Disordered eating behaviors describe a range of irregular eating behaviors, such as emotional and nonrestrictive eating (Shomaker & Furman, 2009), which are significant public health challenges in adolescence (Haines et al., 2006). These behaviors are considered to be highly prevalent in Mainland China, with between 2.3% and 17.0% of secondary school students displaying such behaviors (Feng & Abebe, 2017). Disordered eating behaviors may have serious consequences (Shomaker & Furman, 2009), be associated with being overweight, and be a risk factor for the development of further eating disorders, such as binge eating (Jendrzyca & Warschburger, 2016).

Although researchers have established the influence of psychosocial risk factors on disordered eating behaviors, additional evaluations are needed: First, although analysis of adolescents’ disordered eating behaviors is well documented (Bartholdy et al., 2017; Eisenberg & Neumark-Sztainer, 2010; Sparti et al., 2019), few researchers have examined potential mechanisms that explain disordered eating behaviors in preadolescents aged from 9 to 12 years (Munkholm et al., 2016). This gap in the literature needs to be filled because disordered eating behaviors are also common during childhood, and, as well as increasing sociopsychological problems (Herle et al., 2020), they may be involved in numerous physical health issues that track into adolescence. As the prevalence of eating disorders increases after age 12, they can be fatal if ignored (e.g., suicidality; Swanson et al., 2011). Second, few researchers have worked on developing methods of early identification and targeted interventions, which may reduce disordered eating during the preadolescent and adolescent years (Bratland-Sanda & Sundgot-Borgen, 2015; Le Grange & Loeb, 2007). Thus, we considered weight stigma, weight bias internalization, and core self-evaluation as factors that may contribute to an increase in disordered eating behaviors among preadolescents and adolescents.

Weight stigma, which is a prevalent problem in adolescents (Hand et al., 2017), refers to the societal devaluation of and negative attitudes held about people because of their weight (Puhl et al., 2013). This includes dislike of people who are overweight (negative affectivity), stereotyping of overweight people (belief about a person), and negative behavior toward them (discrimination; Daníelsdóttir et al., 2010). Weight stigma is also known as weight bias, weight-based teasing, weight-based discrimination, and weight-based bullying, all of which may pose a risk to individuals’ physical and psychological health (Pearl et al., 2015; Puhl & Heuer, 2010; Puhl et al., 2016). Weight bias internalization has also been well documented as a predictive variable for disordered eating behaviors (Durso et al., 2012). Further, core self-evaluation, as a predictor of not only self-awareness but also induced eating, is associated with eating disorders (Qi & Cui, 2019; Tay et al., 2019).

Although there is a lack of information on the combined effects of weight bias internalization and core self-evaluation on the development of disordered eating behaviors, individuals with greater weight bias internalization are likely to display disordered eating behaviors. In contrast, as individuals with high core self-evaluations may have difficulty in activating weight bias internalization, this may contribute to a decrease in their disordered eating behaviors. To our knowledge, no researchers have examined the relationships among the four constructs of disordered eating behaviors, weight stigma, weight bias internalization, and core self-evaluation in one sample. Thus, it is vital to investigate the factors that may play a mediating role in the relationship between weight stigma and disordered eating behaviors.

Literature Review and Hypotheses

Weight Stigma and Disordered Eating Behaviors

Weight stigma is an important contributing factor to the multifactorial development of disordered eating behaviors (O’Brien et al., 2016). As weight stigmas formed early in life may predict later adverse eating behaviors (e.g., eating as a coping strategy), the health consequences of weight stigma may extend into adulthood (Puhl et al., 2017). Neumark-Sztainer et al. (2002) found in a survey involving anthropometric measurements of 4,746 adolescents at public middle and high schools, that those who deviated from the average range for weight status had more frequent exposure to weight stigma, which is significantly associated with disordered eating behaviors. In a prospective study called Project Eating Among Teens, conducted with 2,516 adolescents who completed a survey at Time 1 (1998–1999) and Time 2 (2003–2004), Haines et al. (2006) found that weight stigma predicted disordered eating behaviors at a 5-year follow-up. Although many researchers have found that weight stigma is prevalent among children and adolescents (Crystal et al., 2000), it is less clear whether preadolescents and adolescents who experience greater (vs. less) weight stigma, are more likely to engage in disordered eating behaviors.

