Does Increased Body Mass Index Cause Pain and Impact Overall Quality of Life in Case of Venous Insufficiency?

Abstract

Objective: Chronic venous insufficiency is the most common vascular disease of the lower extremity. It is predicted that obesity, which is one of the risk factors of venous insufficiency, would influence the clinical appearance of the disease. The purpose of this study is to investigate the changes in pain scores and overall quality of life of patients with venous insufficiency, according to body mass index.
Materials and Methods: Patients (n:63) who applied to the sports medicine clinic with lower extremity pain, and were found to have venous insufficiency in examinations were included in the study. After noting their demographic data, patients’ height and body weight measurements were performed and body mass indices calculated. The patients were divided into four groups based on their body mass index (BMI). The visual analog scale and the EQ5D quality of life scale were then applied to the patients.
Results: According to their BMI, there were 16 patients in Group 1 (22.6 kg/m²), 23 patients in Group 2 (27.5 kg/m²), 17 patients in Group 3 (32.6 kg/m²), and seven patients in Group 4 (37.5 kg/m²). There were no statistically significant differences between the groups in terms of demographic data or degree of venous insufficiency. The visual analog scale score and the EQ5D score were 4.1 ± 2.9 and 0.7 ± 0.2 in Group 1; 4.7 ± 2.9 and 0.6 ± 0.3 in Group 2; 6.3 ± 2.1 and 0.5 ± 0.1 in Group 3; and 7.9 ± 2 and 0.3 ± 0.2 in Group 4, respectively. Statistical analysis revealed a statistically significant difference between the groups in terms of their EQ5D score (p:0.01). Although visual analog scale score increased in parallel with body mass index, there was no statistically significant difference (p:0.055). Body mass index was found to be negatively and moderately correlated with pain (p:0.004, r: -0.40) and overall quality of life (p:0.003, r: -0.40).
Conclusions: This study revealed that the increase in body mass index affects pain and quality of life independently of the severity of insufficiency.

Introduction

Obesity is a community health problem that is increasing throughout the world at an alarming rate (1,2). More than one billion people across the world are overweight, while 300 million suffer from obesity (3). More than 50% of the adults in the United States have a body mass index in the 25.0-29.9 kg/m² range, almost one third have a body mass index above 30 kg/m² and 5% have a body mass index above 45 kg/m² (4,5). In addition to adults, 14-18% of American children have been found to be overweight, while 80% of individuals between the ages of 11 and 15 have been found to have multiple risk factors related to physical inactivity and diet (4,6). In Turkey, 17.2% of the individuals over the age of 15 have obesity, 34.8% are overweight, 44.2% have normal body weight, and 3.9% are underweight. In terms of gender, 20.9% of women are obese and 30.4% are overweight, while 13.7% of men are obese and 39.0% are overweight (7).

The prevalence of obesity is high in all nations across the world and has been increasing in recent years (8). This has led to an increase in the prevalence of other diseases such as cancer, diabetes, insulin resistance, arthritis, hypertension, hyperlipidemia, heart diseases, and vascular diseases as well, since it is a risk factor for these diseases (7,9-11). Obesity does not only increase the risk of these diseases, but also weakens physical functions of patients, increases their sense of pain, and reduces quality of life (8). In one study conducted in the general population, it was reported that life quality of underweight individuals or obese individuals decreased, and increased body mass index led to negative effects on health (12). Multiethnic general population studies revealed that diabetes, hypertension, cardiovascular diseases, and musculoskeletal system diseases caused decrease in quality of life on their own (13). In another study, it was pointed out that many different psychosocial factors affected quality of life, but obesity was the most significant independent factor for low quality of life (14).

Chronic diseases accompanied by obesity are expected to worsen the quality of life. For example, patients with moderate or severe osteoarthritis and obesity were reported to have more limited activity and higher pain (15). Gardner et al. reported that individuals with metabolic syndrome and obesity had worse physical function, health-related quality of life, intermittent claudication, and peripheral circulation (16). Oeser et al. found that obesity was an independent risk factor for lower functional capacity and higher inflammatory marker levels in patients with lupus erythematosus (8).

