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Published in final edited form as: Sleep Health. 2023 Nov 27;10(1):60–64. doi: 10.1016/j.sleh.2023.10.014

Weight Bias Internalization is Positively Associated with Insomnia Symptom Severity in Young Women with Disordered Eating

Kara A Christensen Pacella 1, Kelsie T Forbush 2
PMCID: PMC10922884  NIHMSID: NIHMS1949532  PMID: 38016909

Abstract

Objective:

Social stigma has been associated with disparities in sleep heath; however, one type of stigma that has been less evaluated is weight bias internalization (WBI). Previous studies have shown inconsistent results linking WBI and sleep problems and few have examined associations with insomnia.

Methods:

Women with disordered eating (N = 173, Mage = 20.22, SD = 1.70, range = 18–25) completed questionnaires measuring insomnia symptoms, WBI, alcohol use, and dysphoria. Linear regression tested associations between WBI and insomnia symptom severity, after adjusting for demographic variables, alcohol use, and dysphoria.

Results:

WBI, alcohol use, and dysphoria were significantly positively associated with insomnia symptom severity above-and-beyond demographic variables.

Conclusions:

Although effect sizes were small, WBI was associated with greater insomnia symptom severity. Results add to the growing literature examining the associations of stigma with sleep health.

Keywords: weight stigma, insomnia, sleep, disparities

Introduction

A growing body of literature has examined disparities in sleep health related to experiencing stigma (Billings et al., 2021; Butler et al., 2020; Christensen et al., 2023; Grandner et al., 2016; Patel et al., 2010; Patterson & Potter, 2019); however one source of stigma that has been comparatively less studied in sleep health is weight-based stigma. Enacted weight stigma is discrimination or prejudice based on shape/weight; whereas weight bias internalization (WBI) is self-devaluation based on negative weight-based stereotypes (Durso & Latner, 2008; Pearl & Puhl, 2014; Puhl et al., 2018). WBI is experienced across the weight spectrum; however, it is more common among those with higher body weights and those who believe that weight is under personal control (Prunty et al., 2020).

It is important to examine WBI, as some theories posit that WBI mediates the relation between enacted weight stigma and health outcomes (Tylka et al., 2014), with a systematic review finding preliminary support for this hypothesis (Bidstrup et al., 2022). Furthermore, several systematic reviews and meta-analyses have found direct associations between WBI and psychopathology, including greater depression and anxiety above-and-beyond BMI (Pearl & Puhl, 2018); poorer general mental health (Emmer et al., 2020); and worse negative mental health (e.g., higher negative affectivity, depression), worse positive mental health (e.g., lower positive affect, self-esteem), higher emotion dysregulation, and poorer social functioning (Romano et al., 2023).

WBI may be a common stressor that impacts sleep functioning. One study found that 24% of adults in a community sample reported high levels of WBI (Prunty et al., 2020). Stress has been associated with sleep disturbance (e.g., Yap et al., 2020), resulting in a vicious cycle in which stress increases sleep problems, which further exacerbates stress. WBI has also been linked to increased symptoms of psychological distress, such as depression and anxiety symptoms, which are bi-directionally associated with sleep disturbances (Alvaro et al., 2013).

Few studies have examined the relation between WBI and sleep and results have been inconsistent. One study found that WBI in women was associated with poorer sleep quality through elevated psychological distress (Craven & Fekete, 2022); however, in another study, WBI in men was associated with difficulty sleeping in one sample, but not the other (Himmelstein et al., 2019). A mixed-gender study of Iranian adolescents found a significant correlation between insomnia and WBI (r = .29), but did not examine their association in further detail (Lin et al., 2020). Taken together, the evidence for a link between WBI and sleep problems is inconclusive, especially given the variability in populations studied, sleep parameters, and study design.

One sleep problem of interest is insomnia, which has been associated with greater psychopathology, poorer physical health, and poorer quality-of-life (LeBlanc et al., 2007). Understanding how WBI is associated with insomnia could help elucidate potential sources of sleep health disparities and offer opportunities for intervention targets.

