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The Weight-Related Abuse Questionnaire (WRAQ): Reliability, validity, and clinical utility
Eating Behaviors 19 (2015) 150–154
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Eating Behaviors
The Weight-Related Abuse Questionnaire (WRAQ): Reliability, validity, and clinical utility Jessica K. Salwen a,⁎, Genna F. Hymowitz b a b
Department of Psychology, Stony Brook University, Stony Brook, NY 11794-2500, United States Departments of Psychology, Psychiatry, & Surgery, Stony Brook University, Stony Brook, NY 11794-2500, United States
a r t i c l e
i n f o
Article history: Received 8 March 2015 Received in revised form 5 June 2015 Accepted 16 September 2015 Available online xxxx Keywords: Weight-related abuse Weight-related teasing Eating disorders Obesity Stigma
a b s t r a c t Weight-related teasing (WRT)/stigmatization may be distinct from teasing and general abuse and may differentially impact adult outcomes. As WRT increases in severity so do depression and disordered eating. Currently, there are no validated measures designed to assess abuse specific to weight. Thus, we developed the WeightRelated Abuse Questionnaire (WRAQ) and validated it in young adult and clinically obese populations. The WRAQ was administered to 3 samples of participants: 292 undergraduate students, 382 undergraduate students, and 59 individuals seeking bariatric surgery. Concurrent validity was assessed via measures of WRT and general childhood abuse. Convergent validity was assessed with measures of depression and disordered eating. Study 1 data were used to further develop the structure of the WRAQ. Study 2 indicated that the WRAQ had excellent psychometric properties (based on factor analyses and reliability/scale consistency analysis) and strong concurrent and convergent validity, supporting the validity of the questionnaire. 6-month test-retest reliability was also good. In Study 3 responses on the WRAQ converged well with interview responses, showed good psychometric properties, and showed moderate correlations with measures of childhood abuse and psychopathology. The WRAQ has strong psychometric properties and is strongly associated with measures of current psychopathology. Additionally, it fills a gap in the assessment literature and may be a beneficial tool for determining which individuals are at increased risk for psychopathology. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Weight is a common reason for being bullied in school (Puhl, Peterson, & Luedicke, 2013, Jan) and obese children/adolescents are at an increased risk for weight-related teasing (WRT; verbal teasing specific to one's weight or shape [e.g., name calling]), by classmates (odds ratio = 6.3–9.6) and family members (odds ratio = 3.3–4) (Lumeng et al., 2010; Neumark-Sztainer et al., 2002, Jan). Similarly, 51% of overweight/obese adults and 97.9% of pre-bariatric surgery patients report experiencing stigmatization from their families (Puhl & Brownell, 2006, Oct; Friedman et al., 2005, May). Further, while general childhood abuse (defined as emotional, physical, or sexual abuse or emotional or physical neglect) occurs in approximately 35.1% of the general population (Scher, Forde, McQuaid, & Stein, 2004, Feb), rates range from 61 to 69% in individuals with extreme obesity (Grilo et al., 2005, Jan; Salwen, Hymowitz, Vivian, & O'Leary, 2014, Mar; Williamson, Thompson, Anda, Dietz, & Felitti, 2002). However, WRT is likely distinct from general abuse and may have a unique impact on
⁎ Corresponding author. E-mail addresses: [email protected] (J.K. Salwen), [email protected] (G.F. Hymowitz).
http://dx.doi.org/10.1016/j.eatbeh.2015.09.001 1471-0153/© 2015 Elsevier Ltd. All rights reserved.
adult outcomes (Salwen et al., 2014, Mar; Salwen, Hymowitz, Bannon, & O'Leary, 2015, Jan 27). While questionnaires exist to assess WRT in children/adolescents and weight-related stigmatization in adults, there are no validated measures designed to assess more severe forms of WRT. A 2010 metaanalysis indicated that to assess negative experiences related to weight, researchers typically use the Perception of Teasing Scale (POTS) (Thompson, Cattarin, Fowler, & Fisher, 1995, Aug), or the Physical Appearance Related Teasing Scale (PARTS) (Thompson, Fabian, Moulton, Dunn, & Altabe, 1991, Jun), both developed over 20 years ago, or unvalidated, self-designed questions (Neumark-Sztainer et al., 2002, Jan). While Puhl, Peterson, and Luedicke (Puhl et al., 2013, Jan) recently investigated