Intersecting gender identity and racial/ethnic inequities in eating disorder risk factors, symptoms, and diagnosis among U.S. college students: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy

INTRODUCTION

There are documented inequities in eating disorders (EDs) by gender and race/ethnicity, yet, little is known about population-level prevalence of ED risk factors, symptoms, and diagnosis at the intersection of diverse gender and racial/ethnic identities.

METHODS

Data from the Healthy Minds Study 2015-2019 (N = 251,310 U.S. university students) were used in a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). Participants were nested in 35 intersectional strata given by all combinations of 5 gender and 7 racial/ethnic categories. Multilevel logistic models with participants at level 1 and intersectional strata at level 2 were used to estimate stratum-specific predicted prevalence estimates for self-reported thin-ideal internalization, ED symptoms, and ED diagnosis. The variance partition coefficient (VPC) was calculated to quantify the contextual effect of the strata.

RESULTS

There was considerable heterogeneity in the predicted prevalence of our ED outcomes across the strata (e.g., .3%-18.3% for ED diagnoses). There were large disparities in all three outcomes, with transgender participants of color having a higher predicted prevalence than expected based on the additive effects of gender and race/ethnicity. Moderation by race/ethnicity was also apparent, such that racial/ethnic disparities were wider within the cisgender groups relative to the transgender groups. VPCs indicated that ~10% of the total variance in ED outcomes was due to intersectionality between gender and race/ethnicity, over and above variance due to individual-level differences.

CONCLUSION

Findings suggest that gender and racial/ethnic disparities in EDs are interrelated, underscoring the need to develop preventive interventions centering health equity.

PUBLIC SIGNIFICANCE

Despite evidence that sexism, racism, and cissexism (i.e., anti-transgender prejudice) can impact EDs risk, little research examines the social patterning of EDs at the intersection of diverse gender and racial/ethnic identities. Using data from a sample of 250,000 U.S. university students, this study found that gender and racial/ethnic disparities in eating disorder risk are interrelated, highlighting the need to develop health equity centered preventive interventions.

Evaluating whether a peer-led dissonance-based eating disorder prevention program prevents onset of each eating disorder type

BACKGROUND

This study tested whether the dissonance-based Body Project eating disorder prevention program reduced onset of subthreshold/threshold anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and purging disorder (PD) over long-term follow-up.

METHODS

Data were combined from three prevention trials that targeted young women at high-risk for eating disorders (N = 1092; M age = 19.3). Participants were randomized to Body Project groups led by peer educators or expressive writing/educational controls and completed masked diagnostic interviews over 2- to 4-year follow-ups. Logistic regressions tested whether onset of each eating disorder over follow-up differed between Body Project and control participants.

RESULTS

Peer-led Body Project groups produced a 46% reduction in onset of subthreshold/threshold BN and a 62% reduction in onset of PD relative to controls over follow-up. Rates of onset of subthreshold/threshold AN and BED did not significantly differ between peer-led Body Project participants and control participants.

CONCLUSIONS

Results support the dissemination of the peer-led Body Project for reducing future onset of BN and PD. This study and recent research suggest that thin-ideal internalization, the risk factor for eating disorders targeted in the Body Project, may be more relevant for predicting onset of BN and PD compared to AN and BED. Findings support the development of a version of the Body Project aimed to reduce risk factors that have predicted future onset of all four types of eating disorders (e.g. overvaluation of weight/shape, fear of weight gain), which may more effectively prevent all eating disorder types.

Thin, muscular, and fit-ideals: Prevalence and correlates in undergraduate women

Objective: The current study aimed to compare endorsement of the muscular- and thin-ideals alone, as well as simultaneous endorsement of both as representative of the fit-ideal and examine potential negative correlates of each type of ideal internalization. Participants: Participants were 300 female undergraduate students. Methods: Participants completed measures of internalization of the thin- and muscular-ideals, body dissatisfaction, body checking, and body avoidance. Results: Analyses revealed that approximately 24.9% of participants endorsed scores in the upper quartile on thin-ideal internalization, and 27.4% of participants fell in the upper quartile of muscular-ideal internalization, while 10.3% endorsed high internalization of both ideals. Analyses revealed that individuals endorsing only the thin-ideal reported significantly higher levels of body dissatisfaction and body avoidance than those endorsing the fit-ideal. Conclusions: Overall, findings suggested that thin- and muscular-ideal internalization present different patterns of association depending on whether an individual endorses one or both of these body ideals.

