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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. REFERENCES

Stigma associated with being overweight or obese is widespread. Given that weight loss is difficult to achieve and maintain, researchers have been calling for interventions that reduce the impact of weight stigma on life functioning. Sound measures that are sensitive to change are needed to help guide and inform intervention studies. This study presents the weight self-stigma questionnaire (WSSQ). The WSSQ has 12 items and is designed for use only with populations of overweight or obese persons. Two samples of participants—one treatment seeking, one nontreatment seeking—were used for validation (N = 169). Results indicate that the WSSQ has good reliability and validity, and contains two distinct subscales—self-devaluation and fear of enacted stigma. The WSSQ could be useful for identifying individuals who may benefit from a stigma reduction intervention and may also help evaluate programs designed to reduce stigma.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. REFERENCES

Obesity is a growing and multifaceted problem that is compounded by pervasive stigmatization. Behavioral interventions designed to help people lose weight have for the most part shown poor long-term outcomes, as most people regain lost weight within 3–5 years (1,2). As a result, many researchers have called for a focus on improving the lives of obese persons with or without weight reduction (3,4).

The stigma of being overweight has been called debilitating because it cannot be concealed and others see obesity as controllable (5). Obese individuals are perceived as weak-willed, self-indulgent, and immoral (6). Negative attitudes regarding obesity are widespread, socially acceptable, and learned early in life (7,8). Evidence for weight-based stigmatization has been documented in work (9), education (10,11), and health-care settings (12,13). Evidence suggests that stigmatizing experiences occur frequently in the context of personal relationships with family, friends, and co-workers (14).

This negative social atmosphere has been implicated in the development of depressive symptoms, feelings of helplessness, isolation, and poor general psychological functioning among obese people (3,4,14). Obese individuals can be acutely aware of the negative attributions others make toward them and tend to narrow their world considerably to avoid perceived social scorn. Obese people frequently report decreased physical and social activities, impaired sexual functioning, and poor self-image (15)—a cluster of factors that contribute to increased stigma and worsening of medical conditions (16).

Stigma is a multidimensional concept. Enacted stigma refers to directly experienced social discrimination in areas such as employment, housing, interpersonal relationships, and reduced access to services (17). In addition, people are frequently aware of stigma directed at others who share similar characteristics, fear it being directed at them, and also come to think stigmatized thoughts about themselves. Internalized or self-stigma refers to this self-devaluation and the fear of enacted stigma that results from one's identification with a stigmatized group (17).

Currently, there is no validated measure of weight self-stigma as defined above. This constrains researchers who wish to directly evaluate the extent to which weight stigma contributes to negative health outcomes. In addition, a reliable measure of weight stigma will allow researchers to begin to measure the impact of interventions for weight stigma and to examine whether changes in this variable mediate other health outcomes of interest.

Commonly used research measures in this area focus on evaluations of obese people. For example, the attitudes toward obese people scale (ATOP) (18) is a widely used measure that focuses on perceptions and attitudes about other people. The beliefs about obese persons (BAOP) (18) assesses one's beliefs about the causes of obesity in general. Although these concepts are related to weight stigma, both measures focus on others or obesity in the abstract. Neither of these measures addresses the core personal experience of shame, negative self-evaluation, or perceived discrimination that is part of weight self-stigma.

Researchers also adapt measures that were not designed for use with obese people, such as the Rosenberg self-esteem scale (19). However, it has been shown that modifying measures may have resulted in a lack of sensitivity and restricted ability to capture variance in some studies, e.g., (14). Other researchers have chosen to focus on a specific aspect of stigma such as body dissatisfaction, for example, by using the body dissatisfaction subscale of the eating disorders inventory (20). Finally, some researchers have chosen to focus on exposure to stigmatizing situations (21).

Durso and Latner (22) recently published the weight bias internalization scale (WBIS), which has helped to fill the gap on measures focusing on weight-based self-stigma. The WBIS is a 19-item measure focusing on self-devaluation due to being overweight or obese. The WBIS has good psychometrics and shows a strong relationship to binge eating, body image, and general psychopathology (22). It is not yet known whether the WBIS is sensitive to interventions, but the WBIS is a promising step forward.