Weight Bias Internalization and Disordered Eating Behaviors

Weight bias internalization is defined as the negative stereotypes and self-statements individuals with an abnormal weight status apply to themselves (Kahan & Puhl, 2017). Puhl et al. (2007) proposed that obese individuals who internalize weight stigma may be particularly vulnerable to its negative impact on disordered eating behaviors. In a survey involving 197 lean adult community volunteers, Schvey and White (2015) found that weight bias internalization significantly predicted binge eating and binging/purging behaviors, suggesting that participants who displayed binging or purging behaviors had high weight bias internalization. Similarly, Zuba and Warschburger (2017) showed that weight bias internalization was significantly associated with higher levels of restrained eating among school-aged children. Thus, weight bias internalization may lead to disordered eating behaviors. In addition, weight stigma could play a key role in facilitating weight bias internalization (Pearl et al., 2014; Tylka et al., 2014). Previous empirical findings show that weight bias internalization has a unique effect on disordered eating behaviors, and mediates the influence of weight stigma on disordered eating behaviors (O’Brien et al., 2016; Pelfrey, 2017).

Core Self-Evaluation and Disordered Eating Behaviors

Core self-evaluation is an assessment by individuals of their own human value, efficacy, and personal ability, and it has typically been operationalized as two lower order traits: self-esteem and self-efficacy (Dou et al., 2016). Many researchers have investigated the relationship between core self-evaluation and disordered eating behaviors (Qi & Cui, 2019). Some have shown that more frequent disordered eating behaviors were related to lower self-esteem because of higher weight stigma (Kornilaki, 2015; Libbey et al., 2008; Zhimeng, 2018). Similarly, Croll et al. (2002) and Loth et al. (2014) found that low self-esteem was a significant personal predictor of engagement in disordered eating behaviors during adolescence.

Core self-evaluation represents a broad personality trait that strongly influences the effect of weight stigma on disordered eating behaviors. For example, Friedman et al. (2005) found that individuals with strong (vs. weak) antifat views had lower self-esteem. Similarly, in a study of 11-year-old obese children, higher weight stigma was found in those who had lower appearance esteem and lower global self-esteem, compared to children with a normal weight (Kornilaki, 2015). Some researchers have suggested that weight stigma is linked to disordered eating behaviors and low self-esteem (Eisenberg et al., 2003; Harriger & Thompson, 2012), and others have found that core self-evaluation serves as a mediator that helps explain the relationship between weight stigma (e.g., self-devaluation) and disordered eating behaviors (Almenara et al., 2017). Therefore, when considering the link between weight stigma and disordered eating behaviors, it is reasonable to assume that core self-evaluation may act as a mediator.

Weight Bias Internalization and Core Self-Evaluation

It is generally agreed that weight bias internalization is inversely related to core self-evaluation, and is positively correlated with weight stigma and disordered eating behaviors (Hilbert et al., 2014; Pötzsch et al., 2018; Zuba & Warschburger, 2018). Durso and Latner (2008) and Durso et al. (2012) found that weight bias internalization accounted for a significant proportion of variance in other domains (e.g., fat phobia, self-esteem), and was strongly related to different domains of eating disorder psychopathology. Hübner et al. (2015) and Pearl et al. (2014) found that individuals with lower (vs. higher) general self-efficacy had high weight bias internalization. According to the model of self-stigma, if a stigma becomes relevant to the self it is likely to reduce self-esteem and self-efficacy, and can lead to a lack of goal-related behavior (Corrigan et al., 2009; Watson et al., 2007). As not everyone in a stigmatized group who internalizes weight bias has diminished core self-evaluation, core self-evaluation can be a mediating variable in the self-stigma process (Hilbert et al., 2014). Pötzsch et al. (2018) found that preadolescents and adolescents who demonstrated higher (vs. lower) weight bias internalization were more likely to display disordered eating behaviors. Lau (2001) reported a significant correlation between negative self-evaluation and eating concerns. Individuals with positive (vs. negative) core self-evaluation are less likely to develop disordered eating behaviors (Decaluwé & Braet, 2005); thus, positive core self-evaluation is a crucial preventive factor for disordered eating behaviors and weight bias internalization.

