Jessica F. SaunderspersName, Sarah NutterpersName, Shelly Russell-MayhewpersName (2022date). “Examining the Conceptual and Measurement Overlap of Body Dissatisfaction and Internalized Weight Stigma in Predominantly Female Samples: A Meta-Analysis and Measurement Refinement Study..” Frontiers in Global Women's Healthtitle·j.
Object of study — the conceptual and measurement overlapterm·key between body dissatisfactionterm and internalized weight stigmaterm
Research question — whether internalized weight stigmaterm is a construct separate from body dissatisfactionterm or one construct with two labels
Contribution — a meta-analysisterm·mth showing strong overlap moderated by sample type and BMIterm, and refined scales with 10 weight-stigma and 4 body-dissatisfaction items
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | the overlap of body dissatisfaction and internalized weight stigma in the existing literature — “In addition to these contributions, these concepts have been found to overlap to various degrees in existing literature.” | |
| claim-type | existence — “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.” | |
| method — evidence | — “Given the potential heterogeneity in both samples and measurement, we conducted each meta-analysis using random effects models.” | |
| object of study — evidence | — “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.” | |
| research question — evidence | — “Given these blurred boundaries and the array of terms used to describe internalized weight stigma, it is imperative to examine whether internalized weight stigma is a separate construct from body dissatisfaction, with error in existing measures contributing to conceptual overlap, or if they represent one construct with two distinct labels.” | |
| contribution — evidence | — “The two scales resulting from the EFA and CFA consisted of 10 items quantifying internalized weight stigma and four items quantifying body dissatisfaction.” | |
| mechanism | eating pathology severity As eating pathology becomes clinically significant, other clinical indicators may weaken the link between the two constructs. — “First, it may be that, as eating pathology severity becomes clinically significant, the strength of the relation between the concepts of internalized weight stigma and body dissatisfaction weakens, because other relevant clinical indicators are related to one or both concepts.” | mechanisms[0] |
| sense | body dissatisfaction (Grogan) - negative evaluations of body size, shape, muscularity and weight, against an ideal body — “Despite increased efforts at inclusion in the literature, we assert that the connection between body image and weight remains strong, as evidenced by Grogan's ( 3 ) definition of body dissatisfaction as “negative evaluations of body size, shape, muscularity/muscle tone, and weight, and it usually involves a perceived discrepancy between a person's evaluation of his or her body and his or her ideal body” (p. 4).” | senses[0] |
| sense | internalized weight stigma (Durso and Latner) - distinct from body image, being about weight and shape only — “In considering definitions and conceptualizations of internalized weight stigma, Durso and Latner ( 6 ) described it as distinct from body image, as it does not describe an individual's feelings about characteristics of the body beyond weight and shape.” | senses[1] |
| sense | body dissatisfaction and internalized weight stigma (Meadows and Higgs) - possibly separate conceptualizations of a single factor — “Recently, Meadows and Higgs ( 12 ) examined the conceptual overlap of internalized weight stigma, body dissatisfaction, and self-esteem, the results of which suggested these constructs may be separate conceptualizations of a single factor.” | senses[2] |
| relation | body dissatisfaction —distinct-from→ internalized weight stigma — As conceptualized and defined, body dissatisfaction and internalized weight stigma are two distinct concepts. — “As conceptualized and defined, body dissatisfaction and internalized weight stigma are two distinct concepts.” | concept_edges[0] |
| weight | body dissatisfaction —distinct-from→ internalized weight stigma — 0.8 — “As conceptualized and defined, body dissatisfaction and internalized weight stigma are two distinct concepts.” | concept_edges[0] |
| relation | internalized weight stigma —same-as→ self-directed weight stigma — In contrast, internalized weight stigma, also referred to as self-directed weight stigma, involves holding negative attitudes about oneself because of self-perceived excess body weight and devaluation of the self, based on societal pressures ( 6 ). Internalized weight stigma is also associated with numerous negative health outcomes, including depression ( 7 ), poorer psychological well-being ( 8 ), reduced engagement in physical activity ( 1 ), disordered eating behavior ( 9 ), and EDs ( 10 , 11 ). — “In contrast, internalized weight stigma, also referred to as self-directed weight stigma, involves holding negative attitudes about oneself because of self-perceived excess body weight and devaluation of the self, based on societal pressures ( 6 ). Internalized weight stigma is also associated with numerous negative health outcomes, including depression ( 7 ), poorer psychological well-being ( 8 ), reduced engagement in physical activity ( 1 ), disordered eating behavior ( 9 ), and EDs ( 10 , 11 ).” | concept_edges[1] |
| weight | internalized weight stigma —same-as→ self-directed weight stigma — 0.9 — “In contrast, internalized weight stigma, also referred to as self-directed weight stigma, involves holding negative attitudes about oneself because of self-perceived excess body weight and devaluation of the self, based on societal pressures ( 6 ). Internalized weight stigma is also associated with numerous negative health outcomes, including depression ( 7 ), poorer psychological well-being ( 8 ), reduced engagement in physical activity ( 1 ), disordered eating behavior ( 9 ), and EDs ( 10 , 11 ).” | concept_edges[1] |
| relation | exploratory factor analysis —same-as→ EFA — To adequately refine the existing measures of internalized weight stigma and body dissatisfaction, we first split the sample into two random halves to allow for both an exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) with the sample. — “To adequately refine the existing measures of internalized weight stigma and body dissatisfaction, we first split the sample into two random halves to allow for both an exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) with the sample.” | concept_edges[2] |
| weight | exploratory factor analysis —same-as→ EFA — 0.9 — “To adequately refine the existing measures of internalized weight stigma and body dissatisfaction, we first split the sample into two random halves to allow for both an exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) with the sample.” | concept_edges[2] |
| relation | Body mass index —same-as→ BMI — 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. — “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.” | concept_edges[3] |
| weight | Body mass index —same-as→ BMI — 0.9 — “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.” | concept_edges[3] |
| replication | original | |
| limitation | The factor analyses used only one common measure of each construct. — “First, our exploratory and confirmatory factor analyses were limited to one common measure of each construct and does not fully explore the measurement overlap in all measures commonly used in the literature.” | limitations[0] |
| limitation | The measurement study used a college sample and no clinical sample. — “Second, our examination of measurement overlap was limited to a college sample and did not include a clinical sample of individuals engage in clinical weight management or treatment for eating disorders.” | limitations[1] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | The pooled correlation between body dissatisfaction and internalized weight stigma was r = 0.61. — “For the entire sample, the random effects model with a 95% confidence interval yielded a correlation of r = 0.61, 95% CI[0.57, 0.65], Z = 20.97, p < 0.001.” | content_tags.findings[0] |
| finding | The relation between the two constructs is strongest at lower BMI and weakens as BMI increases. — “This significant moderation effect indicates that the relation between body dissatisfaction and internalized weight stigma is highest for individuals with lower BMI and decreases in strength as BMI increases.” | content_tags.findings[1] |
