Clinical correlates of the weight bias internalization scale in a sample of obese adolescents seeking bariatric surgery

Personality dimensions, depression, and eating behavior in individuals seeking bariatric surgery: a cluster analysis

Introduction

Psychiatric comorbidity is frequent in bariatric surgery candidates. This study aimed to classify bariatric surgery patients according to patterns of preoperative measures of the severity of the eating disorder (ED), depression, and personality traits.

Methods

In the present cross-sectional study, 115 adult candidates for bariatric surgery (75 females, 65.22% of sample; mean age 37) were considered for analysis. Patients' sociodemographic and psychopathological variables were collected. K-Means clustering analysis was adopted to classify bariatric surgery candidates according to their preoperative Eating Disorder Inventory-2 (EDI-2) scores. In addition, we assessed depression and personality traits using the Beck Depression Inventory-2 (BDI-2) and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2).

Results

Cluster analysis based on EDI-2 revealed two preoperative patterns: higher severity (n = 39), and low severity (n = 76). The more severe EDI-2 group had higher scores on the BDI-2 and presented higher scores on several MMPI-2 dimensions, particularly those related to anxiety (Psychasthenia, Anxiety, Fears, Obsessiveness), depression (Depression, including both content and clinical MMPI-2 subscales), externalizing symptoms (Anger, Cynicism, Type A Behavior), and social functioning (Social Introversion, Family Problems, Work Interference).

Discussion

Eating disorders symptoms in candidates for bariatric surgery are closely related to depression and different psychological conditions assessed with MMPI-2. These psychological variables should be evaluated preoperatively and targeted with more specific psychological interventions.

Exploring the interplay of weight-based teasing and sociodemographic factors in adolescent weight bias internalization

OBJECTIVE

Research has highlighted the potential adverse effects of weight bias internalization (WBI) on adolescents, but there has been little examination of WBI and sources of weight teasing (family, peers, or both) or across racial/ethnic diversity of adolescents. We aimed to examine the relationship between WBI and sources of weight teasing across sociodemographic characteristics and weight status in a diverse community sample of adolescents.

METHODS

Data were collected from a U.S. sample of 1859 adolescents aged 10-17 years (59% female; 43% White, 27% Black or African American, and 25% Latino). An online questionnaire was used to assess participants' experiences of weight teasing from family members, peers, or both, and their weight status, weight-related goals, WBI, and sociodemographic characteristics.

RESULTS

Adolescents experiencing weight teasing from both family and peers reported the highest levels of WBI, while those reporting no teasing exhibited the lowest levels. These patterns were observed across sex, race/ethnicity, weight status, and weight goals, and persisted after controlling for depressive symptoms. Notably, family influences played a salient role, with adolescents reporting higher WBI if teased by family only compared to teasing from peers only. Sex and racial differences were also observed in adolescents' experiences with weight-based teasing.

CONCLUSION

Our study reveals associations between adolescent weight-based teasing, WBI, and sociodemographic factors. Weight-based teasing, whether from family and peers or from family only, was associated with increased WBI. Interventions targeting weight stigma in youth should not be limited to peer-focused efforts, but should also emphasize supportive family communication.

Negative familial weight talk and weight bias internalization in a US sample of children and adolescents

BACKGROUND

Negative familial weight talk may contribute to higher weight bias internalization in pre- and early adolescents (hereafter referred to as children) and may differ by gender, weight status, and race and ethnicity.

OBJECTIVE

Examine the relationship between negative familial weight talk and weight bias internalization and examine differences by gender, weight status, and race and ethnicity.

METHODS

We cross-sectionally analysed 5th-7th graders (10-15 years old) living in Massachusetts (n = 375, 52.3% girls, 21.3% BMI ≥85th percentile, 54.8% non-Hispanic White). Negative familial weight talk frequency during the past 3 months was self-reported and discretized as 'never,' 'occasionally' (1-9 times) and 'often' (>9 times); the Modified Weight Bias Internalization Scale assessed weight bias internalization. Generalized linear models estimated the relationship between negative familial weight talk and weight bias internalization and sub-analyses estimated the relationship across gender, weight status, and race and ethnicity. Results are summarized as ratios of means (RoM).

RESULTS

Children experiencing negative familial weight talk occasionally (RoM = 1.12, p = 0.024) and often (RoM = 1.48, p < 0.001) had significantly higher weight bias internalization than children who never experienced it. In sub-analyses, experiencing negative familial weight talk often was associated with higher weight bias internalization among girls (RoM = 1.66, p < 0.001), boys (RoM = 1.32, p = 0.007), children with BMI <85th percentile (RoM = 1.44, p = 0.007) and BMI ≥85th percentile (RoM = 1.39, p = 0.001), and non-Hispanic White children (RoM = 1.78, p < 0.001), but not Hispanic (RoM = 1.25, p = 0.085) or non-Hispanic Black children (RoM = 1.20; p = 0.31).

CONCLUSIONS

Frequent negative familial weight talk was associated with higher weight bias internalization across gender and weight status and in non-Hispanic White children only.

Exploring the association between internalized weight bias and mental health among Canadian adolescents

BACKGROUND

Internalized weight bias (IWB) has been identified as a correlate of higher depressive and anxiety symptoms in adolescents with higher weights. However, there has been limited investigation into how IWB relates to positive mental health and whether these associations differ across genders.

OBJECTIVES

To examine the associations between IWB and mental health (depression, anxiety, flourishing) in adolescents with higher weights, and to test the potential moderating role of gender.

METHODS

Canadian adolescents with higher weights (N = 7538, 60% boys, 36% girls, 4% gender diverse, ages 12-19) from the COMPASS study completed a survey during the 2021-2022 school year. Data were analysed using generalized linear models.

RESULTS

Highest IWB and poorest mental health were noted within gender diverse adolescents, followed by girls then boys. Gender moderated the relationship between higher IWB and higher depression, higher anxiety and lower flourishing, with the strongest relationships noted among girls.

CONCLUSION

IWB interventions should be tailored to gender subgroups that may be particularly vulnerable to maladaptive mental health outcomes associated with IWB. System-level changes that mitigate perpetuation of weight bias and discrimination which lead to IWB are also essential, particularly for girls.

The relationship between internalised weight bias and biopsychosocial outcomes in children and youth: a systematic review

OBJECTIVE

To synthesise the evidence on the relationships between internalised weight bias (IWB) and biopsychosocial health outcomes in individuals ≤ 25 years.

METHODS

A systematic review was conducted by searching five scientific databases up to May 2022 to retrieve studies that investigated associations between IWB and biopsychosocial outcomes. Articles with participants ≤ 25 years, at least one validated measure of IWB, one measure of a biopsychosocial outcome, and were observational were included. Excluded articles involved systematic literature reviews, case study reports, intervention studies, meta-analyses, grey literature, pilot, and feasibility studies. Quality assessment was carried out using the American Dietetic Association Quality Criteria Checklist. The protocol was registered with PROSPERO, ID number CRD42022323876.

RESULTS

Two hundred and sixty-six articles were identified. Nineteen were eligible for inclusion, (15 cross-sectional and 4 prospective). The Weight Bias Internalization Scale and the Weight Self-Stigma Questionnaire were the most used tools to assess IWB with large heterogeneity in tool types used to assess biopsychosocial measures. IWB had positive associations with psychopathology, eating disorder symptomology, higher BMI, being female, and experiences of weight stigma. It was negatively associated with quality of life, body image, physical activity, social ability, self-esteem, and socioeconomic status.

DISCUSSION

IWB associated with adverse biopsychosocial outcomes in children and youth populations. IWB may be more clinically relevant in assessing at-risk children and youth than physical weight due to its psychosocial aspects and ability to expand beyond the scope of BMI. Research would benefit from better assessment tools designed for children and youth that accurately measure IWB. Future research should focus on increased diversity and longitudinal study designs with children and youth-specific populations.

Development of the PROMIS pediatric stigma and extension to the PROMIS pediatric stigma: skin item banks

PURPOSE

To develop the PROMIS Pediatric Stigma (PPS) and Skin (PPS-Skin) by constructing a common metric for measuring stigma in children with various conditions, while capturing the unique features of each condition.