Previous studies have shown that weight stigma predicts weight bias internalization and core self-evaluation, which further affect disordered eating behaviors. For example, Hilbert et al. (2014) found that core self-evaluation mediated the relationship between weight bias internalization and health status, and O’Brien et al. (2016) showed that weight bias internalization mediated the effect of weight stigma on disordered eating behaviors. Similarly, Ratcliffe and Ellison (2015) showed that weight stigma was a vulnerability factor for the development of disordered eating behaviors.

The Current Study

We tested two mediation models in this study. In the first model we proposed that weight stigma and disordered eating behaviors would be mediated by weight bias internalization, and jointly mediated by both weight bias internalization and core self-evaluation (hypothesized model). In the second model we proposed that weight stigma and disordered eating behaviors would be mediated by core self-evaluation, and jointly mediated by both core self-evaluation and weight bias internalization (alternative model).

Micali et al. (2015) found significant demographic differences (e.g., school grade and gender) in primary and secondary school students’ disordered eating behaviors. Further, in a nationally representative face-to-face interview survey of 10,123 adolescents, Swanson et al. (2011) found significant gender differences in the prevalence of eating disorders (e.g., binge eating disorder, bulimia nervosa). Therefore, we also examined differences in the tendency to display disordered eating behaviors among primary and secondary students in Grades 4 through 9. In general, these students are aged from 11 to 13 years, and are either preadolescents or early adolescents (Xin & Chi, 2008), which are critical time periods for the onset of dieting. As the desire for thinness or obesophobia increases with age, there is a strong likelihood that dieting or restrained eating, a major risk factor in disordered eating behaviors, will continue (Kaneko et al., 1999). Thus, we proposed the following hypotheses:
Hypothesis 1: Weight stigma will be positively correlated with disordered eating behaviors and weight bias internalization, whereas core self-evaluation will be negatively correlated with weight bias internalization, disordered eating behaviors, and weight stigma.
Hypothesis 2: Weight stigma will predict disordered eating behaviors via weight bias internalization and core self-evaluation, and the association of weight stigma with disordered eating behaviors will be mediated by weight bias internalization.
Hypothesis 3: Weight stigma will predict disordered eating behaviors via core self-evaluation and weight bias internalization, and the association of weight stigma with disordered eating behaviors will be mediated by core self-evaluation.

Method

Participants

Participants were recruited from seven primary and secondary schools (classified according to rural and urban areas) in Fujian, Mainland China. These schools agreed to provide a list of potential participants, and 421 aged from 9 to 14 years (M_age = 11.14, SD = 2.01) in Grades 4–9 voluntarily took part in the study. There were 221 male and 200 female participants, of whom 237 were primary school students and 184 were secondary school students. They represented a range of weight categories.

Procedure

Psychology graduates administered the paper-and-pencil survey, and explained to participants that the survey was anonymous, and that its purpose was to promote healthy children and youth through an exploration of the role of weight stigma in disordered eating behaviors. Data were collected during regular school hours. Participants’ height and weight measurements were taken in 20-minute individual testing sessions, and each head teacher was present to help if necessary. This study was approved by the Fujian Normal University ethics committee. Participants and their parents gave informed written consent, and each participant received a notebook as compensation for taking part in the study.

Measures

Antifat Attitudes Test
We assessed weight stigma using a modified version of the Antifat Attitudes Test (Lewis et al., 1997), which comprises three subscales: social/character disparagement, physical/romantic unattractiveness, and weight control/blame. Responses are rated on a 5-point Likert scale ranging from 1 = never to 5 = very often. We reworded some items to make them more sensitive, for example, “I prefer not to associate with my classmate because they are overweight” was used instead of “I prefer not to associate with my classmate because of their weight.” Higher scores indicate higher weight stigma. The Antifat Attitudes Test has been translated into Chinese (Chencheng, 2012), and used with children and adolescents. Cronbach’s alpha was greater than .70, which indicates acceptable internal consistency reliability (Janz & Becker, 1984).

