0026sup2; while BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2; is classified as obese (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Globally, the prevalence rate of obesity has tripled in 1975 with more than 1.9\u0026nbsp;billion adults classified as overweight in 2016, of whom over 650\u0026nbsp;million adults were obese. In addition, more than 38.2\u0026nbsp;million children under the age of 5 years were obese in 2019 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In another word, about one-third of the world's population is classified as overweight or obese (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Furthermore, a recent study has projected that the prevalence of adult obesity will continue to increase and by 2030 one out of two adults will have obesity and 1out of 4 will have severe obesity in the USA (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eObesity is a multifactorial metabolic disorder where environmental factors and genetic predisposition interact to manifest its features and complexity. It is recognized as an illness and an aggravator of many other preventable chronic diseases such as cardiovascular diseases, certain types of cancer, diabetes type 2 and all-cause mortality. In addition, obesity is found to be associated with other diseases including: asthma, infertility, cataracts, sleep apnea, gallstones, and others (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBeing obese or overweight or even underweight is not only considered as a predisposing factor for many chronic diseases but also has a major influence on Quality of life (HRQOL). HRQOL, a multidimensional concept, can't be expressed simply with terms like wellbeing, or life satisfaction. HRQOL is a reflection of social, emotional, physical, mental, and environmental aspects of life (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, health related quality of life (HRQOL) is an individual perception about health and how health affects the ability to function in life (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecently, a huge advance has been established in the main three modalities to manage obesity :lifestyle intervention, pharmacotherapy and weight loss operations including bariatric surgery (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Reduction in weight, particularly more than 5% of body weight, is related to decreased risk of incidence of obesity-comorbidities and has been established to improve health of obese patients, however, this finding is not significantly clear according to quality of life of obese. In general, excess weight could have a great influence on daily activity, emotional status, and acceptance of self-image (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This was well demonstrated in the literature, moreover, there is much evidence of the association between impairment of physical and mental aspects of HRQOL and elevated BMI (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). On another hand, improvement in domains of HRQOL related to weight loss was established in many randomized controlled trials (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In addition, many lifestyle interventions for weight management such as dietary intervention accompanied with physical activity may help in the improvement of HRQOL of obese and overweight individuals (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor obese attending weight management programs in the West Bank, no data are available about their HRQOL and further changes in the HRQOL as a consequence of their weight management. This study aims to assess the effect of weight management programs applied in dietetic centers in the West Bank on overweight/obese individuals' quality of life before and after weight loss.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe current study has followed a quasi-experimental study design and was conducted to determine the impacts of weight loss on quality of life using a validated and reliable questionnaire. The study was conducted among adult participants who attended Nutri Health, a specialized dietetic center located in the West Bank, to participate in weight management programs. Participants were eligible to enroll in the study if their ages were over 18-year-old and if their BMI was \u0026gt;\u0026thinsp;25 kg /m\u0026sup2;, as verified by an objective measurement taken by trained dieticians in registered centers. The study was conducted between 1st of May 2019 and 30th of November 2020. All eligible participants who visited Nutri Health centers of Ramallah, Jenin, Tulkarm, Nablus and Hebron during the period of the study were invited to take part. The study included all participants who met the eligible criteria, completed assessment and had complete data required for analysis at baseline and after 3-month follow up. Trained data collection dieticians assisted participants in completing the quality-of-life questionnaire properly, and conducted all assessments of nutritional status at baseline and after 3 months. Participants were freely adopting any dietary programme recommended by the dieticians. Compliance with the programme, weight monitoring and follow-ups were conducted weekly.\u003c/p\u003e \u003cp\u003eQuality of life Questionnaires were administered to the participants at baseline and at the end of 3 months follow-up assessment.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAssessment\u003c/h2\u003e \u003cp\u003eWeight and height measurements were recorded at baseline and after three months. The measurement was done according to the standard anthropometric techniques. Body weight was measured to nearest 0.1 kg by using an electronic scale while height was determined to the nearest 0.5 cm at the head level by using a tape measure fixed to the wall. Body mass index was calculated as body weight in kilogram divided by height squared in meter (kg/m\u0026sup2;). BMI was classified according to WHO classification: less than 18.5\u0026thinsp;=\u0026thinsp;underweight, 18.5-24.99\u0026thinsp;=\u0026thinsp;normal weight, 25-29.99\u0026thinsp;=\u0026thinsp;overweight, 30-34.99\u0026thinsp;=\u0026thinsp;obese class I, 35-39.99\u0026thinsp;=\u0026thinsp;obese class II and \u0026ge;\u0026thinsp;40 as obese class III (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The body composition was done by using bioelectronics impedance (BIA), a Korean brand model of Mediagate BOCA X1\u0026reg;. Anthropometric and body composition were repeated twice and then averaged.\u003c/p\u003e \u003cp\u003eThe Arabic version of self-administered 36-SF health questionnaire was used to assess participants HRQOL (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The 36-SF HRQOL is considered a superior and relatively simple instrument to assess HRQOL and can be used to a general or specific population. The validity and reliability of this questionnaire were established in the past (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It is composed of 36 items that assess the following eight HRQOL domains or scales: Physical functioning, General health, Role limitation due to physical health, Energy/Fatigue, Body pain, Emotional wellbeing, Role limitation due to emotional problems and Social functioning. Responses to each question within the domain were added up to achieve scores ranging from 0-100, where 0 indicates the worst health status and 100 indicates the best health status.