The purpose of the current study was to develop and evaluate a new measure of weight self-stigma, the weight self-stigma questionnaire (WSSQ), designed to capture the multidimensional nature of weight-related stigma and to detect the impact of effective interventions targeting this variable. The WSSQ seeks to measure both self-devaluation and fear of enacted stigma, with an emphasis on development that could make the WSSQ sensitive to intervention effects. Below, we examine the basic factor structure, reliability, and construct validity of the WSSQ and then test its sensitivity to change as a result of targeted intervention.

Methods and Procedures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. REFERENCES

Initial scale development

The WSSQ was based primarily on concurrent work in the area of substance abuse stigma (23). Items came from an initial pool of over 300 items that reflected various domains thought to be related to stigma (shame, blameworthiness, incompetence, moral weakness, concealment, devaluation of self, perceived discrimination, and helplessness) and were adapted from a number of well-established measures including the Rosenberg self-esteem scale (19), internalized stigma of mental illness scale (24), the stigmatizing situations inventory (21), and the ATOP scale (18).

A focus group of four researchers who had previously published in the area of stigma met and examined the pool of items, selecting 30 for an initial version of the WSSQ. The 30-item version of the scale was administered to a group of 10 overweight participants who were receiving treatment at a local weight loss clinic. After receiving feedback, minor wording changes were made, and eight items were dropped that were identified as confusing or redundant. The resulting 22-item measure was evaluated in the current study.

Sample 1 method: cross-sectional

Participants and procedures. One-hundred forty-seven participants were recruited for a larger study on eating and drug-taking behaviors using advertisements in local newspapers, the Internet, and the community. Participants were phone screened and then scheduled for an appointment. Participants were at least 19 years of age and English speaking. There were no other exclusion criteria. A total of 85 out of 147 participants had a BMI of ≥25, and were included in the current study, as the WSSQ was not designed for use with normal or underweight populations (see Table 1 for sample characteristics).

Table 1.  Demographic characteristics
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Study procedures were conducted at research laboratory facilities at a medical hospital campus in the Western United States. Participants arrived, verified their age, and reviewed the consent form. Height was measured, and weight was recorded using a professional grade scale. Each participant completed a series of questionnaires and two behavioral tasks (i) a go no-go inhibition task on the computer, where participants were asked to press a bar when certain words appeared on a screen and refrain from pressing other times, and (ii) a task that required participants to choose pressing a bar for food or money. Total procedure time averaged 2.5 h. Participants were reimbursed with a $75 gift card for their time.

Sample 2 method: clinical outcome

Participants and procedures. Sample 2 included 84 participants who had completed at least 6 months of any structured weight loss program in the past 2 years that were recruited from a local weight loss clinic through flyers and from the community through advertisements in local newspapers. There were no exclusion criteria based on psychiatric, medical, or substance use disorders (see Table 1 for sample characteristics).

Study procedures for sample 2 were conducted at research laboratory facilities at a university in the Western United States. In an intake session, informed consent was given, psychological assessments were administered, and research personnel recorded weight. Participants were then randomly assigned to conditions. Control participants were placed on a wait list, and those in the experimental condition were provided a 1-day mindfulness and acceptance-based workshop based on acceptance and commitment therapy (25) that was designed to reduce weight stigma and increase quality of life. Assessments were repeated 3 months later. For a detailed sample characteristics and outcomes of the intervention (see ref. 26).

Measures

BMI. For purposes of parametric analysis, weight was converted to BMI using the formula: BMI = ((weight in pounds/height in inches squared) × 703).

General health questionnaire (GHQ). The GHQ (27) is a 12-item, 4-point Likert rating scale that measures psychological distress with items on somatic symptoms, anxiety, depression, and social dysfunction. It has good reliability and validity (28) in screening for psychiatric problems in a general population.

Brief symptom inventory (BSI). The BSI (29) is a 53-item Likert rating scale used to assess nine-symptom dimensions—somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism; and three global indexes—global severity index, positive symptom distress index, and positive symptom total. The BSI has good reliability and validity, and is used to screen for the presence of psychological disorders (30).