Weight Bias Internalization Scale for Children
We translated into Chinese the 10-item Weight Bias Internalization Scale for Children (Zuba & Warschburger, 2018), to measure participants’ internalized weight stigma. We defined weight bias internalization in this study as the degree to which participants across weight categories had internalized weight stigma by applying negative stereotypes to themselves (Pakpour et al., 2019). Participants rate the items on a 7-point Likert scale ranging from 1 = totally disagree to 7 = totally agree. A sample item is “I am less attractive than other people because of my weight.” Higher scores represent higher internalized bias. Cronbach’s alpha was .85 in this study and the scale’s test–retest reliability was acceptable (r = .83).

Core Self-Evaluation Scale
The nine-item Chinese version (Ren & Ye, 2009) of the Core Self-Evaluation Scale (Judge et al., 2003) was used to assess participants’ generalized self-evaluation. Participants rated the items on a 5-point Likert scale ranging from 1 = totally disagree to 5 = totally agree, with some items being reverse-scored. A sample item is “I think I’m useless when I fail.” This scale is a single-factor measure and higher scores indicate higher generalized self-evaluation. Cronbach’s alpha was .83 in this study.

Dutch Eating Behavior Questionnaire for Children
We used the Chinese version (Wang et al., 2018) of the Dutch Eating Behavior Questionnaire for Children (van Strien & Oosterveld, 2008) to measure participants’ disordered eating behaviors. This instrument comprises three subscales: emotional eating (e.g., “When I feel blue, I often overeat”) external eating (e.g., “Do you feel like eating whenever you see or smell good food?”), and restrained eating (e.g., “I do not eat some foods because they make me fat”). Participants rate the items on a 4-point Likert scale ranging from 1 = seldom to 4 = often. Higher scores indicate more dietary restraint and overeating tendencies. In Wang et al.’s (2018) Chinese version, Cronbach’s alphas were .83 for emotional eating, .72 for external eating, and .77 for restrained eating, and in this study Cronbach’s alphas were also over .70 for all subscales.

Demographic Variables
Participants gave the following demographic details: age, grade (0 = primary school, 1 = secondary school), and gender (0 = boy, 1 = girl).

Data Analysis

We used SPSS 23.0 and Mplus 7.0 for data analysis and processing. First, we performed a series of independent-samples t tests to assess demographic differences in disordered eating behaviors, using G*Power 3.1.9.2 to calculate the effect size (Cohen’s d). Second, we used Pearson product-moment correlations to establish the correlations between the main variables. Third, we adopted structural equation modeling with Mplus 7.0 to evaluate the significance of mediating effects using nonparametric percentile bootstrapping analysis and maximum likelihood estimation. A model is considered to have a good fit to the data if the ratio of chi square (χ²) to degrees of freedom (df) is close to 2, comparative fit index (CFI) and Tucker–Lewis index (TLI) values are higher than .90, and the root mean square error of approximation (RMSEA) is lower than .08 (Schermelleh-Engel et al., 2003). In line with Preacher et al. (2007), we considered a mediating effect significant when the 95% bias-corrected confidence interval (CI) did not contain zero.

Results

Demographic Differences in Disordered Eating Behaviors

The results show there were weak but statistically significant differences in the prevalence of disordered eating behaviors according to gender (t = −2.19, p < .05, d = 0.20). There were also more strongly significant differences according to grade (t = −8.45, p < .001, d = 0.30).

Correlations Among Study Variables

A correlation matrix is presented in Table 1. The main variables were significantly correlated: Weight stigma was positively correlated with both weight bias internalization and disordered eating behaviors, and core self-evaluation was negatively correlated with weight stigma, weight bias internalization, and disordered eating behaviors. Thus, Hypothesis 1 was supported.

Testing the Hypothesized Model

We examined the roles of core self-evaluation and weight bias internalization as mediators in the relationship between weight stigma and disordered eating behaviors via structural equation modeling, which allows several methods of estimating the associations between latent variables. If an association is of interest, the appropriate representation of measurement error through a single observed variable can be used for a single-factor measure (Sass & Smith, 2006).