| finding | After removing overlapping items, the two scales correlated at r = 0.28, down from 0.69. — “The scales were significantly but not redundantly correlated with one another, r = 0.28, 95% CI [0.16, 0.39], p < 0.001 when the redundant items were removed.” | content_tags.findings[2] |
| quantity | 42,128 — — “Combined, these 48 studies featured 42,128 participants.” | content_tags.quantities[0] |
| key-terms | body dissatisfaction, internalized weight stigma, construct proliferation, concept creep, meta-analysis, body mass index, factor analysis, measurement overlap, thin-ideal internalization, eating disorders |
| concept | body dissatisfaction — an individual's negative cognitions and emotions about their body — “As conceptualized and defined, body dissatisfaction and internalized weight stigma are two distinct concepts. Body dissatisfaction is defined as an individual's negative cognitions and emotions about their body ( 3 ). Consistently, body dissatisfaction emerges as the most potent risk factor for EDs for women ( 4 ).” | concepts[0] |
| concept | internalized weight stigma — involves holding negative attitudes about oneself because of self-perceived excess body weight and devaluation of the self, based on societal pressures — “In contrast, internalized weight stigma, also referred to as self-directed weight stigma, involves holding negative attitudes about oneself because of self-perceived excess body weight and devaluation of the self, based on societal pressures ( 6 ). Internalized weight stigma is also associated with numerous negative health outcomes, including depression ( 7 ), poorer psychological well-being ( 8 ), reduced engagement in physical activity ( 1 ), disordered eating behavior ( 9 ), and EDs ( 10 , 11 ).” | concepts[1] |
| concept | self-directed weight stigma — internalized weight stigma — “In contrast, internalized weight stigma, also referred to as self-directed weight stigma, involves holding negative attitudes about oneself because of self-perceived excess body weight and devaluation of the self, based on societal pressures ( 6 ). Internalized weight stigma is also associated with numerous negative health outcomes, including depression ( 7 ), poorer psychological well-being ( 8 ), reduced engagement in physical activity ( 1 ), disordered eating behavior ( 9 ), and EDs ( 10 , 11 ).” | concepts[2] |
| concept | concept creep — occurs as concepts are continuously influenced by the changing social environment — “According to Haslam ( 14 ), these shifts are referred to as concept creep, which occurs as concepts are continuously influenced by the changing social environment.” | concepts[3] |
| concept | construct proliferation — the process by which distinct research streams build research around ostensibly unique, but empirically indistinguishable, constructs — “In commenting on a perceived widespread issue with empirical redundancy in Industrial-Organizational (IO) psychology research, Le et al. ( 15 ) coined the term construct proliferation to describe the process by which distinct research streams build research around ostensibly unique, but empirically indistinguishable, constructs.” | concepts[4] |
| concept | thin-ideal internalization — pressure from media, family, and peers to achieve a thin figure — “According to the sociocultural model of disordered eating, a key predictor of body dissatisfaction is thin-ideal internalization ( 85 ), with thin-ideal internalization conceptualized as pressure from media, family, and peers to achieve a thin figure ( 86 ).” | concepts[5] |
| concept | Egger's test — examines whether the intercept from the linear regression equation is significantly different from zero — “We assessed publication bias by implementing Egger's test ( 24 ), which examines whether the intercept from the linear regression equation is significantly different from zero.” | concepts[6] |
| concept | exploratory factor analysis — not defined in this paper's own words; a statistical method that finds which items group together as underlying factors — “To adequately refine the existing measures of internalized weight stigma and body dissatisfaction, we first split the sample into two random halves to allow for both an exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) with the sample.” | concepts[7] |
| concept | EFA — exploratory factor analysis — “To adequately refine the existing measures of internalized weight stigma and body dissatisfaction, we first split the sample into two random halves to allow for both an exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) with the sample.” | concepts[8] |
| concept | Body mass index — not defined in this paper's own words; body weight relative to height — “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.” | concepts[9] |
| concept | BMI — Body mass index — “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.” | concepts[10] |
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Examining the Conceptual and Measurement Overlapterm·key of Body Dissatisfactionterm and Internalized Weight Stigmaterm in Predominantly Female Samples: A Meta-Analysisterm·mth and Measurement Refinement Study.
Abstract Both body dissatisfactionterm and internalized weight stigmaterm have been identified as risk factors for many negative health outcomes for women, including depression and eating disordersterm·key. 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-analysisterm·mth on articles published prior to February 2022 to demonstrate the conceptual and measurement overlapterm·key between body dissatisfactionterm and internalized weight stigmaterm as currently quantified. We identified 48 studies examining the interrelation between body dissatisfactionterm and internalized weight stigmaterm 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 indexterm (BMIterm) moderated these relations such that individuals with higher self-reported BMIterm were more likely to report lower correlations between the constructs. This concept proliferation, stronger for individuals with lower BMIsterm and community samples, necessitates the need change how we conceptualize and measure body dissatisfactionterm and internalized weight stigmaterm. To this end, we conducted study two to refine existing measures and lessen the degree of measurement overlapterm·key between internalized weight stigmaterm and body dissatisfactionterm, 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 stigmaterm, which were analyzed using an exploratory followed by a confirmatory factor analysisterm·key. In our attempts to modify two existing measures of internalized weight stigmaterm and body dissatisfactionterm, the majority of the internalized weight stigmaterm items were retained. In contrast, most of the body dissatisfactionterm items either cross-loaded onto both factors or loaded on to the internalized weight stigmaterm factor despite being intended for the body dissatisfactionterm 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 dissatisfactionterm, across the existing corpus of body dissatisfactionterm scales.
Introduction Both body dissatisfactionterm and internalized weight stigmaterm are robust predictors of disordered eating and the development of clinically significant eating disordersterm·key for women [EDs; ( 1 , 2 )]. As conceptualized and defined, body dissatisfactionterm and internalized weight stigmaterm are two distinct concepts. Body dissatisfactionterm is defined as an individual's negative cognitions and emotions about their body ( 3 ). Consistently, body dissatisfactionterm emerges as the most potent risk factor for EDs for women ( 4 ). Body dissatisfactionterm also has wide-ranging effects on health outcomes, including decreased self-esteem and engagement in physical activity, and increased risk for depression ( 2 , 5 ). In contrast, internalized weight stigmaterm, also referred to as self-directed weight stigmaterm, involves holding negative attitudes about oneself because of self-perceived excess body weight and devaluation of the self, based on societal pressures ( 6 ). Internalized weight stigmaterm is also associated with numerous negative health outcomes, including depression ( 7 ), poorer psychological well-being ( 8 ), reduced engagement in physical activity ( 1 ), disordered eating behavior ( 9 ), and EDs ( 10 , 11 ).