ORWELL 97 scale (ORWELL). The ORWELL (31) is an 18-item Likert rating scale that measures obesity-related quality of life. It measures satisfaction with functioning in various life domains (e.g., sexuality). It has shown good reliability and validity (31,32) in use with obese populations.

ATOP scale. The ATOP (18) is a 20-item Likert rating scale that focuses on perceptions and attitudes about obese people. Participants are asked to indicate the degree to which they agree with statements such as, “Most people feel uncomfortable when they associate with obese people.” High scores reflect positive attitudes. It has acceptable reliability and validity in adult populations. The ATOP had a Cronbach's α of 0.76 in the current study.

BAOP scale. The BAOP (18) is an eight-item Likert rating scale that assesses beliefs about the causes of obesity. Participants are asked to indicate the degree to which they agree with statements such as, “Obesity is really caused by a lack of willpower.” Higher scores represent the belief that obesity is not within the control of the individual. The BAOP has adequate reliability in adult samples. The BAOP had a Cronbach's α of 0.71 in the current study.

Three-factor eating questionnaire (TFEQ). The TFEQ (33) is a 51-item instrument that contains three subscales measuring restraint, disinhibition, and hunger. The items consist of 36 closed questions with a forced, true/false response and 15 Likert rating items. The TFEQ has high internal consistency for the three scales in samples of dieters and free eaters.

Acceptance and action questionnaire. The acceptance and action questionnaire (AAQ) (32) is a nine-item Likert rating scale that assesses overall levels of experiential avoidance, cognitive fusion, and action in the face of emotional barriers (e.g., “Emotions cause problems in my life”). It has good reliability and validity (32).

AAQW. The AAQ for weight (AAQW) (34) is a 22-item Likert rating scale that measures acceptance of weight-related thoughts and feelings, and the degree to which they interfere with valued action (e.g., “I try hard to avoid feeling bad about my weight or how I look”). The AAQW has displayed good preliminary psychometrics and construct validity (34).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. REFERENCES

Scale refinement

In order to properly examine scale characteristics, we combined the data from our two samples (N = 169). We examined each of the 22 items for skewness and found no problems. We then conducted an exploratory principal components analysis with varimax rotation. After examining the scree plot, it appeared that a two- or three-factor solution fit the data and accounted for 56.33% of the observed variance. In examining the three-factor solution, items clustered along clear theoretical dimensions with little cross loading. Factor 1 contained items that pertained to fear of enacted stigma and discrimination related to weight. Factor 2 contained items related to self-devaluation and shame related to weight. Factor 3 contained items that measure general levels of shame.

Due to the high correlations between factors, we ran a principal components factor analysis using an oblique rotation, forcing three factors. Items clustered theoretically as described above with low cross loadings. We then examined inter-item correlations and found a significant amount of redundancy among items on the enacted stigma factor. We eliminated items that loaded on factor 3 because it was theoretically inconsistent with the goals of our measure. Factor 3, or general shame, seemed too close theoretically to existing devices that measure a general sense of shame and stigma without any specific relationship to weight.

For the remaining items, we examined item-total correlations and correlation matrices for the fear of enacted stigma subscale and worked to remove items that were highly redundant with other scale items and so added little additional useful variability. We concurrently examined data from sample 2 to determine which items were most sensitive to change as a result of the stigma intervention. This was accomplished by examining within-group paired t-tests by item from baseline to follow-up, and between group ANOVAs on changes from baseline to follow-up. We used an iterative process to identify a sample of items that were both sensitive to change and also contributed unique variability. This resulted in removing an additional six items from the fear of enacted stigma subscale. We conducted another principal components analysis with an oblique rotation with the 12 remaining items. The data fit a two-factor solution well, with six items loading on the enacted stigma subscale and six items loading on the weight self-stigma subscale. The result is a 12-item weight self-stigma scale with two distinct but correlated subscales—fear of enacted stigma and weight-related self-devaluation. Scale items, item-scale correlations, and factor loadings are presented in Table 2.