verbal, relational and physical “weight based victimization”, they too used an unvalidated measure. Researchers who have assessed more severe WRT, including being “attacked” due to weight, have not behaviorally defined attacked and thus it is unclear what participants were endorsing (Puhl & Brownell, 2006, Oct; Friedman et al., 2005 May). Other studies assessing WRT and/or stigmatization provide few data regarding more severe negative weightrelated events (Lumeng et al., 2010; Neumark-Sztainer et al., 2002 Jan). To more fully capture variability in individual's experiences, we developed the construct of weight-related abuse (WRA), defined as “significant verbal or physical victimization or maltreatment specific
J.K. Salwen, G.F. Hymowitz / Eating Behaviors 19 (2015) 150–154
to one's weight.” This study aimed to develop a measure of WRA, the Weight-Related Abuse Questionnaire (WRAQ), and validate it in a young adult population and a clinically obese population. Our development and validation samples were college student populations, as late adolescence to early adulthood is the peak age of onset for disordered eating behaviors (Ji, Hiripi, Pope, & Kessler, 2007 Feb 1). Following the analysis of psychometric data from the development sample, the scale was slightly altered. We then assessed the WRAQ in a second sample of undergraduate students, including test-retest reliability data for a subsample of participants. To assess concurrent validity, we compared the WRAQ to the POTS weight subscale (Thompson et al., 1995 Aug), the most commonly used measure for assessing WRT (Menzel et al., 2010 Sep), and the Childhood Trauma Questionnaire-Short Form (CTQ-SF) (Bernstein et al., 2003 Feb), a commonly used measure of childhood abuse used to validate a number of other measures of maltreatment (Tonmyr, Draca, Crain, & Macmillan, 2011 Oct). Regarding convergent validity, research consistently indicates that experiencing any kind of teasing/bullying is associated with increases in psychological, physical, and social problems one year later and in adulthood (Arseneault, Bowes, & Shakoor, 2010 May; Takizawa, Maughan, & Arseneault, 2014; Fekkes, Pijper, Fredriks, Vogels, & Verloove-Vanhorick, 2006; Gladstone, Parker, & Malhi, 2006 Mar; Sesar, Barišić, Pandža, & Dodaj, 2012; Storch et al., 2004). More frequent/severe WRT and general abuse lead to greater symptoms of depression and disordered eating in adolescents and individuals with extreme obesity (Friedman et al., 2005, May; Grilo et al., 2005, Jan; Eisenberg, Neumark-Sztainer, & Story, 2003, Aug) and a recent metaanalysis showed moderate effect sizes for the relationships between WRT and dietary restraint (.35) and WRT and binging and/or purging (.36) (Menzel et al., 2010, Sep). Night eating is also associated with childhood abuse, depression, and binge eating (Allison, Grilo, Masheb, & Stunkard, 2007, Dec; Canetti, Berry, & Elizur, 2009, Mar; Fischer et al., 2007, Jun) in community samples and individuals seeking bariatric surgery. Further, common consequences of WRT (e.g., unhealthy weight control, binge eating) are related to long-term weight gain (Fairburn, Cooper, Doll, Norman, & O'Connor, 2000, Jul; Neumark-Sztainer et al., 2007, Nov; Neumark-Sztainer, Wall, Story, & Standish, 2012, Jan). Thus, we compared the WRAQ to symptoms of depression, disordered eating (binge eating, night eating, and unhealthy weight control), and body mass index (BMI). Lastly, to further assess the clinical utility of the WRAQ, we evaluated its psychometric properties in a sample of pre-bariatric surgery patients, and compared the verbal abuse subscale to interview-based reports of WRT. The final form of the WRAQ is a 15-item questionnaire that retrospectively assesses the average frequency of negative weight-related events before the age of 21, including an 8-item verbal abuse (VA) subscale and 7-item physical abuse (PA) subscale. Items are rated from 0 (never) to 6 (more than 20 times per year); a mean score is computed, with final scores ranging from 0 to 6. Participants who endorse abuse on a subscale are asked, “What was the impact of these occurrences on you? Did you feel…” They are provided with a list of 14 possible emotional reactions and rate each emotion from 0 (not at all) to 5 (extremely), with total scores ranging from 0 to 70. Participants are also asked about duration, perpetrators, and body size at the time of the abuse. The online supplement includes information on questionnaire development and data for the development study (Study 1).