Given the similarities between these two concepts in definition as well as in associated health outcomes, it is important to examine if measurement tools are assessing each construct as intended, or if the lines between the measurement of body dissatisfactionterm and internalized weight stigmaterm are blurred. Recently, Meadows and Higgs ( 12 ) examined the conceptual overlap of internalized weight stigmaterm, body dissatisfactionterm, and self-esteem, the results of which suggested these constructs may be separate conceptualizations of a single factor. Adding to the confusion, Austen et al. ( 13 ) note the interchangeable use of terms to refer to internalized weight stigmaterm, which can further blur boundaries between concepts if researchers are interchangeably using terms that were intended to hold distinct meaning.
Conceptual Overlap: Concept Creepterm·dom or Construct Proliferationterm·dom?
Given these blurred boundaries and the array of terms used to describe internalized weight stigmaterm, it is imperative to examine whether internalized weight stigmaterm is a separate construct from body dissatisfactionterm, with error in existing measures contributing to conceptual overlap, or if they represent one construct with two distinct labels. In discussing the evolution of constructs, Haslam ( 14 ) noted that semantic shifts in our understanding of concepts over time can expand and blur the measurement boundaries between two or more concepts. According to Haslam ( 14 ), these shifts are referred to as concept creepterm·dom, which occurs as concepts are continuously influenced by the changing social environment.
As hypothesized by Meadows and Higgs ( 12 ), however, the relationship between body dissatisfactionterm and internalized weight stigmaterm may be better explained by reconceptualizing them as a single construct. In commenting on a perceived widespread issue with empirical redundancy in Industrial-Organizational (IO) psychology research, Le et al. ( 15 ) coined the term construct proliferationterm·dom to describe the process by which distinct research streams build research around ostensibly unique, but empirically indistinguishable, constructs. Construct proliferationterm·dom can impede the creation of knowledge by researchers from different research streams, preventing the collaboration and influence that may come from such partnerships ( 15 , 16 ). Although construct proliferationterm·dom was coined to describe empirical redundancies in IO research, scholars in other areas of psychology have acknowledged its utility in removing redundancies from psychological research overall ( 17 ). Regardless of whether the relationship between body dissatisfactionterm and internalized weight stigmaterm suffers from concept creepterm·dom or construct proliferationterm·dom, a lack of clarity on the nature of their conceptual overlap will potentially have direct and cascading effects on research and clinical practice. Given the deleterious consequences of both internalized weight stigmaterm and body dissatisfactionterm, it is critical both are measured accurately so clinicians and researchers target the necessary constructs in future interventions.
Body Dissatisfactionterm and Internalized Weight Stigmaterm: an Examination of Conceptual Overlap In identifying ways to move an examination of conceptual overlap forward, Meadows and Higgs ( 12 ) suggested replicating their results with alternative measures of internalized weight stigmaterm. Additionally, Austen et al. ( 13 ) noted a Delphi study with a panel of experts may provide an additional opportunity to add clarity to definitions and understandings of these constructs. We assert that, prior to replicating and extending the results of Meadows and Higgs ( 12 ), it may be useful to survey conceptual overlap within existing literature quantitatively. Further, while the Delphi method is a useful and rigorous method for consensus-building among experts and can contribute to clarifying issues in an area of research, it is a complex and time-consuming approach that involves surveying many experts as well as engaging in efforts to reduce bias in findings, due to the subjective nature of the method ( 18 , 19 ). Further examination of the relationship between body dissatisfactionterm and internalized weight stigmaterm quantitatively provides the opportunity to strengthen the foundation of evidence to support further investigation into potential concept creepterm·dom or construct proliferationterm·dom.
To this end, we conducted a meta-analysisterm·mth of research examining internalized weight stigmaterm and body dissatisfactionterm. After conducting the meta-analysisterm·mth and identifying the measures of body dissatisfactionterm and internalized weight stigmaterm that demonstrate the most and the least conceptual overlap, we conducted an empirical study in a sample of racially and ethnically diverse college-attending women. This study aimed to refine existing measures of body dissatisfactionterm and internalized weight stigmaterm identified in the meta-analysisterm·mth as suitable for community samples of women, while removing the conceptual overlap.
Although researchers have recently conducted a meta-analysisterm·mth of internalized weight stigmaterm and related body image correlates, including body dissatisfactionterm, positive body image, and weight control beliefs ( 20 ), we identified two important limitations of this meta-analysisterm·mth that we seek to address in our current meta-analysisterm·mth. First, in identifying papers that measured negative body image, Romano et al. ( 20 ) included papers that measured appearance, weight, or shape dissatisfaction as well as body shame, weight-contingent self-worth, body image flexibility, body image avoidance, self-objectification, and appearance anxiety. We assert that many, if not all, of these latter concepts may be regarded as distinct constructs (e.g., body shame and self-objectification: Fredrickson and Roberts, ( 21 ); McKinley and Hyde, ( 22 )) and may not adequately quantify construct proliferationterm·dom between body dissatisfactionterm and internalized weight stigmaterm. Thus, to focus more narrowly on the concept of body dissatisfactionterm, we limited our analysis to papers measuring appearance, weight, or shape dissatisfaction. Second, given that researchers have examined internalized weight stigmaterm in both clinical and community-based samples, but have yet fully to compare differences in the degree of internalized weight stigmaterm in these populations, we were also interested in examining potential differences in clinical and community-based samples. Population-based differences were not examined in the analysis conducted by Romano et al. ( 20 ) but may further our understanding of which groups are most affected by the conceptual and measurement overlapterm·key.
Study 1: Systematic Review and Meta-Analysisterm·mth of Existing Literature Method Search Strategy and Eligibility Criteria In conducting our search, we examined the search strategies of two previous systematic reviews on internalized weight stigmaterm ( 1 , 20 ), and utilized the search terms for internalized weight stigmaterm that were first identified by Pearl and Puhl ( 1 ) and also used by Romano et al. [( 20 ): weight bias internalization; weight bias internalisation; internalized weight bias; internalised weight bias; internalized weight stigmaterm; internalised weight stigma; self-directed weight stigmaterm; self-directed weight bias; weight self-stigma]. The search was conducted in seven databases on January 31, 2022, by the second author: PubMed, SCOPUS, Science Direct, EMBASE, PsychINFO, CINAHL, and Web of Science. Studies were included if they were written in English, tested human participants, quantitatively measured both body dissatisfactionterm (defined as measuring dissatisfaction with appearance, weight, and/or shape) and internalized weight stigmaterm, and were peer reviewed. The search yielded 585 abstracts after the removal of duplicates ( n = 1,032), which were screened by the first and second authors. Of the 76 papers that were identified for full-text screening, 48 were included in the systematic review and 43 in the meta-analysisterm·mth. Given the small number of studies examining these constructs in child and adolescent samples ( n = 5), we included these in the systematic review for descriptive purposes but not the meta-analysisterm·mth. Papers were excluded from the systematic review and meta-analyses ( n = 28) for the following reasons: ( 1 ) not measuring both constructs in question ( n = 4), ( 2 ) conference abstracts, theses, and dissertations ( n = 8), ( 3 ) or the correlation not being available from the study authors ( n = 16). The search structure and process are summarized in Figure 1 . Notably, we identified an additional 20 papers that were not included in the meta-analysisterm·mth conducted by Romano et al. ( 20 ), two of which were published online after October 2021, when their search was conducted.
