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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 1873 .
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 century .
Even today, the stereotype of a patient with anorexia is that of a young, female Caucasian who is well-educated and from the upper socioeconomic 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, too .
Eating disorders are severe psychiatric illnesses, influenced by many factors, including genetic predisposition, environmental stressors, neurobiology, psycho-social stressors and more. Eating disorders do not discriminate by age, gender, socioeconomic status, nationality, culture, or race. Eating disorders have been identified around the world, including ethnic minority groups, demonstrating the non-bias of these illnesses.
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-Caucasians .
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 risk .
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 nations .
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 stomach .
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 symptoms .
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 behavior is different in ethnic minority groups, with Mexican American women, for example, less likely than Caucasians to seek treatment for their eating disorder.
Ruling out any potential ethnicity-bias can be helpful in better identifying eating disorders among minorities, particular in cultures in which eating disorders are stigmatized and/or generally underestimated. This can also be an important step toward early intervention and awareness among various ethnic cultures, both which are needed to continue challenging the stereotypes of eating disorders among minorities.
Interestingly, Mexican American women become more likely to seek treatment as they become more acculturated . Outreach to these populations may be necessary if early intervention is to be achieved.
This may also include the inclusion of different ethnicities in educational resources about eating disorders.
Understanding cultural differences may also be helpful in identifying more effective approaches for assessing and screening for eating disorders in various ethnicities and minorities.
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 esteem8.
They are also most likely to practice weight control .
Latina women score somewhere in the middle in terms of self-esteem, specifically regarding their weight, and body satisfaction.
Studies have shown that Latinas have eating disorders and body image concerns at rates comparable to or greater than non-Latina whites. Other research has demonstrated that Latina women may struggle with conflicting cultural expectation, where within their own families, larger bodies are generally celebrated. However, this conflicts with a Caucasian culture that promotes a thinner body ideal.
Latina women specifically may face barriers in seeking treatment for an eating disorder, including the high cost of treatment and stigma of seeking psychological help.
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 attractiveness .
They are also the least likely to practice weight control .
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 group .
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 eating , and that it was this symptom that caused the most distress among all these women .
Asian American Women
Asian Americans seem to have specific risks for eating disorders, with a trend in evidence towards a high incidence of anorexia .
In one study, Asian American participants came from higher income, achievement-orientated families and had extreme concern about meeting parental expectations . 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 rationalizing their restrictive eating as being due to bloating or poor appetite .
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 significant .
Culturally, Asians often deny or minimize symptoms of illnesses, especially those such as mental illnesses, which are considered taboo . 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, too .
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 Americans .
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” .
This suggests that the cognitive-behavioral model may need to be adapted for use in ethnic minority groups.
As always, treatment for eating disorders should be comprehensive and individualized whenever possible. Taking cultural preferences and ethnicity into account should also be considered in treatment and when devising a treatment approach. Eating disorder treatment specialists may benefit from collaborating as a multi-disciplinary team to address what forms of treatment may be most effective for a particular ethnicity and/or culture.
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.
Connecting with resources can help increase awareness of eating disorders among minorities, improving diagnostic rates and overall prognosis. Currently, the National Eating Disorder Association (NEDA) and the Academy for Eating Disorders (AED) offer a number of resources specific for various ethnicities and minority groups.
Continuing to bring awareness to culture-specific obstacles for eating disorder identification and treatment can help alleviate some of the barriers that individuals with eating disorders may be facing.
References:: 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
[7}: 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
The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.
We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.
Published on June 23, 2017.
Edited And Updated By: Crystal Karges, MS, RDN, IBCLC.
Reviewed By: Jacquelyn Ekern, MS, LPC on June 23, 2017.
Published on EatingDisorderHope.com