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Eating disorders: a transcultural perspective

N. Shuriquie

Introduction

It is plausible that eating disorders have a sociocultural cause. They are classically perceived as western culture-bound syndromes associated with culture-driven factors, such as unrealistic expectations of slenderness and attractiveness, changes in the role of women, and social standards and attitudes towards obesity.

The drive to be thin is not universal. In many non-Western countries plumpness has traditionally been considered attractive and associated with fertility and caring. While many non-Western societies show a positive relationship between increased body weight and higher social class, the opposite relationship is found in Western societies. Furnham and Albahai [1] argued that in societies where food is plentiful the idea of slenderness is constantly imposed via the media and peer pressure; while countries where the availability of food fluctuates, plumpness is often the feminine ideal.

Classification of eating disorders

According to the ICD-10 classification [2] eating disorders are divided into two important syndromes: anorexia nervosa and bulimia nervosa.

• Anorexia nervosa. For a definite diagnosis, all the following are required: body weight maintained at least 15% below the level expected, the weight loss is self-induced, there is body image distortion and widespread endocrine disorder.

• Atypical anorexia nervosa. For the diagnosis of atypical anorexia nervosa, one or more of the key features of anorexia nervosa is absent.

• Bulimia nervosa. For a definite diagnosis, all the following are required: persistent preoccupation and craving for food, frequent attempts to counteract the fattening effects of food and a morbid fear of being fat.

• Atypical bulimia nervosa. For the diagnosis of atypical bulimia nervosa, one or more of the key features is absent.

Less specific disorders include:

• Overeating associated with other psychological disturbances. In which overeating is a reaction to distressing events.

• Vomiting associated with other psychological disturbances. For example, hyperemesis gravidarum.

Transcultural studies (Table 1)

Mukai and colleagues [3] examined the influence of family and friends on the eating disorder tendencies of Japanese adolescent girls. It was observed that the perception of being overweight rather than actually being overweight was associated with eating disorder tendencies. Mukai argued that contemporary Japanese society shares many values with Western society, including the thin body standard for bodily attractiveness in women, but that the thin body ideal for Japanese women is not necessarily the result of recent Western influences but is itself a tradition in Japan.

Mumford and Whitehouse [4] suggested that eating disorders may be common among Asian girls in the United Kingdom. They found that Asian girls who most frequently used Asian languages and wore Asian dress had the highest mean scores on both the Eating Attitude Test (EAT) [5] and Body Shape Questionnaire (BSQ) [6]. The EAT questionnaire was introduced as a self-reporting, 40-item questionnaire. It was designed to measure the characteristic symptoms of anorexia nervosa and bulimia nervosa. The scoring uses a system in which the three categories at the non-anorectic end of the six-point Likert scale are scored zero; the other categories score 1, 2 and 3 for each question. The EAT-40 when validated was found to discriminate well between normal and anorectic females. The cut-off point is 30. There is also a valid short version EAT-26 with a cut-off point of 21. The BSQ was developed as a measure of an individual's dissatisfaction with his/her body shape, found in association with eating disorders. Items are derived from transcripts of interviews with anorectic and bulimic patients. The BSQ is scored one to six on a Likert scale, with a cut-off point of 140. Mumford and Whitehouse [4] argued that more traditional Asian girls may be experiencing greater internal conflict, for example about issues of identity, as they grow up within two sets of cultural values. The greater the difference between those cultures, the greater the internal conflicts and anxieties which arise. Another contributing factor could be the more rigid family structure within traditional Asian families, leading to greater inter-generational conflict.

Bryant-Waugh and Lask [9] reported four cases of anorexia nervosa in Asian children in the UK. They argued that the more traditional the family, the more the possibility of sociocultural conflict about such issues as arranged marriage, dress norms, contact with the opposite sex and the role of females in cooking and at mealtimes. They believe that young people growing up in a juxtaposition between two different cultures may experience confusion. DiNicola [10] has proposed a transcultural hypothesis that anorexia nervosa can be viewed as a "cultural change syndrome" whose onset may be triggered by conditions of sociocultural flux. Bulik [11] and Kope and Sack [12] argue that stresses relating to immigration and acculturation may lead to the emergence of eating disorders in populations not previously considered at risk.

Eating disorders in Arab adolescent girls and women (Table 2)

In a study involving female students attending universities in London and Cairo, students were recruited to determine the prevalence of eating disorders within an Arabic culture and to investigate the possible effects of exposure to Western culture upon eating disorders [13]. The rate of bulimia nervosa was 12% in the London group, which was the highest rate of bulimia nervosa ever reported for any group of women living in Britain. No clinical cases were found in the Cairo group.