PRISMA diagram results from database searches through meta-analysisterm·mth.
Meta-Analysisterm·mth A meta-analysisterm·mth of the 43 identified articles and follow-up analyses of sub-groups (clinical vs. college/community) and of BMIterm as a potential moderator were conducted using Meta-Essentials , a set of excel workbooks for meta-analysisterm·mth ( 23 ) to calculate the standard errors, moderators, and group-level differences and SPSS 28.0 to produce the forest plot. Data were independently extracted and analyzed by the first author. Given the potential heterogeneity in both samples and measurement, we conducted each meta-analysisterm·mth using random effects models. Where studies included more than one measure of body dissatisfactionterm (two subscales of the MBSRQ or EDE-Q were administered), we averaged the correlations so as to not include each participant more than once. This choice was also made as some studies report this composite correlation within their manuscript. In instances where data from male and female or race sub-samples were analyzed separately, we entered the study in the meta-analysisterm·mth twice (once for each sample). Q and I 2 were calculated to determine heterogeneity, with I 2 expressing the percentage of variability attributable to heterogeneity rather than sampling error. As such, possible I 2 values range from 0 to 100% with higher values representing greater heterogeneity. We assessed publication bias by implementing Egger's testterm ( 24 ), which examines whether the intercept from the linear regression equation is significantly different from zero. A statistically significant intercept indicates that publication bias is likely present. We examined group differences between clinical and community samples as the manifestations of body dissatisfactionterm and internalized weight bias were likely to differ between these groups, and considered BMIterm as a moderator because again, the way these constructs interrelate may depend upon body size and the lived experiences associated with that body size.
Results Systematic Review Within the 48 papers that examined the correlation between body dissatisfactionterm and internalized weight stigmaterm, nine scales were used to assess body dissatisfactionterm in adults: the weight and shape concern subscales of the Eating Disorderterm·key Examination Questionnaire or Eating Disorderterm·key Examination [EDE-Q, ( 25 , 26 ); n = 15], multiple different subscales of the Multidimensional Body-Self Relations Questionnaire [MBSRQ, ( 27 ); n = 13], the BSQ [( 28 ); n = 6], the body dissatisfactionterm subscale of the Eating Disorderterm·key Inventory [EDI, ( 29 ); n = 2], the Body Uneasiness Test [( 30 ); n = 1], the Male Body Attitudes Scale-Revised [( 31 ); n = 1], the Weight Concerns Scale n = 1 ( 32 ), the body dissatisfactionterm subscale of the Eating Pathology Symptoms Inventory (EPSI ( 33 ); n = 1) and the Body Image States Scale [( 34 ); n = 1]. Two adult studies and two youth studies used researcher-created item(s). The remaining youth studies used either the EDE-Q ( n = 1) or the Physical Self-Description Questionnaire [PSDQ; ( 35 ); n = 1].
In adult and youth samples, internalized weight stigmaterm was quantified by 10 different iterations of the WBIS: the original 11-item scale [( 6 ); n = 18], the WBIS modified for all body weights with 11 items [WBIS-M; ( 1 ); n = 10], a 10-item version [( 36 ); n = 4], a modified 10-item version ( n = 1), the 19-item WBIS [( 6 ); n = 2], a modified 9-item Italian version [( 37 ); n = 1], a modified 10-item German version (34; n = 1), a modified Greek version ( 38 ), a modified Spanish version (( 39 ); n = 1), and the WBIS for children ( n = 2). The remaining adult studies quantified internalized weight stigmaterm through administration of the Weight Self Stigma Questionnaire [( 40 ); n = 6] and the self-stigma sub-scale of the Acceptance and Action for Weight Questionnaire [AAQ-W; ( 41 ); n = 1].
We divided the 48 studies into three groups: studies of individuals with clinically significant ED characteristics or those seeking treatment for an eating and or weight concern ( n = 19, see Table 1 ), studies with community-based or college student samples ( n = 29, see Table 2 ), and child/adolescent samples ( n = 5, contained within Tables 1 , 2 ), as the manifestations of body dissatisfactionterm and internalized weight stigmaterm and the interrelation between these constructs were likely to differ between these groups.
Systematic review of clinical samples.
Systematic review of community samples.
Clinical Samples Participants in these 19 studies were either bariatric surgery patients ( n = 6), in an outpatient weight loss clinical intervention ( n = 10), or patients clinically identified as having binge eating disorderterm·key or bulimia ( n = 3). Across all measures of body dissatisfactionterm and internalized weight stigmaterm, the reported correlations ranged from 0.23 to 0.82 (see Table 1 ). The MBSRQ ( n = 5) and EDE-Q/EDE ( n = 9) were the most administered measures of body dissatisfactionterm among clinical samples. Five studies found moderate to strong correlations between WBIS or WSSQ scores and scores on the: (a) appearance evaluation sub-scale [0.36-0.40; ( 49 , 52 )]; (b) appearance orientation subscale [0.29-0.48; ( 45 , 49 , 52 )]; and (c) the body areas satisfaction subscale [0.37-0.41; ( 43 , 46 , 52 )] of the MBSRQ. The EDE and EDE-Q weight and shape concern subscales also correlated moderately to strongly, but not redundantly, with the WSSQ [0.23-0.40; ( 42 , 55 )] and stronger still with the 11-item WBIS [0.37-0.72; ( 10 , 50 , 51 , 54 , 57 )]. Scores on the BSQ were strongly related to scores on the WBIS [0.51-0.66; ( 44 , 47 )] and the self-stigma subscale of the AAQ-W [0.70; ( 58 )]. Finally, scores on the Body Uneasiness Test were very strongly correlated with scores on a revised, 9-item Italian version of the WBIS [0.77; ( 37 )].
