More Ethnic Minorities Are Suffering From Eating Disorders
Article Contributed by Sharon McConville, MB, BCh, BAO
What Is An Eating Disorder?
Eating disorders have been described in Western literature for centuries, with the term “anorexia nervosa” being coined by a British physician, Sir William Gull, in 18731.
In the non-Western world, eating disorders have really only emerged in the medical literature since the late 1970s; however, people have been writing about eating-related illnesses internationally for much longer.
In Japan, Kagawa described a ‘non-eating illness’, fushokubyo, in the seventeenth century2.
Even today, the stereotype of a patient with anorexia is that of a young, female Caucasian who is well-educated and from the upper socio-economic class, but – just as we now know that not everyone with an eating disorder is young or female – research increasingly shows that eating disorders happen to people of other ethnic backgrounds, too2.
Is It All Down To Westernization?
Many studies have suggested that it is the Westernization of non-Western cultures and of ethnic minorities living within Western cultures (such as Hispanic people and African Americans) which is causing a rise in the incidence of eating disorders among non-Caucasians2.
In other words, whereas previously a person living in a non-Western culture might have been protected by a society which did not value thinness, he or she might now be susceptible to an eating disorder due to the encroachment of Western values.
Is There a Connection Between Eating Disorders and Race?
Within the United States, for example, it has been shown that the level of “acculturation” (the degree to which a person adopts the values, attitudes and identity of the culture into which they immigrate) affects the level of eating disorder risk3.
This “Westernization theory” has been challenged by researchers who cite examples such as that of Curaçao, where it is culturally acceptable to be overweight and yet the prevalence of anorexia is as high as in Western nations4.
Similarly, a study of Iranian women living in the United States and in Iran (where Western media are banned) showed few differences in levels of disordered eating between the two groups, despite the fact that those living in Iran wore a full body covering which obscured size and shape. Iranian women in Iran were more likely to exercise excessively to lose weight and to desire an empty stomach5.
Are Health Professionals Aware That Non-Westerners Get Eating Disorders?
Whether or not we accept the Westernization theory, the key message is that people with ethnic minority backgrounds suffer from eating disorders. It is important that healthcare professionals are aware of this because of data from the 1996 National Eating Disorders Screening Program.
Latina and Native American participants specifically were less likely than Caucasians to receive a referral for further evaluation or care no matter how severe their symptoms6.
This program showed that ethnic minority participants with self-acknowledged eating and weight concerns were less likely than Caucasians to have been asked about eating disorder symptoms by a doctor.
Doctors May Be Overlooking Minorities
Healthcare professionals must not overlook eating disorders in minority populations and should also realize that treatment-seeking behaviour is different in ethnic minority groups, with Mexican American women, for example, less likely than Caucasians to seek treatment for their eating disorder.
Interestingly, Mexican American women become more likely to seek treatment as they become more acculturated7. Outreach to these populations may be necessary if early intervention is to be achieved.
How Do Major Ethnic Groups Differ In Their Eating And Weight Concerns In The United States Today?
The key groups that have been studied most are Caucasian Americans, Hispanic Americans, African Americans and Asian Americans.
In general, Caucasian American women have the lowest body satisfaction, rate themselves lowest on sexual attractiveness, and have the lowest self-esteem regarding their weight as well as the lowest self esteem generally8.
They are also most likely to practice weight control9.
Latina women score somewhere in the middle in terms of self-esteem, self-esteem specifically regarding their weight, and body satisfaction.
African American Women
African American women had the highest self-esteem generally, the highest self-esteem regarding their weight, the greatest body satisfaction – regardless of their actual size – and the highest self-rating on sexual attractiveness8.
They are also the least likely to practice weight control9. It is postulated that this is because African American concepts of beauty are more flexible. This can be healthy, but it also carries its own risk as rates of overweight and obesity are high among this group9.
It is also notable that, while Caucasians, Latinas and African Americans differ significantly in their levels of body dissatisfaction and dietary restraint, they did not differ in their reports of binge eating10, and that it was this symptom that caused the most distress among all these women11.
Asian American Women
Asian Americans seem to have specific risks for eating disorders, with a trend in evidence towards a high incidence of anorexia12. In one study, Asian American participants came from higher income, achievement-orientated families and had extreme concern about meeting parental expectations12.