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Asian, 8.3% Hispanic, 5.9% African American, and 6.5% other. Participants' BMIs ranged from 15.81–48.91 (M = 24.91, SD = 5.14; 4.2% = underweight, 50.5% = healthy weight, 31.2% = overweight, 9.1% = obese, and 5% = extremely obese). 2.1.2. Procedure Following Human Subjects Review Board approval, participants completed study questionnaires online and in-person (for copyright reasons). 2.1.3. Measures Body mass index (BMI) was measured using self-reported height and weight. Childhood Trauma Questionnaire-Short Form (CTQ-SF) (Bernstein et al., 2003, Feb) measured general childhood abuse. Night Eating Questionnaire (NEQ) (Allison et al., 2008, Jan) measured night eating. Perception of Teasing Scale (POTS) (Thompson et al., 1995, Aug) measured WRT. Questionnaire on Eating and Weight Patterns — Revised (QEWP-R) (Yanovski, 1993, Jul). The QEWP-R measured binge eating symptoms and unhealthy weight control behaviors (vomiting, fasting for at least 24 h, exercising for more than 1 h, or taking more than twice the recommended dose of laxatives, diuretics, or diet pills). Quick Inventory of Depressive Symptomatology (QIDS) (Rush et al., 2003, Sep 1) measured depressive symptoms. In-depth information on the procedure and measures is included in the online supplement. 2.2. Results & discussion All participants were assessed using the WRAQ-VA and PA subscales. Data from men and women were combined, as the total WRAQ score did not differ significantly by gender, t (380) = .56, p = .22. Factor analyses showed good convergence for both the VA and PA subscales, and on each of these subscales, items broke down into mild and severe factors. Reliability analyses showed strong internal consistency for both scales and moderate to good 6-month test-retest reliability. The online supplement includes specific details regarding factor analyses. The VA and PA subscales of the WRAQ both show significant correlations with similar variables (see Table 1), supporting good concurrent and convergent validity. Means and standard deviations for each item are presented in Table 2. Results of Study 2 suggest that the WRAQ is a valid instrument for assessing WRA. Reliability and factor analyses indicated that the VA and PA subscales are psychometrically sound, the items are related to one another, and responses are consistent across time. Furthermore, these data suggest that the WRAQ subscales are clearly associated with scales designed to assess similar constructs. The WRAQ subscales also showed moderate to high correlations with symptoms of depression and eating disorders, variables the literature suggests are associated with WRA. Although college students/young adults are at a heightened risk for depressive disorders and eating disorders, the populations described above are not clinical populations, thus we also evaluated this measure in a sample of pre-bariatric surgery patients. 3. Study 3 3.1. Method
2. Study 2 2.1. Method 2.1.1. Participants Participants were 382 undergraduates (56.8% women) ages 18–39 (M = 19.26, SD = 2.12). Ethnicities were 49.9% Caucasian, 29.6%
3.1.1. Participants Participants were 59 patients (83.3% women) ages 19–64 (M = 40.66, SD = 12.37) who completed pre-bariatric surgery psychological evaluations. Ethnicities were 72.4% Caucasian, 12.1% Hispanic, 8.6% African American, and 6.8% other. Participants' BMIs ranged from 34.72 to 68.35 (M = 44.31, SD = 8.35; 3.4% = class I obesity [30–
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Table 1 Correlations among variables for Study 2. WRAQ Verbal WRAQ Verbal WRAQ Physical POTS CTQ BMI NEQ BED UWC
WRAQ Physical
–
.51*** –
POTS
CTQ
BMI
NEQ
BED
.78*** .41*** –
.35*** .29*** .37*** –
.41*** .20*** .44*** .22*** –
.26*** .17** .19*** .26*** .11* –
.29*** .14** .24*** .22*** .16** .36*** –
UWC .24*** .25*** .21*** .21*** .13* .20*** .24*** –
QIDS .29*** .20*** .26*** .242*** .04 .48*** .30*** .16**
*p b .05; **p b .01; ***p b .001. WRAQ = Weight-Related Abuse Questionnaire; POTS = Perception of Teasing Scale; CTQ = Childhood Trauma Questionnaire; BMI = Body Mass Index; NEQ = Night Eating Questionnaire; BED = Questionnaire on Eating and Weight Patterns Binge Eating subscale; UWC = Questionnaire on Eating and Weight Patterns Unhealthy Weight Control subscale; QIDS = Quick Inventory of Depressive Symptomatology. N = 291 for all correlations except the CTQ (N = 271).
34.9], 41.4% = class II obesity [35–39.9], and 55.2% = class III obesity [40 and up]). 3.1.2. Procedure Data for this study were collected as part of a larger longitudinal study investigating biopsychosocial variables affecting post-bariatric surgery success. 3.1.3. Measures Study 3 utilized the CTQ-SF (Bernstein et al., 2003, Feb), NEQ (Allison et al., 2008, Jan), QEWP-R (Yanovski, 1993, Jul), the QIDS (Rush et al., 2003, Sep 1) and an item from a pre-surgical interview asking “were you teased or criticized about your weight by anyone when you were younger?” 3.2. Results & discussion Participants were assessed using the WRAQ VA and PA subscales. Data from men and women were combined, as neither VA nor PA scores differed significantly by gender (t (46) = −1.33, p = .22 and t (46) = −.56, p = .58, respectively). Factor analyses showed good convergence for the VA and PA subscales, though there were slight differences from Study 2 in the items that loaded as mild versus severe on the PA subscale. Reliability analyses showed strong internal consistency for both scales. Further, WRAQ VA scores were higher for individuals who also reported being teased during the interview, t (35) = −3.11, p = .004, and 73% of participants responded consistently across the WRAQ and interview item. Details of factor analysis data are included in the supplement.
The VA and PA subscales of the WRAQ also showed significant correlations with similar variables, thus supporting moderately good convergent validity. The WRAQ subscales correlated highly with each other, r (58) = .51, p b .001, and with the CTQ total score (verbal abuse: r (53) = .38, p = .007 and physical abuse: r (53) = .30, p = .03). The WRAQ VA subscale also correlated moderately with BMI, r (58) = .27, p = .04 and the WRAQ PA subscale correlated moderately with the QIDS, r (52) = .31, p = .03. Other correlations were not significant; all of these correlations should be interpreted with caution due to the small sample size. Means and standard deviations for each item are presented in Table 2. These data suggest that the WRAQ maintains strong psychometric properties in a clinical/medical population, and thus its utility is generalizable beyond a young adult sample. Furthermore, the WRAQ is not only reliable across time, as demonstrated in Study 2, it is also reliable across measurement strategies. In fact, the WRAQ was more sensitive to abuse history than the clinical interview, suggesting it may be a better initial screen for WRA. These results also further highlight the associations between the WRAQ subscales and measures of eating pathology, depression, and BMI.