METHODS

Data from 860 children, ages 8-17, with a diagnosis of epilepsy, pNF (neurofibromatosis type 1 associated neurofibroma plexform), MD (muscular dystrophy), cancer, or skin conditions recruited from three projects were analyzed. Children with epilepsy, pNF and MD (sample-1) completed the original 18-item Neuro-QoL Stigma, while children with cancer and skin conditions (e.g., atopic dermatitis, psoriasis, and genetic skin disorders; sample-2) completed a 16-item version and 6 additional skin related items. Exploratory factor analysis (EFA) and confirmatory analysis (CFA) were used to evaluate unidimensionality of 24 stigma items. Differential item functioning (DIF) was used to evaluate measurement equivalence on group, gender, age, and conditions. Item response theory model (IRT) was used to construct the final measure.

RESULTS

Sufficient unidimensionality was supported by both EFA and CFA. No items showed significant DIF indicating stable measurement properties across groups of comparison. All items fit the IRT model and were able to be calibrated together to form the PPS which consists of 18 core items. The PPS-Skin (18 cores items + 6 skin items) was developed by calibrating 6 skin items onto the common metric as the PPS.

CONCLUSIONS

We used IRT techniques to successfully develop the PPS and the PPS-Skin, which share a common metric and account for unique and common concerns related to chronic conditions.

A systematic review of weight stigma and disordered eating cognitions and behaviors

Weight stigma is persistent across contexts and is associated with disordered eating cognitions and behaviors. This systematic review aimed to examine the existing literature that has explored the relationship between weight stigma and disordered eating cognitions and behaviors. We specifically examined three dimensions of weight stigma - experienced, anticipated, and internalized - and adopted an inclusive conceptualization of outcomes related to disordered eating (including constructs such as binge eating, body dissatisfaction, and other cognitions and behaviors such as dietary restraint, unhealthy weight control behaviors, and drive for thinness). We searched PubMed, Embase, CINAHL, Web of Science, Sociological Abstracts, and PsycINFO for English-language, peer-reviewed articles and dissertations with quantitative methodology published through October 2023. The search resulted in 242 articles meeting inclusion criteria. A narrative review found a consistent relationship between greater weight stigma and more disordered eating cognitions and behaviors. Methodological and theoretical limitations are discussed, as are critical avenues for future research and potential clinical implications stemming from this body of research. Given the widespread nature and impact of weight stigma on disordered eating, it is imperative that we intervene to address weight stigma at all levels, from the structural to the intrapersonal.

Psychometric Properties of the WBIS/M in a Representative Prebariatric Sample: Evidence for an Improved 10-Item Version

INTRODUCTION

The Weight Bias Internalization Scale and the Modified Weight Bias Internalization Scale are well-established self-report questionnaires for assessing weight bias internalization, which is widespread among bariatric patients. However, among this group, psychometric properties of the Weight Bias Internalization Scale have only been examined in small samples showing unsatisfactory model fit and have not been explored for the modified questionnaire.

METHODS

This study psychometrically evaluated and compared the Weight Bias Internalization Scale and Modified Weight Bias Internalization Scale in a large sample of prebariatric patients (N = 825, mean age = 46.75 years, SD = 11.55) regarding item characteristics, model fit to unidimensionality, reliability, construct validity, and measurement invariance.

RESULTS

Item 4 of both questionnaires showed low corrected item-total correlations (<0.40) and was therefore removed from the scales. The new 10-item versions showed improved item characteristics, internal consistency, model fit to unidimensionality, and convergent and divergent validity when compared to the 11-item versions. The best psychometric properties were found for the 10-item version of the Modified Weight Bias Internalization Scale.

CONCLUSION

The 10-item version of the Modified Weight Bias Internalization Scale surpasses the other versions studied in all psychometric properties. Therefore, it should be used in prebariatric patients to detect weight bias internalization and provide them with psychological interventions that could improve bariatric surgery outcomes.

Validation of the Modified Weight Bias Internalization Scale (WBIS-M) among First-Generation Asian Immigrants

Internalized weight bias (i.e., the application of negative weight-based stereotypes to one's self-evaluation) is associated with adverse physical and mental health outcomes. The 10-item version of the Modified Weight Bias Internalization Scale (WBIS-M) is one of the most commonly used measures to assess internalized weight bias. However, studies examining the psychometric properties of the WBIS-M are limited in racially minoritized U.S.-based populations. The current study sought to examine the factor structure of the 10-item version of the WBIS-M in a sample of first-generation Asian immigrants, as both native and foreign-born Asian populations have consistently demonstrated higher rates of weight-related concerns relative to other racially minoritized groups. Confirmatory factor analysis was used to assess the factor structure, and a multiple indicator multiple cause modeling approach was used to assess associations between internalized weight bias and sociodemographic predictors. Results confirm the unidimensionality of the WBIS-M and provide preliminary support for a nine-item version. Identifying as a woman (p = .027) and perceiving oneself as overweight (p < .001) were significantly associated with greater internalized weight bias. When working with Asian and Asian American clients, mental health service providers should be aware of potential weight-related concerns and may consider using the WBIS-M to assess for internalized weight bias.

Depression and Anxiety as Predictors of Metabolic and Bariatric Surgery Completion Among Ethnically Diverse Patients

BACKGROUND

Mental health conditions including depression and anxiety are often prevalent among metabolic and bariatric surgery (MBS) patients, but it is not known if these conditions predict the decision to complete the procedure and if this varies by race and ethnicity. This study aimed to determine if depression and anxiety are associated with MBS completion among a race/ethnically diverse sample of patients.

METHODS

This prospective cohort study included participants who were referred to an obesity program or two MBS practices between August 2019 and October 2022. Participants completed the Mini International Neuropsychiatric Interview (MINI) instrument to determine history of anxiety and/or depression, as well as MBS completion status (Y/N). Multivariable logistic regression models determined the odds of MBS completion by depression and anxiety status adjusting for age, sex, body mass index, and race/ethnicity.

RESULTS

The sample consisted of 413 study participants (87 % women, 40% non-Hispanic White, 39% non-Hispanic Black, and 18% Hispanic). Participants with a history of anxiety were less likely to complete MBS (aOR = 0.52, 95% CI = 0.30-0.90, p = 0.020). Women had increased odds of a history of anxiety (aOR = 5.65, 95% CI = 1.64-19.49, p = 0.006) and of concurrent anxiety and depression (aOR = 3.07, 95% CI = 1.39-6.79, p = 0.005) compared to men.

CONCLUSIONS

Results showed that participants with anxiety were 48% less likely to complete MBS compared to those without anxiety. Additionally, women were more likely to report a history of anxiety with and without depression versus men. These findings can inform pre-MBS programs about risk factors for non-completion.

Self-Compassion May Have Benefits for Body Image among Women with a Higher Body Mass Index and Internalized Weight Bias

Negative attitudes towards one’s own body are common among women and are linked to adverse consequences including negative affect, low self-esteem, and eating pathology. Self-compassion has been found effective in improving body image; however, few published studies have examined self-compassion in populations with higher BMIs despite the positive correlation between weight and body dissatisfaction. The current study examined the efficacy of a self-compassion letter-writing exercise versus two active control groups in response to a negative body image induction. The sample of college-aged females (M age = 20.91 years; SD = 5.47) was split between higher and lower BMI to determine whether self-compassion affects body image, affect, and self-esteem differently across weight groups. Weight bias internalization (WBI: i.e., internalization of society’s negative stigma against those with higher BMIs) was examined as a moderator of this relationship in the higher BMI group. Results suggest that letter writing improved body image regardless of condition (p < 0.001). The self-compassion exercise promoted more adaptive body image (p = 0.007) and self-compassion (p = 0.013) than one control condition for those with high WBI. Results suggest that self-compassion can be helpful in ameliorating negative body image for females of all sizes, and that levels of WBI may alter the effect of body image interventions.

Refining the conceptualization and assessment of internalized weight stigma: A mixed methods approach

Internalized weight stigma has gained increasing attention in empirical studies, though questions remain about the adequacy of existing measures. The current study utilized a mixed methods approach, including a novel semi-structured interview, to revisit the conceptualization of internalized weight stigma and explore in more depth the stereotypes and impacts of weight reported by individuals with high scores on the widely-used Weight Bias Internalization Scale. All participants were interviewed as part of the screening procedures for two clinical trials (Study 1 n = 84, mean age=47.8 years, 83.3% women, 67.9% Black, mean BMI=39.2 kg/m2; Study 2 n = 129, mean age=50.0 years, 88.4% women, 65.1% white, mean BMI=37.8 kg/m2). The most common weight stereotypes identified were being lazy, lacking willpower or self-control, and having poor eating habits. Up to 66% of participants reported that they did not endorse negative weight stereotypes or apply them to themselves. The most highly identified impacts of weight were on self-image (>70%) and emotions (68-83%), followed by social (37-62%) and health concerns (20-25%). Approximately 60% of participants indicated that weight affected their self-directed thoughts and feelings "very much" to "extremely." Findings have implications for understanding and assessing internalized weight stigma in research and in clinical settings where interventions are needed.