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eWeight management programs\u003c/h2\u003e \u003cp\u003eAll participants were subjected to three-month intensive weight-reducing programs. The dietary plans and physical activity instructions were tailored according to the participants preference and obesity degree. All participants were in good physical health to perform a regular physical activity of 45 minutes a day for 4 days a week. They have received a dietary plan of 4 meals per day: breakfast, lunch, snack, and dinner. The caloric restriction diet contained 800\u0026ndash;1500 Kcal /day and 1000\u0026ndash;1800 Kcal/day for females and males, respectively. Total energy requirement was calculated by using the Harris-Benedict equation for each participant. Participants were subjected to iso-caloric dietary plans throughout three months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAnalysis Statistical package for social science (SPSS) for windows version 20 for statistical analysis was used. All statistical values were considered significant at P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The data were cleaned, before the analysis, from missing data of primary outcomes like weight, height and quality of life data at baseline and after 3-month follow up. Participants who had missed data of primary outcomes were excluded from the final analysis. Variables of quality-of-life domains at baseline and after three months were calculated, then the descriptive statistics such as mean and standard deviation were calculated. By using means, standard deviations analysis, one-way ANOVA and independent sample T-test, the socio-demographic variables were compared with different SF-36 domains at baseline and after 3 months. Changes of each domain score were calculated by the mean difference between scores of domains after 3 months and scores at baseline. Furthermore, paired sample t-test was used to test the significance of changes in various HRQOL parameters (as individual domain scores and total HRQOL score) from baseline to the end of 3-month follow up. Mean change scores of weights and HRQOL scores were calculated from baseline to 3-month follow up. Moreover, analysis of changes in HRQOL after 3 months related to changes in weight was conducted by independent sample T-test after categorizing the participants according to their percentage of weight loss into two main groups (participants lost less than 10% of their initial weight and participants\u0026thinsp;\u0026gt;\u0026thinsp;10% of their initial weight).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAt baseline Six hundred and ten subjects were invited to participate in the study while 516 subjects completed the assessment. Thirty-two subjects were excluded from the final analysis due to missing data in the primary outcome (HRQOL data and weight changes) and 18 participants also were excluded due to they didn\u0026rsquo;t have weight loss or had weight gain instead after three months. Thus, the data of a total of 466 participants were included in the final analysis. The mean age of participants was 33\u0026plusmn;10 years, ranging from 18-68 years old. As shown in Table 1, the majority of participants were females (82.6%), married (63.5), with bachelor degree (57.5%), unemployed (59%) and living in the city (55.6%). Above quarter of the participants had a monthly average income between 1500-3000 NIS (New Israeli shekel).\u003c/p\u003e\n\u003cp\u003eTable 2: A-C, showed the baseline quality of life of the participants according to their socio demographic characteristics. The total score of quality of life at baseline according to sociodemographic variables indicated that there was a significant difference between male and female in overall quality of life score, \u0026nbsp;P\u0026lt;0.05. Males had a mean score of (70\u0026plusmn;17) in total QOL score while females had a mean score of total QOL of (65\u0026plusmn;18). \u0026nbsp;According to age categories, there was a significant difference between participants with different age categories in means of scores of total QOL,(P\u0026lt;0.05). The highest score was for participants who were less than 40 years old (83\u0026plusmn;30), while the lowest scores were for older participants with age of \u0026gt;50 years (46\u0026plusmn;21). According to marital status, single participants had significantly higher scores in overall QOL score among other participants (69\u0026plusmn;16) while the lowest scores were for widowed or separated participants (58\u0026plusmn;20). According to living locations, cities had a significant highest score in the mean of total QOL score ompared with camps or towns p\u0026lt;0.05. \u0026nbsp;Employed participants had significantly higher scores than unemployed participants in total score of QOL (P\u0026lt;0.05); participants who earned an average monthly income over 5000 ILS had a significantly higher score as compared to other participants who earned \u0026nbsp;less. \u0026nbsp;According to the educational level, participants who attained higher education had significantly higher scores in as compared to the other groups \u0026nbsp;with( P\u0026lt;0.05)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Moreover, the sample had a mean\u0026plusmn;(SD) weight of 93.9\u0026plusmn;17.2 kg, and BMI of 35.4\u0026plusmn;5.7kg/m\u0026sup2;. BMI ranged from 25.02 to 58.87kg/m\u0026sup2; with about 76 participants (16.3%) were overweight and the rest were obese.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Among those who completed the study the mean of body weight declined significantly after three months compared to baseline weight. Participants reported a decline of mean \u0026plusmn;SD of weight from 93.9\u0026plusmn;17.2kg to 83.9\u0026plusmn;15.7 kg over three months. Two hundred and twenty-seven participants (49.8%) had a reduction \u0026lt; 10% of their weight while 229 subjects (50.2%) had a reduction \u0026ge; 10% of their weight after 3 months. Moreover, BMI declined as a mean and SD from 35.38\u0026plusmn;5.7 to 31.6\u0026plusmn;5.4. \u003cstrong\u003eFig 1\u003c/strong\u003e shows distribution (%) changes in BMI categories after three months of joining the weight management programs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults of analysis of mean scores of HRQOL domains after 3 months compared to baseline scores shows that participants reported a significant improvement in mean scores of all quality-of-life components after 3 months of joining weight management programs compared to baseline scores (P\u0026lt;0.05). Table 3 summarized the mean scores of all components of HRQOL scales and overall quality of life score. The relationship between weight reduction and change of HRQOL are shown in Table 4, where the results show the higher percent of weight loss is associated with significantly greater improvements in total quality of life and all quality of life subscales after 3 months(P\u0026lt;0.05) with exception in \u003cem\u003eRole limitation due to physical health, Role limitations due to emotional problems\u0026nbsp;\u003c/em\u003eand\u003cem\u003e\u0026nbsp;Pain\u0026nbsp;\u003c/em\u003escales. Participants who lost more than 10% percent of their weight had a greater improvement in overall quality of life and all of its scales with mean\u0026plusmn; SD of 14.6\u0026plusmn;17.6 in overall quality of life score.