Photo Activity on Social Networking Sites and Body Dissatisfaction: The Roles of Thin-Ideal Internalization and Body Appreciation

Objective: According to sociocultural theory, media is associated with detrimental effects on body image. Due to the popularity of social networking sites (SNS) and the prevalence of body image disturbance among young women, the association between them is worth further exploration. This study examined the relationship between photo activity on SNS and body dissatisfaction (BD) and the roles of thin-ideal internalization (TII) and body appreciation (BA) in this relation. Materials and Methods: A total of 746 Chinese female undergraduate students (mean age 20.34 ± 1.47 years) completed a questionnaire measuring SNS photo activity, TII, BD, and BA. Results: (1) Photo activity on SNS was positively associated with BD (r = 0.10, p < 0.01), and TII could mediate this relation (β = 0.07, 95% CI = [0.04, 0.10]). (2) Both the direct effect of SNS photo activity on BD (β = −0.08, p < 0.05) and the mediating effect of TII (β = −0.09, p < 0.01) were moderated by BA. Specifically, these associations were more pronounced for students with lower BA. Conclusion: People exposed to ideal photos or images can shape women’s body image perception via TII, whether in the age of traditional media or the Internet, and BA did not buffer the effect of ideal photos on internalization. Our findings could provide practical suggestions for rational photo activity on SNS and the intervention for BD.

Practitioner eating disorder detection: The influence of health mindset, thin-ideal internalization, orthorexia and gender role

AIMS

The current study sought to determine what factors inhibited psychologists, naturopaths and fitness instructors from detecting an eating disorder (ED), and the discipline differences across these factors.

METHODS

Participants of the online study were 115 health practitioners who consisted of 35 psychologists, 50 naturopathic and 30 fitness practitioners. A vignette describing a female experiencing a sub-threshold bulimic variant without purging was presented alongside ED mental health literacy items such as assessing one's ability to detect a problem. Additional items examined factors that may inhibit detection, including practitioners' level of: thin-ideal internalization, orthorexia, health or fitness mindset (a newly developed scale measuring health and fitness obsessiveness) and gender role identity.

RESULTS

A significant number of naturopaths and fitness instructors (20% and 33.3%, respectively) were found to have elevated orthorexia scores. Similarly, psychologists had the greatest tendency to internalize the thin-ideal (M = 3.60), which was comparable to levels seen in recent research for 20- to 21-year-old females with EDs. The two largest factors inhibiting ED detection were the strength of a health mindset and gender role identity. Practitioners who had higher health mindset scores or who associated with gender identities higher in masculinity traits (ie, either androgynous or masculine gender roles) were more likely to miss detecting an ED.

CONCLUSIONS

While many present ED studies focus upon assessing and changing client cognitions, this study emphasizes the need for further research regarding training interventions to address practitioner cognitions and gender role biases, which may in turn improve ED detection.

Internalization of the Thin-Ideal and Eating Pathology in Kuwaiti Adult Women

Rapid socioeconomic growth, Western acculturation, and thin-ideal internalization are theorized to be linked to dieting, weight concerns, and disordered eating in Arab countries. The purpose of this study was to examine eating pathology and the internalization of Western messages regarding the importance of thinness in a community sample of Kuwaiti women. Participants (N = 83) aged 18–35 years with BMIs between 17.58 and 24.88 (M = 21.30; SD = 1.83) completed measures of thin-ideal internalization and eating pathology. Results demonstrated that approximately 28% of the sample was at risk for eating pathology. Thin-ideal internalization was also found to significantly predict eating pathology. Study findings extend prior research on eating pathology in Arabic nations. This study is the first to examine the internalization of the thin-ideal in a community sample of Kuwait adult women and lends further support to the importance of continued research in this population.

