Eating disorders in the Far East

Latent profile analyses of disordered eating behaviors and nonsuicidal self-injury among Vietnamese adolescents

OBJECTIVE

Comorbidity of disordered eating (DE) behaviors and nonsuicidal self-injury (NSSI) is linked to increased functional impairment. The present study identified subtypes of DE and NSSI comorbidity in a non-Western, low- and middle-income country where there has been particularly little research in this area.

METHOD

Latent profile analyses (LPA) were conducted to identify patterns of subgroup comorbidity in self-reported DE behaviors and NSSI behaviors, in a sample of Vietnamese high-school students (N = 1451, 51% female). Parallel-process LPA was used to predict NSSI subgroup membership from DE subgroup membership.

RESULTS

A seven-class LPA model was identified for DE: (1) Low frequencies of all DE behaviors; (2) Frequent levels of all DE behaviors; (3) Frequent fasting and purging behaviors; (4) Frequent binge eating only; (5) Moderate binge eating; (6) Moderate fasting and purging behaviors; (7) Exercise and fasting. A two-class (high versus low) model was identified for NSSI. Odds of membership in the high-NSSI class were significantly increased for all DE classes except the class characterized by moderate binge eating. Odds of belonging to the high-NSSI class were highest for those in DE classes involving purging behaviors. Males predominated in classes characterized by high behavior dysregulation.

DISCUSSION

DE and NSSI represent important clinical concerns among Vietnamese youth in urban contexts, and males may show particular vulnerability for certain risk behaviors. The association of classes of DE behaviors to NSSI was particularly strong for classes that involved purging, highlighting the importance of this specific behavior for understanding comorbidity of DE and NSSI.

PUBLIC SIGNIFICANCE

Disordered eating and nonsuicidal self-injury (NSSI; hurting oneself without intending to die) commonly co-occur. There has been less research on disordered eating and NSSI among individuals from non-Western or low/middle-income countries. We examined patterns of these behaviors in a school-based sample of Vietnamese adolescents. We found that patterns of disordered eating distinguished by purging showed particular links to NSSI, which could have implications for screening and treatment.

The impact of ongoing westernization on eating disorders and body image dissatisfaction in a sample of undergraduate Saudi women

PURPOSE

This study addressed the prevalence of eating disorders and levels of eating pathology, body image, and psychological comorbidities in undergraduate women in Saudi Arabia. It examined the role of the current internalization of western culture that is under way in that country, focusing on political and economic issues rather than on issues such as media exposure per se.

METHOD

Participants were 503 Saudi female university students (mean age = 19.78 years). Each completed a diagnostic measure of eating disorders and measures of disordered eating attitudes and behaviours, body image, depression, social anxiety, and self-esteem. They also completed a measure of the internalization of western culture, specific to current political and cultural developments in Saudi Arabia.

RESULTS

Eating disorder prevalence and pathology rates among undergraduates females were comparable to western levels, though the pattern was more one of bulimic than anorexic pathology. Internalization of western values was associated with eating pathology, body image, and psychological comorbidities.

CONCLUSION

Eating disorders are not an exclusively western issue, as the levels in Saudi undergraduate women are similar to those in western cultures (though they tend more towards bulimic than anorexic presentations). Internalization of western values appears to be key to this pattern. LEVEL OF EVIDENCE : Level III, case-control analytic study.

Psychological Risk Factors for the Development of Restrictive and Bulimic Eating Behaviors: A Polish and Vietnamese Comparison

The aim of this paper is to identify psychological factors which are culture specific or common predictors for restrictive and bulimic behaviors towards eating for young women raised in different cultures. The study included 661 young women from Poland (n = 233) and Vietnam (n = 428). Subjects filled-in the Eating Disorders Inventory (EDI-3) and the Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS), and body measurements were collected to calculate anthropometric indices. Women form Vietnam were less satisfied with their appearance than were their Polish peers, but Vietnamese showed a lower level of preoccupation with being overweight and fear of obesity. Intercultural differences indicate that Vietnamese women show greater intensities for psychological variables, connected with restrictive and bulimic eating behaviors, verified in the research model: low self-esteem, personal alienation, interpersonal insecurity, interpersonal alienation, emotional dysregulation, interoceptive deficits, perfectionism and asceticism, and anxiety.

The associations among emotional factors, personality traits, and addiction-like eating: A study on university students in six Asian countries/regions

OBJECTIVE

Addiction-like eating (AE) is characterized by food cravings and loss of control over excessive food consumption. This study investigated the associations among emotional factors, personality traits, and AE symptoms in Asian young adults.

METHOD

This study included 6,823 Asian university students in South Korea, China, Singapore, Hong Kong/Macao, Japan, and Taiwan. Participants completed the modified Yale Food Addiction Scale (mYFAS) and scales on the Big-Five personality traits, impulsivity, anxiety, and depression.

RESULTS

6.2% of the participants met the mYFAS (DSM-IV-TR) food addiction diagnostic threshold. Participants from South Korea (7.9%) had the highest rate of food addiction, while participants from Japan (5.1%) and Taiwan (4.1%) reported the lowest rates. Emotional factors of anxiety and depression were the most robust correlates of AE symptoms, followed by country/region and personality factors of higher impulsivity, higher extraversion, and lower agreeableness. Personality correlates were region-specific. Higher impulsivity was a significant correlate for participants from South Korea and Taiwan, higher extraversion for participants from Singapore and Japan, and lower agreeableness for participants from China and Taiwan. Gender was also a significant correlate for participants from South Korea, Hong Kong/Macao, and Taiwan.

