A meta-analysis of associations between weight bias internalization and conceptually-related correlates: A step towards improving construct validity

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.

Weight stigma and mental health outcomes in early-adolescents. The mediating role of internalized weight bias and body esteem

BACKGROUND

Weight stigma is increasingly common in early adolescence and may lead to weight bias internalization, with negative consequences for mental health outcomes. This study aimed to: examine the relations of perceived weight stigma and internalized weight bias with early adolescents' internalizing symptoms and disordered eating behavior; explore the mediating role of internalized weight bias on the relations of perceived weight stigma with internalizing symptoms and disordered eating behaviors; examine body esteem as a mediator between internalized weight bias and mental health outcomes.

METHODS

A sample of 406 early adolescents (59.6% girls) aged between 11 and 13 participated in this cross-sectional study. They completed self-report measures assessing perceived weight stigma, internalized weight bias, body esteem, internalizing symptoms and disordered eating.

RESULTS

Path analysis indicated that perceived weight stigma was positively related with internalizing symptoms and internalized weight bias. Further, internalized weight bias was negatively related with body esteem and positively related with internalizing symptoms and disordered eating. Internalized weight bias mediated the relations of perceived weight stigma with internalizing symptoms, disordered eating and body esteem. Further, body esteem mediated the relations of internalized weight bias with internalizing symptoms and disordered eating behavior.

CONCLUSIONS

The findings highlight internalized weight bias as a psychological mechanism potentially explaining negative links of weight stigma with internalizing symptoms and disordered eating in early adolescence. The results emphasize the need for early intervention during this developmental stage, in order to prevent psychological and behavioral outcomes of weight stigma and internalized weight bias.

Demographic, socioeconomic and life-course risk factors for internalized weight stigma in adulthood: evidence from an English birth cohort study

Background

Obesity is highly stigmatized, with negative obesity-related stereotypes widespread across society. Internalized weight stigma (IWS) is linked to negative outcomes including poor mental health and disordered eating. Previous evidence examining population groups at higher risk of experiencing IWS comes from small, nonrepresentative samples. Here, we re-assess previously reported associations of IWS with demographic, socioeconomic, and wider social factors in a large general population birth cohort study for the first time.

Methods

In the Avon Longitudinal Study of Parents and Children (ALSPAC), we explored differences in IWS at age 31 years by sex, ethnicity, socioeconomic factors, sexual orientation, and family and wider social influences, using confounder-adjusted multivariable regression.

Findings

In models adjusted for potential confounders and BMI in childhood, adolescence, and adulthood (N = 4060), IWS was higher for females (standardized beta: 0.56, 95% CI: 0.50, 0.61), sexual minorities (0.17 S.D. higher, 95% CI: 0.09, 0.24), and less socioeconomically advantaged individuals (e.g., 0.16 S.D. higher (95% CI: 0.08, 0.24) for participants whose mothers had minimum or no qualifications, compared to a university degree). The social environment during adolescence and young adulthood was important: IWS was higher for people who at age 13 years felt pressure to lose weight from family (by 0.13 S.D., 95% CI: 0.03, 0.23), and the media (by 0.17, 95% CI: 0.10, 0.25), or had experienced bullying (e.g., 0.25 S.D., 95% CI: 0.17, 0.33 for bullying at age 23 years).

Interpretation

Internalized weight stigma differs substantially between demographic groups. Risk is elevated for females, sexual minorities, and socioeconomically disadvantaged adults, and this is not explained by differences in BMI. Pressure to lose weight from family and the media in adolescence may have long-lasting effects on IWS.

Funding

The ESRC, MRC, NIHR, and Wellcome Trust.