4. General discussion Overall, these studies indicate that the WRAQ is a psychometrically sound questionnaire for the retrospective assessment of WRA in clinical and non-clinical samples. Both the VA and PA subscales of the WRAQ have good internal consistency and test-retest reliability and concurrent and convergent validity. Clinically, high correlations between the WRAQ subscales and symptoms of disordered eating and depression
Table 2 Means, standard deviations and rates of endorsement for items from the WRAQ subscales. Sample 2
Verbal abuse subscale 1. Someone laughed at you because of your weight 2. Someone called you names because of your weight 3. Someone criticized you or put you down because of your weight 4. Someone yelled at you because of your weight 5. Someone embarrassed you in front of others because of your weight 6. Someone forced you to go on a diet because of your weight 7. Someone harassed you because of your weight 8. Someone threatened to abandon you because of your weight Physical abuse subscale 1. Someone poked or pinched you because of your weight 2. Someone grabbed you because of your weight 3. Someone threw something at you because of your weight 4. Someone pushed you because of your weight 5. Someone tripped you (or tried to) because of your weight 6. Someone hit you because of your weight 7. Someone kicked you because of your weight
Sample 3
Mean
SD
Endorsed
Mean
SD
Endorsed
1.57 1.49 1.62 .96 1.32 .67 .86 .23
1.91 1.86 1.88 1.64 1.72 1.36 1.50 .79
53.8% 53.5% 57.2% 34.4% 50.7% 27.6% 34.9% 11.3%
2.26 2.33 2.38 1.29 1.95 .76 1.40 .10
2.24 2.29 2.24 2.02 2.27 1.48 2.11 .67
58.6% 60.3% 60.3% 39.7% 51.7% 27.6% 39.7% 3.4%
.43 .37 .16 .16 .18 .13 .08
1.11 1.08 .65 .68 .71 .59 .35
18.3% 14.9% 8.6% 7.3% 8.4% 6.5% 5.2%
.50 .38 .38 .45 .28 .38 .14
1.37 1.21 1.28 1.33 1.02 1.25 .83
13.8% 11.3% 11.3% 13.8% 8.6% 12.1% 3.4%
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suggest the WRAQ may also help identify individuals at higher risk for these psychological difficulties, or whose psychopathology is complicated by their developmental history. While it is important to consider the potential for bias in reporting on the WRAQ, as it is a retrospective measure, research indicates that individuals are more likely to underreport than over-report instances of abuse on retrospective measures (Hardt & Rutter, 2004, Feb). Furthermore, retrospective reporting biases are generally not substantial enough to invalidate reports of events that can be reasonably operationalized (Hardt & Rutter, 2004, Feb). In addition, the relatively high prevalence of WRA reported across our samples and the substantial and negative impact of WRA highlight the importance of refining ways to validly and reliably measure this construct (Puhl et al., 2013, Jan; Hardt & Rutter, 2004, Feb). Future research could involve administration of the WRAQ as a current report to more fully validate this questionnaire. Although we used both clinical and non-clinical samples to evaluate the WRAQ, evaluation of the psychometrics of the WRAQ in other clinical populations is warranted. One population of particular interest is individuals diagnosed with eating disorders, as previous research suggests that WRT plays a role in the development of disordered eating, including binge eating and unhealthy weight control (Grilo et al., 2005, Jan; Benas & Gibb, 2008; Haines, Neumark-Sztainer, Eisenberg, & Hannan, 2006, Feb). However, no existing measure of WRA has been validated in a population of individuals with eating disorders. Future research could evaluate not only the psychometrics of the WRAQ in these populations, but also the impact of WRA on eating disorder development, maintenance, and/or recovery. 4.1. Conclusions The WRAQ is a reliable and valid measure of weight-related verbal and physical abuse in clinical and non-clinical samples, and may be a useful tool for identifying individuals at risk for disordered eating or depression. Future studies should evaluate the validity of the WRAQ in other clinical populations and researchers should continue to evaluate the role of WRA in the development and maintenance of disordered eating and obesity. Role of funding sources The authors did not receive any funding for any part of this research or manuscript preparation. Contributors Jessica Salwen (JKS) worked to develop the items in the WRAQ under the supervision and with advising by Genna Hymowitz (GFH). JKS was primarily responsible for the protocol development and data collection for studies 1 and 2, and JKS and GFH developed the protocol and collected study 3 data together. JKS and GFH both conducted literature searches. JKS performed statistical analyses. JKS wrote the first draft of the manuscript with the exception of the discussion. GFH wrote the first draft of the discussion. Both authors contributed to and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgments The authors wish to thank Drs. Dina Vivian and Daniel O'Leary for their assistance with the development of the WRAQ.