DISCUSSION

Emotional and personality factors are important correlates of AE symptoms among Asian young adults.

Estimated prevalence of eating disorders in Singapore

OBJECTIVE

There is a lack of research on the prevalence of eating disorders (EDs) in Singapore. The aims of our study were to (a) estimate the prevalence of EDs, risk status, and help-seeking behaviors among adults in Singapore, (b) examine gender differences between ED status groups, and (c) characterize clinical profiles of ED status groups.

METHOD

We administered a cross-sectional survey that included a validated EDs screening tool to adults in Singapore.

RESULTS

A total of 797 Singaporean adults ages 21-77 years completed the ED screen. The majority of participants screened positive for a current DSM-5 clinical ED (6.2%), other specified feeding or ED (37.0%) or at high risk of developing an ED (19.5%). Only 1.6% of those who screened positive for an ED reported currently being in treatment. The ratio of males to females who screened positive for an ED was nearly 1:1. The clinical profiles of ED groups were consistent with the clinical presentations found in Western nations.

DISCUSSION

This is the first study in Singapore to estimate the prevalence of EDs in a large sample of adults. Results highlight the urgent need for more ED research and expansion of prevention and treatment programs to address the high prevalence of ED psychopathology in Singapore.

The changing profile of eating disorders and related sociocultural factors in Japan between 1700 and 2020: A systematic scoping review

OBJECTIVE

The purpose of this study was to investigate the changing profile of the phenotypic expression of eating disorders (EDs) and related sociocultural factors in Japan between 1700 and 2020.

METHOD

The authors conducted a systematic scoping review in accordance with the PRISMA statement guidelines for scoping reviews.

RESULTS

Findings indicate that Kampo doctors reported more than 50 patients with restrictive EDs in the 1700s, when Japan adopted a national isolation policy. On the other hand, only a few reports of EDs were found between 1868 and 1944, when rapid Westernization occurred. After World War II, providers began diagnosing patients with anorexia nervosa (AN) around 1960. Patients reported experiencing fat phobia, but did not engage in restriction for achieving slimness. However, after the 1970s, Japan experienced a rise in patients with AN who engaged in restriction to achieve thinness. Cases of patients who engaged in binge/purge symptomatology increased after the 1980s, followed by a steady increase in total ED cases after the 1990s. At various time points, providers attributed family conflicts, internalization of a thin ideal of beauty, changing food environments, and pressures associated with traditional gender roles to the onset and maintenance of EDs in Japan.

DISCUSSION

Findings reveal that restrictive EDs were present as early as the 18th century; Japanese patients may present with both "typical" and "atypical" forms of AN; ED symptoms can persist in the absence of Western influence; and sociocultural factors, such as gender-specific stressors and family dynamics, may contribute to EDs for Japanese populations.

Body Dissatisfaction, Restrictive, and Bulimic Behaviours Among Young Women: A Polish-Japanese Comparison

The growing number of women, who are characterized by restrictive and bulimic behaviours towards their own body is observed especially in countries influenced by Westernalization. However, there is a lack of cross-cultural studies in this area. The main aim of the present study was to examine the psychological and socio-cultural risk factors for eating disorders in Polish and Japanese women. A cross-sectional research study was conducted among 18- to 29-year old Polish (n = 89) and Japanese (n = 97) women. The variables were measured using the Sociocultural Attitudes Towards Appearance Scale SATAQ-3, and the Eating Disorders Inventory EDI-3. The descriptive and comparative statistics, Spearman's rho, and the stepwise regression analysis were used. The global internalization of socio-cultural standards of body image proved to be a significant predictor of Body Dissatisfaction among Polish and Japanese women. The main analysis showed a significant relation between the Drive for Thinness and Interoceptive Deficits in the group of Japanese women, as well as a correlation between Drive for Thinness and Asceticism in the group of Polish women. The obtained results could improve the prevention aimed the dysfunctional eating behaviours. However, the cultural nuances need to be considered in understanding the risk factors for eating disorders.

Body Image as Well as Eating Disorder and Body Dysmorphic Disorder Symptoms in Heterosexual, Homosexual, and Bisexual Women

Body image disturbance is a core symptom of eating disorders (EDs) and body dysmorphic disorder (BDD). There is first evidence that females' body image differs depending on sexual orientation, with heterosexual women (HEW) appearing to show more body image disturbance symptoms than homosexual women (HOW). Such disparities might be moderated by everyday discrimination experiences and involvement with the lesbian community. However, to date, there has been no comprehensive assessment of a broad range of body image facets such as drive for thinness, leanness, and muscularity; body avoidance; body checking and body dissatisfaction; and ED and BDD pathology as well as moderating factors. Moreover, studies have often neglected bisexual women (BIW). A total of N = 617 women (n = 180 HOW, n = 322 HEW, n = 115 BIW) completed an online survey assessing the various facets of body image, ED and BDD pathology, discrimination experiences, and involvement with the lesbian community. Significant group differences were found regarding drive for leanness and thinness, body checking, investment behavior, and body ideal (all p<.05). BIW showed significantly more body checking than HOW. Compared to HEW, HOW reported a significantly lower drive for leanness and thinness as well as compared to HEW and BIW less investment behavior. HOW preferred a body ideal with significantly more body fat than did HEW (all p<.05). In contrast, no differences emerged in body dissatisfaction, drive for muscularity, body-related avoidance, ED and BDD pathology, and body image disturbance (all p>.05). In all groups, discrimination experiences were positively related to ED and BDD pathology and to body image disturbance (all p < .05); however, discrimination was significantly correlated with more body image facets in HEW than in HOW or BIW. Involvement with the lesbian community was positively correlated with a larger ideal body size in HOW (p < .05) and negatively correlated with drive for muscularity in BIW (p < .05). Despite the group differences in several body image facets, we found no consistent evidence of increased vulnerability to body image disturbance or associated pathology depending on sexual orientation. However, in HEW, discrimination experience might pose a risk factor for the development of body image-related pathology and single facets of body image disturbance.