Body Image and Sociocultural Predictors of Body Image Dissatisfaction in Croatian and Chinese Women

In the current paper, two different studies were designed to investigate body image dissatisfaction and perception of the attractive female body in Chinese and Croatian women and men using the correlational and experimental study research approach. Study 1 comprised 266 Chinese (160 women; 106 men) and 261 Croatian participants (161 women; 100 men). Women from both countries were asked to complete the measures of the Contour Rating Scale, SATAQ - 4, Body Area Scale and demographic data, while men were asked to complete the measures of the Contour Rating Scale and demographic data via online surveys. The obtained results indicated that thin internalization predicted body image dissatisfaction in both samples. Besides, while both samples scored relatively high on thin-ideal internalization, Chinese women, who were also in general less satisfied with their body image, had higher scores. Chinese women also scored higher on musculature internalization and felt more pressure from family, friends, and media to conform to standard beauty norms compared to Croatian women. The samples also differed in their perceptions of preferable body size, where Chinese women had a more negative perception of their actual body size. The obtained results furthermore revealed that Chinese men preferred thinner women compared to Croatian men. Moreover, both samples misjudged what their female counterparts found attractive, thinking that women wanted to have even thinner bodies than they actually reported. Similarly, women from both cultures revealed a preference for thinner figures than the ones selected as the most attractive by the opposite sex. Finally, in Study 2, experimental manipulation of thin-ideal was used to examine whether thin priming affected body image dissatisfaction. The obtained results revealed that when primed with thin-ideal women from both countries felt lower satisfaction with their body size. The observed effect was stronger for Chinese participants. Limitations of the current study are discussed in the conclusion.

Emphasizing the "Cultural" in Sociocultural: A Systematic Review of Research on Thin-Ideal Internalization, Acculturation, and Eating Pathology in US Ethnic Minorities

A large body of research suggests that thin-ideal internalization is a robust predictor of eating pathology in women and, to some degree, in men. Recent research is exploring the relationships between thin-ideal internalization and culture-specific factors that may be salient to women and men who live in the US but are marginalized based on racial or ethnic background, such as acculturation. This systematic review summarizes published articles examining the relationships among thin-ideal internalization, acculturation-related constructs (including assimilation, marginalization, biculturalism, and acculturative stress), and eating pathology in US adults. Following the PRISMA method, 15 empirical studies met inclusion criteria. Although existing literature was sparse and conflicting in large part due to heterogeneity in acculturation measures, results yielded some support for positive correlational relationships between acculturative stress, thin-ideal internalization, and eating pathology for both men and women (in 4 out of 5 relevant studies). Research on other aspects of acculturation (eg, integration, assimilation) is mixed, with some existing research suggesting a positive relationship and other research finding no statistically significant relationship. Future research would particularly benefit from a gold-standard, multidimensional transcultural measure of acculturation to examine how the acculturation process relates to thin-ideal internalization and eating pathology in ethnic and racial minorities in the US.

Perceptions of male partner pressure to be thin and pornography use: Associations with eating disorder symptomatology in a community sample of adult women

OBJECTIVE

Partner-specific factors have been neglected in eating disorder (ED) research. The present study examined two partner-specific variables that were hypothesized to be linked to women's ED symptoms: perceived male partner thinness-related pressures and pornography use.

METHOD

Community women (N = 409) in relationships with men completed online anonymous measures of ED symptomatology, perceptions of male partner thinness-related pressure and pornography use, and thin-ideal internalization.

RESULTS

Partner thinness-related pressure was related to higher ED symptomatology, adjusting for age and thinness-related pressures from media, friends, and family. Current and previous partner pornography use were related to higher ED symptomatology, adjusting for age and women's reports of being bothered by this use. Partner thinness-related pressure and previous partner pornography use were associated with ED symptomatology both directly and through thin-ideal internalization, whereas current partner pornography use was directly associated with ED symptomatology.

DISCUSSION

Perceptions of male partner thinness-related pressure and pornography use constitute unique factors associated with women's ED symptomatology that may operate indirectly by positioning women to endorse thinness as a personal standard and directly (e.g., by trying to accommodate their partner's appearance preferences). This study's findings provide initial support for pursuing subsequent investigations to test these partner variables as ED risk factors.

On the measurement of thin-ideal internalization: Implications for interpretation of risk factors and treatment outcome in eating disorders research

OBJECTIVE

Although the Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ) and Ideal Body Stereotype Scale (IBSS) are used interchangeably to assess thin ideal internalization, limited work has examined the assumption that the two measures index the same construct.

METHOD

The current study utilized confirmatory factor analysis to examine whether these measures capture a single construct (one-factor), two constructs (two-factor), or both shared and unique constructs (bifactor). The SATAQ-4R-Internalization: Thin/Low Body Fat subscale and IBSS-Revised were administered to 1,114 college females.

RESULTS

A bifactor model provided the best fit to the data. Further, the SATAQ-4R was more strongly related to disordered eating and body satisfaction than the IBSS-R.