Table 2.  Weight self-stigma questionnaire items, item-scale correlations, and factor loadings from principal components analysis with oblique rotation
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Scale characteristics

The final 12-item version of the WSSQ had a Cronbach's α of 0.878, with subscale α's of 0.869 and 0.812 for the fear of enacted and self-devaluation subscales, respectively. Both the enacted (r = 0.882) and self (r = 0.865) subscales were correlated with the total scale score, and to a lesser degree with each other (r = 0.527) (see Table 3). Test–retest reliability was examined using control participants (n = 44) from study 2 who did not receive the intervention (a 3-month time interval). Test–retest correlations were the following: total scale = 0.787, enacted = 0.804, and self = 0.618. Means and standard deviations for the WSSQ are presented in Table 4.

Table 3.  Bivariate correlations
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Table 4.  Means and standard deviations for WSSQ scores and BMI at baseline by sample
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WSSQ items are rated on a scale of 1 (completely disagree) to 5 (completely agree). Sum scores are calculated for the full scale and each subscale. Items 1–6 constitute the self-devaluation subscale, and items 7–12 constitute the fear of enacted stigma subscale. There are no reverse-scored items.

Validity

To assess construct validity, we conducted bivariate correlations between the 12-item WSSQ and established measures of theoretical interest as well as demographic characteristics. Studies 1 and 2 utilized different measures. When possible, we combined the data from samples 1 and 2 (using sample 2 baseline scores) for age, gender, income, BMI, and AAQW. Sample 2 only (at baseline) was used for correlations with the AAQ, GHQ, and ORWELL. Sample 1 only was used for correlations with the BSI, TFEQ, ATOP, and the BAOP (see Table 3 for results).

Using Cohen's (35) cutoffs for small, medium, and large correlations, the WSSQ correlates highly with obesity-related quality of life (ORWELL) and experiential avoidance of weight-specific thoughts and feelings (AAQW). The WSSQ correlates moderately with BMI, general experiential avoidance (AAQ), psychological distress as measured by both the BSI and GHQ, disinhibition (TFEQ factor 2), and gender (females experience higher levels of stigma overall). Low or no correlations were observed for income, age, eating restraint, and hunger. The WSSQ also appears to be distinct from existing measures of attitudes toward (moderate correlation with ATOP), and BAOP (no significant correlation with BAOP). In general, the two subscales operated similarly across other measures, with a few exceptions. The statistical difference between observed correlation coefficients was examined using suggested guidelines (36) for comparing correlation coefficients. A significant difference was observed between the correlation of fear of enacted stigma and the ORWELL, and self-devaluation and the ORWELL (Z = −2.14). A significant difference was also observed between the correlations for the two WSSQ subscales and the BSI (Z = −2.35).

Sensitivity to change

A primary goal of assessment is its contribution to treatment outcome (37). We examined the WSSQ's sensitivity to change using sample 2. Participants were randomized into the experimental or weight-list control condition. Experimental participants received a 1-day, targeted intervention for weight stigma to help improve general functioning and weight control. The specific methods used taught acceptance, mindfulness, and defusion skills as applied to difficult thoughts, feelings, and bodily sensations (see ref. 26 for full details). Analysis of covariances on 3-month follow-up scores using baseline score as a covariate resulted in the experimental condition showing significantly lower levels of general weight-related stigma, WSSQ total score (F (1, 83) = 28.59, P < 0.001, partial η2 = 0.26—a large effect); significantly lower levels of self-stigma, WSSQ self-score (F (1, 83) = 17.79, P < 0.001, partial η2 = 0.18—a large effect); significantly lower levels of enacted stigma, WSSQ enacted score (F (1, 83) = 22.97, P < 0.001, partial η2 = 0.22—a large effect).

Medium to large effects were also observed for higher quality of life (ORWELL), less psychological distress (GHQ), and lower BMI as a result of the intervention (see ref. 26).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. REFERENCES

The WSSQ is a 12-item Likert-type measure of weight-related self-stigma. To our knowledge, this is the first scale designed to specifically measure multidimensional nature of weight self-stigma, including both self-devaluation and fear of enacted stigma. The WSSQ has two distinct subscales that measure weight-related self-devaluation and fear of enacted stigma; however, it functions well as a single measure.