National population-based data on the incidence, prevalence, and psychiatric comorbidity of eating disorders in Taiwanese adolescents and young adults

OBJECTIVE

Nationwide data on eating disorders (EDs) among East Asian populations are scarce. This study aimed to estimate the prevalence, incidence, and psychiatric comorbidities of EDs in Taiwan.

METHOD

Drawing from the National Health Research Institute database, we identified the study subjects aged 11-34 years who received an ED diagnosis during ambulatory visits or hospitalization from 2001 to 2012. We analyzed the subjects by age and gender. Diagnoses for comorbid psychiatric disorders were entered in the analysis only if they occurred within 1 year before or after the ED diagnosis date. Rates were age- and sex-adjusted to the average population within the study period.

RESULTS

The estimated mean annual incidence was approximately 11.11 (95% CI 10.51-11.72) per 100,000 residents, and the 1 year prevalence was 20.87 (95% CI 20.05-21.70) per 100,000 residents, with evidence of female predominance (female/male ratio = 10.95, 95% CI = 8.97-13.36). Incidence and prevalence peaked at ages 20-24 in females and at ages 25-29 in males. Both rates nearly doubled within a decade. Specifically, the anorexia nervosa trend recently stabilized in females and decreased in males, while that for bulimia nervosa increased in both females and males. The most common comorbid diagnoses were anxiety (53%) and major depressive disorders (22%).

DISCUSSION

The incidence and prevalence of EDs were lower in Taiwan than in Western countries. However, these rates were rapidly rising, notably in males. The majority of Taiwanese ED patients also received a diagnosis for various psychiatric comorbidities, a finding worthy of clinical attention.

Cultural and Western Influences on the Nutrition Transition in Thailand

The impact of economic development and urbanisation on nutrition and dietary changes in transitional countries has been well researched. It generally has been found that there is a positive correlation between economic development, urbanization, and negative nutrition transitions with the result of growing levels of obesity and diet related non-communicable diseases. However, the impact of Western influences and culture on specific eating styles associated with the nutrition transition has been less studied. There is limited information about cultural and Western influences on eating styles in Thailand. Recent findings suggest that Thailand may have progressed further along the nutrition transition model, in terms of unhealthy eating styles, than would be expected based on economic development. This study was designed to determine the prevalence of current eating styles and eating motivations among Thai university students. University students were chosen for evaluation as they are thought to represent the forefront of dietary trends and nutrition changes in a population. Convenience samples from four different universities in south-central and northern Thailand were selected. The following scales were used to assess eating and dieting styles and attitudes among 662 Thai undergraduate and graduate students: Motivation For Eating Scale (MFES), Eating Attitudes Test-26 (EAT-26), and Cognitive Dieting Behavior Scale (CBDS). All scales have been shown to be reliable and valid in previous research. For this study, scales were translated into Thai, reverse translated, and pilot tested to ensure cultural relevancy and the conveyance of intended meanings. Basic demographic information was also obtained, including age, gender, year in school, marital status, height and weight, and income. Results indicated that Thai students exhibit significant levels of dieting behaviour and extrinsic eating based on CBDS and MFES scores (with the exception of environmental eating). For most negative eating styles, females scored higher than males. It was also found that high levels of dieting and extrinsic eating were positively correlated with body mass index, suggesting the possible risk of future weight gain and obesity. While the occurrence of eating disordered attitudes based on EAT-26 scores was low (13%), analysis of EAT-26 scores indicated that the occurrence of eating disordered attitudes was strongly correlated with dieting behaviour among this population. The results support the need for a programme to educate Thai students, especially females, regarding healthy patterns of dieting and eating attitudes in order to prevent future weight gains and eating disorders predicted by the nutrition transition model.

Childhood neglect in eating disorders: A systematic review and meta-analysis

Individuals with eating disorders (EDs) often report a history of early traumatization. Although great attention has been paid to certain types of trauma, such as sexual and emotional abuse, less is known about the occurrence of childhood neglect in individuals with EDs. The aim of the present meta-analysis was to provide an estimate of the prevalence of childhood emotional neglect (EN) and physical neglect (PN) in individuals with EDs. A systematic literature search, a critical appraisal of the collected studies, and a meta-analysis were conducted. An electronic search of EMBASE, PsycINFO, PubMed, and the Cochrane Library from the inception of these databases up to July 2015 was performed. The final meta-analyzed data set included 7 studies focusing on EN in EDs (N = 963) and 6 on PN in EDs (N = 665). Our meta-analytic data showed that among individuals with EDs, the prevalence of childhood EN is 53.3%, whereas 45.4% reported experience of childhood PN. These preliminary findings confirm the high prevalence of childhood EN and PN in ED samples compared to the general population and underline the importance of systematically screening for the presence of neglect as a possible traumatic experience in individuals with EDs, as its presence may have important consequences for the therapeutic approach.