Nasser [14] chose a sample of 15-year-old Egyptian school girls in Cairo for the purpose of studying eating disorders in an Egyptian culture. The study used 420 students from El-Nile secondary school for girls in Cairo and used the EAT-40 questionnaire. He found that dieting was present and there was excessive concern about weight. Twelve partial and three full cases of bulimia nervosa were found, in keeping with the outcome of a screening survey carried out previously on non-Western populations [4,13].

The traditional values of Egyptian society do not over-value a thin body; rather they attach significance to women's fertility and idealize motherhood. For a long time, such values were thought to provide some protection against the development of eating disorders. Nasser's investigation confirmed that morbid eating patterns are emerging in Egyptian society with similar rates to those in Western cultures. The susceptibility of the Egyptian culture to developing such disorders could be based on the easy accessibility of Western values through the media and a readiness to assimilate them. Nasser suggested that adolescent girls were torn between values of autonomy and desire for achievement promoted by long-established feminism and older values that were coming back into society with the revival of Islamic fundamentalism [14]. The identification with Western values stems from images that are easily transmissible by mass communication, a phenomenon referred to as a global culture. Nasser's research is of value, less because of the differences elicited, but more to substantiate the impact of social environments and the influence of the media on the development of abnormal behaviour.

Cultural effects on eating attitudes were studied in an Israeli subpopulation and a group of hospitalized anorectics [15]. Eating attitudes and body image were assessed using the eating attitudes test EAT-26 in an Israeli Jewish female high-school population in five distinct residential settings (kibbutz, moshav, city and two different boarding schools), in five ethnically distinct Arab female high-school populations (Muslim, Christian, Druze, Circassian and Bedouin) and in a group of hospitalized adolescent girls with anorexia nervosa. They hypothesised that the attitudes of those adolescent females most exposed to Western body-shape ideals and simultaneously experiencing a conflict between traditional and modern images of the female role would most resemble the attitudes of anorectics. This was partly supported by the findings. Ethnic differences also emerged in attitudes towards food. All the Arab populations, except the Circassian, showed strong Western influences in their attitudes towards eating and body image and thus might well be prone to epidemics of anorexia and similar eating disorders in the near future. Kibbutz girls were also the most similar in attitude to the anorectic hospitalized group.

Discussion

Mukai's study [3] was the first attempt to examine the presence of abnormal eating attitudes and the influence of family and friends upon Japanese adolescent girls. This study had a number of methodological limitations: first, it included only eleventh-grade girls in a public high school, a sample with a narrow age range; secondly, no attempt was made to interview the girls to ascertain the actual presence of eating disorders among those who scored above the cut-off despite the high percentage of girls (35%) with positive scores on the EAT questionnaire; and finally, the small number (150) of girls who were actually included given the screening nature of the study.

It should be emphasized that in Mumford and Whitehouse's study of eating disorders among Asian schoolgirls in Bradford, the girls were not a real Asian sample as most of them had been born in Britain and all of them had grown up there and spoke English fluently.

In those studies looking at Arabic cultures, Nasser's study of eating disorders in female Arab students attending universities in Cairo and London was limited by the small size of the sample, as result of the availability of female Arab students in London. In the study on abnormal eating attitudes in Egyptian school girls there were a number of methodological limitations. The selection of the school was viewed as a source of bias because of an overrepresentation of professional classes, and a further limitation was caused by interviewing only the positive scorers.

The assessment of eating attitudes in girls from Jewish high schools in five settings and the comparison with Arab girls from five ethnically distinct origins (a comparison of 10 different groups) was complicated, and the ethnic division of the Arab population was arbitrary and unfounded.

Conclusion

Eating disorders are most commonly found in the upper social classes of industrialized countries. Being slim and fit is highly rated in Western cultures where being thin apparently symbolizes certain cherished notions, such as social acceptance, self-discipline, self-control, sexual liberation, assertiveness, competitiveness and class. Dieting in Western culture has become a cultural preoccupation and it may even be argued that eating disorders are simply extensions of normal and socially acceptable modes of behaviour.

In non-Western cultures eating disorders have, until recently, been considered rare and plumpness is the ideal for body weight and feminine beauty. The increasing number of new cases of anorexia nervosa and bulimia nervosa among Asian immigrants to Western countries and the consistent findings of abnormal eating attitudes and eating disorders among Asian and Arab teenagers indicate that these Eastern women have been exposed to Western values.

A review of the available literature showed no study addressing eating disorders in Jordan. However, eating disorders are not uncommon in Jordan and Arab countries and studies in Arab cultures have shown that the percentage of girls with abnormal eating attitudes and eating disorders is approximately equal to international figures [14]. The idea that Arab females might be experiencing a conflict between influential Western values and Arabic and Islamic traditions may explain the emergence of illnesses which have, until recently, been non-existant. Further studies are needed with unbiased samples using larger numbers of teenagers in the high-risk age groups.

References

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