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Contents lists available at ScienceDirect
Eating Behaviors
The Weight-Related Abuse Questionnaire (WRAQ): Reliability, validity, and clinical utility Jessica K. Salwen a,⁎, Genna F. Hymowitz b a b
Department of Psychology, Stony Brook University, Stony Brook, NY 11794-2500, United States Departments of Psychology, Psychiatry, & Surgery, Stony Brook University, Stony Brook, NY 11794-2500, United States
a r t i c l e
i n f o
Article history: Received 8 March 2015 Received in revised form 5 June 2015 Accepted 16 September 2015 Available online xxxx Keywords: Weight-related abuse Weight-related teasing Eating disorders Obesity Stigma
a b s t r a c t Weight-related teasing (WRT)/stigmatization may be distinct from teasing and general abuse and may differentially impact adult outcomes. As WRT increases in severity so do depression and disordered eating. Currently, there are no validated measures designed to assess abuse specific to weight. Thus, we developed the WeightRelated Abuse Questionnaire (WRAQ) and validated it in young adult and clinically obese populations. The WRAQ was administered to 3 samples of participants: 292 undergraduate students, 382 undergraduate students, and 59 individuals seeking bariatric surgery. Concurrent validity was assessed via measures of WRT and general childhood abuse. Convergent validity was assessed with measures of depression and disordered eating. Study 1 data were used to further develop the structure of the WRAQ. Study 2 indicated that the WRAQ had excellent psychometric properties (based on factor analyses and reliability/scale consistency analysis) and strong concurrent and convergent validity, supporting the validity of the questionnaire. 6-month test-retest reliability was also good. In Study 3 responses on the WRAQ converged well with interview responses, showed good psychometric properties, and showed moderate correlations with measures of childhood abuse and psychopathology. The WRAQ has strong psychometric properties and is strongly associated with measures of current psychopathology. Additionally, it fills a gap in the assessment literature and may be a beneficial tool for determining which individuals are at increased risk for psychopathology. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Weight is a common reason for being bullied in school (Puhl, Peterson, & Luedicke, 2013, Jan) and obese children/adolescents are at an increased risk for weight-related teasing (WRT; verbal teasing specific to one's weight or shape [e.g., name calling]), by classmates (odds ratio = 6.3–9.6) and family members (odds ratio = 3.3–4) (Lumeng et al., 2010; Neumark-Sztainer et al., 2002, Jan). Similarly, 51% of overweight/obese adults and 97.9% of pre-bariatric surgery patients report experiencing stigmatization from their families (Puhl & Brownell, 2006, Oct; Friedman et al., 2005, May). Further, while general childhood abuse (defined as emotional, physical, or sexual abuse or emotional or physical neglect) occurs in approximately 35.1% of the general population (Scher, Forde, McQuaid, & Stein, 2004, Feb), rates range from 61 to 69% in individuals with extreme obesity (Grilo et al., 2005, Jan; Salwen, Hymowitz, Vivian, & O'Leary, 2014, Mar; Williamson, Thompson, Anda, Dietz, & Felitti, 2002). However, WRT is likely distinct from general abuse and may have a unique impact on
⁎ Corresponding author. E-mail addresses: [email protected] (J.K. Salwen), [email protected] (G.F. Hymowitz).
http://dx.doi.org/10.1016/j.eatbeh.2015.09.001 1471-0153/© 2015 Elsevier Ltd. All rights reserved.
adult outcomes (Salwen et al., 2014, Mar; Salwen, Hymowitz, Bannon, & O'Leary, 2015, Jan 27). While questionnaires exist to assess WRT in children/adolescents and weight-related stigmatization in adults, there are no validated measures designed to assess more severe forms of WRT. A 2010 metaanalysis indicated that to assess negative experiences related to weight, researchers typically use the Perception of Teasing Scale (POTS) (Thompson, Cattarin, Fowler, & Fisher, 1995, Aug), or the Physical Appearance Related Teasing Scale (PARTS) (Thompson, Fabian, Moulton, Dunn, & Altabe, 1991, Jun), both developed over 20 years ago, or unvalidated, self-designed questions (Neumark-Sztainer et al., 2002, Jan). While Puhl, Peterson, and Luedicke (Puhl et al., 2013, Jan) recently investigated verbal, relational and physical “weight based victimization”, they too used an unvalidated measure. Researchers who have assessed more severe WRT, including being “attacked” due to weight, have not behaviorally defined attacked and thus it is unclear what participants were endorsing (Puhl & Brownell, 2006, Oct; Friedman et al., 2005 May). Other studies assessing WRT and/or stigmatization provide few data regarding more severe negative weightrelated events (Lumeng et al., 2010; Neumark-Sztainer et al., 2002 Jan). To more fully capture variability in individual's experiences, we developed the construct of weight-related abuse (WRA), defined as “significant verbal or physical victimization or maltreatment specific