Community and College Samples Participants in these 25 studies were either recruited from internet survey platforms ( n = 13) or were college students ( n = 9). Participants in these samples ranged in reported body mass indexterm and ethnicities and were predominantly female. Within these samples, body dissatisfactionterm was either measured using the BSQ, EDE-Q, MSBRQ, EDI-BD, and EPSI scales or subscales or by a researcher created single-item. Internalized weight stigmaterm was measured with the WBIS (n =12) or WBIS-M (n = 12), with one study using the self-stigma subscale of WSSQ ( 73 ). These numbers somehow were not updated in the most recent version but this reflects what is indicated in Table 2 . Across all measures of body dissatisfactionterm and WBIS scores, the reported correlations ranged from 0.27 to 0.85 (see Table 2 ). Scores on the weight and shape concern subscales of the EDE-Q were very strongly correlated with scores on the WBIS-M [0.60-0.85; ( 63 , 64 , 78 )] and WBIS [0.36-0.80; ( 9 , 11 , 62 , 74 )]. The reported correlations between BSQ scores and WBIS scores [0.54-0.77; ( 6 , 75 , 76 )], and EDI-BD and WBIS scores [0.69-0.72; ( 68 , 77 )] were of similar strengths. The other measures used in community and college samples were MSBRQ subscales correlated with various iterations of the WBIS [0.40-0.80; ( 12 , 36 , 38 , 59 , 61 , 69 , 70 )], the Male Body Attitudes Scale and 11-item WBIS-M [0.73; ( 60 )], the body dissatisfactionterm subscale of the EPSI and the WBIS-M [0.74-0.76; ( 79 )] and the Body Image States Scale correlated with the 11-item WBIS-M [0.27; ( 80 )]. All but four of the published community or college-based studies we identified reported correlations exceeding a large effect size, some approaching a perfect linear relationship ( 82 ).
Child and Adolescent Samples There was one clinical adolescent sample ( 53 ), where the EDE-Q and 10-item WBIS were administered yielding correlations ranging from 0.55 to 0.82. Gmeiner and Warschburger administered a researcher-created single-item to quantify body dissatisfactionterm and the WBIS-C and found a moderate correlation ( r = 0.36) in a sample of children between the ages of six and 11. The correlation increased to 0.59 in a sample of children and adolescents between the ages of 9-13 ( 81 ). Lin et al. ( 71 ) and Maïano et al. ( 72 ) also found moderate correlations ( r 's = 0.32 and 0.43, respectively) in samples of overweight and obese adolescents.
Meta-Analyses The meta-analysisterm·mth included 48 individual studies [the samples in 55 and 54 were split by gender; the samples in Eisenberg et al. ( 48 ) were split by race; and 66 and 51 both featured two studies]. Given the small number of studies with a youth sample, these studies were excluded from the meta-analysisterm·mth. Combined, these 48 studies featured 42,128 participants. For the entire sample, the random effects model with a 95% confidence interval yielded a correlation of r = 0.61, 95% CI[0.57, 0.65], Z = 20.97, p < 0.001. The Q and I 2 statistics indicated considerable heterogeneity across studies (Q = 869.41, I 2 = 94.59%). We hypothesized that this heterogeneity may be due to the two types of sub-samples under investigation; thus, we proceeded with the sub-group analysis.
Both the variance within groups [Q within ( 54 ) = 69.30, p = 0.02] and variance between groups [Q between ( 1 ) = 17.89, p < 0.001) were significant, suggesting significant differences in the strength of the correlation between clinical and community samples, and also significant variability within each group. As illustrated in Figure 2 , the estimated effect size for the clinical samples was calculated at r = 0.52, 95% CI [0.45, 0.58]. In contrast, the estimated effect size for the community and college samples was calculated at r = 0.67, 95% CI [0.62, 0.71]. There was more heterogeneity in the community and college samples (Q = 634.40, I 2 = 95.6%) compared to the clinical samples (Q = 132.34, I 2 = 86.6%), which were more homogeneous.
Forest plot by sub-group (clinical vs. community) demonstrating stronger correlation in community vs. clinical group.
Finally, we conducted a moderation analysis to examine the role of BMIterm in the relation between body dissatisfactionterm and internalized weight stigmaterm. We extracted the mean BMIterm of each sample and entered these averages into the meta-regression. The random effects model yielded a significant moderation effect, β = −0.39, Z = −3.41, p < 0.001 (see Figure 3 ). This significant moderation effect indicates that the relation between body dissatisfactionterm and internalized weight stigmaterm is highest for individuals with lower BMIterm and decreases in strength as BMIterm increases. Egger's testterm of publication bias indicated that no publication bias was identified, y-intercept = −1.73, 90% CI [−3.61, 0.15], t = −1.88, p = 0.07 (see Figure 4 ).
Moderation by BMIterm, indicating a stronger relation between body dissatisfactionterm and internalized weight stigmaterm for those of lower weight.
Funnel plot assessing publication bias using Egger's testterm.
Discussion Body dissatisfactionterm and internalized weight bias are conceptualized as distinct concepts. Body dissatisfactionterm is defined as an individual's negative cognitions and emotions about their body ( 3 ), whereas internalized weight stigmaterm, also referred to as self-directed weight stigmaterm, involves holding negative attitudes about oneself because of self-perceived excess body weight and devaluation of the self, based on societal pressures ( 6 ). Despite these definitions, the meta-analyses yielded a significant, large correlation between body dissatisfactionterm and internalized weight stigmaterm across all 48 studies, with significantly smaller correlations identified in clinical compared to community and college samples, and only moderate correlations identified in the five child and adolescent studies. The correlation between body dissatisfactionterm and internalized weight stigmaterm in community and college samples bordered on multicollinearity in several instances, and was strongly but not redundant in clinical samples. Significant variability was identified within the clinical and community groups. Body mass indexterm moderated the relation between body dissatisfactionterm and internalized weight stigmaterm; the relation between body dissatisfactionterm and internalized weight stigmaterm was the strongest for individuals with a lower BMIterm and weakened as average sample BMIterm increased.
These results extend on the recent findings by Romano et al. ( 20 ) in three important ways. First, while our meta-analysisterm·mth resulted in a similar overall correlation between internalized weight stigmaterm and body dissatisfactionterm as found by Romano et al. ( 20 ), our results suggest that there are significant differences between clinical and community/college populations, which was not examined in the existing literature. We also examined the relation between body dissatisfactionterm and internalized weight stigmaterm developmentally, with our systematic review yielding consistently lower correlations in the youth samples compared to the adult samples. This finding suggests that the potential measurement issues are limited to adulthood and the measures used in childhood and adolescence are more distinct. Finally, our moderation analyses suggested that BMIterm was a significant moderator of the association between these constructs, which was examined but not discussed in the paper by Romano et al. ( 20 ). Given our calculated overall correlation between body dissatisfactionterm and internalized weight stigmaterm approximated that found by Romano et al., it is possible that highly redundant correlations would again be found in community samples if we examined the related constructs of body shame, weight-contingent self-worth, body image flexibility, body image avoidance, self-objectification, and appearance anxiety that were included in the Romano paper. Future research should examine whether construct overlap between these distinct, yet related constructs, and internalized weight stigmaterm is present among community samples to further improve measurement in the body image field.