The Body Logic Program for Adolescents

The Body Logic Program for Adolescents was developed as a two-stage intervention to prevent the development of eating disorder symptoms. Preliminary results indicate that this program shows promise as an effective prevention effort. The current article provides a detailed description of the protocol for implementing Body Logic Part I, a school-based intervention. A brief review of Body Logic Part II, an intensive family-based intervention for high-risk students, is also provided. Examples of exercises are introduced and goals for practitioners are discussed. The authors hope that by providing this in-depth description of the protocol, researchers and clinicians can use this program in future prevention efforts.

The rise of eating disorders in Asia: a review

Once concentrated among adolescent Caucasian females in high-income Western countries, today, eating disorders (EDs) are truly global. Building upon previous work describing the rise of EDs among cultures in transition, we contextualize the emergence of EDs in Asia by locating this development within the broader discourse about the processes of change that have radically transformed Asian societies over the last three decades. By identifying where EDs are emerging in the region, and by examining their particular expression, our aim is to explicate a fuller story of the relationship between culture and eating disorders. Much of the discussion of EDs in non-Western societies is predicated upon the assumption that an increase in EDs is the by-product of "Westernization", the term used to describe the process by which increased cultural contact with the West results in the transmission of so-called 'Western' ideas and cultural norms to a non-Western culture. While the Westernization literature represents a historical anchor in our understanding of EDs in Asia, we propose that this analysis is incomplete in that societal change in the form of industrialization and urbanization occurring independently from, or in tandem with, "Western" influence are critical factors contributing to the rise of EDs in Asia. Further, our review of eating disorders in Asia suggests that an understanding of the diversity and distinctiveness of the individual countries and cultures that comprise 'Asia' is crucial to understanding the emergence and rise of EDs across this vast region, suggesting that eating disorders are not culture-bound or culture-specific, but rather culture-reactive. Taking into account both the historical influence of Western culture and the more contemporary effects of Asian industrialization and urbanization, key distinctions among respective Asian cultures expands our understanding of the development and expression of EDs globally.

The association between internet and television access and disordered eating in a Chinese sample

OBJECTIVE

China has historically reported a low prevalence of eating disorders. However, the rapid social and economic development of this country as well as Western ideals widely disseminated by television and the Internet have led to distinct patterns of behavioral choices that could affect eating disorder risk. Thus, the current study explored the relation between disordered eating and media use.

METHOD

Participants were females from the 2009 wave of the China Health and Nutrition Survey (N = 1,053). Descriptive statistics were obtained and logistic regression models, stratified by age (adolescents ages 12-17 years and adults ages 18-35 years), were used to evaluate the association of media use with disordered eating.

RESULTS

In adolescents, 46.8% had access to the Internet and those with access averaged one hour per day each of Internet and television use. In adults, 41.4% had access to the Internet, and those with access averaged 1 h per day of Internet use and 2 h per day of television use. Internet access was significantly associated with a subjective belief of fatness (OR = 2.8, 95% CI: 1.6, 4.9) and worry over losing control over eating (OR = 4.8, 95% CI: 2.3, 9.8) only in adults.

DISCUSSION

These findings help characterize the overall pattern of media use and report of eating disorder symptoms in a large sample of female Chinese adolescents and adults. That Internet access in adults was significantly associated with disordered eating cognitions might suggest that media access negatively influences these domains; however, more granular investigations are warranted.

The clinical profile of patients with anorexia nervosa in Singapore: a follow-up descriptive study

INTRODUCTION

The prevalence rate of anorexia nervosa is lower in Asia than in the West, although studies have found that it is on the rise in Asia. This study aims to present the clinical profile of patients presenting with anorexia nervosa in Singapore.

METHODS

The present study used archival data from the Eating Disorder Programme registry of the Department of Psychiatry, Singapore General Hospital, Singapore. Patient records from 2003 to 2010 were collected and analysed. Presenting characteristics of the patients were also compared with those of another local study conducted eight years earlier.

RESULTS

From 2003 to 2010, a total of 271 patients were diagnosed with anorexia nervosa by a psychiatrist in our hospital. Of these, 251 (92.6%) were female and 238 (87.8%) were Chinese. Our patients had a lower mean weight (36.83 kg, p < 0.001) and a lower mean body mass index (BMI) (14.43 kg/m(2), p < 0.001) than patients from the previous local study. Almost half of all our patients (n = 135, 49.8%) were diagnosed with at least one psychiatric comorbidity and 50 (18.5%) had a history of self-harm.

CONCLUSION

The presenting characteristics of our study cohort were similar to those of the Western population. However, the lower presenting weight and BMI in our cohort indicates that cases seen today are more severe than those seen eight years ago. Therefore, it is important to put in place prevention programmes to help adolescents cultivate a healthy body image as well as early intervention programmes to improve detection rates and treatment outcomes.

Disordered eating behaviors in university students in Hanoi, Vietnam

BACKGROUND

The aim of the study was to examine disordered eating behaviors in university students in Vietnam.

METHODS

A total of 244 female university students participated, and 203 data could be analyzed. The Body Mass Index, the SCOFF screening questionnaire and the Eating Disorder Inventory 2 were used to explore disordered eating behaviors.

RESULTS

45.3% of the participants were underweight, 53.2% were normal weight and 1.5% were overweight. 48.8% of students reported two or more yes-responses on the SCOFF screening questionnaire which indicates a high possibility of having eating disorder symptoms. The mean score for underweight subjects (M = 14.79, SD = 6.81) indicated a lower level on the drive for thinness scale of the EDI-2 compared to normal weight subjects (M = 24.65, SD = 6.86) and overweight subjects (M = 31.33, SD = 6.66). Additionally, underweight subjects (M = 27.24, SD = 7.57) were less dissatisfied with their body than normal weight subjects (M = 35.94, SD = 8.67) and overweight subjects (M = 43.33, SD = 11.24). A significant positive correlation appeared between the BMI and the EDI-2. The SCOFF questionnaire showed a statistically significant negative correlation with the BMI and the EDI-2.