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to one's weight.” This study aimed to develop a measure of WRA, the Weight-Related Abuse Questionnaire (WRAQ), and validate it in a young adult population and a clinically obese population. Our development and validation samples were college student populations, as late adolescence to early adulthood is the peak age of onset for disordered eating behaviors (Ji, Hiripi, Pope, & Kessler, 2007 Feb 1). Following the analysis of psychometric data from the development sample, the scale was slightly altered. We then assessed the WRAQ in a second sample of undergraduate students, including test-retest reliability data for a subsample of participants. To assess concurrent validity, we compared the WRAQ to the POTS weight subscale (Thompson et al., 1995 Aug), the most commonly used measure for assessing WRT (Menzel et al., 2010 Sep), and the Childhood Trauma Questionnaire-Short Form (CTQ-SF) (Bernstein et al., 2003 Feb), a commonly used measure of childhood abuse used to validate a number of other measures of maltreatment (Tonmyr, Draca, Crain, & Macmillan, 2011 Oct). Regarding convergent validity, research consistently indicates that experiencing any kind of teasing/bullying is associated with increases in psychological, physical, and social problems one year later and in adulthood (Arseneault, Bowes, & Shakoor, 2010 May; Takizawa, Maughan, & Arseneault, 2014; Fekkes, Pijper, Fredriks, Vogels, & Verloove-Vanhorick, 2006; Gladstone, Parker, & Malhi, 2006 Mar; Sesar, Barišić, Pandža, & Dodaj, 2012; Storch et al., 2004). More frequent/severe WRT and general abuse lead to greater symptoms of depression and disordered eating in adolescents and individuals with extreme obesity (Friedman et al., 2005, May; Grilo et al., 2005, Jan; Eisenberg, Neumark-Sztainer, & Story, 2003, Aug) and a recent metaanalysis showed moderate effect sizes for the relationships between WRT and dietary restraint (.35) and WRT and binging and/or purging (.36) (Menzel et al., 2010, Sep). Night eating is also associated with childhood abuse, depression, and binge eating (Allison, Grilo, Masheb, & Stunkard, 2007, Dec; Canetti, Berry, & Elizur, 2009, Mar; Fischer et al., 2007, Jun) in community samples and individuals seeking bariatric surgery. Further, common consequences of WRT (e.g., unhealthy weight control, binge eating) are related to long-term weight gain (Fairburn, Cooper, Doll, Norman, & O'Connor, 2000, Jul; Neumark-Sztainer et al., 2007, Nov; Neumark-Sztainer, Wall, Story, & Standish, 2012, Jan). Thus, we compared the WRAQ to symptoms of depression, disordered eating (binge eating, night eating, and unhealthy weight control), and body mass index (BMI). Lastly, to further assess the clinical utility of the WRAQ, we evaluated its psychometric properties in a sample of pre-bariatric surgery patients, and compared the verbal abuse subscale to interview-based reports of WRT. The final form of the WRAQ is a 15-item questionnaire that retrospectively assesses the average frequency of negative weight-related events before the age of 21, including an 8-item verbal abuse (VA) subscale and 7-item physical abuse (PA) subscale. Items are rated from 0 (never) to 6 (more than 20 times per year); a mean score is computed, with final scores ranging from 0 to 6. Participants who endorse abuse on a subscale are asked, “What was the impact of these occurrences on you? Did you feel…” They are provided with a list of 14 possible emotional reactions and rate each emotion from 0 (not at all) to 5 (extremely), with total scores ranging from 0 to 70. Participants are also asked about duration, perpetrators, and body size at the time of the abuse. The online supplement includes information on questionnaire development and data for the development study (Study 1).