Using the single-dimension structure of the Chinese version of the Weight Bias Internalization Scale for Children, we parceled the items to improve communalities and reduce random error, and further improve indicator data quality and the fit of the model (Matsunaga, 2008). In addition, the items were parceled into three indicators to improve model fit and to achieve more stable model estimation (Rogers & Schmitt, 2004). Thus, we randomly divided the 10 weight bias internalization items into parcels: Items 3, 6, and 7 were assigned to the first parcel; Items 1, 4, and 8 to the second parcel; and Items 2, 5, 9, and 10 to the third parcel. We also randomly divided the nine core self-evaluation items into parcels: Items 3, 6, and 7 were assigned to the first parcel; Items 4, 8, and 9 to the second parcel; and Items 1, 2, and 5 to the third parcel.

The model fit indices of the hypothesized model (see Figure 1) were as follows: p < .01, χ²(49) = 84.10, CFI = .98, TLI = .97, RMSEA = .04, 95% CI [0.026, 0.056]. These results suggest that the model had a good fit to the data. The relationship between weight stigma and disordered eating behaviors was positive, and was mediated both by weight bias internalization and core self-evaluation, 95% CI [0.044, 0.147], accounting for 24.4% of the total effect of weight stigma on disordered eating behaviors, and by weight bias internalization, 95% CI [0.011, 0.191], accounting for 28.95% of the total effect of weight stigma on disordered eating behaviors. Thus, Hypothesis 2 was supported. In addition, we performed a multiple mediating effects analysis to determine which path had a greater mediating effect and found no significant differences between the components.

Testing the Alternative Model

The model fit indices of the alternative model were as follows: p < .01, χ²(49) = 145.85, CFI = .95, TLI = .93, RMSEA = .06, 95% CI [0.056, 0.081]. These results illustrate that this model also had a good fit to the data. As shown in Figure 2, weight stigma was positively correlated with disordered eating behaviors, and core self-evaluation was negatively correlated with weight stigma, weight bias internalization, and disordered eating behaviors. In addition, the relationship between weight stigma and disordered eating behaviors was mediated by core self-evaluation and weight bias internalization, 95% CI [0.007, 0.068], accounting for 10.84% of the total effect of weight stigma on disordered eating behaviors. We also observed a specific significant indirect effect of weight stigma on disordered eating behaviors via core self-evaluation, 95% CI [0.074, 0.242], accounting for 45.18% of the total effect of weight stigma on disordered eating behaviors. Therefore, Hypothesis 3 was supported. We performed a multiple mediating effects analysis to determine which path had a greater mediating effect, and found a significant difference between the two paths, 95% CI [−0.396, −0.189].

Discussion

In this study we found that weight stigma was associated with higher weight bias internalization, which was associated with lower core self-evaluation, and lower core self-evaluation was associated with higher disordered eating behaviors. These results are consistent with previous findings that a higher risk of weight bias internalization, disordered eating behaviors, and lower core self-evaluation are all linked to weight stigma (Sikorski et al., 2015).

We also observed significant differences in the tendency to display disordered eating behaviors according to school grade and gender. This finding is consistent with previous results that disordered eating behaviors differ by gender (Jendrzyca & Warschburger, 2016), and with previous findings of differences in the prevalence of disordered eating behaviors among Asian students in the 6th, 9th, and 12th grades (Croll et al., 2002).

Our results imply that both the mediation models we examined had a good fit to the data. In the first (hypothesized) model, weight bias internalization and core self-evaluation dynamically linked weight stigma and disordered eating behaviors. The effect of weight bias internalization on disordered eating behaviors, including the indirect effect of weight stigma on disordered eating behaviors, corroborates previous findings that weight bias internalization may worsen the effects of stigmatizing events, such as harmful comments and discrimination, because the stigmatized individual has invested external events with internal meaning (e.g., self-directed shaming), compounding the severity of disordered eating behaviors (Carels et al., 2010; Kahan & Puhl, 2017).