CONCLUSIONS

Despite some limitations the current study shows a tendency in young females in urban Vietnam to be underweight and to develop disordered eating symptoms such as drive for thinness and body dissatisfaction. However, more studies using the SCOFF and the EDI-2 would be needed to verify these findings.

War stress may be another risk factor for eating disorders in civilians: a study in Lebanese university students

OBJECTIVE

Traumatic life events are important risk factors for eating disorders (ED). War has been associated, in military populations, with an increased post-service incidence of ED and an increased mean body mass index. We hypothesize that a modification of eating behavior (EB) related to stress during wartime may increase the risk of developing an ED later on among civilians exposed to war stress during adulthood.

METHODS

This descriptive cross-sectional study was performed in a group of 303 undergraduate young adult students of both sexes from Lebanon, 6 months after the July 2006 war. Modification of EB during wartime, sociodemographic and other potential risk factors were assessed retrospectively. Students were then screened for ED using the SCOFF questionnaire.

RESULTS

SCOFF was positive in 31.4% of the students, with a mean value 41.6% higher among subjects who reported an altered EB during the war. Among subjects with a positive SCOFF screening, 71% had experienced a change of EB during wartime. Alteration of EB during war was related to an odds ratio for a positive SCOFF screening of 2.6 (95% CI 1.54-4.34) and 1.8 (95% CI 1.01-3.21) for non-adjusted and adjusted analysis, respectively.

CONCLUSIONS

Modification of EB related to stress during wartime is associated with an increased risk of eating disorders. Early detection and treatment of eating disorders may be improved by routinely evaluation of EB modification in patients with a past history of war exposure.

Which body features are associated with female adolescents' body dissatisfaction? A cross-cultural study in Australia, China and Malaysia

This study investigated how dissatisfaction with various aspects of the body is associated with overall body dissatisfaction among female adolescents in Western and Asian cultures. Data used in the study were obtained from 58 Malaysian Malays, 95 Malaysian Chinese, 242 Chinese from China, and 81 non-Asian Australians aged 12-19 years (M=15.72, SD=1.72) who were recruited from high schools. Participants completed a questionnaire assessing dissatisfaction with their body overall, and dissatisfaction with varying aspects of their body. Malaysian Chinese were the most dissatisfied with their bodies. After controlling for body mass index (BMI), age and dissatisfaction with weight/shape, upper, middle and lower body, and muscles, dissatisfaction with the face was positively correlated with overall body dissatisfaction among Malaysian Malays and Australians. These findings demonstrate the importance of using assessment measures that address all possible areas of body focus as well as being tailored to the relevant culture.

Anorexia nervosa in a Thai adolescent

In Thailand, anorexia nervosa (AN) has rarely been reported. We report a 13- year-old female adolescent with AN restrictive type, the first from Thailand to meet all Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition - Text Revision (DSM IVTR) criteria for AN. The emergence of a patient with AN in Khon Kaen, a province from the region with the lowest gross domestic product, accentuates the existence of eating disorders in adolescents beyond Thailand capital. Future studies considering sociocultural issues on normal eating attitudes, eating behaviors and body image in Thailand should be conducted.

Classification of feeding and eating disorders: review of evidence and proposals for ICD-11

Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b) the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a severity qualifier "with dangerously low body weight" should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d) bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a uniform minimum duration criterion of four weeks should apply.

The risk of eating disorders among female undergraduates in Taiwan

The objective of this study was to investigate disordered eating among female college students. The study sought to establish a predictive model for the risk of eating disorders in young female university students in Taiwan. A group of 336 student participants were recruited with the results showing that more than one third (43.2%) of the college women surveyed were identified to be at risk for developing an eating disorder. The results of multiple logistic regression showed that bulimia score, elevated depression index, eating binges, the use of laxatives and medicine to control weight, and having lost 20 lb, or more, in the past 6 months were all considered to be risk factors for developing an eating disorder (the corresponding area under receiver operating characteristic curve = 0.905). The results demonstrate that unhealthy dietary behaviors are rapidly spreading among young Taiwanese female students. For the sample described in this article, 67.6% of the female college students had lost weight: 51% had dieted at least once to lose weight, 43% used exercise to lose weight, 24% used low-calorie diets to lose weight, 11% used healthy food to lose weight, 9.2% used rubber clothing and a diet patch to lose weight, 17.9% of the students used weight-loss drugs, and a few students sought medical assistance from weight-loss clinics or actually underwent liposuction (1.5%).

Body image and eating disorders amongst Japanese adolescents. A review of the literature

This review describes the prevalence of eating disorders and disordered eating behaviors as well as factors influencing body image disturbance amongst Japanese adolescents and compares the prevalence and trends with those of Westernized countries. Although eating disorders have been previously regarded as peculiar to Western society, they are now a more global issue with reports of non-Western countries including Japan having increasing rates of eating disorders. As the aetiology of eating disorders is related to societal norms, culture and ethnicity, their study requires an understanding of body image disturbance within different cultural contexts. Although considered less prevalent than in the West, Japan has an early history of eating disorder research and trends outlined in this review suggest that, as in Western countries the interest in, and study of eating disorders in Japan has increased during the 1980s. The prevalence of eating disorders in Japan based on available reviews, epidemiological studies and clinical reports ranges from 0.025% to 0.2% for AN and from 1.9% to 2.9% for BN. Studies suggest that the prevalence of eating disorders has increased significantly during the past two decades but the prevalence is still quite low compared to those in Western countries. Strategies for culturally appropriate prevention are discussed.