An integrative model of weight stigma, body image, and physical activity in adolescents

Negative weight-related experiences and internalized weight stigma have been associated with poorer body image and reduced physical activity in adolescents. However, exploring body image and physical activity as discrete weight stigma outcomes fails to consider the theoretically- and empirically-supported covariation between the two. The present study tested a novel integrated model of the associations among negative weight-related experiences and internalized weight stigma (via weight-related distress), body image (shame, authentic pride, body appreciation), and physical activity. Canadian adolescents (N = 311, M_age ± SD = 16.00 ± 1.01, 75.5% girls) completed a cross-sectional self-report survey. A structural equation model with maximum likelihood robust estimation was tested. Higher negative weight-related experiences were indirectly associated with poorer body image (i.e., higher shame; lower authentic pride and appreciation) through higher weight-related distress. Authentic pride was associated with moderate-to-vigorous physical activity. Higher negative weight-related experiences were indirectly associated with lower physical activity through higher weight-related distress and lower body-related authentic pride. These findings elucidate targetable individual mechanisms and larger systems that could improve body image and foster physical activity among adolescents who encounter negative weight-related experiences and internalized weight stigma.

Spanish validation of the Modified Weight Bias Internalization Scale (WBIS-M) for adolescents

PURPOSE

Weight Bias Internalization (WBI) is pervasive and potentially damaging for health. Little is known about WBI in youth. As negative effects of WBI have been observed when controlling for BMI, measures that allow WBI to be assessed across different weight categories are needed. The Modified Weight Bias Internalization Scale (WBIS-M) is one of the most frequently used scales in this field. Our purpose was to obtain a Spanish validated version of the WBIS-M for adolescents across different weight statuses.

METHODS

The data were collected from 298 secondary students (mean age 14.31; 48.32% girls; 18.8% were overweight and 6.4% had obesity). Internal structure was examined by a cross-validation analysis, using both exploratory and confirmatory factor analyses in different subsamples.

RESULTS

Item 1 showed a psychometric anomalous functioning and was deleted. The one-factor structure of the 10-item version was confirmed with adequate fit ([EFA (KMO = 0.915, χ2(55) = 1075.633, p < 0.0001)]; [CFA (χ2(35) = 200.515; GFI = 0.995; PGFI = 0.992; NFI = 0.991; SRMR = 0.060)]). Internal consistency was high [Formula: see text] ω = 0.93). Significant correlations with the same set of external variables assessed in the original version (anti-fat bias, self-esteem, mood, body dissatisfaction, drive for thinness, binge eating), all of them correlates of WBI in adolescents, were found. Girls and participants with obesity obtained higher scores.

CONCLUSION

The results provide support for the validity and reliability of our WBIS-M version for use with adolescents across weight categories in Spain.

LEVEL OF EVIDENCE

Level III, evidence obtained from well-designed cohort studies.

Examining weight bias before and/or after bariatric surgery: A systematic review

Research examining weight bias in the bariatric population, who may be at greater risk of weight stigma, is scarce. The present study aimed to systematically review the literature for quantitative evidence that explores the medical, psychosocial, and behavioral sequelae associated with experienced, internalized, and/or externalized weight bias in patients seeking or who have undergone bariatric surgery. Five databases were systematically searched for English peer-reviewed quantitative studies, which examined weight bias in a sample of individuals seeking or who had undergone bariatric surgery. Risk of bias was assessed. Twenty-nine studies were included, of which 13 examined internalized weight bias, 12 examined experienced weight bias, 4 examined both, and 0 examined externalized weight bias. Most studies were cross-sectional, and the results showed high risk of bias. The results suggested that both experienced and internalized weight bias were associated with a host of negative psychosocial, behavioral, and medical sequelae. The findings of this review underscore the need for more rigorous research to better understand the relationship between weight bias and bariatric surgery, particularly longitudinally. Future patients may benefit from research developing interventions for reducing weight bias prior to and following bariatric surgery in order to reduce the associated negative correlates and improve outcomes.

Reliability and validity of the Japanese version of the weight bias internalization scale

Objective

The weight bias internalization scale (WBIS) is widely used in several languages. However, there is no Japanese version of the WBIS. The purpose of this study is to develop a Japanese version of the WBIS and to verify its reliability and validity. We translated the original version of the WBIS and had approval from the scale developer. Adults who perceived themselves to be obese completed online baseline survey (N = 285) and two-week follow-up survey (N = 100). We used the Japanese WBIS and scales for obesity-related quality of life, self-esteem, self-efficacy, and depression. We calculated Cronbach’s alpha and intra-class correlation coefficient (ICC) to assess reliability of the WBIS and conducted confirmatory factor analysis (CFA) and correlation analysis to assess its validity.

Results

Cronbach’s alpha was 0.91 at baseline and 0.92 at follow-up, and the ICC was 0.87. CFA showed that a one-factor model demonstrated an acceptable fit (χ2 (44) = 158.6, CFI = 0.93, RMSEA = 0.096, SRMR = 0.051), similar to the original version. As we had hypothesized, overall, the Japanese version of the WBIS was significantly correlated with obesity-related quality of life, self-esteem, self-efficacy, and depression. These results confirmed its adequate reliability and validity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-06221-x.

Weight stigma in patients with overweight and obesity: validation of the Italian Weight Self-Stigma Questionnaire (WSSQ)

PURPOSE

This study aimed to explore the factorial structure of the Italian Weight Self-Stigma Questionnaire (WSSQ) (Study1); and to test structural validity, internal consistency, test-retest reliability, and measurement invariance of the questionnaire across gender, Body Mass Index (BMI), age and occurrence of previous hospitalization for obesity (Study2).

METHODS

At admission into a hospital-based program for weight reduction and rehabilitation, 150 inpatients with overweight/obesity (68% females) completed the WSSQ (Study1). In Study2, in addition to the WSSQ, 446 inpatients (61.9% females) completed the Weight Bias Internalization Scale (WBIS), the Body Uneasiness Test (BUT), and the Center for Epidemiologic Studies Depression Scale (CES-D). A subsample of 40 patients also re-completed the WSSQ at discharge from the hospital.

RESULTS

The Italian WSSQ showed good overlap with the original factorial structure (Study1) and results were confirmed in Study2. Test-retest reliability and convergent validity showed adequate values. Measurement invariance revealed that WSSQ was perfectly invariant across both BMI and the occurrence of previous hospitalizations for obesity. In both studies, the internal consistency of the questionnaire was deemed acceptable.

CONCLUSIONS

The Italian WSSQ is a valid, reliable, and invariant tool for the assessment of weight-related self-stigma among patients with overweight/obesity. Future studies should assess its longitudinal invariance as well as its responsiveness to weight reduction treatments.

LEVEL OF EVIDENCE

V, descriptive study.

Body Checking and Body Image Avoidance as Partial Mediators of the Relationship between Internalized Weight Bias and Body Dissatisfaction

Internalized weight bias is associated with body image disturbances and the development of disordered eating. The association between weight bias internalization and body dissatisfaction has proven difficult to disrupt. In order to develop more effective interventions, we must identify the behavioral targets which account for this robust association. The present study sought to examine whether body checking and body image avoidance mediate the relationship between weight bias internalization and body dissatisfaction. In total, 279 female undergraduates (Mage = 20.13, SD = 4.10) were administered a battery of survey measures. Results demonstrated that body checking partially mediates the relationship between weight bias internalization and body dissatisfaction, Z = 7.42, p < 0.001. Body image avoidance was also found to partially mediate the relationship between weight bias internalization and body dissatisfaction, Z = 70.03, p < 0.001. These findings suggest that body checking and body image avoidance may both partially account for the association between weight bias internalization and body dissatisfaction. These findings extend the existing literature on weight bias internalization by highlighting two behavioral targets for prevention and intervention efforts. Understanding these relationships has important implications for both reducing weight bias internalization and improving body dissatisfaction.