This study examined links between WBI and insomnia in a sample of young women with disordered eating. Studying this population is warranted as higher WBI is associated with higher disordered eating (Romano et al., 2023) and insomnia and disordered eating are proposed to have a bidirectional relationship (Christensen & Short, 2021). It is possible that WBI may contribute to sleep problems frequently reported by people with eating disorders (Kim et al., 2010). We hypothesized that WBI would be positively associated with insomnia symptoms, even after adjusting for dysphoria, alcohol use, and demographic identities that have been associated with sleep health disparities, such as minoritized racial and ethnic identity (Billings et al., 2021; Grandner et al., 2016; Patel et al., 2010) and minoritized sexual orientation (Butler et al., 2020; Christensen et al., 2023; Patterson & Potter, 2019).

Methods

Participants

This study was a secondary analysis of baseline data from an EMA study (Christensen et al., 2021; Christensen Pacella et al., 2023) examining Instagram use and disordered-eating behaviors (DEBs). Eligibility criteria were: female gender, 18–25 years old, at least four DEB episodes (i.e., objective binge eating, self-induced vomiting, diuretic/laxative use, fasting, excessive exercise) per month over the past three months, owning a smartphone, and using Instagram daily. Two participants were removed for being above the age criterion. The final sample consisted of 173 young women (Table 1).

Table 1:

Characteristics of the Sample (N = 173)

M (SD) Range
Age 20.22 (1.70) 18–25
Insomnia symptom severity (ISI) 11.28 (5.49) 0–27
Alcohol use (AUDIT) 6.74 (4.76) 0–21
Dysphoria (IDAS) 18.06 (7.26) 1–34
Weight bias internalization 46.88 (15.20) 11–77
Disordered eating behaviors (Monthly) 24.69 (20.30) 4–95
 Excessive exercise episodes 5.77 (7.06) 0–40
 Fasting episodes 9.66 (11.01) 0–60
 Laxative/diuretic episodes 1.20 (4.21) 0–31
 Objective binge eating episodes 6.98 (6.82) 0–40
 Self-induced vomiting episodes 1.03 (3.35) 0–20
% n
Race
 Asian or Pacific Islander 9.83 17
 Black/African American 1.16 2
 Multiracial 8.67 15
 White 78.61 136
 Missing response 1.73 3
Ethnicity
 Hispanic 13.29 23
 Non-Hispanic 86.71 150
Racial/ethnic Identity
 Minoritized racial/ethnic identity 28.90 50
 Non-Hispanic, White 71.10 123
Sexual Orientation
 Heterosexual 62.43 108
 Minoritized sexual orientation 36.42 63
 Prefer not to say 1.16 2
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Notes: Eleven participants were missing age data. Three participants did not select a race response option and indicated their ethnicity as Hispanic. For insomnia severity, dysphoria, weight bias internalization, total disordered eating behaviors, and excessive exercise N = 172. Disordered eating behaviors were reported as average episodes per month over the previous three months. Minoritized racial/ethnic identity included individuals who identified as Black/African American, Asian or Pacific Islander, or Multiracial, as well as individuals who identified as Hispanic/Latino/a and another racial category (e.g., Hispanic and White or Black/African American). Minoritized sexual orientation included individuals who identified as lesbian, bisexual, queer, questioning, and/or another non-exclusively heterosexual identity.

Procedure

Screening

Participants were recruited through a university-wide screening of eating pathology and Instagram advertisements. Interested participants completed a REDCap survey in which they reported DEBs using questions from the Eating Disorder Diagnostic Scale (Stice et al., 2000).

Study Procedures

Participants completed questionnaires measuring psychopathology, eating behaviors, and insomnia during a baseline session. This was followed by a seven-day EMA protocol. All participants provided informed consent and study procedures were approved by the Institutional Review Board.

Measures

Demographics

Participants reported race, ethnicity, sexual orientation, and age. Race/ethnicity and sexual orientation were dummy coded with 1 representing membership in a minoritized group and 0 representing membership in a non-minoritized group. The reference groups used for this study were Non-Hispanic, White for race/ethnicity and exclusively heterosexual for sexual orientation.