Sociocultural influences on body dissatisfaction and body change behaviors among Malaysian adolescents

Little research on body dissatisfaction and body change behaviors, and the sociocultural influences on them, has been undertaken in non-Western contexts. The current study investigated these variables and the relationships between them among a sample of 529 Malaysian high school students (103 Malays, 344 Chinese and 82 Indians), who completed a set of measures in classroom settings. Chinese girls were more dissatisfied with their bodies than Chinese boys, but no gender difference was found for Malay and Indian participants. Girls were more likely to engage in behaviors to lose weight, and boys were more likely to engage in behaviors to increase muscle. The influence of sociocultural factors on body dissatisfaction and body change behaviors was limited and varied across both sex and ethnicity. Findings are discussed in relation to Western research, and it is concluded that cultural nuances need to be considered when investigating these phenomena.

Disturbed eating behaviors in Taiwanese adolescents with type 1 diabetes mellitus: a comparative study

OBJECTIVES

This study aimed to (i) compare disturbed eating behaviors in adolescents with type 1 diabetes mellitus (T1D) with a matched group of adolescents in Taiwan and (ii) examine the relationships of disturbed eating behaviors to body mass index (BMI) and metabolic control among adolescents with T1D.

METHODS

A cross-sectional study was conducted in southern Taiwan. Seventy-one adolescents with T1D (aged 10-22 yr; 41 females and 29 males) were matched to a group of non-diabetic adolescents. Adolescents completed two self-reported measures of eating behavior, the Bulimic Investigatory Test, Edinburgh and the Eating Attitude Test-26. Metabolic control was assessed by glycosylated hemoglobin A1c levels.

RESULTS

Both adolescent females and males with T1D had more symptoms of bulimia and bulimic behaviors than their non-diabetic peers. There were no group differences in the proportion of subthreshold eating disorders. BMI and metabolic control were significant factors predicting disturbed eating behaviors.

CONCLUSIONS

Both adolescent females and males with T1D exhibited a higher level of disturbed eating behaviors than their non-diabetic adolescent counterparts. Preventive programs that address disturbed eating behaviors should be provided for adolescents with T1D, particularly for adolescents with a high BMI and poor metabolic control.

Comparison of eating disorders and body image disturbances between Eastern and Western countries

Factors associated with the development of eating disorders in countries with non-Western cultures have not been adequately investigated in relation to Westernized countries. We therefore studied 243 girls [age =16.5+/-1.2 (SD)], recruited from schools in India, Tibet, the US and France. They completed the Figure Rating Scale (FRS), the Eating Attitudes Test (EAT), and the Beck Depression Inventory (BDI). The Tibetan group had a lower body mass index (BMI) than the other groups (p<0.0001), which did not differ from each other. All groups differed significantly on socio-economic status (SES), with those living in India having the highest (p<0.0001). Prior to controlling for age, SES, and BMI, there were no significant differences on any psychological measure between the individual countries, or when collapsed by East vs. West. However, after controlling for the same covariates, the Tibetan group selected a significantly larger current (p<0.0001) and ideal body size (p=0.03), compared to all the other countries, and had more body image discrepancy than the American group (p=0.04). After controlling only for BMI, the girls from the East had a larger current and ideal, but no difference on body image discrepancy. Body image discrepancy scores were best predicted by EAT scores and BMI, accounting for 35% of the variance (p<0.0001). EAT scores themselves were best predicted by mother's education, BDI, body image discrepancy, and drug and tobacco use, accounting for 33% of the variance (p<0.0001). Unlike some other studies, we did not observe greater body image discrepancy and eating pathology in Western cultures, whether or not controlling for age, SES, and BMI. There were no differences in eating and depression pathology between those in the US, France, or India. Indeed, the Tibetans, after controlling for their low BMI and SES, had the greatest body image discrepancy.

Tendency toward deliberate food restriction, fear of fatness and somatic attribution in cross-cultural samples

OBJECTIVE

To compare Omani and western teenagers attending schools in Muscat, Sultanate of Oman and Filipino teenagers residing in Manila, Philippines on indices of deliberate food restriction and dieting behavior.

METHODS

The sample consisted of 444 students who were assessed using the cross-culturally valid measure, Eating Attitude Test-26, a subscale of Eating Disorder Inventory to gauge the presence of the drive for thinness or 'fat phobia' and the Bradford Somatic Inventory to elicit the presence of somatization.

RESULT

Significant differences in attitudes to eating, body image and somatization between the western and non-western teenagers were found.

CONCLUSION

This paper suggests that trajectories of eating disorder, such as body image disturbances as expressed in fat phobia and somatization, tend to vary from culture to culture and underscore the view that some of the health related behavior among adolescents need to be examined within socio-cultural contexts.

Two-phase survey of eating disorders in gifted dance and non-dance high-school students in Taiwan

BACKGROUND

Despite a growing body of literature reporting eating disorders (EDs) in non-Western countries in recent years, most of these studies are limited to questionnaire-based surveys or case-series studies. This study aimed to investigate the prevalence and correlates of EDs in Taiwanese high-school students.