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Asian, 8.3% Hispanic, 5.9% African American, and 6.5% other. Participants' BMIs ranged from 15.81–48.91 (M = 24.91, SD = 5.14; 4.2% = underweight, 50.5% = healthy weight, 31.2% = overweight, 9.1% = obese, and 5% = extremely obese). 2.1.2. Procedure Following Human Subjects Review Board approval, participants completed study questionnaires online and in-person (for copyright reasons). 2.1.3. Measures Body mass index (BMI) was measured using self-reported height and weight. Childhood Trauma Questionnaire-Short Form (CTQ-SF) (Bernstein et al., 2003, Feb) measured general childhood abuse. Night Eating Questionnaire (NEQ) (Allison et al., 2008, Jan) measured night eating. Perception of Teasing Scale (POTS) (Thompson et al., 1995, Aug) measured WRT. Questionnaire on Eating and Weight Patterns — Revised (QEWP-R) (Yanovski, 1993, Jul). The QEWP-R measured binge eating symptoms and unhealthy weight control behaviors (vomiting, fasting for at least 24 h, exercising for more than 1 h, or taking more than twice the recommended dose of laxatives, diuretics, or diet pills). Quick Inventory of Depressive Symptomatology (QIDS) (Rush et al., 2003, Sep 1) measured depressive symptoms. In-depth information on the procedure and measures is included in the online supplement. 2.2. Results & discussion All participants were assessed using the WRAQ-VA and PA subscales. Data from men and women were combined, as the total WRAQ score did not differ significantly by gender, t (380) = .56, p = .22. Factor analyses showed good convergence for both the VA and PA subscales, and on each of these subscales, items broke down into mild and severe factors. Reliability analyses showed strong internal consistency for both scales and moderate to good 6-month test-retest reliability. The online supplement includes specific details regarding factor analyses. The VA and PA subscales of the WRAQ both show significant correlations with similar variables (see Table 1), supporting good concurrent and convergent validity. Means and standard deviations for each item are presented in Table 2. Results of Study 2 suggest that the WRAQ is a valid instrument for assessing WRA. Reliability and factor analyses indicated that the VA and PA subscales are psychometrically sound, the items are related to one another, and responses are consistent across time. Furthermore, these data suggest that the WRAQ subscales are clearly associated with scales designed to assess similar constructs. The WRAQ subscales also showed moderate to high correlations with symptoms of depression and eating disorders, variables the literature suggests are associated with WRA. Although college students/young adults are at a heightened risk for depressive disorders and eating disorders, the populations described above are not clinical populations, thus we also evaluated this measure in a sample of pre-bariatric surgery patients. 3. Study 3 3.1. Method
2. Study 2 2.1. Method 2.1.1. Participants Participants were 382 undergraduates (56.8% women) ages 18–39 (M = 19.26, SD = 2.12). Ethnicities were 49.9% Caucasian, 29.6%
3.1.1. Participants Participants were 59 patients (83.3% women) ages 19–64 (M = 40.66, SD = 12.37) who completed pre-bariatric surgery psychological evaluations. Ethnicities were 72.4% Caucasian, 12.1% Hispanic, 8.6% African American, and 6.8% other. Participants' BMIs ranged from 34.72 to 68.35 (M = 44.31, SD = 8.35; 3.4% = class I obesity [30–
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Table 1 Correlations among variables for Study 2. WRAQ Verbal WRAQ Verbal WRAQ Physical POTS CTQ BMI NEQ BED UWC
WRAQ Physical
–
.51*** –
POTS
CTQ
BMI
NEQ
BED
.78*** .41*** –
.35*** .29*** .37*** –
.41*** .20*** .44*** .22*** –
.26*** .17** .19*** .26*** .11* –
.29*** .14** .24*** .22*** .16** .36*** –
UWC .24*** .25*** .21*** .21*** .13* .20*** .24*** –
QIDS .29*** .20*** .26*** .242*** .04 .48*** .30*** .16**
*p b .05; **p b .01; ***p b .001. WRAQ = Weight-Related Abuse Questionnaire; POTS = Perception of Teasing Scale; CTQ = Childhood Trauma Questionnaire; BMI = Body Mass Index; NEQ = Night Eating Questionnaire; BED = Questionnaire on Eating and Weight Patterns Binge Eating subscale; UWC = Questionnaire on Eating and Weight Patterns Unhealthy Weight Control subscale; QIDS = Quick Inventory of Depressive Symptomatology. N = 291 for all correlations except the CTQ (N = 271).
34.9], 41.4% = class II obesity [35–39.9], and 55.2% = class III obesity [40 and up]). 3.1.2. Procedure Data for this study were collected as part of a larger longitudinal study investigating biopsychosocial variables affecting post-bariatric surgery success. 3.1.3. Measures Study 3 utilized the CTQ-SF (Bernstein et al., 2003, Feb), NEQ (Allison et al., 2008, Jan), QEWP-R (Yanovski, 1993, Jul), the QIDS (Rush et al., 2003, Sep 1) and an item from a pre-surgical interview asking “were you teased or criticized about your weight by anyone when you were younger?” 3.2. Results & discussion Participants were assessed using the WRAQ VA and PA subscales. Data from men and women were combined, as neither VA nor PA scores differed significantly by gender (t (46) = −1.33, p = .22 and t (46) = −.56, p = .58, respectively). Factor analyses showed good convergence for the VA and PA subscales, though there were slight differences from Study 2 in the items that loaded as mild versus severe on the PA subscale. Reliability analyses showed strong internal consistency for both scales. Further, WRAQ VA scores were higher for individuals who also reported being teased during the interview, t (35) = −3.11, p = .004, and 73% of participants responded consistently across the WRAQ and interview item. Details of factor analysis data are included in the supplement.
The VA and PA subscales of the WRAQ also showed significant correlations with similar variables, thus supporting moderately good convergent validity. The WRAQ subscales correlated highly with each other, r (58) = .51, p b .001, and with the CTQ total score (verbal abuse: r (53) = .38, p = .007 and physical abuse: r (53) = .30, p = .03). The WRAQ VA subscale also correlated moderately with BMI, r (58) = .27, p = .04 and the WRAQ PA subscale correlated moderately with the QIDS, r (52) = .31, p = .03. Other correlations were not significant; all of these correlations should be interpreted with caution due to the small sample size. Means and standard deviations for each item are presented in Table 2. These data suggest that the WRAQ maintains strong psychometric properties in a clinical/medical population, and thus its utility is generalizable beyond a young adult sample. Furthermore, the WRAQ is not only reliable across time, as demonstrated in Study 2, it is also reliable across measurement strategies. In fact, the WRAQ was more sensitive to abuse history than the clinical interview, suggesting it may be a better initial screen for WRA. These results also further highlight the associations between the WRAQ subscales and measures of eating pathology, depression, and BMI.