Reducing anti-fat bias toward the self and others: a randomized controlled trial

Despite strong evidence linking anti-fat bias directed toward others with markers of self-directed anti-fat bias, there is a dearth of theory-based research examining the cognitive pathways underlying this relationship, and existing bias-reduction intervention efforts have thus far been conducted with exclusive focus on one domain or the other. Cognitive dissonance (CD)-based interventions have been identified as viable for reducing anti-fat bias directed toward the self and others. However, no study has yet examined whether the effects of these domain-specific interventions (e.g., anti-fat bias towards the self) extend to anti-fat bias in the non-targeted domain (e.g., anti-fat bias towards others). The present study aimed to address these gaps in the literature by comparing effects of brief CD-based interventions targeting anti-fat bias directed toward either the self or others on measures of anti-fat bias. Participants (N = 197, female-identifying undergraduates) were randomized to a writing activity prompting cognitive dissonance about either self-directed or other-directed anti-fat bias, or a bias-consistent control condition. Results indicated that participants in the CD intervention conditions showed significantly greater reductions in both explicit self- and other-directed anti-fat biases than those in the control condition, but results did not significantly differ across CD conditions. This supports the potential utility of interventions simultaneously targeting anti-fat bias in both domains and provides insight into the cognitive pathways underlying these related forms of bias.

An examination of the unique contributions of body image and internalized weight bias to psychological well-being outcomes

High correlations between measures of internalized weight bias (IWB) and body image (BI) have resulted in concerns that IWB is conceptually redundant with BI. This investigation examined the contribution of the unique variance of BI and IWB on three important, weight-related factors: self-esteem, depressive symptoms, and body shame. The study included 403 participants recruited through a Qualtrics research panel. Participants were required to be aged 18 + and have a BMI > 25. The sample contained three equally represented, self-identified racial/ethnic groups: Black non-Hispanic (N = 140), Hispanic (N = 133), and White non-Hispanic (N = 130). When BI was entered in the first step of the regression model, it accounted for 14-40% of the variance in various models; the addition of IWB in step two contributed 11-18% of unique variance. By contrast, when IWB was entered in the first step, it accounted for 25-56% of the variance in various models, with the addition of BI contributing between 0% and 2% unique variance. Therefore, even with a high correlation among the constructs of IWB and BI, IWB was able to contribute unique variance in predicting depressive symptoms, self-esteem, and body shame, and is not redundant with the construct of BI.

Comparing measurement of internalized weight stigma and body dissatisfaction

Respective conceptualizations of internalized weight stigma and body dissatisfaction are distinct; however, strong relationships between measures of these two constructs prompts consideration about if these are truly unique constructs or whether current measurement tools are not adequately capturing their uniqueness. In this cross-sectional study, 480 U.S. women (78.8% white; MBMI = 25.9) ages 18-40 years, recruited from Amazon's MechanicalTurk and a mid-sized university, completed an online survey with the Modified Weight Bias Internalization Scale (WBIS-M), a modified Body Parts Satisfaction Scale (BPSS), and other validated measures of body image, eating behavior, and mental health. Exploratory factor analysis of the WBIS-M and the BPSS supported a two-factor solution, although two items from the WBIS-M loaded with BPSS items. After removing these items, the 9-item version of the WBIS-M demonstrated stronger relationships with dysfunctional eating and mental health symptoms than did the BPSS (ꞵ range = 0.32-0.62 vs. 0.01-0.18, respectively). Findings from this study provide evidence to support the validity of WBIS-M and BPSS measuring unique constructs, suggesting that internalized weight stigma can be differentiated from body dissatisfaction. This study also highlights the need for further research that examines current measurement tools for internalized weight stigma and body dissatisfaction.

Longitudinal associations between weight stigma and disordered eating across the weight spectrum

Weight stigma reflects discrimination or stereotyping based on weight, and this construct is associated with body dissatisfaction, low self-esteem, and eating pathology. Recent research suggests that internalizing weight stigma (i.e., endorsing negative stereotypes about one's weight) mediates associations between experienced weight stigma and disordered eating. However, much of this research has been cross-sectional and limited data exist on associations between weight stigma constructs and eating pathology across the weight spectrum. The current study explored whether internalized weight stigma differentially mediates the relationship between experiencing weight stigma and disordered eating symptoms over time in higher-weight versus non-higher-weight individuals. Undergraduate students (N = 661, 80 % Female, 28.5 % higher weight) completed surveys at three time points over six months. Multigroup path analyses tested whether the effects of experienced weight stigma and internalized weight stigma on binge eating, food restriction, and body dissatisfaction differed between the higher-weight and non-higher-weight groups. All models showed improved fit when path estimates were allowed to vary between groups. Mediation analyses indicated a significant indirect effect of experienced weight stigma on binge eating via internalized weight stigma among the higher-weight group but not the non-higher-weight group. Only internalized weight stigma was directly associated with body dissatisfaction across weight status. A direct effect of experienced weight stigma on restriction was found in the non-higher-weight group. Findings suggest that, in general, weight stigma negatively affects body image and eating behavior, although specific effects may vary depending on one's weight.