Exploring weight bias internalization in pregnancy

BACKGROUND

Recent research has shown that pregnant individuals experience weight stigma throughout gestation, including negative comments and judgement associated with gestational weight gain (GWG). Weight bias internalization (WBI) is often a result of exposure to weight stigma and is detrimental to biopsychological health outcomes. The purpose of this study was to explore WBI in pregnancy and compare scores based on maternal weight-related factors including pre-pregnancy body mass index (BMI), obesity diagnosis and excessive GWG.

METHODS

Pregnant individuals in Canada and USA completed a modified version of the Adult Weight Bias Internalization Scale. Self-reported pre-pregnancy height and weight were collected to calculate and classify pre-pregnancy BMI. Current weight was also reported to calculate GWG, which was then classified as excessive or not based on Institute of Medicine (2009) guidelines. Participants indicated if they were diagnosed with obesity by a healthcare provider. Inferential analyses were performed comparing WBI scores according to pre-pregnancy BMI, excessive GWG, and obesity diagnosis. Significance was accepted as p < 0.05 and effect sizes accompanied all analyses.

RESULT

336 pregnant individuals completed the survey, with an average WBI score of 3.9 ± 1.2. WBI was higher among those who had a pre-pregnancy BMI of obese than normal weight (p = 0.04, η2 = 0.03), diagnosed with obesity than not diagnosed (p < 0.001, Cohen's d = 1.3), and gained excessively versus not (p < 0.001, Cohen's d = 1.2).

CONCLUSIONS

Pregnant individuals who have a higher BMI, obesity and gain excessively may experience WBI. Given that weight stigma frequently occurs in pregnancy, effective person-oriented strategies are needed to mitigate stigma and prevent and care for WBI.

Examining the Conceptual and Measurement Overlap of Body Dissatisfaction and Internalized Weight Stigma in Predominantly Female Samples: A Meta-Analysis and Measurement Refinement Study

Both body dissatisfaction and internalized weight stigma have been identified as risk factors for many negative health outcomes for women, including depression and eating disorders. In addition to these contributions, these concepts have been found to overlap to various degrees in existing literature. We conducted a systematic review and meta-analysis on articles published prior to February 2022 to demonstrate the conceptual and measurement overlap between body dissatisfaction and internalized weight stigma as currently quantified. We identified 48 studies examining the interrelation between body dissatisfaction and internalized weight stigma in predominantly female samples. Stronger correlations between these two constructs, some bordering on multicollinearity, were prevalent in community samples compared to clinical samples and with some but not all the commonly used measures in the body image and weight stigma fields. Body mass index (BMI) moderated these relations such that individuals with higher self-reported BMI were more likely to report lower correlations between the constructs. This concept proliferation, stronger for individuals with lower BMIs and community samples, necessitates the need change how we conceptualize and measure body dissatisfaction and internalized weight stigma. To this end, we conducted study two to refine existing measures and lessen the degree of measurement overlap between internalized weight stigma and body dissatisfaction, particularly in community samples of women. We aimed to clarify the boundaries between these two concepts, ensuring measurement error is better accounted for. Female university students completed existing measures of body satisfaction and internalized weight stigma, which were analyzed using an exploratory followed by a confirmatory factor analysis. In our attempts to modify two existing measures of internalized weight stigma and body dissatisfaction, the majority of the internalized weight stigma items were retained. In contrast, most of the body dissatisfaction items either cross-loaded onto both factors or loaded on to the internalized weight stigma factor despite being intended for the body dissatisfaction factor, suggesting that the measurement issues identified in recent prior research may be due not only to the way we conceptualize and quantify weight stigma, but also the ways in which we quantify body dissatisfaction, across the existing corpus of body dissatisfaction scales.

Translation and validation of the Greek version of the Modified Weight Bias Internalization Scale in an adult population

Weight bias internalization (WBI) has been identified as a global public health concern, which is associated with significant psychological and physical consequences. Despite increased interest in WBI worldwide, cross-cultural research is limited by the lack of availability of validated measures. The aim of the current study was therefore to translate into Greek and validate the Modified Weight Bias Internalization Scale (WBIS-M), the most widely used instrument in the measurement of WBI. An online convenience sample of 642 participants (364 women and 278 men) completed the Greek translation of the WBIS-M and validated the measures of satisfaction with appearance, investment in appearance, weight/appearance anxiety, body appreciation, dysfunctional eating habits and global self-esteem to assess convergent validity. Principal factor and confirmatory analyses revealed that the WBIS-M upheld its one-factor structure. The WBIS-M showed adequate internal consistency, convergent validity and 3-week test-retest reliability. These findings provide support for the cross-cultural equivalence of the WBIS-M and for the utility of this measure in Greek-speaking populations.

Simply too much: the extent to which weight bias internalization results in a higher risk of eating disorders and psychosocial problems

PURPOSE

Weight bias internalization (WBI) is associated with negative health consequences such as eating disorders and psychosocial problems in children. To date, it is unknown to what extent WBI considerably raises the risk of negative outcomes.

METHODS

Analyses are based on cross-sectional data of 1,061 children (9-13 years, M = 11, SD = 0.9; 52.1% female) who filled in the WBI scale (WBIS-C). First, ROC analyses were run to identify critical cut-off values of WBI (WBIS-C score) that identify those who are at higher risk for psychosocial problems or eating disorder symptoms (as reported by parents). Second, it was examined whether WBI is more sensitive than the relative weight status in that respect. Third, to confirm that the cut-off value is also accompanied by higher psychological strain, high- and low-risk groups were compared in terms of their self-reported depressive symptoms, anxious symptoms, body dissatisfaction, and self-esteem.

RESULTS

WBIS-C scores ≥ 1.55 were associated with a higher risk of disturbed eating behavior; for psychosocial problems, no cut-off score reached adequate sensitivity and specificity. Compared to relative weight status, WBI was better suited to detect disturbed eating behavior. Children with a WBIS-C score ≥ 1.55 also reported higher scores for both depressive and anxious symptoms, higher body dissatisfaction, and lower self-esteem.

CONCLUSION

The WBIS-C is suitable for identifying risk groups, and even low levels of WBI are accompanied by adverse mental health. Therefore, WBI is, beyond weight status, an important risk factor that should be considered in prevention and intervention.

LEVEL OF EVIDENCE

Level III, cross-sectional analyses based on data taken from a well-designed, prospective cohort study.

The role of weight stigma in weight regain in bariatric surgery

Obesity is highly stigmatized, and individuals who undergo bariatric surgery are subject not only to weight stigma, but also to stigma related to the procedure itself. Patients lost to follow-up after surgery make estimating the amount of regain occurring after surgery difficult, and often patients fail to follow up due the shame of weight regain. Patients report difficulty following the diet necessary to maintain weight loss. Additionally, when they seek support after surgery, they often encounter stigmatizing messaging related to weight. Weight bias internalization, weight stigma, and stigma about having the surgery all contribute to feelings of social isolation, disordered eating, and reduced motivation to engage in physical activity. In this chapter, we present evidence for the impact of stigma on bariatric surgery outcomes and discuss the behavioral, physiological, and emotional processes that contribute to weight regain.

Eating Disorder Symptomatology Among Adolescents Presenting for Bariatric Surgery Candidacy: Examining Differences by Sex and Racial Minority Status

BACKGROUND

Research on adolescent bariatric surgery candidates is limited by insufficient inclusion of ethnic minorities and males, and lack of consideration of the full spectrum of disordered eating behaviors (i.e., restriction, compensatory behaviors [e.g., purging], overeating/binge eating behaviors).

OBJECTIVES

The current study investigated differences in the full range of disordered eating behaviors across sex and ethnicity among adolescents seeking bariatric surgery.

SETTING

Teaching hospital, United States.

METHODS

Data were collected using retrospective chart review of 79 adolescent bariatric surgery candidates (59% female, 46.8% Hispanic, MBMI = 50.2, SDBMI = 10.0, Mage = 17.3, SDage = 2.02) who had completed the self-reported Eating Disorder Diagnostic Scale for DSM-5 at intake.

RESULTS

Approximately 33% of study participants met self-reported criteria for an eating disorder, with 35% endorsing binge eating behaviors and 50% endorsing compensatory behaviors. Few differences in behavior frequencies were observed across sex or racial/ethnic status.

CONCLUSIONS

Findings underscore the importance of assessing the full spectrum of disordered eating behaviors among adolescent bariatric surgery candidates.