There are several potential explanations for the differences observed between clinical and community samples in the extant literature. First, it may be that, as eating pathology severity becomes clinically significant, the strength of the relation between the concepts of internalized weight stigmaterm and body dissatisfactionterm weakens, because other relevant clinical indicators are related to one or both concepts. A second possible explanation is that this difference relates to individual body weight, or body mass indexterm (BMIterm). The studies to date with clinical samples have all examined these constructs in individuals in larger bodies seeking medically-supervised weight loss or psychiatric treatment for binge eating disorderterm·key, whereas the community samples typically include individuals with a wide range of BMIsterm. We explored this possibility without an a priori hypothesis, because prior research has shown that both body dissatisfactionterm and internalized weight stigmaterm occur regardless of actual or perceived body weight ( 11 ), and that BMIterm does not consistently correlate with internalized weight stigmaterm ( 49 ). Moreover, the correlation between internalized weight stigmaterm and body dissatisfactionterm consistently remains strong even when controlling for BMIterm in the statistical model ( 76 ). However, we found a strong, negative effect of BMIterm across the 48 existing studies, suggesting that as BMIterm increases, the strength of the relation between body dissatisfactionterm and internalized weight bias decreases. This finding is contrary to what one may have expected, as it would follow theoretically that internalized weight stigmaterm might have a greater negative impact on the body dissatisfactionterm of individuals who live in larger bodies and are exposed to greater rates of weight stigma and discrimination in their community.
A third explanation for the differences identified between clinical and community samples surrounds the measurement of these two constructs, particularly for individuals with lower BMIsterm. Although all of the measures administered in each study demonstrated acceptable psychometric properties, our examination of the interrelations between body dissatisfactionterm and internalized weight stigmaterm identified (a) measures that approach multicollinearity with one another in both clinical and college or community samples (EDE-Q and WBIS), (b) measures that are very highly correlated with one another in community samples and highly, but not redundantly, correlated in clinical samples (BSQ and WBIS), and (c) measures that have, to date, only been administered in clinical samples but may show promise in quantifying body dissatisfactionterm and internalized weight stigmaterm in community samples (subscales of the MBSRQ correlated with WBIS; WSSQ).
Only the WBIS or WBIS-M were used to quantify internalized weight stigmaterm in the college and community samples, aside from one study by Meadows et al. ( 73 ) that used the self-stigma subscale of WSSQ in a sample of people self-identifying as living in larger bodies. This is likely a function of the fact that the scale has been normed with individuals across the weight spectrum ( 76 ), and was the most psychometrically-sound option of the existing measures for community samples with individuals of varying body sizes. Example items of the WBIS include “ I am less attractive than most other people because of my weight ” and “ my weight is a major way that I judge my value as a person .” The correlations between body dissatisfactionterm and WBIS scores were quite high in each of the community and college samples, regardless of the measure of body dissatisfactionterm administered. In their meta-analysisterm·mth, Romano et al. ( 20 ) indicate that the inclusive language of the WBIS-M scale may contribute to its redundant correlations with body dissatisfactionterm, arguing that “the weight-neutral language of [the WBIS-M], which is important from a weight stigma reduction and inclusivity perspective, may also draw out aspects of individuals' negatively valenced body image to a greater extent than is evident when the term “overweight” is used” (p. 8). The one exception to the high correlations with the WBIS and WBIS-M was seen in the data from Selensky and Carels ( 80 ) who used state, rather than trait-based measures.
On the other hand, the WSSQ was more regularly administered to clinical samples and consistently demonstrated moderate correlations with body dissatisfactionterm measures. The WSSQ may be a stronger indicator of internalized weight stigmaterm not only in clinical samples, but also in community and college samples. This suggestion aligns with the findings of Meadows et al. ( 73 ) who found strong, but not redundant correlations between the WSSQ and the Appearance Evaluation subscale of the MSBRQ in a community sample of MTurk participants. We recommend that future research examine the psychometric properties of the WSSQ across weight statuses to ascertain if it is a psychometrically sound measure for quantifying internalized weight stigmaterm in lower weight individuals. This would allow for the examination of the interrelations between WSSQ and body dissatisfactionterm scores in community or college samples to confirm whether these moderate correlations replicate in non-clinical groups. Likewise, several of the various MBSRQ sub-scales were only administered to the clinical samples, and these may be a strong alternative when assessing body dissatisfactionterm and in college and community samples.
The redundant correlations between body dissatisfactionterm and internalized weight stigmaterm, particularly for the community samples may also have occurred because some items included within both body dissatisfactionterm and internalized weight stigmaterm measures more strongly relate to conceptualizations of the other concept, thus blurring concept boundaries and contributing to construct proliferationterm·dom for all samples. One recent study ( 78 ) found that, while highly correlated with one another, body dissatisfactionterm scores were not significant predictors of quality-of-life scores in college students, whereas internalized weight stigmaterm scores were significant predictors. This finding suggests that there are nuances in the predictive power of scores on these measures and the amount of variance these constructs explain in certain outcomes. However, the extremely strong correlations between body dissatisfactionterm and internalized weight stigmaterm in the community and college samples may point to a larger measurement problem: perhaps the commonly used measures of body dissatisfactionterm and internalized weight stigmaterm among community samples of women are not measuring their intended constructs. This was a question we sought to explore in Study 2.
Study 2: Examining and Removing Conceptual Overlap From Measures of Body Dissatisfactionterm and Internalized Weight Stigmaterm Given our findings in study one, we conducted study two to refine existing measures and lessen the degree of measurement overlapterm·key between internalized weight stigmaterm and body dissatisfactionterm, particularly in community samples of women. In refining these measures, we aimed to clarify the boundaries between these two concepts, ensuring measurement error is better accounted for ( 16 ), and produce new measures of each construct for use in research and clinical practice. Such an improvement to existing measures would allow researchers and clinicians to better tease apart the interactive and additive roles of body dissatisfactionterm and internalized weight stigmaterm on disordered eating and other psychological outcomes for women, and to design strong prevention programs specifically tailored to each of these risk factors.
Method The data are a part of a larger unpublished measurement validation study examining weight stigma and body image. After learning about the study requirements and providing informed consent, female participants ( n = 492) provided demographic information and completed the standardized measures. All undergraduate Psychology majors over the age of 18 were eligible to participate; given the differing ways body dissatisfactionterm manifests by gender, we limited our current sample to female-identifying participants. Participation occurred online via the Qualtrics survey platform in exchange for course credit. All procedures were approved by the Institutional Review Board at a large, urban institution in the southeastern US.
Participants The sample was predominantly Hispanic or Latina (66.5%; n = 327), followed by 14% Black ( n = 69), 11.4% White ( n = 56), 2.6% Asian ( n = 13), 2.6% Biracial or bi-ethnic ( n = 13), 0.8% Middle Eastern ( n = 4), 0.4% South Asian ( n = 2), 0.4% Alaskan or Pacific Islander ( n = 2), 0.2% Southeast Asian ( n = 1), and 1% Other ( n = 5). Participants, all enrolled in an undergraduate Psychology degree, ranged in age from 18 to 54 ( M = 22.98, SD = 5.57).