Examining the role of experiential avoidance and valued action in the negative effects of weight self-stigma

Harmful effects of weight self-stigma on quality of life and health behaviors have been well-established. However, the processes that lead to these negative outcomes are less understood. Psychological inflexibility is defined as a pattern of rigid psychological reactions dominating over values and meaningful actions. A lack in valued action is characterized by the absence of activities that are connected to what is personally meaningful. In this secondary analysis, we aim to extend research by examining two subprocesses of psychological inflexibility, experiential avoidance and lack of valued action, as statistical mediators of the relations between weight self-stigma and quality of life/health behavior outcomes. Baseline data from a clinical trial comparing weight loss maintenance interventions in a sample of 194 adults living with overweight or obesity and seeking treatment is analyzed. Results show that greater experiential avoidance and lower valued action were significantly related to lower quality of life and satisfaction with social roles, as well as greater depression, anxiety, and binge eating. Further, results from a parallel mediation analysis indicated that weight self-stigma is indirectly related to anxiety, disinhibited eating, and hunger through the relationship with experiential avoidance and lack of valued action.

Weight Bias Internalization and Psychosocial, Physical, and Behavioral Health: A Meta-Analysis of Cross-Sectional and Prospective Associations

Coinciding with widespread efforts to address obesity, weight bias internalization (a process of self-devaluation wherein individuals apply weight-biased stereotypes to themselves) has gained increased attention as a robust correlate of poor health outcomes. The present meta-analysis aimed to provide the largest quantitative synthesis of associations between weight bias internalization and health-related correlates. Studies that provided zero-order correlations for cross-sectional or prospective associations between weight bias internalization and physical, psychosocial, and behavioral health correlates were included in the meta-analysis. Meta-regression determined whether these associations differed based on demographic (sex/gender, race, age), anthropometric (body mass index), and study-level (publication status, sample type, study quality) moderators. Data for 149 (sub)samples were identified that included between 14 and 18,766 participants (M sample size = 534.96, SD = 1,914.43; M age = 34.73, SD = 12.61, range = 9.95-65.70). Results indicated that greater weight bias internalization was concurrently associated with worse psychosocial (e.g., negative and positive mental health, social functioning), physical (e.g., BMI, weight maintenance, health-related quality of life [HRQoL]), and behavioral health (e.g., disordered eating behaviors, healthy eating, physical activity) across most constructs, with effects ranging from small to very large in magnitude. Preliminary evidence also suggested that greater weight bias internalization was subsequently associated with less weight loss and increased negative mental health. Notable variations in the nature and magnitude of these associations were identified based on the health-related correlate and moderator under consideration. These findings indicate that weight bias internalization is linked to multiple adverse health-related outcomes and provide insight into priorities for future research, theory building, and interventions in this area.

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.

Relationships between weight bias internalization and biopsychosocial health outcomes: A prospective study in Chinese adolescents

OBJECTIVE

An extensive literature has documented the deleterious effects of weight bias internalization (WBI) on biopsychosocial health outcomes. Still, this research is largely confined to the Western context. Furthermore, few studies have explored associations between WBI and biopsychosocial health outcomes, including in non-Western adolescent populations.

METHOD

The present study explored the longitudinal relationships between WBI and body dissatisfaction, disordered eating, psychosocial impairment related to eating disorder features, and psychological and physical well-being in a sample (N = 1549; aged 11-18 years at baseline) of Chinese adolescents. Relationships between study variables were examined between two waves of data measurement (Time 1, baseline, and Time 2, 6-month). Cross-lagged and multivariate models were used to explore prospective relationships between WBI and biopsychosocial correlates.