DISCUSSION

Results indicate that the two most commonly used measures of internalization capture both shared and unique constructs. While both measures appear to contribute to the assessment of a global internalization factor, the SATAQ-4R may be better suited to assess personal acceptance of and desire to achieve a thin body, while the IBSS-R may be better suited to assess an awareness or acknowledgement of broader sociocultural ideals (e.g., toned, shapely bodies). Continued psychometric investigation of the scales is recommended in order to ensure targeted assessment of the intended constructs.

Thin-ideal internalization and body dissatisfaction in Sri Lankan adolescents

In this study, a survey of Sri Lankan adolescents explored relationships between thin-ideal internalization and body dissatisfaction-issues that have received greater research attention in East Asia and the West. Girls scored lower in thin-ideal internalization and awareness and higher in self-esteem compared to boys; however, unlike in previous studies, body dissatisfaction did not differ significantly by gender. Hierarchical linear multiple regression analyses revealed that self-esteem moderated the relationship between thin-ideal internalization and body dissatisfaction among girls, but this was not observed for boys. Self-esteem as a protective factor against body dissatisfaction among Sri Lankan female adolescents was confirmed.

An experimental investigation of the consequences and social functions of fat talk in friendship groups

OBJECTIVE

Fat talk is a form of self-degrading, thin-ideal endorsing communication that occurs within female friendship groups. Previous studies have suggested negative associations with wellbeing, but have been predominantly correlational and based on self-report. This study aimed to assess the causal relationship between fat talk and the correlates of disordered eating (thin-ideal internalization, body dissatisfaction, negative affect, and dieting intentions) by experimentally manipulating fat talk in existing friendship groups and measuring naturalistic expression of fat talk and its effects.

METHODS

Participants were 85 women aged 17-25 who completed the experiment in friendship pairs. They were randomly assigned to a condition in which their friend expressed fat talk, positive body talk, or neutral talk.

RESULTS

This study found evidence of a causal link between listening to friends fat talk and increased correlates of disordered eating. The negative effects of listening to fat talk were fully mediated by fat talk expression. This study also revealed a social function of fat talk, whereby participants rated their friends more positively when they were perceived to behave consistently with group norms, either pro- or anti-fat talk. Positive body talk showed none of the negative effects of fat talk, and was considered socially acceptable regardless of existing friendship group norms.

DISCUSSION

These findings indicate that fat talk is a mechanism through which the thin ideal is transmitted between individuals. Interventions at the level of the friendship group to challenge norms and communication styles may break the link between societal risk factors and individual risk of eating disorders.

Translation and validation of a Spanish version of the Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4)

OBJECTIVE

The goal of this study was to create a Spanish version of the Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4) and examine its factorial validity, reliability, and convergent validity in a sample of women from Spain.

METHOD

Two hundred and sixty female college students from Spain completed the Spanish version of the SATAQ-4 and measures for eating pathology.

RESULTS

Internal consistency was high; data from EFA and CFA supported the original five-factor structure; and results showed good convergent validity with measures of body-image and eating problems.

DISCUSSION

Results strongly support the psychometric properties of the Spanish version of SATAQ-4 and its use to examine perceived pressure for thinness from parents, peers and the media; and thin- and muscular/athletic-ideal internalization in Spanish-speaking adult women.

An Examination of Influences on Body Dissatisfaction Among Asian American College Females: Do Family, Media, or Peers Play a Role?

OBJECTIVE

The etiology of body dissatisfaction and its correlates (eg, disordered eating) among ethnic minorities is generally unknown. The purpose of this study was to replicate the tripartite model of influence in an Asian American college female sample in order to examine this relationship.

PARTICIPANTS

Participants were 80 undergraduate Asian American females between the ages of 18 and 25.

METHODS

Participants completed a survey that included the Tripartite Influence Scale, Body Parts Satisfaction Scale, and Sociocultural Attitudes towards Appearance Questionnaire-3.

RESULTS

Mediation analyses indicated that thin-ideal internalization fully mediated the relationship between media influence and body dissatisfaction and partially mediated the relationship between peer influence and body dissatisfaction. Family influence did not significantly predict body dissatisfaction.

CONCLUSIONS

Asian American college females experience body dissatisfaction through mechanisms that have not been examined in detail. These factors must be considered when creating targeted health promotion strategies and developing best practices for eating disorder assessment and treatment protocols at university health centers.

