Weight stigma refers to negative attitudes, beliefs, and stereotypes based on a person’s weight, and is pervasive across education, healthcare, media, and the workplace (Lee et al., 2021; Puhl et al., 2007). Some weight-normative public health campaigns invoke weight stigma and shame in hopes of motivating people to lose weight (Vartarian & Smith, 2013). However, rather than promoting health, weight stigma is associated with numerous adverse mental health outcomes, such as disordered eating, depression, anxiety, stress, body dissatisfaction, poor self-esteem, satisfaction with life, and substance use (Friedman et al., 2005; Haines et al., 2006; Papadopoulos & Brennan, 2015; Puhl & Heuer, 2009; Puhl et al., 2006; Puhl & Lessard, 2020; van Vuuren et al., 2019). Similarly, experienced weight stigma has negative physical health correlates, such as increased cortisol reactivity, avoidance of healthcare, reduced engagement in physical exercise, and arterial pressure (Forhan, Risdon, & Solomon, 2013; Himmelstein et al., 2014; Jackson & Steptoe, 2017; Muennig, 2008; Schvey et al., 2014). Finally, weight stigma is associated with adverse social and academic outcomes, such as rejection by peers and lower classroom engagement (Puhl & Lessard, 2020).
Given the toll of weight stigma, it is important to determine the best ways to measure and address weight stigma. The implications of terminology choice when discussing weight are clear. For people trying to lose weight, the terms “fat,” “obese,” and “extremely obese” used by healthcare providers have been rated as the most undesirable (Puhl et al., 2013). Further, individuals preferred that providers merely referenced individuals’ weight rather than use terms viewed by individuals with higher weight as stigmatizing (Puhl et al., 2013). A systematic review of 33 studies elaborates further; Puhl & Lessard (2020) found a preference for neutral terminology (e.g., “weight”) over terms like “fat” and “obese” across most of these studies. Children have reported feeling upset that their parents described them as “large,” “fat,” “obese,” and “overweight,”; they preferred for their parents to use the terms “healthy weight” or “normal weight” (Puhl et al., 2022). Despite being consistently described by individuals with lived experience as stigmatizing, most current measures of weight stigma still use the medical language (e.g., “obese” and “overweight”) Most of these measures were developed before the stigma of these terms was well understood, suggesting the language they use may be outdated.
Recently, the American Psychological Association recommended using inclusive language when discussing body size and weight (APA, n.d.). They reiterated the points outlined by Meadows & Danielsdottir (2016) that suggest using neutral terms such as “weight” or “higher weight” and suggest psychologists not use person-first language as there is no consensus on whether this is preferred (Liebowitz, 2015). Similarly, the National Institute of Health recommends using “person with higher weight, higher-weight individual, person with a larger body, or other similar neutral descriptors, rather than person with obesity or overweight” (NIH, 2023). Clearly, there is a growing movement to modify the terminology we use to describe people with higher weight. Perhaps, more terminology changes will support a less stigmatizing environment for those with higher weight.
Besides conveying stigma, the term “obese” lacks a solid definition and meaning. In a position statement from the World Obesity Federation, Nutter and colleagues (2023) provide further reason to omit the word in most settings, highlighting the varied obesity definitions proposed by public health organizations. For example, the World Health Organization (WHO; 2024) defines obesity as “abnormal or excessive fat accumulation that presents a risk to health.” Conversely, the CDC defines obesity as a body mass index (BMI) greater than 30.0 (Center for Disease Control and Prevention, 2022). However, a 2022 position statement from the WHO challenges the CDC’s definition, stating that BMI-based approaches to obesity fail to acknowledge the location and function of adipose tissue, as it relates to adiposity-based chronic disease (World Health Organization, 2022). Additionally, Nutter and colleagues (2023) note that definitions of obesity that rely on BMI or other anthropometric metrics fail to capture obesity as a chronic disease. A previous study from Okorodudu and colleagues (2010) supports this position, pointing out that weight and health are not always synonymous and that so-called adiposity-related health impairments can occur in those within the “healthy weight” range (when using BMI as a descriptor of one’s weight-related health).
Given that the term “obesity” is poorly defined and is viewed as stigmatizing, testing modified versions of these measures is warranted. In our team’s search for measures examining weight stigma toward others that use more neutral language descriptors (e.g., higher weight, larger-bodied), we could not find any. We noted that the Weight Bias Internalization Scale (Durso & Latner, 2008), a measure of internalized weight bias, had a modified version that changed the term “overweight” to “my weight,” and maintained good reliability and validity (Pearl & Puhl, 2014). Thus, in the present study, we sought to adapt the Attitudes Towards Obese Persons (ATOP; Allison et al., 1991) scale, a frequently used measure of weight stigma toward others. We compared the original ATOP scale to a modified version of the instrument, using neutral terms such as “higher weight.” We hypothesized there would be no difference in endorsed negative attitudes toward those with higher weight between those who completed the original ATOP compared to those who completed the modified version. Finally, given the original ATOP factor structure has been inconsistently replicated (Ambwani et al., 2014; Marek et al., 2021) since its validation study (Allison et al., 1991), we examined the factor structure of both ATOP samples (ATOP original and ATOP modified). Given the stigmatizing effects of terms like “obese,” this study was conducted in hopes of gathering a better understanding of how weight-related terminology used in a research measure might relate to different attitudes towards individuals of higher weight.