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- Methods and procedures
Objective: The present study developed the Weight Bias Internalization Scale (WBIS), an 11-item measure assessing internalized weight bias among the overweight and obese.
Methods and Procedures: An Internet sample was recruited through online community discussion groups and snowball sampling via e-mail. Women (n = 164) and men (n = 34) with a BMI >25 kg/m2 completed the WBIS and the Antifat Attitudes Questionnaire (AAQ), as well as measures of self-esteem, body image, mood disturbance, drive for thinness, and binge eating.
Results: Results indicate that the WBIS had high internal consistency (Cronbach's α = 0.90) and correlated significantly with antifat attitudes but was not a completely overlapping construct (r = 0.31). The scale showed strong partial correlations with self-esteem (r = −0.67), drive for thinness (r = 0.47), and body image concern (r = 0.75), controlling for BMI. Internalized weight bias was also significantly correlated with measures of mood and eating disturbance. Multiple regression analyses were conducted using WBIS scores, antifat attitudes, and BMI as predictor variables of body image, mood, self-esteem, and binge eating. WBIS scores were found to significantly predict scores on each of these measures.
Discussion: The WBIS showed excellent psychometric properties and construct validity. The study highlights the importance of distinguishing antifat attitudes toward others from internalized weight bias, a construct that may be closely linked with psychopathology.
Weight bias has been shown to be a highly prevalent form of discrimination and is associated with a wide range of adverse effects for individuals who are overweight or obese. In a recent study, Carr and Friedman (1) reported that persons classified as obese were 40–50% more likely to experience major discrimination as a result of their weight status. Friedman et al. (2) found that >75% of a sample of overweight and obese persons had experienced seven of eleven types of stigmatizing situations, ranging from being avoided to being physically attacked, at some point in their life. These stigmatizing situations have been shown to occur in a variety of contexts, including employment practices, medical and health settings, educational settings, and in housing markets and public accommodations (3).
Among those who are overweight or obese, the incidence of weight-based discrimination has been positively associated with depression, general psychiatric symptoms, and body image concern, and negatively associated with self-esteem (2,4,5). Among those overweight individuals who have faced discrimination, an association emerged between eating disturbance and a belief in weight-based stereotypes (6). However, this belief in weight-based biases may affect all overweight individuals, not only those who have faced discrimination, through internalization of negative social messages about being overweight. Knowledge of how these internalized messages affect overweight individuals may help to address mixed results in our understanding of the development and/or maintenance of psychopathology seen in this group (e.g., refs. 7,8,9).
Much research examining weight bias has focused on the existence of antifat attitudes in the general population. Several measures of explicit antifat attitudes have been developed to examine the existence and correlates of weight bias, including the Antifat Attitudes Questionnaire (AAQ) (10), the Antifat Attitudes Test (11), and the Attitudes Toward Obese Persons and Beliefs About Obese Persons scales (12). These questionnaires have been used to measure weight bias in nonoverweight people, but they have begun to be used with samples of people who are overweight and obese (e.g., ref. 2). Studies using these scales have shown that antifat attitudes are held by both nonoverweight and overweight individuals (13) and that overweight persons do not hold more favorable attitudes toward other overweight persons (14). This finding of strongly held antifat attitudes among overweight adults has also been shown among overweight children (15).
In using traditional measures of weight bias for individuals who are themselves overweight, the assumption has been made that measuring these individuals’ biased attitudes about obesity is synonymous with measuring self-stigma. Thus for someone who is overweight, a score on traditional measures of antifat attitudes which reflects a bias is seen as an internalized attitude about the self. However, the endorsement of an item on traditional antifat bias measures may simply indicate biased beliefs about other overweight individuals, as previous measures of antifat attitudes do not assess whether an individual believes that negative attributions about obesity are true of himself or herself.
The present study sought to define and investigate the internalization of weight bias as a construct that may be distinct from antifat attitudes and one that may not be adequately measured by antifat attitudes scales. The key feature that may distinguish internalization of weight bias from antifat attitudes is the type of attribution made. Specifically, antifat attitudes are attributions made about the “other” whereas internalization of weight bias consists of attributions made about the “self.” We hypothesize that these “self” attributions have a harmful influence on the individual who makes them.
Internalization of weight bias is also hypothesized in the present study to be distinct from body image, a multidimensional construct that includes evaluation of and investment in one's physical characteristics (16). Internalized weight bias is different from body image in that it is not a measure of one's internal feelings about one's body—for example, its individual characteristics or how it compares to other persons’ bodies— but is a measure of belief in social stereotypes relating to obesity and negative self-evaluations due to one's weight. These stereotypes include evaluation of one's body weight and shape but are not limited to them. For example, an individual may have poor body image, but that individual may not associate that body image with his or her concept of identity or with a belief that he or she deserves respect from others. And while weight bias internalization may relate to self-esteem, it is a more specific measure of an individual's beliefs about himself or herself that relate directly to stereotypes about weight and shape. Internalization of weight bias may influence an individual's self-esteem but may be associated with different types or degrees of functional impairment and may have differential impact for different populations.