Genetic and environmental influences on thin-ideal internalization across puberty and preadolescent, adolescent, and young adult development

OBJECTIVE

Mean-levels of thin-ideal internalization increase during adolescence and pubertal development, but it is unknown whether these phenotypic changes correspond to developmental changes in etiological (i.e., genetic and environmental) risk. Given the limited knowledge on risk for thin-ideal internalization, research is needed to guide the identification of specific types of risk factors during critical developmental periods. The present twin study examined genetic and environmental influences on thin-ideal internalization across adolescent and pubertal development.

METHOD

Participants were 1,064 female twins (ages 8-25 years) from the Michigan State University Twin Registry. Thin-ideal internalization and pubertal development were assessed using self-report questionnaires. Twin moderation models were used to examine if age and/or pubertal development moderate genetic and environmental influences on thin-ideal internalization.

RESULTS

Phenotypic analyses indicated significant increases in thin-ideal internalization across age and pubertal development. Twin models suggested no significant differences in etiologic effects across development. Nonshared environmental influences were most important in the etiology of thin-ideal internalization, with genetic, shared environmental, and nonshared environmental accounting for approximately 8%, 15%, and 72%, respectively, of the total variance.

DISCUSSION

Despite mean-level increases in thin-ideal internalization across development, the relative influence of genetic versus environmental risk did not differ significantly across age or pubertal groups. The majority of variance in thin-ideal internalization was accounted for by environmental factors, suggesting that mean-level increases in thin-ideal internalization may reflect increases in the magnitude/strength of environmental risk across this period. Replication is needed, particularly with longitudinal designs that assess thin-ideal internalization across key developmental phases.

Self-esteem, social support, collectivism, and the thin-ideal in Latina undergraduates

Thin-ideal internalization (TII) reflects agreement that thinness equates with beauty. TII is a risk factor for body dissatisfaction and eating pathology; this phenomenon and its correlates, however, are just beginning to be studied in Latina undergraduates. This study examined the ability of self-esteem, social support, and collectivism to predict TII in 279 Latina undergraduates. It was hypothesized that higher levels of self-esteem, social support, and collectivism would predict lower levels of TII. Cross-sectional data were analyzed using multiple regression; the model was significant, p<.01. Although both self-esteem and social support negatively correlated with thin-ideal internalization, only self-esteem accounted for a significant amount of variance. Results indicate that investigations of self-esteem as a protective factor against TII in Latina undergraduates would be fruitful, as would how self-esteem and social support affect the relationship between TII and other variables. Implications and limitations are discussed.

Maintenance factors for persistence of bulimic pathology: a prospective natural history study

OBJECTIVE

To characterize the natural course of bulimia nervosa and identify potential maintenance factors that predict persistence of bulimic pathology in order to advance knowledge of processes that perpetuate this eating disturbance and permit the design of more efficacious treatments.

METHOD

We followed 96 women with threshold or subthreshold bulimia nervosa over a 1-year period with quarterly interviews.

RESULTS

There were high rates of remission and relapse on a month-to-month basis, but remission became more likely to persist after a period of approximately 4 months of symptom abstinence. Initial elevations in thin-ideal internalization, expectations for reward from eating, and binge frequency predicted greater time to remission of binge eating. Initial elevations in dietary restraint and compensatory behavior frequency predicted greater time to remission of compensatory behaviors.

DISCUSSION

Results imply that treatments for eating disorder may be more effective if they can reduce thin-ideal internalization, eating expectancies, and ineffective dieting and produce rapid cessation of binge eating and compensatory behaviors.

Racial/ethnic differences in Body Mass Index: the roles of beliefs about thinness and dietary restriction

The greater BMI of African American relative to Caucasian women is implicated in racial/ethnic disparities in health outcomes. The principal aim of the current study was to evaluate a theoretical account of racial/ethnic differences in BMI. Thin-ideal internalization, the perceived romantic appeal of thinness, dietary restriction, weight, and height were assessed via self-report measures on a sample of female undergraduates of African American (n=140) and Caucasian (n=676) race/ethnicity. Using structural equation modeling, support was obtained for the primary hypothesis that racial/ethnic differences in BMI are explained by Caucasian women's greater thin-ideal internalization and perceived romantic appeal of thinness, thereby resulting in greater levels of dietary restriction. Current findings illustrate the potential for racial/ethnic differences in sociocultural standards of appearance to influence racial/ethnic disparities in physical health, of which BMI is a marker, via effects on weight control behavior.