Internalized weight bias and loss-of-control eating following bariatric surgery

OBJECTIVE

Internalized weight bias (IWB), or negative weight related self-evaluation, is associated with eating-disorder psychopathology and common among patients seeking bariatric surgery, but little is known about the clinical presentation of IWB post-operatively. This study examined IWB and clinical correlates among adult patients with loss-of-control (LOC) eating post-sleeve gastrectomy surgery.

METHODS

Participants (N = 145) were sleeve gastrectomy patients seeking treatment for eating/weight concerns and experiencing regular LOC eating approximately 6 months following surgery. Eating-disorder features were assessed with the Eating Disorder Examination-Bariatric Surgery Version interview (EDE-BSV) and participants completed established measures assessing IWB, depression, and mental and physical components of quality of life.

RESULTS

IWB was not associated significantly with percent excess weight loss, age, or gender, but White participants reported significantly greater IWB than Non-White participants. IWB was significantly associated with greater eating-disorder psychopathology, depression, and lower perceived mental quality of life. Hierarchical regression analysis revealed that IWB significantly predicted variance in eating-disorder psychopathology above and beyond other related variables.

CONCLUSIONS

Findings suggest that IWB is common and associated with a range of heightened eating-disorder and psychosocial difficulties among patients experiencing LOC eating following bariatric surgery. Future research exploring the longitudinal post-operative prognostic significance of IWB is recommended.

Adverse Childhood Experiences and Weight Stigma: Co-Occurrence and Associations with Psychological Well-Being

Prior research has demonstrated that individuals with a higher body weight (i.e., obesity) have a relatively high incidence of adverse childhood experiences (ACEs) (e.g., abuse, neglect). Individuals with obesity are also susceptible to experiencing and internalizing weight stigma. Negative physical and mental health consequences have been associated with both ACEs and weight stigma, yet the interplay between these factors has not been explored. The current study examined ACEs in a sample of 105 treatment-seeking adults with obesity who all reported having experienced and internalized weight stigma (90.5% women, 70.5% non-Hispanic White, mean age=49.1 years). The study aimed to 1) provide a descriptive overview of rates of ACEs in this unique sample of adults with potentially high psychological vulnerability and 2) assess associations between ACEs, weight stigma, and psychological well-being. Over three-fourths of participants (76.2%) reported experiencing at least one ACE. The total number of ACEs was significantly associated with more frequent experiences of and greater distress about weight stigma during childhood, as well as higher current perceived stress. Experiencing weight stigma for the first time in childhood was also associated with more reported ACEs. ACEs of abuse were associated with more lifetime reported experiences of weight stigma and greater internalization, use of eating as a strategy to cope with weight stigma, and higher perceived stress. These findings have implications for early identification of and tailored interventions for individuals who have experienced adverse events and weight stigma at a young age.

Validation of the modified weight bias internalization scale in a Spanish adult population

Weight bias internalization has received considerable attention in recent years and has been associated with serious psychological and physical consequences in Westernized societies. The modified weight bias internalization scale (WBIS-M) is one of the most frequently used instruments for assessing internalized weight stigma across different body weight categories. The aim of this study was to adapt the WBIS-M for use in Spanish adult populations. The sample consisted of 678 participants from the Spanish general population recruited through the internet, 79.6% of whom were women. The scale was translated into Spanish and then backtranslated. To study the internal structure, a cross-validation analysis was carried out including both exploratory and confirmatory factor analyses to assess the scale's psychometric properties. Internal consistency was evaluated using Cronbach's alpha and McDonald's omega and a test-retest was conducted to assess one-month stability. Results confirmed that the Spanish adaptation of the WBIS-M is an 11-item unidimensional scale, like the original version and shows excellent psychometric properties. In conclusion, the Spanish WBIS-M version seems to be a robust psychometric tool for use in clinical and research settings.

Predictors of surgical intervention for those seeking bariatric surgery

BACKGROUND

Bariatric surgery has been found to be effective in the treatment of severe obesity. Studies have shown that the majority of eligible patients do not undergo surgery.

OBJECTIVES

It is important to identify variables that may impact patient decision making and potentially lead to the disproportionate underutilization of bariatric surgery.

SETTING

The study was conducted at one academic medical center in central Pennsylvania.

METHODS

Bariatric patients who participated in a preoperative psychological assessment from 2017 to early 2020 completed comprehensive self-report questionnaires addressing sociodemographic variables, health history, psychopathology, and eating behaviors. Body mass index was calculated based on clinical measurements of each patient at the start of the preoperative program. Sociodemographic variables and self-report instrument scores were compared between those who completed surgery and those who did not.

RESULTS

Of the 1234 participants, significant differences were found between the compared variables. All minority groups were less likely to undergo surgery than White patients. Participants reporting higher impairment were less likely to progress to surgery. Impairments across 3 behavioral eating assessments were associated with a lower likelihood of surgery.

CONCLUSION

There are multiple factors that contribute to patient progression to surgery, and ultimately whether the patient undergoes bariatric surgery. Results show a need for further investigation surrounding the sociodemographic and psychosocial variables that influence the patient's advancement to surgery. Both providers and patients could benefit from a deeper understanding of potential barriers to utilization of bariatric surgery.

An exploratory examination of internalized weight stigma in a sample living with food insecurity

Internalized weight stigma (IWS) is associated with various health concerns, regardless of body size. One weakness of existing IWS research is that it largely lacks diverse study populations. One recent exception, however, found increasing IWS was associated with higher levels of food insecurity (FI) in a low-income, majority Latinx sample. Using the same sample (N = 530), the present study further explored levels of IWS as compared to documented (mostly White/European) samples; we also investigated IWS in relation to three dichotomous eating disorder (ED) outcomes (e.g., any/no vomiting). Finally, based on previous qualitative findings regarding dietary restraint in the most severe level of FI, we explored the independent contribution of dietary restraint and IWS to cross-sectional risk of ED pathology. Results indicated that individuals living with FI experience IWS at concerning levels. Additionally, IWS played a small yet significant role in cross-sectional risk for ED pathology regardless of FI severity, while dietary restraint contributed to independent risk only in those with the most severe FI. Findings suggest that IWS is prevalent in this marginalized population, associated with ED pathology, and that the effect of dietary restraint on risk for ED pathology appears to uniquely impact those living with severe FI.

Bidirectional relationships between weight stigma and pediatric obesity: A systematic review and meta-analysis

This study for the first time quantified concurrent and bidirectional relationships between weight stigma and weight status in children, with age and gender as moderators. A literature search was conducted in PubMed, Web of Science, and PsycINFO for studies examined associations between weight stigma and weight status among children aged 6-18 years. Twenty-five studies (20 cross-sectional studies and five longitudinal studies) from six countries with 101,036 participants were included in review, and 18 were included in meta-analysis. Weight and height were self-reported in nine studies, otherwise objectively measured. With data from 17 cross-sectional studies and baseline portions of four longitudinal studies, meta-analysis showed weight stigma and overweight/obesity were associated (pooled OR = 3.12, 95% CI: 2.71, 3.60), they were also associated across age and gender. Body mass index (BMI) was associated with greater weight stigma (pooled r = 0.38, 95% CI: 0.32, 0.43). Age modified such association. Weight stigma predicted increased BMI from three longitudinal studies (pooled β = 1.12, 95% CI: 0.78, 1.45); another two longitudinal studies reported BMI predicted greater weight stigma. Data were inadequate for age- or gender-stratified analyses. Findings supported positive concurrent and bidirectional relationships between weight stigma and weight status. Timely obesity and weight stigma interventions to protect children well-being are needed.

Examining Weight Bias and Loss-of-Control Eating among Individuals Seeking Bariatric Surgery

OBJECTIVE

Externalized weight bias (EWB), directed towards others, and internalized weight bias (IWB), directed towards the self, are thought to exacerbate obesity and disordered eating and may be important factors to assess and understand among individuals seeking bariatric surgery. This study examined clinical correlates (pre-surgical BMI, depressive symptoms, weight self-efficacy, and shape/weight overvaluation) of both EWB and IWB among individuals presenting for bariatric surgery with and without regular loss-of-control eating (LOC eating).

METHODS

A total of 316 adults presenting for bariatric surgery completed established self-report measures to assess EWB, IWB, depressive symptoms, weight self-efficacy, and core symptoms of disordered eating including LOC eating and overvaluation of shape/weight.