In Hypothesis 2 we tested the first model, with weight bias internalization and core self-evaluation as mediators of the association between weight stigma and disordered eating behaviors. Results show that weight bias internalization alone had a greater effect compared with the combined effects of weight bias internalization and core self-evaluation on this association. Thus, our findings suggest that weight bias internalization was correlated with more severe disordered eating behaviors in participants with high weight stigma, and that weight bias internalization and core self-evaluation are important factors linking weight stigma to disordered eating behaviors. This is consistent with previous findings demonstrating that for individuals with more stigma experiences, who consequently have more opportunities to internalize negative messages as being self-relevant, there is a negative association with positive group identity, and, in turn, a negative association with higher self-esteem (Frable et al., 1997; Porter & Washington, 1993). Likewise, high weight stigma may enhance individuals’ weight bias internalization, resulting in a higher prevalence of disordered eating behaviors. This inference is consistent with the results of a study conducted among undergraduate students, which suggest that weight stigma was a predictive factor of disordered eating cognitions (e.g., weight bias internalization), and that this, in turn, made a unique contribution to disordered eating behaviors (Pelfrey, 2017).

In Hypothesis 3 we tested the second (alternative) model, examining whether weight stigma predicted disordered eating behaviors via core self-evaluation and weight bias internalization, and if the association of weight stigma with disordered eating behaviors was mediated by core self-evaluation. Results show that in this model core self-evaluation and weight bias internalization mediated the relationship between participants’ weight stigma and disordered eating behaviors. Thus, we propose that weight stigma in preadolescents and adolescents is decisive in predicting disordered eating behaviors because of their lower core self-evaluation and weight bias internalization. This proposal is consistent with previous findings that individuals with high core self-evaluation and a positive group identity at a younger age may make better health-related decisions and engage in health-protective behaviors (Corrigan et al., 2009; Watson et al., 2007). Further, we found that core self-evaluation alone had a greater effect compared with the combined effects of core self-evaluation and weight bias internalization. We suggest that this result can be explained by the model of self-stigma, according to which core self-evaluation is crucial for self-regulation and motivation, and in which core self-evaluation is a central variable (Hilbert et al., 2014). This explanation is consistent with previous findings that an individual’s core self-evaluation is also an important determinant for the development of disordered eating behaviors (Qi & Cui, 2019), that is, individuals who have lower (vs. higher) core self-evaluation and feel hopeless about their capacity to change are likely to maintain an eating disorder (Decaluwé & Braet, 2005; Fairburn et al., 2003).

We have added to the literature by applying multilevel mediation analysis to explain the effect of weight stigma on disordered eating behaviors via the mediators of weight bias internalization and core self-evaluation, in preadolescent and adolescent participants across various weight categories. However, there are some limitations in this study. First, we concentrated on two models comprising four variables and may have overlooked other relevant variables (e.g., stress in other domains of life, fear of weight gain). Second, the measures were all self-reports of attitudes and behavioral intention. The question remains whether our results would hold if we were to include manipulations, such as priming overweight stereotypes, exposure to stigmatizing content, self-identification as overweight, and reduction of self-esteem and self-efficacy, which lead to individuals maintaining disordered eating behaviors. Third, future researchers could hold face-to-face structured interviews to evaluate disordered eating behaviors from a qualitative perspective. Finally, as our sample size was relatively small and drawn from one region in China, the generalizability of our findings to other populations is uncertain. Future researchers could increase the sample size and use a clinical sample for increased representativeness.

Despite these limitations, we have provided evidence for the external validity of weight stigma, weight bias internalization, and core self-evaluation as predictors of disordered eating behaviors in preadolescents and adolescents. Significant individual differences in these variables should be considered when investigating disordered eating behaviors. As the development of disordered eating behaviors is a complex process that is not easy to explore, it is imperative to gain a thorough understanding of how weight stigma may predict disordered eating behaviors, by manipulating methodologies more ecologically valid than those we used in this study. Our findings may help practitioners to design effective psychological interventions aimed at improving core self-evaluation and reducing weight bias internalization among students in Grades 4 through 9, who display disordered eating behaviors and who have higher weight stigma.

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Yiduo Ye, School of Psychology, Fujian Normal University, Qishan Campus, No. 1 Keji Road, Shangjie, Fuzhou, Fujian 350117, People’s Republic of China. Email: [email protected]