\u003c/p\u003e\n\u003cp\u003eThe highest number of change or improvement as absolute change (baseline score subtracted from follow up score) was in\u0026nbsp;\u003cem\u003ePhysical functioning\u003c/em\u003e in group 2 (participants who lost more than 10% of their weight) with a mean of 18.9\u0026plusmn;27.3 compared with participants who lost less than 10% of their weight with a mean of 10.9\u0026plusmn;23.8.\u003c/p\u003e\n\u003cp\u003eFinally, a comparison of HRQOL change based on participants\u0026apos; socio-demographic characteristics shows that males had greater improvements in several HRQOL scales after weight reduction than females with an exception in changes in\u003cem\u003e\u0026nbsp;Role of limitation due to the emotional problems\u003c/em\u003e scale. \u003cem\u003ePhysical functioning\u003c/em\u003e and \u003cem\u003eEnergy/Fatigue\u003c/em\u003e significantly have improved in males more than females (with p=0.014, 0.040 respectively). On the other hand, according to marital status significantly the greatest number of improvements in HRQOL was in participants who were widowed or separated, so according to the marital status of participants the significant improvement in the number of HRQOL scales was in overall HRQOL, \u003cem\u003eSocial,\u003c/em\u003e and \u003cem\u003ePain\u003c/em\u003e HRQOL subscales(P\u0026lt;0.05) with mean\u0026plusmn; SD of 16.8\u0026plusmn;22.7, 15.4\u0026plusmn;24 and 26.9\u0026plusmn;31.7 respectively. In addition, according to the employment status of participants, unemployed participants had a greater improvement in the number of HRQOL scores that was significantly (P\u0026lt;0.05) in \u003cem\u003eRole limitation due to physical health\u003c/em\u003e and \u003cem\u003eGeneral health\u003c/em\u003e subscales than employed participants. Moreover, participants who earned an average monthly income between 3000-5000 had a significantly (p = 0.047) greater improvement in \u003cem\u003ePhysical functioning\u003c/em\u003e than other participants. Participants who live in towns had significantly (p=0.041) greater improvements in the total HRQOL and \u003cem\u003eRole limitations due to physical health\u0026nbsp;\u003c/em\u003ethan others who live in cities or camps. Finally, improvements in \u003cem\u003ethe Emotional\u0026nbsp;\u003c/em\u003econcept of HRQOL were significantly higher among participants who had primary education with (P=0.032) than others.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study was conducted to evaluate the impact of weight reduction programs on HRQOL among overweight/obese adults after 3 months of weight management. In general, the results showed a decline in weight after three months of dietary management however more than half of participants had a reduction of more than 10% of their initial body weight with a mean loss of about 10 Kg during three months. Compared to a previous studies of weight management programs based on a combination of dietary management and physical activity in a previous study a baseline to 6 month-weight loss was about 9.4% in participants who completed intensive lifestyle approaches which have included low caloric eating and 30 mints of daily walking (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Also, the current finding is in line with another study that showed a mean weight loss of about 9.3% of initial body weight after 14 weeks of a low caloric diet program combined with physical activity (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In addition, most obese participants have a mean loss of 5\u0026ndash;10% of their initial body weight after 12\u0026ndash;18 months of lifestyle modification (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Moreover, a modest weight loss of about 6\u0026ndash;7% was achieved either by calorie-restricted diet or increased physical activity in obese postmenopausal women after 16 weeks of intervention (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In contrast, an average weight loss was 20% of initial body weight and a significant reduction in fat mass was in 63.7% of ninety two participants following 3 months of a very-low-calorie ketogenic diet with more than 24.2% of participants reached a weight loss of more than 20% of initial body weight (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). An explanation to why participants may differ in their weight loss degree was the adherence. Many studies showed an association between weight loss and adherence regardless of dietary intervention; however, many participants find it difficult to adhere to a weight loss diet due to limitation of food intake (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Additionally, adherence to daily calorie restriction declined after about 4 weeks (one month) and continued to decrease (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, concerning HRQOL participants have reported a significant improvement in mean scores of all HRQOL components compared to baseline scores after weight reduction. This finding is consistent with many previous studies that showed a linear relationship between weight change and HRQOL (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Moreover, current findings showed that higher percentage of weight loss was associated with significantly greater numbers of improvement and changes in the quality of life and all HRQOL subscales after 3 months. Greater improvement with exceptions in \u003cem\u003eRole limitation due to physical health, Role limitations due to emotional problems\u003c/em\u003e and \u003cem\u003ePain\u003c/em\u003e scales, was reported with subjects losing more than 10% of their initial weight compared to those who lost less than 10% of their weight. Such results are consistent in many studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e); in which a greater acute weight loss intervention with a mean loss of an average weight loss of 10% was associated with improved HRQOL. The highest improvement in HRQOL in our study was in \u003cem\u003ePhysical functioning\u003c/em\u003e domain after three months of weight reducing-program and this was consistent with previous results from a study showed that loss of about 15 Ibs (~\u0026thinsp;7.5 kg) or more was associated with 0.89 point improvement in Physical component score (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) also after 3 and 6 months of reduced caloric diet (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In addition, most of the previous studies reported improvement in the physical aspect of 36-SF more frequently than mental /psychological or emotional aspect (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, the