RESULTS

Bidirectional relationships were observed between WBI and biopsychosocial correlates in Chinese adolescents. Adjusting for covariates and other predictor variables, higher body dissatisfaction, disordered eating, psychosocial impairment, and psychological distress at Time 1 predicted higher WBI at Time 2. Furthermore, higher WBI at Time 1 predicted higher body dissatisfaction, disordered eating, psychosocial impairment, and psychological distress at Time 2.

DISCUSSION

Weight bias internalization and psychosocial correlates were interrelated across time in Chinese adolescents. Improving WBI might be promising in the prevention of eating and body image disturbances and diminished psychosocial well-being. Similarly, reducing eating and body image disturbances and improving psychosocial well-being might be useful prevention targets in reducing WBI in Chinese adolescents.

PUBLIC SIGNIFICANCE

The present study represents an initial effort to explore bidirectional relationships between WBI and biopsychosocial health outcomes in Chinese adolescents. Findings suggest bidirectional relationships between WBI and psychosocial variables, highlighting the potential utility of incorporating WBI interventions into eating pathology and poor psychosocial well-being prevention designs for Chinese adolescents.

Baseline Characteristics and Their Associations with Body Composition of Active-Duty Service Members Enrolling in a Randomized Controlled Trial of a Weight Management Program

INTRODUCTION

Increasing rates of overweight and obesity among military service members (SMs) necessitate the implementation of weight management interventions. Evidence for the effectiveness of military weight management interventions is mixed. Effectiveness may be impacted by individual sociodemographic, psychiatric, psychological, and behavioral factors. Baseline data from SMs who were overweight/obese or at risk of failing body composition or physical fitness tests and enrolling in a weight management randomized controlled trial were used to examine (1) individual characteristics of this sample as a whole and by gender and (2) relationships between those characteristics and body composition metrics that are targeted by military weight management interventions. Understanding these relationships may inform intervention approaches.

MATERIALS AND METHODS

Active duty SMs (N = 178) who enrolled in a randomized clinical trial of the Navy's weight management program "ShipShape" at a large military hospital provided data at their baseline visit. Because of gender differences in average body fat percentage (BF%) and underrepresentation of women SMs in research, independent samples t-tests and chi-square analyses were used to examine differences between male and female SMs across study variables. Multiple regression analyses were used to examine relationships of sociodemographic, psychiatric, psychological, and behavioral variables with body composition metrics, including weight, body mass index (BMI), BF%, and waist circumference (WC).

RESULTS

Participants (61% female; Mage = 29.66 ± 6.92 years; 59.60% White) had an average BMI in the "obese" range (MBMI = 33.1 ± 3.9 kg/m2). Female participants had significantly higher BF% and significantly lower weight and WC than male participants. Compared to male participants, females reported significantly higher rates of pain and headache diagnoses, lifetime diagnosis of an anxiety disorder, lifetime treatment for a mental health concern, lifetime experiences of sexual trauma/harassment and military sexual trauma, and higher current anxiety and post-traumatic stress disorder symptoms. Across all SMs, body composition metrics were significantly associated with several demographic variables, including gender, age, marital status, Asian race, and Black race. Higher weight-related stigma was significantly associated with higher weight, BMI, BF%, and WC. Additionally, more emotional eating was significantly associated with higher BF%, and higher weight-loss confidence was significantly associated with higher BMI. Sociodemographic, psychiatric, psychological, and behavioral variables predicted the greatest variance in BF% compared to other body composition metrics evaluated.

CONCLUSIONS

Participants in this study were more likely to be female, relatively young members of the Navy with overweight/obesity, who endorsed pain-related medical conditions, probable mental health conditions, and traumatic experiences at relatively high rates. Despite high endorsement of anxiety, depression, and post-traumatic stress disorder symptoms in this group, only weight-related stigma consistently emerged as significantly associated with body composition metrics. Regression results varied by body composition metric, with the most variance explained in BF%, suggesting that BF% may relate most strongly to sociodemographic, psychiatric, psychological, and behavioral variables associated with weight management. These results highlight the need for weight management programs that address weight-related stigma and mental health concerns of SMs to maximize the effectiveness of intervention efforts.

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.

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.