4. General discussion Overall, these studies indicate that the WRAQ is a psychometrically sound questionnaire for the retrospective assessment of WRA in clinical and non-clinical samples. Both the VA and PA subscales of the WRAQ have good internal consistency and test-retest reliability and concurrent and convergent validity. Clinically, high correlations between the WRAQ subscales and symptoms of disordered eating and depression
Table 2 Means, standard deviations and rates of endorsement for items from the WRAQ subscales. Sample 2
Verbal abuse subscale 1. Someone laughed at you because of your weight 2. Someone called you names because of your weight 3. Someone criticized you or put you down because of your weight 4. Someone yelled at you because of your weight 5. Someone embarrassed you in front of others because of your weight 6. Someone forced you to go on a diet because of your weight 7. Someone harassed you because of your weight 8. Someone threatened to abandon you because of your weight Physical abuse subscale 1. Someone poked or pinched you because of your weight 2. Someone grabbed you because of your weight 3. Someone threw something at you because of your weight 4. Someone pushed you because of your weight 5. Someone tripped you (or tried to) because of your weight 6. Someone hit you because of your weight 7. Someone kicked you because of your weight
Sample 3
Mean
SD
Endorsed
Mean
SD
Endorsed
1.57 1.49 1.62 .96 1.32 .67 .86 .23
1.91 1.86 1.88 1.64 1.72 1.36 1.50 .79
53.8% 53.5% 57.2% 34.4% 50.7% 27.6% 34.9% 11.3%
2.26 2.33 2.38 1.29 1.95 .76 1.40 .10
2.24 2.29 2.24 2.02 2.27 1.48 2.11 .67
58.6% 60.3% 60.3% 39.7% 51.7% 27.6% 39.7% 3.4%
.43 .37 .16 .16 .18 .13 .08
1.11 1.08 .65 .68 .71 .59 .35
18.3% 14.9% 8.6% 7.3% 8.4% 6.5% 5.2%
.50 .38 .38 .45 .28 .38 .14
1.37 1.21 1.28 1.33 1.02 1.25 .83
13.8% 11.3% 11.3% 13.8% 8.6% 12.1% 3.4%
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suggest the WRAQ may also help identify individuals at higher risk for these psychological difficulties, or whose psychopathology is complicated by their developmental history. While it is important to consider the potential for bias in reporting on the WRAQ, as it is a retrospective measure, research indicates that individuals are more likely to underreport than over-report instances of abuse on retrospective measures (Hardt & Rutter, 2004, Feb). Furthermore, retrospective reporting biases are generally not substantial enough to invalidate reports of events that can be reasonably operationalized (Hardt & Rutter, 2004, Feb). In addition, the relatively high prevalence of WRA reported across our samples and the substantial and negative impact of WRA highlight the importance of refining ways to validly and reliably measure this construct (Puhl et al., 2013, Jan; Hardt & Rutter, 2004, Feb). Future research could involve administration of the WRAQ as a current report to more fully validate this questionnaire. Although we used both clinical and non-clinical samples to evaluate the WRAQ, evaluation of the psychometrics of the WRAQ in other clinical populations is warranted. One population of particular interest is individuals diagnosed with eating disorders, as previous research suggests that WRT plays a role in the development of disordered eating, including binge eating and unhealthy weight control (Grilo et al., 2005, Jan; Benas & Gibb, 2008; Haines, Neumark-Sztainer, Eisenberg, & Hannan, 2006, Feb). However, no existing measure of WRA has been validated in a population of individuals with eating disorders. Future research could evaluate not only the psychometrics of the WRAQ in these populations, but also the impact of WRA on eating disorder development, maintenance, and/or recovery. 4.1. Conclusions The WRAQ is a reliable and valid measure of weight-related verbal and physical abuse in clinical and non-clinical samples, and may be a useful tool for identifying individuals at risk for disordered eating or depression. Future studies should evaluate the validity of the WRAQ in other clinical populations and researchers should continue to evaluate the role of WRA in the development and maintenance of disordered eating and obesity. Role of funding sources The authors did not receive any funding for any part of this research or manuscript preparation. Contributors Jessica Salwen (JKS) worked to develop the items in the WRAQ under the supervision and with advising by Genna Hymowitz (GFH). JKS was primarily responsible for the protocol development and data collection for studies 1 and 2, and JKS and GFH developed the protocol and collected study 3 data together. JKS and GFH both conducted literature searches. JKS performed statistical analyses. JKS wrote the first draft of the manuscript with the exception of the discussion. GFH wrote the first draft of the discussion. Both authors contributed to and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgments The authors wish to thank Drs. Dina Vivian and Daniel O'Leary for their assistance with the development of the WRAQ.
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