RESULTS

IWB and EWB were not associated with pre-surgical BMI, age, or sex, but were both significantly higher among White than non-White participants. Adjusting for race, IWB and EWB were significantly associated with greater eating disorder psychopathology and depressive symptoms and with less weight-related self-efficacy. Participants who endorsed regular LOC eating (53.5% of the sample) endorsed significantly lower weight self-efficacy and higher IWB, EWB, depressive symptoms, and overvaluation of shape/weight.

CONCLUSIONS

Findings suggest that regular LOC eating is common among individuals seeking bariatric surgery and associated with a range of heightened eating disorder and psychosocial concerns including both IWB and EWB. Future research exploring the longitudinal significance of the relationship between these two forms of weight bias and LOC eating is indicated.

Prevalence and correlates of weight bias internalization in weight management: A multinational study

Weight bias internalization (WBI) is an understudied form of internalized stigma, particularly among treatment-seeking adults with overweight/obesity. The current study surveyed 13,996 adults currently engaged in weight management in the first multinational study of WBI. From May to July 2020, participants in six Western countries completed the Modified Weight Bias Internalization Scale (WBIS-M) and measures of weight change, health behaviors, psychosocial well-being, and health-related quality of life (HRQOL). Participants were majority white, female, middle-aged, and categorized as having overweight or obesity based on body mass index. Results showed higher mean WBIS-M scores among participants in the UK, Australia, and France than in Germany, the US, and Canada. Across all countries, and controlling for participant characteristics and experiences of weight stigma, WBIS-M scores were associated with greater weight gain in the past year. Participants with higher WBIS-M scores also reported poorer mental and physical HRQOL, less eating and physical activity self-efficacy, greater engagement in eating as a coping strategy, more avoidance of going to the gym, poorer body image, and greater perceived stress. Few interaction effects were found between experiences and internalization of weight stigma. Overall, the current findings support WBI as a robust correlate of adverse weight-related health indices across six Western countries. Prospective and experimental studies are needed to determine directionality and causality in the relationship between WBI and poor health outcomes.

Disinhibition and Subjective Hunger as Mediators Between Weight Bias Internalization and Binge Eating Among Pre-Surgical Bariatric Patients

PURPOSE

Weight bias internalization, or the process of applying negative weight-related attitudes and beliefs to oneself, is an important construct in regard to patients pursuing bariatric surgery. Weight bias internalization (or internalized weight bias) has been previously associated with depressive symptoms and binge eating among pre-surgical bariatric patients. However, a gap in the literature exists pertaining to how certain eating behaviors may mediate the relationship between weight bias internalization and binge eating. The present study assessed the role of eating behaviors (i.e., cognitive restraint, disinhibition, and hunger) as mediators between weight bias internalization and binge eating symptoms when controlling for depression.

MATERIALS AND METHODS

A total of 708 adults (Mage = 42.91; White = 95.3%; women = 79.4%) seeking bariatric surgery at a tertiary academic medical center in the Appalachia region of the USA were included in this retrospective study. Patients completed validated measures of weight bias internalization, eating behaviors, and depression as part of a routine, psychological evaluation in order to determine surgical clearance.

RESULTS

Disinhibition and hunger were significant mediators in the relationship between weight bias internalization and binge eating beyond the role of depressive symptoms alone.

CONCLUSION

Disinhibited eating, or the tendency to experience a loss of control and eating in response to negative emotions, as well as subjective feelings of hunger are important dimensions of eating, particularly as related to weight bias internalization and binge eating. Weight bias internalization is an important factor to consider among pre-surgical bariatric patients and warrants additional treatment considerations.

Validation of the Weight Bias Internalization Scale for Mainland Chinese Children and Adolescents

Weight stigma internalization among adolescents across weight categories leads to adverse psychological consequences. This study aims to adapt and validate a Chinese version of the Weight Bias Internalization Scale for Mainland Chinese children and adolescents(C-WBIS). A total of 464 individuals aged 9 to 15 years participated in the present study. Based on item response theory (IRT) and classical test theory (CTT), we selected the items for the C-WBIS and evaluated its reliability and validity. The item response theory yields support for the one-dimensional factor mode. All item parameters fit the IRT model (albeit within an adequate range), eight items were adopted. No evidence of significant differential item functioning (DIF) was found for gender and age groups. The C-WBIS was correlated with the Core Self-Evaluation Scale (CSES) and two subscales of the Social Anxiety Scale for Children (SAS), which indicated an acceptable criterion-related validity. The C-WBIS is a reliable and valid measure that can be used as a psychometrically sound and informative tool to assess weight bias internalization among children and adolescents.

Internalized Weight Bias, Teasing, and Self-Esteem in Children with Overweight or Obesity

Background: Although 2/3 of US adults and nearly 1/3 of US children have overweight or obesity, weight stigma is common. Many with overweight or obesity ascribe negative ideas to themselves, resulting in internalized weight bias (IWB). In adults, IWB has been associated with psychosocial problems; however, this relationship has been studied little in children. This study aims to describe IWB in children with overweight and obesity and to study the association of children's IWB with experienced weight bias, self-esteem, and their parents' IWB. Methods: Children ages 9-18 with overweight or obesity completed the Weight Bias Internalization Scale (WBIS), Rosenberg Self-Esteem Scale, and Perception of Teasing Scale; parents completed the Weight Bias Internalization Scale-Modified and the Perceived Weight Discrimination Scale. Descriptive statistics were used to assess IWB, self-esteem, and experienced weight stigma. Chi-square and t-tests were used to examine associations between categorical and continuous variables, respectively. Multivariate linear regression was used to identify correlates of IWB in children. Results: Of 111 child participants, the median WBIS score was 2.8 out of 7. Higher IWB was associated with more peer teasing (p < 0.001) and lower self-esteem (p < 0.001). IWB in children was not associated with child BMI z-score (p = 0.590) or higher parent IWB (p = 0.287). Conclusions: Children with overweight and obesity who have experienced more teasing by peers or who have lower self-esteem are more likely to have a higher IWB. However, increasing child BMI z-score and parent IWB are not associated with higher child IWB.

Internalized weight bias in patients presenting for bariatric surgery

INTRODUCTION

Internalized weight bias (IWB) is significantly related to poor psychosocial health outcomes in patients with increased body mass index (BMI). The objective of this study was to evaluate the psychometric properties and correlates of the Weight-Bias Internalization Scale in a pre-surgical bariatric population.

METHODS

Self-report measures were administered to patients prior to surgery. Measures assessed internalized weight bias, body dissatisfaction, depression, anxiety, quality of life, and eating behaviors. Statistical methods included confirmatory factor analysis to examine the factor structure [of the WBIS] in this population, descriptive statistics, correlations, and hierarchical linear regression between continuous variables to determine patterns of associations, and t-tests to compare levels of IWB between the current sample and previously documented samples.

RESULTS

Confirmatory factor analysis indicated an acceptable fit using a one-factor structure for the WBIS, with one item removed. Mean WBIS in the current sample was comparable to that documented in a community sample of adults with overweight and obesity, as well as a sample of adolescents seeking bariatric surgery. Additionally, IWB was positively associated with body dissatisfaction, restrained, emotional, and external eating, depression, and anxiety, and negatively associated with quality of life. Further, individuals endorsing episodes of loss of control over eating had significantly higher WBIS scores.

CONCLUSIONS

This study highlights the strong pattern of associations with measures of body image, disordered eating, and quality of life point toward the relevance of IWB to bariatric patients' experiences. Future studies to explore the longitudinal effects of IWB in a post-bariatric population are needed particularly to understand psychosocial and surgical health outcomes.

Intrapersonal predictors of weight bias internalization among elementary school children: a prospective analysis

BACKGROUND

Weight-related stigmatization is a widespread problem. Particularly the internalization of weight-related stereotypes and prejudices (weight bias internalization, WBI) is related to mental and physical health impairments. To date, little is known about the risk factors of WBI. Previous studies are mainly cross-sectional and based on adult samples. As childhood is a sensitive period for the development of a healthy self-concept, we examined predictors of WBI in children.

METHODS

The final sample included 1,463 schoolchildren (6-11 years, 51.7% female) who took part in a prospective study consisting of three measurement waves. The first two waves delivered data on objective weight status and self-reported weight-related teasing, body dissatisfaction, relevance of one's own figure, self-esteem and depressive symptoms; WBI was measured during the third wave. To examine predictors of WBI, we ran hierarchical regression analyses and exploratory mediation analyses.