This concern could be correlated with levels of perfectionism, which is an important predictor of anorexia.
Interestingly, in Asian Americans with anorexia, fear of fatness is commonly absent, with patients rationalising their restrictive eating as being due to bloating or poor appetite12.
This is important because Asian Americans with eating disorders who participate in screening with standard eating disorder questionnaires often appear to be less ill than their non-Asian peers even though clinically their eating disorder is just as significant12.
Culturally, Asians often deny or minimize symptoms of illnesses, especially those such as mental illnesses, which are considered taboo12. This could explain the absence of the ‘fear of fatness’ symptom; however, it has been pointed out that anorexia without any self-reported fear of fatness exists in Western culture, too13.
Does A One-Size-Fits-All Approach To Treatment Work?
There is some evidence that the factors that underlie disordered eating behaviors differ between ethnic minority groups. This has substantial implications for treatment.
Take cognitive behavioral therapy, for example, which is based on the cyclical principle that dietary restraint can lead to disordered eating such as bingeing, and that bingeing often leads to purging and dietary restraint.
One study found that dietary restraint was caused by different factors according to ethnicity, and that it was only in Caucasians that dietary restraint was related to binge eating, with anxiety causing binge eating in Latinas and “peer insecurity” causing binge eating in African Americans10.
What’s more, although Latinas used vomiting for weight control more frequently than Caucasians, there was no link between binge eating and purging for either Latinas or African Americans – in other words, there was no “binge-purge cycle”10. This suggests that the cognitive-behavioural model may need to be adapted for use in ethnic minority groups.
How Minorities And Eating Disorders Relate
In summary, there is a large body of research examining the incidence and characteristics of eating disorders in ethnic minority populations; however, because of the sheer number of groups studied, a lot of work has yet to be substantiated. It is clear that eating disorders do occur in minority groups and may present in different ways according to culture.
It is also important to note that they may not present (or may present later) because of ethnically-specific barriers to accessing treatment. Healthcare professionals should be aware of the diversity in eating disorder symptoms and possible underlying mechanisms in planning screening and treatment.
- Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica) (1873) William Withey Gull, published in the ‘Clinical Society’s Transactions, vol vii, 1874, p22
- Soh, NL, Touyz, SW and Surgenor, LJ: Eating and body image disturbances across cultures: a review. European Eating Disorders Review 2006;14:54-65
- Allegria M et al: Prevalence and correlates of eating disorders in Latinos in the United States. International Journal of Eating Disorders 2007;40:S15-21
- Hoek, HW et al: Lack of relation between culture and anorexia nervosa – results of an incidence study on Curaçao. The New England Journal of Medicine 1998;338:1231-1232
- Abdollahi, P and Mann, T: Eating disorder symptoms and body image concerns in Iran: Comparisons between Iranian women in Iran and in America. International Journal of Eating Disorders 2001;30:259-268
- Becker, AE et al: Ethnicity and differential access to care for eating disorder symptoms. International Journal of Eating Disorders 2003;33:205-212
- Cachelin, FM et al: Factors associated with treatment seeking in a community sample of European American and Mexican American women with eating disorders. European Eating Disorders Review 2006;14:422-429
- Miller, KJ et al: Comparisons of body image dimensions by racve/ethnicity and gender in a university population. International Journal of Eating Disorders 2000;27:310-316
- Chao YM et al: Ethnic differences in weight control practices among US adolescents from 1995-2005 International Journal of Eating Disorders 2008;41:124-133
- White, MA and Grilo, CM: Ethnic differences in the predictors of eating and body image disturbances among female adolescent psychiatric inpatients. International Journal of Eating Disorders 2005;38:78-84
- Franko, DL et al: Cross-ethnic differences in eating disorder symptoms and related distress. International Journal of Eating Disorders 2007;40:156-164
- Lee HY and Lock, J: Anorexia nervosa in Asian-American adolescents: do they differ from their non-Asian peers? International Journal of Eating Disorders 2007;40:227-231
- Fairburn, CG et al: A cognitive behavioural theory of anorexia nervosa. Behaviour Research and Therapy 1998;37:1-13
Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on June 5, 2014
Published on Eating Disorder Hope.com, Eating Disorders Information & Resources