Çetin el al. found that subjective pain sensation increased in parallel with disease severity (17), while Rossi et al. disclosed that health-related quality of life decreased in parallel with disease severity in patients suffering chronic venous insufficiency (18). However, the number of studies on the pain level and health-related quality of life according to body mass index levels in patients with chronic venous insufficiency is limited. This study is designed to cover this gap. The purpose of this study is to investigate the change in pain scores and overall quality of life of patients with venous insufficiency according to body mass index.

Material and Methods

A total of 63 patients admitted to the sports medicine clinic, with lower extremity pain and who were found to have venous insufficiency through clinical examinations and photoplethys-mography measurements (17) were enrolled in this study. The patients had no history of lower extremity injury or surgery, osteoarthritis and drug use. After noting demographic data of the patients, height and body weight measurements were performed to calculate body mass index. Patients were divided into four groups based on their body mass index values: those with a body mass index between 18.5-24.9 kg/m2 (Group 1); those with a body mass index between 25.0-29.9 kg/m2 (Group 2); those with a body mass index between 30.0-34.9 kg/m2 (Group 3), and those with a body mass index over 35.0 kg/m2 (Group 4), (19). Patients who suffered bilateral venous insufficiency were considered to be more severe.

The visual analog scale (VAS) was used to determine the level of pain (18), and the EQ5D scale was used to assess the life quality (12). The visual analog scale involves the patient’s subjective interpretation of pain between 0 and 10 on a visual scale (18). The EQ5D scale which was tested for Turkish validity and reliability by Kahyaoğlu assesses quality of life under the following dimensions: mobility, self-care, usual activities, pain/discomfort & anxiety/depression. The subject chooses one of the three options (‘no problem’, ‘some problem’, and ‘major problem’) for each item. A total of 243 different possible health results are identified using the scale and an index score varying between 0 and 1.00 is produced as a result (20). The Local Ethics Committee approved the study.

Statistical Analysis
SPSS v22.0 software was used for data analysis. Descriptive statistics was utilised to identify the data and the Kruskal Wallis test was applied to determine differences among independent groups. In parameters where a difference was detected, Bonferroni corrected Mann Whitney-U test was applied to determine which groups caused the difference. Pearson correlation analysis was done to determine the relationship between the scales and body mass index. Statistical significance level was accepted as p<0.05. Results were presented as mean ± standard deviation.

Results

There were 16 patients (15 females/one male, four unilateral/12 bilateral extremity) in Group 1; 23 patients (18 females/five males, eight unilateral/15 bilateral extremity) in Group 2; 17 patients (15 females/two males, two unilateral/ 15 bilateral extremity) in Group 3; and seven patients (all females and bilateral extremity) in Group 4. There were no statistically significant differences between the groups in terms of age, height, sex, affected extremity, or degree of venous insufficiency (p˃0.05), (Table 1).

Table 1. Physical characteristics

Figure 1. VAS pain score and EQ5D quality of life score (n: 63)

Discussion

It was found in this study that increased body mass index led to an increase in pain and decreased health-related quality of life in chronic venous insufficiency patients with similar clinical stages and refilling times. Body mass index was found to be negatively correlated with pain and quality of life.

Venous diseases are frequently seen in the society, particularly in women, and impose high socio-economic burden, thereby causing loss of labour and decreased quality of life (21,22). Major risk factors concerning the disease include genetic predisposition, standing for prolonged periods of time, thrombophlebitis and lower extremity history, number of pregnancies and obesity (23). Most studies in the literature focus on the relationship between pain level and disease stage in patients with chronic venous insufficiency (18). In addition to pain, there are also studies focusing on the correlation of degree of clinical findings and progress of the disease with health-related quality of life (18,24).

Recent studies investigated clinical effects of stage and severity of chronic venous insufficiency and reported that progression of the disease increased symptoms in patients. When progress of the disease was stopped or slowed down by medical or exercise treatment, it was observed that subjective assessments of patients were positively affected; pain decreased, independence increased, and quality of life improved (22,25,26). On the other hand, health authorities are alarmed by obesity as an epidemic affecting all nations across the world. Strategic plans are developed in an attempt to minimize the burden caused by obesity on individuals and communities. Given this, it is a matter of interest how obesity affects complaints of patients with accompanying chronic diseases, and how these patients should be treated. In studies on different diseases such as vascular disease, diabetes and metabolic syndrome, it was found that characteristic findings and course of disease might change, and that symptoms might increase when accompanied by high body mass index/obesity (11,14,23,27).