Alcohol Use Disorder Identification Test (AUDIT)

The AUDIT (Saunders et al., 1993) is a ten-item screening measure of alcohol use. In this study, the AUDIT demonstrated acceptable internal consistency (α = .77).

Insomnia Severity Index (ISI)

The ISI (Bastien et al., 2001) is a seven-item measure evaluating the severity of insomnia over the past two weeks. In this study, the ISI demonstrated good internal consistency (α = .83).

Inventory of Depression and Anxiety Symptoms- II- Dysphoria scale (IDAS-II)

The IDAS-II Dysphoria (Watson et al., 2012) is a ten-item scale evaluating depressed mood. In this study, the dysphoria scale demonstrated good internal consistency (α = .85).

Weight Bias Internalization Scale- Modified (WBIS-M)

The WBIS-M (Pearl & Puhl, 2014) is an eleven-item measure evaluating internalization of weight-based stereotypes. The WBIS-M was adapted from the WBIS (Durso & Latner, 2008) to be more broadly applicable for individuals across the weight spectrum. Sample topics include anxiety about weight due to concerns about judgment and extent to which one’s weight guides self-value. Items are summed to create a total score, with higher scores indicating WBI. In this study, the WBIS-M demonstrated good internal consistency (α = .93).

Statistical Analysis

Due to limited missing data in the WBI (n = 1), ISI (n = 1), dysphoria (n = 1), and sexual orientation variables (n = 2) we chose to use listwise deletion resulting in a final analytic sample of N = 168 (2.89% missing). We conducted a linear regression using IBM SPSS (v28) entering minoritized racial/ethnic identity, minoritized sexual orientation, alcohol use, dysphoria, and WBI as independent variables, with insomnia symptom severity as the dependent variable.

Results

The overall model was significant, R2 = .19, F(5) = 7.53, p <.001. Alcohol use, dysphoria, and WBI were positively associated with insomnia symptom severity. Minoritized racial/ethnic minority identity and sexual orientation were not significantly associated with insomnia symptom severity (Table 2). Squared semi-partial correlation coefficients showed that dysphoria accounted for the most unique variance in insomnia symptom severity (6.9%), followed by WBI (2.9%), and alcohol use (2.0%). We report a visualization of the zero-order correlation between WBI and insomnia symptom severity in Figure 1.

Table 2:

Linear Regression Predicting Insomnia Symptom Severity

Unstandardized B SE ß p 95% CI Squared semi-partial correlation
Constant 2.94 1.54 .058 −0.11, 5.98
Sexual Orientation −0.93 0.84 - .269 −2.60, 0.73 0.006
Race/Ethnicity 0.50 0.86 0.04 .568 −1.21, 2.20 0.002
Alcohol use 0.17 0.08 0.15 .045 0.003, 0.33 0.020
Dysphoria 0.23 0.06 0.31 < .001 0.11, 0.35 0.069
Weight bias internalization 0.07 0.03 0.19 .018 0.01, 0.13 0.029
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N = 168. Bolded values indicate statistical significance p <.05. Demographic variables were dummy-coded with 0 indicating a non-minoritized reference group and 1 indicating a minoritized group. The non-minoritized reference groups were Non-Hispanic White (race/ethnicity) and heterosexual (sexual orientation).

Figure 1: Correlation between WBI and Insomnia Symptoms.

Figure 1:

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Discussion

Consistent with our hypothesis, WBI was significantly positively associated with insomnia severity. This study adds new information to how WBI is linked to sleep problems, specifically insomnia, and builds upon growing evidence of a significant association between stigma and poor sleep health (Nwanaji-Enwerem et al., 2022). Although the effect of including WBI was relatively small; the unique variance of WBI (2.9%) was larger than alcohol use (2.0%), which is a common predictor of poorer sleep quality (e.g., Zheng et al., 2021).