METHODS

The study subjects consisted of all the female high-school students enrolled in the gifted dance class in 2003 in Taiwan (n=655) and non-dance female students randomly chosen from the same school (n=1251). All the participants were asked to complete self-report questionnaires, including the 26-item Eating Attitudes Test (EAT-26) and the Bulimic Investigatory Test Edinburgh (BITE). All the screen positives and an approximate 10% random sample of the screen negatives were then interviewed using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders Patient Version (SCID-I/P).

RESULTS

The prevalence of individual EDs was much higher in the dance [0.7% for anorexia nervosa (AN), 2.5% for bulimia nervosa (BN) and 4.8% for EDs, not otherwise specified (EDNOS)] than in the non-dance (0.1, 1.0 and 0.7% respectively) students. Multivariate logistic regression analyses revealed that being in the dance class, higher concern about body shape and lower family support were correlates of EDs for all students, whereas lower parental education level was associated with EDs only for non-dance students.

CONCLUSION

EDs were more prevalent in the weight-concerned subpopulation. Although AN is still rare, BN has emerged as a comparable prevalent disorder in Taiwan, as in Western countries.

Eating disorders across two cultures: does the expression of psychological control vary?

OBJECTIVE

Because both the expression of eating disorder (ED) symptoms and preferred psychological control styles may be affected by culture, the purpose of the present study was to examine whether the expression of psychological control in women with EDs varies across two cultures.

METHOD

North European Australian and Chinese Singaporean women (n = 117) with anorexia nervosa (n = 36), bulimia nervosa (n = 13) and eating disorders not otherwise specified (n = 3), and without an ED (n = 65) recruited in Australia and Singapore completed a multidimensional inventory assessing sense of control, domains of control, preferred means by which to gain control, and motivation for control.

RESULTS

Although the normative control profile for each culture differed slightly, control profiles among those with an ED were very similar across both cultures. However, the directionality and extent of specific aspects of control pathology associated with the presence of an ED differed across cultures. North European Australians with an ED were much more deviant from the cultural norm than their Chinese Singaporean ED counterparts in relation to overall sense of control, methods of gaining control, and control in the domain of body. Chinese Singaporean woman with an ED were much more deviant from the cultural norm than their North European Australian ED counterparts in the domain of control over impulses.

CONCLUSIONS

Having an ED powerfully distorts psychological control irrespective of culture. However the degree, directionality, and form of the displacement from normal control styles is also culture dependent. This has implications for treatments that attempt to redress or correct control issues in people with an ED in other cultures.

A comparison of disordered eating attitudes and behaviors among Filipino and American college students

OBJECTIVE

The purpose of this study was to compare the levels of eating disordered attitudes and behaviors among college students in the United States and the Philippines.

DESIGN

A convenience-based cross-sectional survey.

SETTING

General education classes in one college in Manila and another in the Western US.

PARTICIPANTS

340 college students.

INTERVENTIONS

A paper-pencil survey was given to the students in the classroom consisting of Eating Attitudes Test (EAT-26) and demographic variables.

MAIN OUTCOME MEASURES

Eating disordered attitudes and behaviors (scoring 20 or more on EAT-26) was the dependent variable, while gender and country of residence were the two main independent variables.

ANALYSIS

Frequency distributions, chi-squares, and logistic regression analysis were employed to summarize and analyze the data.

RESULTS

Filipino students were 10.9 times (p-value <0.0001) more likely to have eating disordered attitudes and behaviors than their American counterparts controlling for the demographics collected. This relationship remained significant when regression models were done for each gender separately. In addition, married students and more specifically married female students were more likely to have eating disordered attitudes and behaviors than single students or single females.

CONCLUSIONS AND IMPLICATIONS

Arguments are made as to why higher levels of eating disordered attitudes and behaviors are observed among Filipino college students. These results provide important information about the levels of eating disordered attitudes and behaviors in the Philippines and may be useful for developing future education programs.

Epidemiological study of the influence of family and socioeconomic status in disorders of eating behaviour

OBJECTIVE

To analyse the differences in family functioning and socioeconomic status between subjects with disorders of eating behaviour and the healthy population, considering the possible relationship of these factors with the psychic characteristics of patients, with consumption of various substances, and with sexual practices.

DESIGN

Case-control study.

SETTING

'Puerta del Mar' University Hospital (Andalusia, Spain).

SUBJECTS

Conducted on a sample of 120 patients with AN and BN, and 240 controls with an identical distribution by age and sex.

INTERVENTIONS

SCOFF, eating disorder inventory (EDI), Apgar family and socioeconomic questionnaires are utilised.

RESULTS

Patients with disorders of eating behaviour present greater family dysfunctioning than controls; among cases, this difference is greater in the acute forms, but there are no differences between recent situations or crises due to previous episodes. Family dysfunction is associated with higher scores of multiple subscales of the EDI, which is corroborated on analysing each of the Apgar parameters independently. Family functioning is not associated with other variables such as breast-feeding or consumption of toxic substances. Socioeconomic status does not differentiate cases from controls, or acute situations from evolving ones, or new episodes from other crisis episodes, although differences may be found in the psychic manifestations according to social class.

CONCLUSIONS

It is confirmed that family functioning has an influence in these types of disorder, in their evolution and in the psychic characteristics of the patients, without any evidence being found of a relationship between these disorders and socioeconomic status.

Dietary polyunsaturated fatty acids and anorexia nervosa: is there a link?