RESULTS

Lower parental education level, higher child weight status, female gender, experience of teasing, higher body dissatisfaction, higher figure-relevance, and higher depression scores were found to be predictive for higher WBI scores. Body dissatisfaction (only for girls) and the relevance of one's own figure (both genders) mediated the association between self-esteem and WBI; no weight-related differences were observed.

CONCLUSIONS

Our study offers longitudinal evidence for variables that enable the identification of children who are at risk for WBI. Thus, the findings deliver starting points for interventions aimed at the prevention of adverse health developments that come along with WBI.

Psychometric testing on two weight stigma instruments in Iran: Weight Self-Stigma Questionnaire and Weight Bias Internalized Scale

PURPOSE

This study aimed to comprehensively and thoroughly examine the psychometric properties of two commonly used weight-related self-stigma instruments on Iranian adolescents with overweight or obesity: Weight Self-Stigma Questionnaire [WSSQ] and Weight Bias Internalization Scale [WBIS].

METHODS

After ensuring the linguistic validity of both the WSSQ and WBIS in their Persian versions, 737 Iranian adolescents with overweight or obesity (male = 354; mean age = 15.8 ± 1.3 years; body mass index = 30.0 ± 4.8 kg/m²) completed both questionnaires and other relevant measures regarding their depression, anxiety, stress, dietary self-efficacy, weight efficacy lifestyle, quality of life, body fat, self-esteem, body shape preoccupation, and sleepiness.

RESULTS

In the scale level, the confirmatory factory analysis verified the two-factor structure for the WSSQ and the single-factor structure for the WBIS. The factorial structures were further found to be invariant across gender (male vs. female) and across weight status (overweight vs. obesity). Additionally, both the WSSQ and WBIS had promising properties in internal consistency, test-retest reliability, separation reliability, and separation index. In the item level, all items but WBIS item 1 (infit mean square = 1.68; outfit mean square = 1.60) had satisfactory properties in factor loadings, corrected item-total correlation, test-retest reliability, and infit and outfit mean square. Moreover, all the items did not display substantial differential item functioning (DIF) across gender and across weight status.

CONCLUSION

Both the WSSQ and WBIS were valid instruments to assess the internalization of weight bias for Iranian adolescents with overweight or obesity.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

The Association Between Weight-Based Teasing from Peers and Family in Childhood and Depressive Symptoms in Childhood and Adulthood: A Systematic Review

RECENT FINDINGS

Depressive symptoms may be a psychological correlate of weight-based teasing from peers and/or family. However, it is unclear whether the association of weight-based teasing with depressive symptoms differs by time (short term vs. long term), sex (males vs. females), or source (family vs. peers).

PURPOSE

The purpose of this systematic review was to (1) examine whether the frequency of weight-based teasing differs according to sex and source and; (2) examine whether the association of weight-based teasing with depressive symptoms varies according to time, sex, and source.

METHODS

On February 16, 2018, a combination of keywords within three concepts, (i) children and adults, (ii) weight-based teasing source, and (iii) mental health outcomes, were searched in four databases (PubMed, PsycINFO, Scopus, and Web of Science) for relevant articles. Cross-sectional and longitudinal original research articles were included, and studies were excluded if the relationship between weight-based teasing and depressive symptoms was not explicitly measured.

RESULTS

The search yielded 3572 articles, and nineteen studies were included in the final analysis. Experiences of weight-based teasing occurred significantly more among girls than boys. Weight-based teasing was significantly associated with depressive symptoms in both short and long term. Weight-based teasing exhibited a greater association with depressive symptoms in girls vs. boys and when it came from multiple sources than from either source alone. However, it remains uncertain whether one source of teasing is more common than the other, since only two studies found peers to be a more common source of weight-based teasing compared to family. Weight-based teasing from peers and family is associated with depressive symptoms, and girls are more psychologically vulnerable than boys. Interventions are required to reduce weight-based teasing and its harmful psychological effects.

A prospective study on the link between weight-related self-stigma and binge eating: Role of food addiction and psychological distress

OBJECTIVES

This prospective study investigated the link between weight-related self-stigma and binge eating by (a) examining the temporal association between weight-related self-stigma and binge eating; (b) investigating the mediating role of food addiction in the association between weight-related self-stigma and binge eating; and (c) examining the mediating role of psychological distress in the association between weight-related self-stigma and binge eating.

METHOD

Participants comprised 1,497 adolescents (mean = 15.1 years; SD = 6.0). Body mass index and weight bias were assessed at baseline; psychological distress (i.e., depression, anxiety, and stress) assessed and food addiction at 3 months; and binge eating at 6 months. The mediation model was analyzed using Model 4 in the PROCESS macro for SPSS with 10,000 bootstrapping resamples.

RESULTS

There was no significant direct association between weight-related self-stigma and binge eating. However, food addiction and psychological distress significantly mediated the association between weight-related self-stigma and binge eating.

DISCUSSION

These findings highlight the indirect association between weight-related self-stigma and binge eating via food addiction and psychological distress. Consequently, intervention programs targeting food addiction and psychological distress among adolescents may have significant positive effects on outcomes for weight-related self-stigma and binge eating. The findings will be beneficial to researchers and healthcare professionals working with adolescents during this critical developmental period.

Weight-related stigma and psychological distress: A systematic review and meta-analysis

BACKGROUND & AIMS

Individuals who are overweight or who have obesity are likely to perceive or experience unfriendly treatment (i.e., weight-related perceived stigma) from different sources such as work colleagues because of the stigma towards excess weight. People who are overweight may accept such stigma and devalue themselves (i.e., weight-related self-stigma).

METHODS

A systematic review and meta-analysis was conducted to examine the relationship between weight stigma (including weight-related self-stigma and weight-related perceived stigma) and psychological distress (including depression and anxiety) using random-effects meta-analyses. Utilizing five academic databases (PubMed, Scopus, WOS, Embase and ProQuest) and keywords related to weight stigma and psychological distress, empirical studies focusing on the association between weight stigma and psychological distress were selected. The timeline for the searched papers was from the inception of each database to the end of August 2019.

RESULTS

Eligible studies (N = 30; 25 on weight-related self-stigma and eight on weight-related perceived stigma) were analyzed with a total of 9345 participants experiencing weight-related self-stigma, and 15,496 experiencing weight-related perceived stigma. The pooled associations were moderate between weight-related self-stigma and psychological distress (corrected Fisher's Z = 0.40 for depression; 0.36 for anxiety) and between perceived stigma and depression (Fisher's Z = 0.44).

CONCLUSIONS

Results of the meta-analysis demonstrated that weight stigma is associated with psychological distress. The comprehensive search of the literature and rigorous methodology employed are the two major strengths in the present study. Because self-stigma and perceived stigma are different concepts, their associations with psychological distress should not be merged together.

Weight bias internalization in a commercial weight management sample: prevalence and correlates

OBJECTIVE

Weight bias internalization (WBI) is associated with poor weight-related health. The purpose of this study was to identify the prevalence and correlates of WBI in a large sample of adults in a commercial weight management programme.

METHODS

WW (the new Weight Watchers) members participated in an online survey. Participants (N = 18,769) completed the 10-item Weight Bias Internalization Scale - Modified (WBIS-M) and the Weight Self-Stigma Questionnaire (WSSQ). Participants reported details about weight-stigmatizing experiences, including the onset, frequency and distress, and interpersonal sources of weight stigma. Participants self-reported their demographics, weight history, and height and weight (to compute body mass index [BMI]).

RESULTS

Weight bias internalization was relatively high compared with the general population (mean WBIS-M score = 4.3 ± 1.4; mean WSSQ total score = 35.2 ± 9.7). WBI was higher among participants who were female, younger and had higher BMIs (p < 0.001) and lower among those who were Black and were widowed or had a romantic partner (p < 0.001). Onset of weight stigma in childhood and young adulthood, and recent distress due to weight stigma, predicted higher WBI. Extended family and school sources of weight stigma had weaker associations with WBI than did other interpersonal sources.

CONCLUSIONS

Weight bias was internalized by a significant proportion of adults enrolled in a commercial weight management programme. A phenotype of WBI includes demographic characteristics and the timing and sources of weight stigma.

Psychometric properties of the Weight Self-Stigma Questionnaire (WSSQ) among a sample of overweight/obese French-speaking adolescents

PURPOSE

The Weight Self-Stigma Questionnaire (WSSQ) was recently developed to assess the internalization of weight stigma among English-speaking overweight and obese adults. The objective of the present study was to develop and examine the psychometric properties of a French version of the WSSQ, as well as its applicability to adolescents.