results of other clinical studies varied according to the type of intervention and HRQOL measurement tools but, most of them demonstrated greater improvement in HRQOL within the group of greater weight loss independently of the type of intervention (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). One potential explanation of the improvement in \u003cem\u003ePhysical functioning, Social and Vitality (Energy/Fatigue)\u003c/em\u003e subscales after weight loss is that adiposity induces inflammation, hypertension and insulin resistance which in turn impair cardiac, atrial and skeletal muscle elasticity and functioning leading to a decrease in physical functioning and performance (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In addition, at baseline participants with higher BMI showed lower scores in 36-SF concepts. Especially, in physical and emotional domains. Many previous studies showed the similar trends of the negative association between BMI and HRQOL however, participants with higher BMI had significantly reduced physical Quality of Life and there was an inverse linear relationship (as the level of BMI became higher the scores in physical component became lower) across different BMI categories even in absence of chronic diseases (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Impairment in HRQOL was particularly in the physical aspect, pain and vitality (energy/fatigue) where the lowest score was in obese class III participants. This is in agreement with previous studies showed that dimensions of mobility and pain are the largest components negatively affected by obesity (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), while physical functioning and vitality were the lowest scores in male outpatient with BMI\u0026thinsp;\u0026gt;\u0026thinsp;35 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Regarding to the mental aspect of quality of life some studies showed a weak association between BMI and the mental aspect of HRQOL, in contrast, a meta-analysis has shown that impairment was mainly in obese class III participants and that was less obvious in other classes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This finding is not surprising as obesity and its complications result in numerous emotional and mental problems that interfere with social life and relationships with others, in addition to a decrease in self-esteem. However, many biological studies explained this result by bi-direction causal\u0026ndash;relationship of mental conditions such as anxiety, depression and mood disorders (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). With regard to pain and physical functioning impairment, increasing in weight and BMI have contributed negatively to the mechanical load on joints and have shown an impact on physical functioning of obese interfering with their daily activities. Many obese have recognized that obesity was a great limitation in their physical performance(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Nevertheless, to address the relationship between obesity and impairment in HRQOL few studies have investigated the underlying mechanism. The general explanation was that obesity will lead to low -grade inflammation that underlines the biological, physiological and psychological etiology of impaired HRQOL (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is not surprising that improvements in HRQOL may differ according to gender, age, socio-demographic and socioeconomic status. However, in this study, levels of improvement in HRQOL after weight reduction were greater in males than females except \u003cem\u003ein Role of limitation due to emotional problems.\u003c/em\u003e Moreover, in this study, single, employed, living in cities, earned an average income of more than 5000 ILS and had a higher educational level participants have reported higher HRQOL. This finding is in agreement with a previous study that showed a significantly lower HRQOL was reported in un-employed, low income, less educated and chronic conditions participants (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Moreover, understanding the relationship between HRQOL and socioeconomic, socio-demographic status is a complicated process due to the fact that different aspects of socioeconomic-demographic status affect the health and HRQOL either separately or by overlapping at different levels of life (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"Heading\"\u003eLimitations\u003c/b\u003e:\u003c/div\u003e \u003cp\u003eThe study was conducted during COVID-19 pandemic and collecting data wasn\u0026rsquo;t easy. This also confined the follow-up period to be short. Another limitation was that male patients normally don\u0026rsquo;t attend these weight management centers, this explained the high percent of female participants in the study.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eFor practitioners, it is recommended to focus on a dietary programme that suits the patient and has the ability to reduce 10% of total body weight rather than adopting strict regimen. HRQOL should be an important derive to lose weight and should be part of the weight management outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion the implementation of various weight reducing programs including a combination of moderate exercise and a caloric restriction diet, has been proven to induce weight loss. Moreover, HRQOL has significantly improved as body weight is reduced after three months of weight management. In addition, the levels of HRQOL improvement were positively associated with the level of weight loss. With physical functioning being the most improved subscale, partly and presumably due to decreased level of inflammation due to shifts in gut microbiota. Relationships between weight loss, HRQOL and microbiota composition should be investigated. Finally, gender, socio-demographic, and socioeconomic factors played a major role in HRQOL at baseline and the level of improvement after 3 months of weight management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Internal Review Board for Research Ethics at An-Najah National University\u0026nbsp;on 31\u003csup\u003est\u003c/sup\u003e March 2019. In addition, data collection was performed in accordance with the Declaration of Helsinki. The eligible participants were given informed consent before the onset of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis work has no source of fund\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMA and MB shared the study design, interpreting the results and finalized the manuscript writing, UA, collected data and wrote the first draft. All authors reviewed and approved the final draft.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank An-najah University and NurtiHealth center for their cooperation and support during the data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrganization WH. World Health Organization obesity and overweight fact sheet. 2016. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Physical status: The use of and interpretation of anthropometry. Report of a WHO Expert Committee: World Health Organization; 1995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChooi YC, Ding C, Magkos F. The epidemiology of obesity. Metabolism. 2019;92:6\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWard ZJ, Bleich SN, Cradock AL, Barrett JL, Giles CM, Flax C, et al. 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J Nutr Educ Behav. 2014;46(2):90\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayes M, Baxter H, M\u0026uuml;ller-Nordhorn J, Hohls J, Muckelbauer R. The longitudinal association between weight change and health‐related quality of life in adults and children: a systematic review. Obes Rev. 2017;18(12):1398\u0026ndash;411.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePan A, Kawachi I, Luo N, Manson JE, Willett WC, Hu FB, et al. Changes in body weight and health-related quality of life: 2 cohorts of US women. Am J Epidemiol. 2014;180(3):254\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePayne M, Starr KP, Orenduff M, Mulder H, McDonald S, Spira A, et al. Quality of life and mental health in older adults with obesity and frailty: associations with a weight loss intervention. J Nutr health aging. 2018;22(10):1259\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChao AM, Wadden TA, Walsh OA, Gruber KA, Alamuddin N, Berkowitz RI, et al. Changes in health-related quality of life with intensive behavioural therapy combined with liraglutide 3.0 mg per day. Clin Obes. 2019;9(6):e12340.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverman MN, Deuster PA. Biological mechanisms underlying the role of physical fitness in health and resilience. Interface focus. 2014;4(5):20140040.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBusutil R, Espallardo O, Torres A, Mart\u0026iacute;nez-Galdeano L, Zozaya N, Hidalgo-Vega \u0026Aacute;. The impact of obesity on health-related quality of life in Spain. Health Qual Life Outcomes. 2017;15(1):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliva-Moreno J, Gil-Lacruz A. Body weight and health-related quality of life in Catalonia, Spain. Eur J Health Econ. 2013;14:95\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYancy WS Jr, Olsen MK, Westman EC, Bosworth HB, Edelman D. Relationship between obesity and health-related quality of life in men. Obes Res. 2002;10(10):1057\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAvila C, Holloway AC, Hahn MK, Morrison KM, Restivo M, Anglin R, et al. An overview of links between obesity and mental health. Curr Obes Rep. 2015;4:303\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh K, Kondal D, Shivashankar R, Ali MK, Pradeepa R, Ajay VS, et al. Health-related quality of life variations by sociodemographic factors and chronic conditions in three metropolitan cities of South Asia: the CARRS study. BMJ open. 2017;7(10):e018424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRezaei S, Hajizadeh M, Salimi Y, Moradi G, Nouri B. What explains socioeconomic inequality in health-related quality of life in Iran? A Blinder-Oaxaca decomposition. J Prev Med Public Health. 2018;51(5):219.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Socio-demographic characteristics of participants, presented as number and %.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.61774744027304%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.679180887372014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.703071672354948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.10580204778157%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.51194539249147%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.679180887372014%\" valign=\"top\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.703071672354948%\" valign=\"top\"\u003e\n \u003cp\u003e17.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e82.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.10580204778157%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eMaterial status\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.51194539249147%\" valign=\"top\"\u003e\n \u003cp\u003eSingle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.679180887372014%\" valign=\"top\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.703071672354948%\" valign=\"top\"\u003e\n \u003cp\u003e33.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e63.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.10580204778157%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eCurrent employment status\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.51194539249147%\" valign=\"top\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.679180887372014%\" valign=\"top\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.703071672354948%\" valign=\"top\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eUnemployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.10580204778157%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.51194539249147%\" valign=\"top\"\u003e\n \u003cp\u003ePrimary school (less than 10 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.679180887372014%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.703071672354948%\" valign=\"top\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eSecondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e33.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eBachelor or equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e57.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eHigher education (Master or doctoral)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.10580204778157%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eArea of living\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.51194539249147%\" valign=\"top\"\u003e\n \u003cp\u003eTown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.679180887372014%\" valign=\"top\"\u003e\n \u003cp\u003e186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.703071672354948%\" valign=\"top\"\u003e\n \u003cp\u003e39.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eCity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eCamps\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.10580204778157%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eMonthly average income\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.51194539249147%\" valign=\"top\"\u003e\n \u003cp\u003eLess than 1500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.679180887372014%\" valign=\"top\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.703071672354948%\" valign=\"top\"\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003e1500-3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e27.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003e3000-5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.51020408163265%\" valign=\"top\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.479591836734693%\" valign=\"top\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.010204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e24.