Measures WBIS-M As the modified WBIS is the only existing measure of internalized weight stigmaterm that has been validated in college samples as well as in samples across the weight spectrum, we administered the WBIS-M ( 76 ) with the goal of refining the scale to better quantify weight stigma. The WBIS-M consists of 11 items rated on a six-point scale ranging from strongly disagree to strongly agree, with higher scores indicative of higher levels of internalized weight stigmaterm. The Cronbach's α for the WBIS-M was 0.83.
BASS The results of our meta-analysisterm·mth indicated that the smallest amount of conceptual overlap between internalized weight stigmaterm and trait body dissatisfactionterm consistently occurred when body dissatisfactionterm was quantified by the BASS subscale of the MSBRQ ( 27 ). Thus, we administered the BASS for measure refinement in the current study. The BASS consists of nine items rated on a five-point scale, ranging from very dissatisfied to very satisfied. We reversed the coding of each item, so a higher score was indicative of greater body dissatisfactionterm. The scale quantifies dissatisfaction with one's face (facial features and complexion), hair (color, thickness, and texture), lower torso (buttocks, hips, thighs, and legs), mid torso (waist and stomach), upper torso (chest, breasts, shoulders, arms), muscle tone, weight, height, and overall appearance. The Cronbach's α for the BASS was 0.83.
Data Analysis To adequately refine the existing measures of internalized weight stigmaterm and body dissatisfactionterm, we first split the sample into two random halves to allow for both an exploratory factor analysisterm (EFAterm) and confirmatory factor analysisterm·key (CFA) with the sample. We then conducted an EFAterm with the 11 items from the WBIS-M and the nine items from the BASS. As we were seeking two distinct scales, one that quantifies internalized weight bias and one that quantifies body dissatisfactionterm, we fixed the number of factors extracted to two. As internalized weight stigmaterm and body dissatisfactionterm are likely to correlate even once the conceptual overlap has been removed, a promax oblique rotation was applied. Upon establishing which items to retain and which to remove based on EFAterm factor loadings, we conducted a CFA with the retained items and the other half of the sample.
Results There was a very small amount of missing data (0.3-0.7% of the BASS items) that were missing completely at random, Little's χ ( 2 , 227 ) 2 = 2311.68, p = 0.103. Missing data were imputed using expectation maximization in SPSS 26.0. The EFAterm yielded a Kaiser-Meyer-Olkin Measure of Sampling Adequacy value of 0.94 (seeking values >0.80) and a significant Bartlett's test of sphericity, indicating the data were suitable for an EFAterm. The two factors extracted explained 56.33% of the variance in the 20 items. As indicated in Table 3 , the first item in the WBIS-M ( Because of my weight, I am just as competent as anyone ) cross-loaded on both factors, and was not retained as an item in our revised WBIS-M. This aligns with prior research using the WBIS ( 49 ). On the BASS, dissatisfaction with the lower torso, muscle tone, and overall appearance each cross-loaded on the two factors. The dissatisfaction with weight and dissatisfaction with mid-torso items loaded on to the internalized weight stigmaterm factor and were eliminated. We retained four items on the BASS and 10 items on the WBIS-M. The retained items from the BASS quantified dissatisfaction with height, face, upper torso, and hair. All the other items demonstrated statistical overlap with the retained WBIS-M items. The scales were significantly but not redundantly correlated with one another, r = 0.28, 95% CI [0.16, 0.39], p < 0.001 when the redundant items were removed. Before removal of the five BASS and one WBIS-M item, the correlation between the scales was r = 0.69, 95% CI [0.62, 0.75], p < 0.001.
Exploratory factor analysisterm factor loadings of BASS and WBIS-M items.
We next conducted a CFA with the other half of the sample ( n = 246) to test the model fitness of the two factors. We allowed for error terms to correlate within the internalized weight stigmaterm scale. The data demonstrated univariate normality with no skewness or kurtosis values greater than the absolute value of 1.3. The data did demonstrate multivariate non-normality (kurtosis = 41.21) and subsequent analyses were bootstrapped with 1,000 resamples to account for the non-normality. The 14-item model (10 items on the WBIS factor and 4 on the BASS factor) fit the data well: CFI = 0.97, TLI = 0.96, RMSEA = 0.05, 90% CI [0.04, 0.07], p-close = 0.17. All items loaded significantly onto their respective factor. Standardized factor loadings ranged from 0.38 to 0.66 for the BASS items and 0.56 to 0.88 for the WBIS items.
Discussion In our attempts to modify two existing measures of internalized weight stigmaterm and body dissatisfactionterm, the majority of the internalized weight stigmaterm items (10 out of 11) loaded strongly onto the internalized weight stigmaterm factor, with one item cross-loading on both the internalized weight stigmaterm and body dissatisfactionterm factors. This same item showed low inter-item correlations in a prior scale translation and validation study ( 83 ). In contrast, the majority of the body dissatisfactionterm items (five out of nine) either cross-loaded onto both factors or loaded on to the internalized weight stigmaterm factor despite being intended for the body dissatisfactionterm factor. The two scales resulting from the EFAterm and CFA consisted of 10 items quantifying internalized weight stigmaterm and four items quantifying body dissatisfactionterm. None of the retained body dissatisfactionterm items referred to weight or size of body parts. This suggests that the measurement issues identified in recent prior research ( 12 , 79 ) may be due not only to the way we conceptualize and quantify internalized weight stigmaterm, but also the ways in which we conceptualize and quantify body dissatisfactionterm, across the existing corpus of body dissatisfactionterm scales.
For example, many of the BSQ items are directly related to being “fat,” rather than referring to body dissatisfactionterm more generally (e.g., “ has being undressed, such as when taking a bath, made you feel fat? ”). Similarly, half of the items in the body dissatisfactionterm subscale of the EDI refer to the self-perception that one is “too large.” Given these size-focused item, it is important to consider whether these items truly quantify body dissatisfactionterm. Rather than quantifying an individual's negative cognitions and emotions about their body ( 3 ), these items may be described as more accurately measuring an individual's negative attitudes about oneself because of self-perceived excess body weight, or internalized weight stigmaterm ( 6 ). Although the existing body dissatisfactionterm measures demonstrate strong psychometric properties ( 84 ), these measures may be unintentionally measuring internalized weight stigmaterm simultaneously along with body dissatisfactionterm. Although the BASS and WBIS-M showed the smallest correlations in our meta-analysisterm·mth (study 1), many of the items from the BASS appear to be measuring internalized weight stigmaterm in study 2. Given this conceptual overlap, we suggest using a modified BASS in clinical and research situations where it is important to measure the distinct effects of body (dis)satisfaction and internalized weight stigmaterm.