There has been little research examining the link between dietary fat intake and the symptoms and consequences of anorexia nervosa. In this selective literature review, the potential significance of poly-unsaturated fatty acids is discussed. It is hypothesised that dietary restriction causes essential fatty acid deficiencies and poly-unsaturated fatty acid abnormalities, which might contribute to the physical and mental symptoms and the maintenance of the disorder. The examination of epidemiology, symptoms, co-morbidity, and consequences suggest that poly-unsaturated fatty acid and phospholipid abnormalities are significant in anorexia nervosa. This will be an important area for future research, and may lead to the development of new interventions.

The Eating Disorder Inventory-2 in Japanese clinical and non-clinical samples: psychometric properties and cross-cultural implications

OBJECTIVE

To determine the usefulness of and cross-cultural differences in the Japanese version of the eating disorder inventory-2 (EDI-2).

METHOD

A Japanese version of the EDI-2 was administered to a consecutive series (1995-2001) of 91 Japanese eating disordered inpatients and 119 matched non-clinical controls. Scores were compared with each other and with those of Canadian data previously reported. Internal consistencies were also examined.

RESULTS

All subscales (except Ascetism) reached sufficient internal consistencies. The patients' mean scores were significantly higher than controls on most subscales. Restricting anorexics (AN-R) scored higher than controls on body dissatisfaction (BD) and Social Insecurity (SI) subscales. Purging bulimics (BN-P) scored higher than controls on most subscales, except for maturity fears (MF) and SI subscales. Scores of binge-eating/purging type anorexics (AN-B/P) were higher than controls on all subscales. AN-B/P and BN-P scored higher than AN-R on bulimia (B) subscale. Comparison with Canadian subjects showed that Japanese control subjects scored significantly higher on the MF, ineffectiveness (I), impulse regulation (IR), SI subscales, and lower on the perfectionism (P) subscale.

DISCUSSION

The EDI-2 is useful and reliable in understanding Japanese clinical and non-clinical samples. High MF and low P subscales in our samples confirm previous findings in Chinese samples suggesting meaningful cultural differences in the emphasis placed on family bonds and individual accomplishments. In addition, high I, IR, and SI scores in Japanese non-clinical samples may reflect recent problems in Japanese culture.

Risk factors for anorexia nervosa: a national cohort study

OBJECTIVE

To identify possible risk factors for anorexia nervosa through national registers.

METHOD

The study includes the entire Swedish population of 989,871 individuals born between 1973 and 1982. Patients with anorexia nervosa were identified through the Swedish Hospital Discharge Register from November 1990 to December 1999. Information about sociodemographic, perinatal, and psychosocial variables was obtained from different national registers. Attributable risk (AR) was calculated for potential risk factors.

RESULTS

Females had the highest AR for hospital admission because of anorexia nervosa (89.2%). Another important risk factor was having parents born in northern, central, or eastern Europe (AR: 49.3%). Psychosocial risk factors also were associated with an increased risk for anorexia nervosa (AR: 7.6%), whereas perinatal complications had an AR of only 3.6%.

DISCUSSION

The most important risk factors were related to the sociocultural context of the individual, thus supporting hypotheses of a sociocultural etiology of anorexia nervosa.

Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology

The authors explore the extent to which eating disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN), represent culture-bound syndromes and discuss implications for conceptualizing the role genes play in their etiology. The examination is divided into 3 sections: a quantitative meta-analysis of changes in incidence rates since the formal recognition of AN and BN, a qualitative summary of historical evidence of eating disorders before their formal recognition, and an evaluation of the presence of these disorders in non-Western cultures. Findings suggest that BN is a culture-bound syndrome and AN is not. Thus, heritability estimates for BN may show greater variability cross-culturally than heritability estimates for AN, and the genetic bases of these disorders may be associated with differential pathoplasticity.

Sociocultural and developmental influences on body dissatisfaction and disordered eating attitudes and behaviors of Asian women

This study is an examination of the influence of sociocultural and developmental factors on body dissatisfaction and disordered eating attitudes and behaviors in two Asian populations: 298 Taiwanese-American (TA) women undergoing acculturating changes and 347 Taiwanese (T) women undergoing modernizing changes. Contrary to the initial hypothesis, body dissatisfaction rates and disordered eating attitudes and behaviors were found to be significantly higher in the T group. Subjects in the T group had higher Taiwanese ethnic identity scores but also lower perceptions of maternal control. Body dissatisfaction was found to be a moderating variable between ethnic identity and disordered eating attitudes and behaviors for the TA group only. The "girl next door" hypothesis, based on the social comparison theory, was set forth to help explain why this result was found only in the TA group. In the T group, ethnic identity and body dissatisfaction were independently associated with disordered eating. Results failed to support a link between parental control and the development of an eating disorder, and implications from a cross-cultural perspective are addressed.

Eating attitudes in high school students in the Philippines: a preliminary study

PURPOSE

The purpose of this study was to examine the prevalence of abnormal eating attitudes among high school students from Pasig Catholic College in the Philippines.

METHODS

Two survey questionnaires, the Eating Attitudes Test (EAT) and Beck's Depression Inventory (BDI), were administered to 932 high school students. The height and weight of the subjects were measured, and their body mass indices (BMI) calculated.

RESULTS

The prevalence of abnormal eating attitudes according to the EAT scores was 14.5 +/- 3.2% among males and 15.0 +/- 3.5% among females, comparable to the 7-22% found in Western countries. There was a weak correlation between the EAT scores and BMI (r=0.180, p=0.01), and between the EAT scores and Beck's Depression Inventory (r=0.187, p=0.01).

CONCLUSIONS

The results indicate the presence of abnormal eating attitudes among Filipino high school students from Pasig Catholic College, which suggests that further study of eating disorders and their associated risks is warranted.