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Table 2:A \u0026nbsp;Quality of Life of participants according to gender and age groups \u0026nbsp;at baseline\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQOL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003e385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e18-39 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e40-50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e50-51 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical \u0026nbsp;functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e75\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e58\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e57\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003eRole limitation \u0026nbsp;due to physical health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e81\u0026plusmn;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e83\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e80\u0026plusmn;33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e83\u0026plusmn;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e75\u0026plusmn;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e76\u0026plusmn;37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003eRole limitation due to emotional problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e75\u0026plusmn;41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.015*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e61\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026plusmn;46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.624\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003eEnergy/fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e51\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e55\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e51\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e53\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e49\u0026plusmn;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e46\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003eEmotional well \u0026ndash;being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e56\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e55\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e56\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e59\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e56\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.793\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003eSocial functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e73\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.969\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.022*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e61\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e52\u0026plusmn;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e60\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e55\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.96629213483146%\" valign=\"top\"\u003e\n \u003cp\u003eTotal QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e66\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026plusmn;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.951845906902086%\" valign=\"top\"\u003e\n \u003cp\u003e.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\" valign=\"top\"\u003e\n \u003cp\u003e61\u0026plusmn;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.791332263242376%\" valign=\"top\"\u003e\n \u003cp\u003e60\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.98876404494382%\" valign=\"top\"\u003e\n \u003cp\u003e.008**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Significant at p value \u0026lt;0.05, *:p\u0026lt;.05,**:p\u0026lt;.01 by using the independent samples T-test.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: B Quality of Life of participants according to gender and age groups \u0026nbsp;at baseline\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"590\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.677966101694917%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.152542372881356%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eLiving place\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eQOL/socio-demographic factor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003e(157)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003e(296)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003cp\u003e(13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003eTown\u003c/p\u003e\n \u003cp\u003e(186)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003eCity\u003c/p\u003e\n \u003cp\u003e(259)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003eCamps\u003c/p\u003e\n \u003cp\u003e(21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical \u0026nbsp;functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e78\u0026plusmn;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e73\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e61\u0026plusmn;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eRole limitation \u0026nbsp;due to physical health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e84\u0026plusmn;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e79\u0026plusmn;33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e76\u0026plusmn;36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e84\u0026plusmn;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e85\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.050*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eRole limitation due to emotional problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e66\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e56\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e66\u0026plusmn;43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.484\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eEnergy/fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e55\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e50\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e40\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e49\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e53\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e51\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.099\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eEmotional well \u0026ndash;being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e57\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e56\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e52\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e55\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e58\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e50\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.081\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eSocial functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e66\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.709\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.291\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e72\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e49\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.096\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e60\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.029*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026plusmn;22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.095\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003eTotal QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.35593220338983%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.830508474576272%\" valign=\"top\"\u003e\n \u003cp\u003e58\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.491525423728813%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.169491525423728%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.813559322033898%\" valign=\"top\"\u003e\n \u003cp\u003e.033*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Significant at P\u0026lt;0.05, *:p\u0026lt;.05,**:p\u0026lt;.01 by using one -way ANOVA test.