The CEAP classification (classification of severity of varicose veins) and other venous scoring systems, which classify venous insufficiency do not consider body mass index. Padberg et al. (27) designed their study by taking into account this gap in the literature and reported that patients with morbid obesity developed more serious venous symptoms. Typical chronic venous insufficiency symptoms were observed in one third of patients with a body mass index over 40 kg/m2, and it was reported that increased body mass index led to increased symptoms in patients (27). Rossi et al. reported that patients with higher clinical degree according to the CEAP classification had higher body mass index values, although they were not statistically significant. Also, it was highlighted that pain and health-related quality of life were affected by increased clinical severity according to CEAP (18).

In a study where patients who randomly received four different treatment options were followed-up for six months, it was reported that there was no difference between treatment groups and that the negative effect of the disease on the quality of life increasingly continued despite treatment (28). In another study from Turkey, factors such as advanced age, high body mass index, prolonged working times, and regular drug use were found to be correlated with decreased quality of life (29).

Although this is the first study in the literature that investigates clinical symptoms according to body mass index classification, it has certain limitations. The first limitation is the inability to analyse other parameters which might have affected the clinical appearance of the disease. The second limitation is the low number of patients in the study. This study does not include any patients in the underweight (˂18.5 kg/m2) and extreme obesity (˃40 kg/m2) categories according to World Health Organization’s body mass index classification. The third limitation is a result of the fact that the study was carried out in a hospital, and only those patients possibly with more pain have applied to a physician, which might have influenced the results.

Conclusion

It was found in our study that the increase in body mass index led to an increase in pain level and a decrease in health-related quality of life. Obesity is known to be one of the manageable risk factors of chronic venous insufficiency. Cumulative symptoms of venous insufficiency also increase when the disease is accompanied by obesity. As in many chronic diseases (30), primary treatment of venous insufficiency must include lowering body weight to an optimal level and fighting obesity.

Cite this article as: Ercan S, Cetin C. Does increased body mass index cause pain and impact overall quality of life in case of venous insufficiency? Turk J Sports Med. 2017;52:127-32.
*Bu çalışma, “Venöz yetmezlikli hastalarda kalf kası egzersizlerinin venöz fonksiyona ve kas gücüne etkisi (The effect of calf muscle exercises on venous functions and muscle strength in patients with chronic venous insufficiency)” başlıklı tıpta uzmanlık tezinden üretilmiştir.

