Clinical Correlates of the Weight Bias Internalization Scale in a Sample of Obese Adolescents Seeking Bariatric Surgery

Public health concerns regarding the high prevalence of obesity among children and adults worldwide often stem from the health and financial costs associated with obesity’s medical sequelae. (1–3) However, obesity is also associated with a host of deleterious psychosocial consequences including psychiatric diagnoses, mood disturbances, binge eating and decreased self-esteem and quality of life. (3–6) While little is known about the mechanisms linking obesity with psychological problems, one possibility is that this relationship is partially explained by the experience of weight bias. The incidence of weight-based discrimination has increased by 66% since 1995 (7), and is now on par with rates of racial discrimination.(8) Further, weight bias is more socially acceptable than other common forms of bias such as racism or sexism, and is observed in multiple domains, including employment, education, housing opportunities, health care, and portrayal in the media. (9) The widespread social acceptability of weight bias, as illustrated by its ubiquity in the media and lack of preventative legislation, (9) contributes to strong anti-fat attitudes expressed by non-overweight as well as overweight and obese people.(10) Such anti-fat attitudes have also been shown among overweight children (11) and weight bias directed towards obese children has increased over the last several decades, (12) with stigmatizing attitudes beginning as early as preschool.(13) In fact, Latner and Stunkard found that elementary-school aged youth would rather befriend an individual with various physical disabilities, such as facial disfigurement, than an obese peer.(12) Overweight and obese individuals report experiences of peer rejection and harassment in every phase of education, from elementary school through high school and college.(14) Research demonstrates that youth who have experienced weight-based stigmatization and teasing have increased risk of depression, low self-esteem, body dissatisfaction, suicidality, unhealthy weight control behaviors, and disordered eating.(11) Importantly, many of these studies control for body mass index (BMI), indicating that the stigmatizing experience itself, rather than body weight, is contributing to these adverse psychological outcomes. While many minorities or stigmatized groups tend to demonstrate ‘in-group’ preferences (15), the extant literature has found that overweight and obese individuals lack these favorable ‘in-group’ attitudes. In fact, overweight and obese persons endorse similarly high anti-fat attitudes as their normal weight counterparts.(10) The lack of favorable ‘in-group’ attitudes observed in overweight and obese individuals may be a result of the widespread social acceptability and prevalence of weight bias. This may partially explain why overweight individuals are especially likely to internalize negative weight-based stereotypes.(16,17) While antifat attitudes are pervasive in American society, Durso and Latner (18) argue that various measures used to assess antifat attitudes among overweight and non-overweight individuals fail to distinguish between weight bias and the internalization of that bias. Therefore, Durso and Latner (18) developed the Weight Bias Internalization Scale (WBIS) to separate weight-based attributions made about “the other” from weight-based attributions made about “the self.” The authors suggest that attributions about one’s self, which reflect the internalization of weight bias, rather than just the presence of antifat attitudes, is an important contributing factor to negative psychological outcomes among overweight or obese individuals. The distinction between perceptions of the attitudes of others and attitudes toward one’s group is a critical one for understanding responses to stigma. With respect to racial and ethnic bias, for example, Crocker et al. found that whereas perceptions of others’ attitudes were not consistently related to well-being, members of racial and ethnic minority groups who personally held their group in lower esteem systematically experience lower levels of personal well being. (19) In their initial study of the WBIS, Durso and Latner (18) demonstrated excellent reliability and validity of the scale based on an internet community sample of overweight and obese adults. In addition, the scale showed strong partial correlations with self-esteem, eating disturbances, depression, and anxiety while controlling for body mass index (BMI). Furthermore, they demonstrated that the WBIS was able to explain variance in measures of psychopathology and self-esteem beyond other measures of explicit antifat attitudes as well as BMI which were not found to be associated with those psychological measures. Given that youth are particularly vulnerable to weight stigma (20), and disordered eating patterns and mood disturbances frequently emerge during adolescence (21–23), it is critical to explore the impact of internalized weight stigma on the psychological well-being of obese adolescents. To our knowledge, no studies have explored weight bias internalization using the WBIS in obese youth. Thus, the goal of the current study was to examine the psychometric properties and clinical correlates of internalized weight bias as measured by the WBIS in a sample of male and female adolescents seeking weight loss surgery. Based on Durso and Latner’s findings, (18) we hypothesized that the WBIS would exhibit good psychometric properties in a sample of severely obese youth and that internalized weight bias would be associated with greater levels of psychopathology. Specifically, we expected that higher scores on the WBIS would be associated with higher levels of depression, anxiety, general maladaptive behaviors and disordered eating behaviors and cognitions and lower quality of life. We also hypothesized that the WBIS would be positively associated with the presence of current or past psychiatric diagnoses, psychiatric treatment, and past serious suicidal ideation.