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: C Quality of Life of participants accoding to gender and age groups \u0026nbsp; at baseline\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.826923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.243589743589745%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eEmployment status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.493589743589743%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.94230769230769%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eAverage monthly \u0026nbsp; \u0026nbsp; salary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.493589743589743%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQOL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003cp\u003e(191 )\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(275)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;1500\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;( 101)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e1500_3000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(130)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e3000-5000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;5000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical \u0026nbsp;functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e74\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e75\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e75\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003eRole limitation \u0026nbsp;due to physical health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e85\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e78\u0026plusmn;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.014*\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e82\u0026plusmn;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e84\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e79\u0026plusmn;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e83\u0026plusmn;33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.717\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003eRole limitation due to emotional problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.408\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026plusmn;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.592\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003eEnergy/fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e53\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e50\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e51\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e55\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e50\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e53\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.327\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003eEmotional well \u0026ndash;being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e59\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e54\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.013*\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e52\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e57\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e59\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.021*\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003eSocial functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e72\u0026plusmn;22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e74\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.451\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e66\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026plusmn;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.337\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.050*\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e66\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.870\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.853932584269664%\" valign=\"top\"\u003e\n \u003cp\u003eTotal QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.359550561797754%\" valign=\"top\"\u003e\n \u003cp\u003e68\u0026plusmn;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.92776886035313%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.014*\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32263242375602%\" valign=\"top\"\u003e\n \u003cp\u003e67\u0026plusmn;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.507223113964686%\" valign=\"top\"\u003e\n \u003cp\u003e.439\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*:p\u0026lt;05 ,\u0026sup1;:by using independent sample T test ,,\u0026sup2;:by using \u0026nbsp;one way ANOVA.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"588\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eTable 3: Changes in QOL at baseline and after three months presented as mean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003eQuality of life domain\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003eAt baseline\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003eAfter 3 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003eTotal QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e66\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e77\u0026plusmn;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical \u0026nbsp;functioning\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026plusmn;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e86\u0026plusmn;22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003eRole limitation \u0026nbsp;due to physical health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e81\u0026plusmn;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e93\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003eRole limitation due to emotional problems\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e80\u0026plusmn;37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003eEnergy/fatigue\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e51\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003eEmotional well \u0026ndash;being\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e56\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e64\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003eSocial functioning\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e78\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003ePain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e77\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.91156462585034%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.965986394557824%\" valign=\"top\"\u003e\n \u003cp\u003e77\u0026plusmn;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.775510204081632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSignificant at P\u0026lt;0.05, **:p\u0026lt;.001 by using \u0026nbsp;paired samples T-test\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"565\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eTable 4: \u0026nbsp;Relationship between reduction in weight and changes in quality of life\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003eScale of change\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003eGroup 1 (\u0026lt; 10%weight reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003eGroup 2(\u0026ge; 10%weight reduction\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003eChange in Physical functioning \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e10.9\u0026plusmn;23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e18.9\u0026plusmn;27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e0\u003c/ins\u003e.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Change in Role limitation due to physical health \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e10.4\u0026plusmn;28.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e14.7\u0026plusmn;35.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e0\u003c/ins\u003e.158\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Change in Role limitation due to emotional problem \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e14.3\u0026plusmn;39.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e18.5\u0026plusmn;43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e0\u003c/ins\u003e.293\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Change Energy/fatigue\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e9.2\u0026plusmn;18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e15.8\u0026plusmn;21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e\u0026lt;0\u003c/ins\u003e.00\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e1\u003c/ins\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Change in Emotional well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e6.4\u0026plusmn;14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e9.3\u0026plusmn;16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e0\u003c/ins\u003e.050*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Change in Social functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e6.3\u0026plusmn;20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e10.1\u0026plusmn;20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e0\u003c/ins\u003e.047*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Change in Pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e10.8\u0026plusmn;23.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e14.4\u0026plusmn;25.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e0\u003c/ins\u003e.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Change in General health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e9.3\u0026plusmn;18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e15.4\u0026plusmn;20.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e0\u003c/ins\u003e.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.08510638297872%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Change in Total QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.80851063829787%\" valign=\"top\"\u003e\n \u003cp\u003e9.7\u0026plusmn;15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.0354609929078%\" valign=\"top\"\u003e\n \u003cp\u003e14.6\u0026plusmn;17.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cins cite=\"mailto:Microsoft%20Office%20User\" datetime=\"2024-02-03T12:17\"\u003e0\u003c/ins\u003e.002**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSignificant at P\u0026lt;0.05, **: p\u0026lt;.001 by using \u0026nbsp;paired samples T-test\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Obesity, Weight management, quality of life, 36-SF HRQOL.","lastPublishedDoi":"10.21203/rs.3.rs-4365276/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4365276/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObesity is a primary health issue. This study aimed at assessing health related quality of life (HRQOL) among overweight/obese adults. Participants were referred to Nutri Health centers in the West Bank for weight management programs during the period between 1 of May 2019 to 30 November 2020. A total of 466 participants were involved in the study. Body composition, anthropometric measurements, socio-demographic data, and HRQOL were determined at baseline and after 3 months. The results showed a significant decline in the mean weight of participants from 93.9\u0026thinsp;\u0026plusmn;\u0026thinsp;17.2Kg to 83.9\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7 kg. More than half (51.3%) of participants had weight reduction more than 10%. Participants reported significant improvement in all components of (36-SF) HRQOL after 3 months compared to baseline scores. Moreover, participants with \u0026ge;\u0026thinsp;10% loss of baseline weight had a greater improvement in the overall HRQOL scores by 14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;17.6 (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) compared to 9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.0 for those who lost\u0026thinsp;\u0026lt;\u0026thinsp;10% baseline body weight. Moreover, the \u003cem\u003eRole limitation due to physical health\u003c/em\u003e achieved the highest score after 3 months by (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) of 93.0\u0026thinsp;\u0026plusmn;\u0026thinsp;20.7 compared to baseline score of 80.8\u0026thinsp;\u0026plusmn;\u0026thinsp;32.2. The highest improvement was reported in \u003cem\u003ePhysical functioning\u003c/em\u003e with 18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;27.3 and 10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;27.3 for participants who lost\u0026thinsp;\u0026ge;\u0026thinsp;10% and \u0026lt;\u0026thinsp;10%, respectively. In conclusion, weight management programs seemed to be not only effective to induce weight loss but also to improve HRQOL. The mechanism behind this improvement should be investigated in light of decreased levels of inflammation and changes in gut microbiota.\u003c/p\u003e","manuscriptTitle":"Short –Term Weight Management Programs Improve the Quality of Life of Attendees of the Dietetic Centers in the West Bank","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-13 15:44:11","doi":"10.21203/rs.3.rs-4365276/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c53b9359-396e-4612-99ed-1186fabd0a4a","owner":[],"postedDate":"May 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-13T15:44:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-13 15:44:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4365276","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4365276","identity":"rs-4365276","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}