References

1. Alegre MM, Knowles MH, Robison RA, et al. Mechanics behind breast cancer prevention-focus on obesity, exercise and dietary fat. Asian Pac J Cancer Prev. 2013; 14(4):2207-12.
2. Menegoni F, Galli M, Tacchini E, et al. Gender‐specific effect of obesity on balance. Obesity (Silver Spring). 2009;17(10):1951-6.
3. Matrangola SL, Madigan ML. The effects of obesity on balance recovery using an ankle strategy. Hum Mov Sci. 2011;30(3):584-95.
4. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-55.
5. Kushner RF, Ryan DH. Assessment and lifestyle manage-ment of patients with obesity: clinical recommendations from systematic reviews. JAMA. 2014;312(9):943-52.
6. Leech RM, McNaughton SA, Timperio A. The clustering of diet, physical activity and sedentary behavior in children and adolescents: a review. Int J Behav Nutr Phys Act. 2014;11:4. doi: 10.1186/1479-5868-11-4.
7. Durgun HM, Dursun R, Zengin Y, et al. The effect of body mass index on trauma severity and prognosis in trauma patients. Ulus Travma Acil Cerrahi Derg. 2016;22(5): 457-65.
8. Oeser A, Chung CP, Asanuma Y, et al. Obesity is an independent contributor to functional capacity and inflammation in systemic lupus erythematosus. Arthritis Rheum. 2005;52(11), 3651-9.
9. Fowkes FG, Lee AJ, Evans CJ, et al. Lifestyle risk factors for lower limb venous reflux in the general population: Edinburg Vein Study. Int J Epidemiol. 2001;30(4):846-52.
10. Ross R, Janssen I, Dawson J, et al. Exercise‐induced reduction in obesity and insulin resistance in women: a randomized controlled trial. Obes Res. 2004;12(5):789-98.
11. Lean ME. Pathophysiology of obesity. Proc Nutr Soc. 2000;59(3):331-6.
12. Søltoft F, Hammer M, Kragh N. The association of body mass index and health-related quality of life in the general population: data from the 2003 Health Survey of England. Qual Life Res. 2009;18(10):1293-9.
13. Wee HL, Cheung YB, Li SC, et al. The impact of diabetes mellitus and other chronic medical conditions on health-related Quality of Life: Is the whole greater than the sum of its parts? Health Qual Life Outcomes. 2005;3:2.
14. Mannucci E, Petroni ML, Villanova N, et al. Clinical and psychological correlates of health-related quality of life in obese patients. Health Qual Life Outcomes. 2010;8:90.
15. van Dijk GM, Veenhof C, Schellevis F, et al. Comorbidity, limitations in activities and pain in patients with osteoarthritis of the hip or knee. BMC Musculoskelet Disord. 2008;9:95.
16. Gardner AW, Montgomery PS, Parker DE. Metabolic syndrome impairs physical function, health-related quality of life, and peripheral circulation in patients with intermittent claudication. J Vasc Surg. 2006;43(6): 1191-6.
17. Cetin C, Serbest MO, Ercan S, et al. An evaluation of the lower extremity muscle strength of patients with chronic venous insufficiency. Phlebology. 2016;31(3):203-8.
18. Rossi FH, Volpato MG, Metzger PB, et al. Relationships between severity of signs and symptoms and quality of life in patients with chronic venous disease. J Vasc Bras. 2015;14:22-8.
19. Oreopoulos A, Padwal R, McAlister FA, et al. Association between obesity and health-related quality of life in patients with coronary artery disease. Int J Obes (Lond). 2010;34(9):1434-41.
20. Kahyaoğlu Süt H. Akut koroner sendromlu hastalarda yaşam kalitesi: EQ-5D ölçeğinin geçerlilik ve güvenirlik çalışması. Trakya Üniversitesi Sağlık Bilimleri Enstitüsü Yüksek Lisans Tezi. Edirne: Trakya Üniversitesi; 2009.
21. Akbulut B, Tok M, Uçar Hİ, et al. Common venous system disorders: prevalence, risk factors, and management. Anatol J Clin Investig. 2009;3:113-9.
22. Guex JJ, Myon E, Didier L, et al Chronic venous disease: health status of a population and care impact on this health status through quality of life questionnaires. Int Angiol. 2005;24(3):258-64.
23. Fowkes FG, Evans CJ, Lee AJ. Prevalence and risk factors of chronic venous insufficiency. Angiology. 2001;52(Suppl 1): S5-15.
24. Kurz X, Lamping DL, Kahn SR, et al. Do varicose veins affect quality of life? Results of an international population-based study. J Vasc Surg. 2001;34(4):641-8.
25. O'Brien J, Edwards H, Stewart I, et al. A home‐based progressive resistance exercise programme for patients with venous leg ulcers: a feasibility study. Int Wound J. 2013;10(4):389-96.
26. Subhedar R, Dave P, Mishra P, et al. A study evaluating the effects of Bombay Hospital Physiotherapy Program and conventional physio-therapy exercise program on geriatric patients presenting with calf pain. Int J Physiother Res. 2015;3(2):955-9.
27. Padberg F Jr, Cerveira JJ, Lal BK, et al. Does severe venous insufficiency have a different etiology in the morbidly obese? Is it venous? J Vasc Surg. 2003;37:79-85.
28. Çeviker K, Şahinalp Ş, Çiçek E, et al. Quality of life in patients with chronic venous disease in Turkey: influence of different treatment modalities at 6-month follow-up. Qual Life Res. 2016;25(6):1527-36.
29. Soydan E, Yılmaz E, Baydur H. Effect of socio-demographic characteristics and clinical findings on the quality of life of patients with chronic venous insufficiency. Vascular. 2017;25(4):382-9.
30. Corica F, Corsonello A, Apolone G, et al. Metabolic syndrome, psychological status and quality of life in obesity: the QUOVADIS study. Int J Obes (Lond). 2008; 32:185-91.

Many thanks to Prof. Dr. Turhan YAVUZ for his assistance in photoplethysmography measurements.