METHODS

The sample comprised 156 overweight and obese adolescents (81 boys, 75 girls, M_age = 16.31). The factor validity and the convergent validity of the French version of the WSSQ were examined using a confirmatory factor analysis and a structural equation model, respectively.

RESULTS

The a priori two-factor structure of the WSSQ and the composite reliability of its subscales (self-devaluation and fear of enacted stigma) were supported. Convergent validity analyses revealed that both WSSQ subscales were significantly and (a) negatively correlated with measures of self-esteem and physical appearance, and (b) positively correlated with measures of anxiety, depression, fear of negative appearance evaluation, and eating-related pathology (fear of getting fat, eating-related control, food preoccupation, vomiting-purging behaviors, and eating-related guilt subscales). However, no significant relation was found between the WSSQ subscales and body mass index.

CONCLUSION

These results suggest that the French version of the WSSQ has acceptable psychometric properties and can be used to assess weight self-stigma among overweight and obese adolescents.

Psychometric properties and measurement invariance of the Weight Self-Stigma Questionnaire and Weight Bias Internalization Scale in children and adolescents

Given the negative consequences of weight bias, including internalized weight stigma, on health outcomes, two instruments—the Weight Self-Stigma Questionnaire (WSSQ) and Weight Bias Internalization Scale (WBIS)—have been developed. However, their psychometric properties are yet to be tested for Asian pediatric populations. Method:Participants aged 8 to 12 years (N = 287; 153 boys) completed the WSSQ and the WBIS, and they were classified into either a group with overweight or a group without overweight based on self-reported weight and height. Results:Both WSSQ and WBIS had their factor structures supported by confirmatory factor analyses (CFAs). The measurement invariance of two-factor structure was further supported for WSSQ across gender and weight status. The measurement invariance of single-factor structure was supported for WBIS across gender but not across weight status. Conclusions:WSSQ and WBIS were both valid to assess the internalization of weight bias. However, the two instruments demonstrated different properties and should be applied in different situations.

Weight-based victimization from friends and family: implications for how adolescents cope with weight stigma

BACKGROUND

Youth with overweight and obesity commonly experience weight-based victimization. The ways that these youth cope with victimization can adversely impact their health. Despite considerable evidence that family members and friends are common perpetrators of weight-based victimization, the relationships among different sources of victimization and coping responses of youth are unknown.

OBJECTIVES

The present study examined the relationships between weight-based victimization from four sources (friends, peers, family members and teachers) and stigma-specific coping responses in adolescents using linear regression.

METHODS

Adolescents (ages 13-18 years; N = 148) enrolled in a national weight loss camp completed questionnaires about demographics, weight bullying, sources of teasing and internalized weight bias.

RESULTS

Teasing sources explained a large proportion of the variance in coping strategies for weight-based victimization. Weight teasing from friends was associated with greater frequency of negative emotions. Weight teasing from peers and friends were associated with greater frequency of coping via avoidance behaviours, while teasing from family was associated with fewer avoidance behaviours. Adolescents reported wanting more support from parents and stronger school policies to address weight-bullying.

CONCLUSIONS

These results suggest associations between weight-teasing sources and coping mechanisms. Interventions should examine the role of coping strategies to protect against adverse health effects of weight-based victimization.

What's Weight Got to Do With It? Mental Health Trainees' Perceptions of a Client With Anorexia Nervosa Symptoms

This study examined the effect of client body mass index (BMI) on diagnostic impressions and perceptions of mental health trainees. Participants read a vignette of a mock female client presenting for treatment with symptoms of anorexia nervosa. Participants were randomly assigned to one of three conditions in which the client was described as “underweight,” “normal weight,” or “overweight.” Results revealed that participants assigned to the “underweight” condition diagnosed the client with anorexia nervosa or atypical anorexia nervosa more frequently than participants assigned to the “overweight” or “normal weight” conditions. There was no difference based on client BMI when the more general diagnosis of other specified feeding or eating disorder (OSFED; previously known as eating disorder not otherwise specified [EDNOS]) was included, however. Participants in the “overweight” and “normal weight” conditions recommended fewer therapy sessions for the client than participants in the “underweight” condition. Furthermore, participants more strongly endorsed weight-based stereotypes to describe the client when she was “overweight” than “normal weight” or “underweight.” Contrary to hypotheses, however, participants reported moderately positive attitudes toward treating the client regardless of BMI. These preliminary findings support initiatives aimed at providing training on weight stigma and eating disorders to mental health professionals.

Weight Bias Internalization Among Adolescents Seeking Weight Loss: Implications for Eating Behaviors and Parental Communication

Background: Emerging evidence has demonstrated a high prevalence of weight bias internalization (WBI) among adults, as well as consistent links between internalization and adverse psychological and physical health. However, research examining WBI in youth and its impact on their health is scarce, especially among youth seeking weight loss treatment who may be particularly vulnerable to weight stigma from peers and parents. To address this research gap, the present study assessed WBI in a weight loss treatment-seeking sample of adolescents, examining associations between internalization and adolescents' eating behaviors and parental weight-related communication. Methods: Adolescents (N = 148, M _age = 15.97 years), completed online self-report measures to assess WBI (using the modified version of the WBI Scale), body weight, binge eating, eating as a coping strategy, and weight teasing from peers and family members. Adolescents also reported on the frequency of parental comments about body weight, parental dieting, and parental encouragement of adolescent dieting. Results: Adolescents expressed a high mean level of internalized weight bias (M = 5.45, SD = 0.88). Higher levels of internalization were observed across increasing body weight categories; no differences were observed for gender or history of weight teasing. WBI was significantly higher among adolescents who reported binge eating and eating to cope with distress. Regression analyses showed that weight-related comments from mothers (but not fathers) significantly predicted adolescents' WBI (including frequency of mothers' comments about adolescents' body weight, comments about their own body weight, and encouragement of their adolescent to diet), as did increased dieting frequency among mothers. Conclusion: The present study provides novel insights to the scant literature on WBI in youth. Findings indicate that WBI is high in both girls and boys engaged in weight loss, and is associated with maladaptive eating behaviors, higher frequency of maternal dieting, and mothers' comments about body weight. These findings have important clinical implications for youth and families engaged in weight loss treatment, and underscore the need for research to clarify adverse effects of internalization on weight-related health in youth and to better understand the role that parental weight communication may have on adolescents' internalization.

Adolescent preferences for weight terminology used by health care providers

BACKGROUND

In light of high rates of obesity and weight stigma in youth, the American Academy of Paediatrics recommends that paediatric health care professionals use appropriate, sensitive and non-stigmatizing language in communication about weight with youth. For these efforts to be effective, there is a need to identify weight-based language preferences among youth with overweight and obesity, as research in this area is scarce.

OBJECTIVES

The present study provides a systematic assessment of youth perspectives of weight-based language used by providers.

METHODS

Adolescents (ages 13-18 years; N = 148) enrolled in a national weight loss camp were surveyed about their preferences for words that health providers use to refer to their body weight. Adolescents completed an online survey and responded to a list of 16 words describing excess body weight, as well as questions assessing demographics, body mass index, and experienced as well as internalized weight stigma.

RESULTS

Adolescents assigned low ratings to words like 'fat', 'large', 'obese' and 'extremely obese', indicating that they would not want providers to use these words when discussing their body weight. In contrast, words like 'weight problem', 'BMI' and 'plus size' were rated among the most preferred words for providers to use. Word preferences varied across gender, body mass index and extent of internalized weight stigma.

CONCLUSIONS

These findings underscore the importance of acknowledging different word preferences among youth, and to avoid making assumptions about what words youth will feel most comfortable using in discussions about their body weight.

Weight bias internalization and health: a systematic review

A robust literature has documented the negative health effects of being the target of weight bias. Weight bias internalization (WBI) occurs when individuals apply negative weight stereotypes to themselves and self-derogate because of their body weight. Compared with experiences of weight bias, less is known about the relationship between WBI and mental and physical health, although more literature on this topic has emerged in recent years. The current systematic review identified 74 studies assessing the relationship between WBI and health and interventions designed to reduce WBI and improve health. Over half of identified studies were published from 2016 to 2017. Results showed strong, negative relationships between WBI and mental health outcomes. Fewer studies have examined the relationship between WBI and physical health, and results were less consistent. Key directions for future research are highlighted, including the need for prospective and experimental studies with greater sample diversity.