Thin-ideal internalization: How much is too much?

Internalization of the thin-ideal is a risk factor for eating disorders that frequently persists into recovery and increases patient risk for relapse. Addressing thin-ideal internalization as a core element of eating disorder prevention and treatment produces significant reductions in eating pathology. However, research has not yet quantified levels of thin-ideal internalization that may signal increased versus decreased risk for disordered eating. To address this gap in the literature, receiver operating characteristic (ROC) curve analysis was used to identify a thin-ideal internalization cutoff score that signified clinically-meaningful eating disorder pathology. 787 college women (age M = 20.17, SD = 2.41; BMI M = 23.58, SD = 5.29) were classified as "healthy" (N = 717) or those with significant disordered eating (N = 70) using established clinical cutoffs for the Eating Disorder Examination-Questionnaire. ROC curve analysis was used to test the performance of the Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4) Internalization: Thin/Low Body Fat subscale in predicting disordered eating status, and to identify a cutoff score that maximized sensitivity and specificity to discriminate between healthy and disordered eating samples. Mean SATAQ-4 internalization scores were 3.29 (SD = 0.92) and 4.27 (SD = 0.62) for healthy and disordered eating participants, respectively. The SATAQ-4 internalization scores were good predictors of disordered eating status (area under the curve = 0.81, 95% CI: 0.76-0.86). The optimal cutoff of 3.78 (measured on a 1-5 Likert scale) yielded a sensitivity of 0.81 and specificity of 0.64. Overall, results provide preliminary support for the discriminant validity of SATAQ-4 thin internalization scores and suggest that even moderate levels of thin-ideal internalization may be predictive of clinically-significant eating pathology. It may be important for prevention and intervention work to actively seek to reduce internalization levels below this clinical cutoff, though future work is needed to bear this out.