General Discussion and Suggestions for Future Research Overall, the results of this research are consistent with previous findings that report strong correlations between internalized weight stigmaterm and body dissatisfactionterm ( 12 , 20 ). Further, our results suggested that the strength of this relationship differs between sample population (clinical vs. community/college) as well as by BMIterm. Our results also suggest that measures of internalized weight stigmaterm as well as measures of body dissatisfactionterm would benefit from further scrutiny in future research to improve the measurement of research questions, interpretation of results, and application of findings.
In their interpretation of results, Romano et al. ( 20 ) state that the association between internalized weight stigmaterm with related concepts lowers the confidence in the literature pertaining to internalized weight stigmaterm. However, our results suggest that consideration ought to be given to the measures of both internalized weight stigmaterm as well as body dissatisfactionterm. According to the sociocultural model of disordered eating, a key predictor of body dissatisfactionterm is thin-ideal internalizationterm ( 85 ), with thin-ideal internalizationterm conceptualized as pressure from media, family, and peers to achieve a thin figure ( 86 ). Although researchers have recognized changes in the nature of the thin-ideal over time, such as the increasing emphasis of leanness as well as muscularity for both women and men ( 87 ), sociocultural beauty ideals that emphasize thinness are inherently anti-fat. Thus, anti-fat messaging is central to existing concepts of internalized weight stigmaterm as well as body dissatisfactionterm, as evidenced by items on commonly used scales measuring both constructs. We argue that, as a construct, internalized weight stigmaterm may be conceptualized as related to but distinct from thin-ideal internalizationterm, due to its narrower focus on the internalization of weight-based stereotypes and negative beliefs, as opposed to the broader characteristics of ideal appearance in Western culture.
In considering the association between internalized weight stigmaterm and body dissatisfactionterm it is important to acknowledge that, although the internalized weight stigmaterm literature is relatively young compared to the literature on body dissatisfactionterm, this does not necessarily indicate a fatal flaw in this, or either, concept. Rather, a consideration of the histories and definitions of each construct over time may help to contribute to further discussion on whether the association between internalized weight stigmaterm and body dissatisfactionterm is best described by concept creepterm·dom or construct proliferationterm·dom. In considering definitions and conceptualizations of internalized weight stigmaterm, Durso and Latner ( 6 ) described it as distinct from body image, as it does not describe an individual's feelings about characteristics of the body beyond weight and shape. They also note that internalized weight stigmaterm is distinct from self-esteem, but that it may contribute to an individual's self-esteem. Further, in describing the history of research on internalized weight stigmaterm prior to the development of the WBIS, Durso and Latner ( 6 ) describe researchers as using measures of explicit weight stigma among higher-weight participants as indicators of internalized weight stigmaterm, but that a distinction exists between weight stigma that is directed toward others vs. the self.
In a review of the history of body image literature, Grogan ( 3 ) highlights that research and clinical work related to body image and eating disordersterm·key until the 1980's reinforced ideas that the construct of body image only encompassed weight and shape. Grogan ( 3 ) also notes that, since the 1980's increased efforts have been made to include individuals across the lifespan as well as men in body image research. Despite increased efforts at inclusion in the literature, we assert that the connection between body image and weight remains strong, as evidenced by Grogan's ( 3 ) definition of body dissatisfactionterm as “negative evaluations of body size, shape, muscularity/muscle tone, and weight, and it usually involves a perceived discrepancy between a person's evaluation of his or her body and his or her ideal body” (p. 4).
Thus, while current definitions of body image and internalized weight stigmaterm may differ, histories, definitions, and measures that focus on body dissatisfactionterm may not be distinct enough to provide a clear boundary between this construct and internalized weight stigmaterm. Romano et al. ( 20 ) acknowledged support for the conceptualization by Meadows and Higgs ( 12 ) of internalized weight stigmaterm and body dissatisfactionterm as tapping into a higher-order construct of body-related self-judgment, along with self-esteem. Given the anti-fat nature of both internalized weight stigmaterm as well as body dissatisfactionterm, we believe that further research examining these constructs as part of a higher-order concept may be warranted.
Strengths, Limitations, and Directions for Future Research This study has several notable strengths. First, the addition of BMIterm and sample population as significant influences on the strength of the relationship between internalized weight stigmaterm and body dissatisfactionterm provide important directions for future research. Second, the exploratory and confirmatory factor analyses investigating the conceptual overlap of two commonly used measures supports our assertion that conceptual overlap is present in the ways in which both internalized weight stigmaterm and body dissatisfactionterm are measured. Finally, our sample in the empirical study consisted of female college students diverse in both age as well as race and ethnicity, suggesting our findings can be extended to a diverse population of women.
We also recognize three important limitations of this work. First, our exploratory and confirmatory factor analyses were limited to one common measure of each construct and does not fully explore the measurement overlapterm·key in all measures commonly used in the literature. Future research on the measurement overlapterm·key of more than two measures within the same sample will provide additional data to characterize the extent and nature of conceptual overlap in body image and internalized weight bias literatures. Second, our examination of measurement overlapterm·key was limited to a college sample and did not include a clinical sample of individuals engage in clinical weight management or treatment for eating disordersterm·key. Future research examining the measurement overlapterm·key of commonly used measures may benefit from the inclusion of both a clinical and community/college sample, given the results of our meta-analysisterm·mth in study one. Third, we echo the limitations of the overall literature noted by Romano et al. ( 20 ) regarding key demographic features of participants in research published to-date. Further research is needed to better understand the conceptual overlap of internalized weight stigmaterm and body dissatisfactionterm among individuals of different age ranges, gender identities, racial identities, and sexual orientations.
Conclusion Although both body dissatisfactionterm and internalized weight stigmaterm are strongly related to the development and maintenance of disordered eating and clinical EDs, we call for the development of new, or refinement of existing, measures that lessen the degree of conceptual overlap between these constructs, thus improving the boundaries between these two concepts and ensuring measurement error is better accounted for ( 16 ). Such an improvement would allow researchers and clinicians to better tease apart the interactive and additive roles of body dissatisfactionterm and internalized weight stigmaterm on disordered eating and other psychological outcomes, and to design strong intervention and prevention programs specifically tailored to each of these risk factors.
Data Availability Statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics Statement The studies involving human participants were reviewed and approved by Florida International University Social and Behavioral Sciences. The patients/participants provided their written informed consent to participate in this study.
Author Contributions JS and SN conducted the systematic review and meta-analyses. JS collected and analyzed the data from study 2. SR-M assisted in writing earlier versions of the manuscript. All authors contributed to the study development and approved the submitted version.
Funding This work was funded by Social Sciences and Humanities Research Council (SSHRC) Grant 435-2018-0116.
Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's Note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.