Given these operational definitions, the present study was undertaken to present psychometric data on a questionnaire designed to measure internalization of weight biases in persons who self-identify as overweight or obese, called the Weight Bias Internalization Scale (WBIS). In addition, this study examined several psychosocial correlates of internalization of weight bias, including mood and self-esteem, and expanded on previous research on internalized weight bias (2,5) by assessing its relationship to body image and eating disturbance. It was hypothesized that the WBIS would be a reliable and valid measure and that weight bias internalization would be associated with greater psychopathology.
- Top of page
- Methods and procedures
Results from the present study demonstrate the excellent psychometric properties of the WBIS in an overweight and obese community sample. Scale and item analysis demonstrated that the WBIS is a highly internally consistent questionnaire that provides a concise measure of internalized weight bias in individuals who are overweight or obese. Validity testing suggests that internalized weight bias is a construct that is related to but distinct from antifat attitudes, and that it correlates with additional measures thought to relate to antifat attitudes, body image, and drive for thinness.
An objective of the present investigation was to explore the relationship between internalized weight bias and several measures of psychopathology. This study showed similar results to previous research by demonstrating a relationship between weight bias and self-esteem, mood states, and body image concern (2,5). While previous studies only measured attitudes toward other people who are overweight, the present results suggest that the more highly one has internalized weight bias, the greater one's body image concern, depression, anxiety, stress, and self-esteem. Extending previous research, this study also demonstrated that higher levels of weight bias internalization are related to greater eating disturbance, including higher levels of drive for thinness as well as more frequent binge eating episodes. An additional interesting finding was that WBIS scores did not correlate with BMI, suggesting that the degree of internalization of weight bias does not depend on an individual's degree of overweight.
Regression data demonstrated that internalized weight bias can significantly predict individual variation on measures of psychopathology and self-esteem. In this sample, an individual's level of internalized weight bias predicted binge eating frequency, self-esteem, dysfunctional mood states, and most strongly predicted body image concern. Importantly, these results demonstrated that internalized weight bias contributed to the variance on these measures above and beyond the variance accounted for by a measure of antifat attitudes or BMI. Indeed, internalized weight bias was the only significant predictor in each of the models tested. These results support the hypothesis that internalized weight bias is not a redundant construct with antifat attitudes and may in fact be a better gauge than traditional antifat attitude questionnaires of the negative effects of biased attitudes among individuals who identify as overweight or obese.
Though the sampling method yielded a wide variety of participants, two important limitations should be noted. First, the sample was made up of significantly more female than male participants. This may have resulted from the description of the study being more appealing to female than male participants, leading to more self-selection by women. Second, in order to gather participants for this survey, recruitment efforts were targeted to obesity-related discussion groups in addition to more general postings. There may be differences between those overweight persons who choose to affiliate themselves with an online forum and those who do not, and the data may not be generalizable to the latter group. That the WBIS scores were of a wide range suggests that the present participants did vary in their levels of internalization and that the results may therefore be generalizable to the larger population of individuals who identify as overweight or obese. Still, replication of these results in additional samples is necessary to be assured of the scale's external validity.
Though confirmatory factor analysis indicated that internalized weight bias could be considered unidimensional, there may still be distinct components to the construct which may have different relationships with psychological functioning. For example, research is needed to test whether scale items which address social stereotypes of obesity can be considered to be part of the same construct as items which address affective responses to being overweight and whether these components have different relationships to psychopathology. Future research using this scale may target specific overweight groups, such as treatment-seeking individuals or members of organizations such as the National Association for the Advancement of Fat Acceptance, and examine the correlates of internalized weight bias. Other research may look to identify protective factors which prevent internalization or moderate its effects. Still other designs may examine histories of weight-based discrimination to see whether internalized weight bias is associated with actual events and whether it makes an individual more vulnerable to the negative effects of discrimination. Linking internalized weight bias to actual discriminatory experiences would further validate this construct; internalization might also help to explain why some individuals may be at greater risk than others of harmful consequences resulting from discrimination. Results presented here offer some parallels to research examining correlates of other forms of internalized bias, such as the finding that internalized homophobia is related to binge eating among gay men (33). Future research is needed to explore the relationship between internalized weight bias and health outcomes, in line with research conducted on internalized racism and cardiovascular disease (34). At present, the results discussed here suggest the importance of further examination of internalized weight bias as a construct that may have a significant impact on the mental health of persons who self-identify as overweight or obese.