The WSSQ appears to have good psychometrics and preliminary construct validity. Cronbach's α is good for both the full scale and two subscales. Principal components analyses reflect a two-factor structure consistent with theory. Construct validity also appears adequate as the WSSQ correlates with other measures largely in the manner we expected.

Both subscales correlate with other measures largely in the manner we would have proposed. However, one interesting finding deserves further attention. The GHQ and BSI measure similar constructs—psychological distress or symptoms—however, the pattern in which they correlate with WSSQ subscales is different. The BSI showed a significantly higher correlation with the WSSQ fear of enacted subscale, whereas the GHQ showed slightly higher, though not significant, correlation with self-devaluation. We do not have a definitive explanation for this pattern. The GHQ was used with a treatment-seeking sample, whereas the BSI was used with a general community sample, making it difficult to draw any conclusions. One possibility is that the treatment-seeking sample reported greater problems with self-devaluation that have manifested in the reporting of psychological symptoms, although further study is needed to determine if there is any validity to this claim.

We were particularly interested in developing a measure that would be useful for studies of interventions targeting weight stigma. Most measure development efforts do not take into account sensitivity to change in the selection of items to be included in the scale. As we wanted to have a measure that would be sensitive to intervention, we included an item-level analysis of sensitivity to change as a result of stigma intervention and used this data to create a measure that showed good sensitivity to targeted intervention.

The current study has limitations. First, we would ideally have a larger, distinct sample from which to conduct a confirmatory analysis of our factor structure. Second, the use of samples from two separate studies resulted in the lack of consistency in measures across samples and a smaller sample size for several correlations. Conversely, the use of two somewhat different samples may increase the generalizability of these results. Finally, sample 2 comprised mostly women (91%), making it more difficult to accurately compare to sample 1 (44% women). Further research with more diverse treatment samples is needed to validate the WSSQ's utility in treatment research.

Researchers have called for interventions to address the pervasive stigma of being overweight or obese, in part because long-term weight loss and maintenance is rarely achieved. The WSSQ will allow researchers to better tailor and measure the impact of interventions designed to alleviate stigma. In addition, the WSSQ may be used to help identify individuals who may benefit from stigma reduction interventions. Future studies could examine the relationship between the WSSQ and actual discriminatory experiences as well as binge-eating behavior, which has been linked with internalized weight stigma in previous research. In addition, the WSSQ should be compared to the recently published WBIS, which is similar but was unavailable at the time we conducted our study. The WBIS does not include fear of enacted stigma, and it is unclear at this time how that will contribute to similarities or differences between the two measures.

The WSSQ may provide additional benefits. The experience of stigma has been linked to experiential avoidance among obese persons (26), substance users (23), and diabetics (38). Experiential avoidance is the tendency to avoid, suppress, or change unwanted thoughts and feelings, even when doing so produces harm. It may be the case that how one copes with stigmatizing thoughts and beliefs is key to predicting the degree to which stigma affects functioning, as has been proposed elsewhere (e.g., 39). The larger study that contributed some of the data for this article showed that a 1-day workshop that targeted experiential avoidance of weight self-stigma was able to improve weight control in a sample of treatment seekers with multiple failed weight loss attempts (26). Reducing experiential avoidance related to weight self-stigma could help create the psychological flexibility needed to engage in healthy behavior and persist over time, representing a new avenue for treatment development. The WSSQ could help guide researchers in this endeavor.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. REFERENCES

Preparation of this manuscript was supported in part by the Department of Veterans Affairs Health Services Research and Development Service Center for Health Care Evaluation. J.L. was supported by a postdoctoral fellowship from the VA Health Services Research and Development Service and Stanford University School of Medicine at the time data were collected for sample 1. The views expressed here are the authors' and do not necessarily represent the views of the Department of Veterans Affairs. No funding was used to conduct the study.

REFERENCES

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. REFERENCES
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