Internalized weight bias in patients presenting for bariatric surgery
Introduction
Evidence has accumulated that internalized weight bias (IWB), or the extent to which individuals with overweight and obesity believe weight-based negative stereotypes about themselves, has a distinct impact on well-being and psychopathology (Durso et al., 2016; Durso & Latner, 2008; Pearl & Puhl, 2018; Roberto et al., 2012). Of particular interest is how IWB relates to disordered eating attitudes and behaviors. Previous research identified IWB has positive associations with global measures of eating disorder psychopathology, as well as measures of eating, shape, and weight concern, and body dissatisfaction (Durso et al., 2012; Durso et al., 2016; Lawson et al., 2020; Roberto et al., 2012). Further, endorsement of weight-based stereotypes was linked to more frequent disordered eating (Baldofski et al., 2016; Durso & Latner, 2008; Pearl & Puhl, 2018; Puhl et al., 2006), including loss of control (LOC) of eating and binge eating symptoms in both community and clinical samples (O'Brien et al., 2016; Pearl & Puhl, 2018). Results regarding associations between IWB and restrained eating have been mixed, with some research having failed to find an association (Durso et al., 2012; Roberto et al., 2012), while others identified a positive relationship (Schvey et al., 2013; Schvey & White, 2015).
As research on IWB is being conducted, it is critical to consider the samples being studied. Research is continuing to emerge regarding IWB in samples of patients presenting for bariatric surgery. Bariatric surgery itself is sometimes perceived as “lazier” and “sloppier” than weight loss via diet and exercise (Fardouly & Vartanian, 2012); these sentiments may make those patients opting to pursue bariatric surgery at particularly high risk for both stigmatizing experiences and IWB, and discourage patients from seeking care sooner. Characterization of whether and how IWB differs in this population can help speak to these patients' experiences; for example, knowledge of whether IWB levels differ between those who seek surgical weight loss and those who do not seek weight loss treatment could help in understanding motivators for seeking treatment. Additionally, IWB negatively correlated with self-reported dietary adherence post-surgically in a sample of patients who had bariatric surgery (Raves et al., 2016). There is also mixed evidence suggestive of a possible negative association between post-surgical weight loss and IWB (Lawson et al., 2020; Lent et al., 2014; Pearl & Puhl, 2018) along with research suggesting a positive association between IWB and exercise avoidance (Han et al., 2018). These findings underscore the relevance of this construct for surgical outcome.
The Weight Bias Internalization Scale (WBIS; Durso & Latner, 2008) was originally developed using an internet sample recruited through online community discussion groups. The scale demonstrated convergent validity with drive for thinness, antifat attitudes, and body image concern, along with high internal consistency. Subsequent research examined the properties of the scale in adults seeking behavioral weight loss and found that removal of two items significantly improved scale reliability (Durso et al., 2016), while removing one item was necessary when the scale was used in a sample of adolescents pursuing bariatric surgery (Roberto et al., 2012). Further, both the original 11-item version and a 7-item version have also been used in samples of post-surgical patients (Han et al., 2018; Lawson et al., 2020). It is currently generally considered appropriate to use the 10-item version of the scale (Roberto et al., 2012), yet there continues to be a lack of consistency in the version of the scale used in samples of patients seeking bariatric surgery.
The goal of the current study was to examine the psychometric properties of the WBIS in a sample of patients presenting for bariatric surgery, as this represents both an understudied and highly relevant group when considering IWB. To accomplish this, we conducted a factor analysis to determine the structure of the WBIS in this sample, compared the current sample mean to those documented in a previous community sample of adults with overweight and obesity and that of adolescents seeking weight-loss surgery, and explored concurrent validity using associations between IWB and depression, anxiety, quality of life, disordered eating, and body dissatisfaction. It was hypothesized that the WBIS would best be represented by a unidimensional construct. Mean comparison between the current sample and previously documented samples was considered exploratory; consequently, no specific hypothesis was made. We specifically chose these samples to compare treatment- versus non-treatment-seeking individuals, as well as to provide preliminary evidence regarding whether levels of IWB in those seeking bariatric surgery vary significantly among age groups. We predicted that the WBIS would positively correlate with body dissatisfaction, restrained, emotional, and external eating, depression, and anxiety, and negatively correlate with quality of life, and that WBIS scores would be higher for those who endorse LOC eating.
Section snippets
Participants and procedures
Data for this analysis were extracted from self-report measures completed by preoperative patients participating in the Surgical Weight Loss Program at Penn State Health. Criteria for inclusion in this analysis included a Body Mass Index (BMI) of greater than or equal to 40 kg/m2, or greater than 35 kg/m2 along with a co-morbid condition. Participants ranged in age from 18 to 70 years. Data were collected from August 2018 to January 2020 and included results from 253 unique patients who
Psychometric properties of the WBIS
Sample demographics are presented in Table 1. WBIS scores did not significantly differ by gender (t(250 = 1.35, p = .18); consequently, subsequent analyses combined data from men and women. t-tests indicated a significant difference between White (n = 189, M = 4.30, SD = 1.29) and non-White participants (n = 59, M = 3.60, SD = 1.28; t(246) = 3.63, p < .001). However, given that analysis of racial and ethnic differences was not a primary objective of the current study, subsequent analyses
Discussion
This study adds to the extant WBIS literature by examining the psychometric properties of this scale within a preoperative sample seeking bariatric surgery. In our sample, the WBIS had high internal consistency with the exception of the one item that was removed from the scale due to poor item-total correlation, consistent with previous literature (Durso et al., 2016; Roberto et al., 2012). Our findings that the WBIS is positively correlated with measures of psychopathology including depression
Author statement
Allison Wagner: Conceptualization, methodology, formal analysis, data curation, writing – original draft, writing – review and editing.
Melissa Butt: Conceptualization, validation, writing – original draft. Writing – review and editing.
Andrea Rigby: Conceptualization, data curation, writing – original draft, writing – review and editing, supervision, funding acquisition.
Funding source
Data collection for this research was supported by the Brad Hollinger Eating Disorders Research Endowment at Penn State Health/Penn State College of Medicine Research Grant 2019–2020, United States of America.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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