In the current study, people experiencing higher levels of WBI reported higher levels of insomnia; however, future studies need to clarify several aspects of the relationship between WBI and insomnia. First, it is unclear how dysphoria should be considered in these models. Due to the limitations of cross-sectional mediation models, we did not examine dysphoria as a mediator. However, other cross-sectional studies have found that depression and anxiety mediated the association between WBI and poorer sleep outcomes (Craven & Fekete, 2022). It is possible that psychological problems may mediate, or partially mediate, the relation between WBI and insomnia. It is also possible that an unmeasured variable in this study may influence WBI, dysphoria, alcohol use, and insomnia symptom severity. For example, social environment, trauma exposure, or general stress may impact self-stigmatization and sleep behaviors. It is also possible that there is a bidirectional association between WBI and insomnia, such that individuals with higher insomnia may be more likely to engage in self-criticism related to WBI. Future studies should use longitudinal analyses to better understand the processes that unfold between WBI, dysphoria, alcohol use, and insomnia symptom severity.

Limitations of this study include cross-sectional analysis of baseline data, which prohibits causal inferences. The sample consisted of only women, which limits generalization to male and non-binary samples. Further, only 29% of the sample belonged to a minoritized racial/ethnic group and 35% belonged to a minoritized sexual orientation group, with different identities (e.g., Black/African American, Hispanic, Asian or Pacific Islander) classified within the same group. Given that weight bias may intersect with racial/ethnic identity and sexual orientation (Panza et al., 2021), future studies are needed to examine associations among people with multiply marginalized identities and evaluate the generalizability of these findings. The sample also had elevated eating-disorder psychopathology, which may correspond to elevated levels of WBI, and limit generalization to non-clinical samples due to range restriction. This study also did not measure other potential confounders of sleep disturbances, such as other sleep disorders, anxiety disorders, trauma exposure, and cigarette smoking.

We did not find significant associations between minoritized racial/ethnic identity or minoritized sexual orientation and insomnia symptom severity, which was surprising given noted disparities in sleep health by race/ethnicity and sexual orientation (Billings et al., 2021; Butler et al., 2020; Christensen et al., 2023; Grandner et al., 2016; Patel et al., 2010; Patterson & Potter, 2019). Overall, this sample reported higher prevalence of minoritized sexual orientation identities compared to larger surveys of college populations (e.g., about 18% reported from data collected over 2016–2019; Hazzard et al., 2020). However, because women identifying as bisexual or questioning are at elevated risks for EDs compared to heterosexual women (Hazzard et al., 2020) and this sample was recruited for elevated disordered eating symptoms, it is not surprising that this sample may have a higher proportion of people with sexual minority identities. However, it is possible that our sample was underpowered to detect demographic differences or that merging different races/ethnicities or sexual orientations as a single variable within the analysis obscured differential effects across groups. Studies are needed to examine these hypotheses in well-powered subgroups. Importantly, race/ethnicity and sexual orientation may not be the appropriate constructs of interest in understanding links between identity and insomnia, instead minority stress or stigma related to race or sexual orientation (Brooks, 1981; Meyer, 2003) may better explain associations.

This study provides further evidence that WBI is associated with negative health outcomes and expands upon the inconsistent literature linking WBI and sleep problems. Clinically, these findings support the need to assess for insomnia among people reporting weight stigma and intervene when appropriate. Further research is needed to establish if there is a causal pathway between WBI and insomnia, as well as determine potential mechanisms of action. If a causal relationship is observed, it may support the use of interventions for WBI (e.g., Davies et al., 2022) to potentially reduce sleep problems.

Acknowledgements:

The authors wish to acknowledge Rhea Mahesh and Noah Oberg for their critical roles in study administration

Funding:

This work was supported by a TL1 postdoctoral fellowship awarded to KACP by Frontiers: University of Kansas Clinical and Translational Science Institute (TL1TR002368) through a CTSA grant from NCATS. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the University of Kansas, University of Nevada Las Vegas, NIH, or NCATS.

Footnotes

Conflict of Interest: The authors report there are no competing interests to declare.

CRediT:

KACP: Conceptualization, methodology, software, validation, formal analysis, investigation, data curation, writing-original draft, writing- review & editing, visualization, supervision, project administration, funding acquisition

KTF: Conceptualization, resources, writing- review & editing, supervision, funding acquisition

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Data Availability Statement:

Data are not publicly available as participants did not provide informed consent for their information to be shared.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data are not publicly available as participants did not provide informed consent for their information to be shared.

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