Eating disorders: lessons from a cross-cultural study

Research on feeding and eating disorders in India: A narrative review

Despite growing evidence of their prevalence, research on feeding and eating disorders (FEDs) in India has been sporadic. This narrative review aimed to summarize the research on FED in India and set priorities for future research and translation of evidence. An electronic search was conducted in the MEDLINE, PsycINFO, and Google Scholar databases to identify relevant English peer-reviewed articles from April 1967 to July 2023. The extracted data from these studies included author names, publication year, research location, type of intervention (for interventional studies), nature of comparator treatments, and main outcomes or findings. We found a rising trend in the prevalence of EDs in India. Adolescent age group, female sex, higher socioeconomic status, family history of mental illness or disordered eating, and borderline personality pattern were risk factors for EDs. For feeding disorders (FDs), childhood age group, malnutrition, pregnancy, psychosis, intellectual disability (ID), and obsessive-compulsive disorder (OCD) were putative risk factors. Both physical and psychiatric comorbidities were common in FEDs. Culture appears to exert a pathoplastic effect on symptom presentation in FEDs; an illustrative example is the documented nonfat phobic variant of anorexia nervosa (AN) in India. Research on management has focused on using assessment tools, investigations to rule out medical comorbidities, psychosocial and family-based psychotherapies, nutritional rehabilitation, pharmacotherapy, and neuromodulation approaches. Whereas the publication output on FEDs in India has increased over the last decade, it remains an under-researched area, with a striking paucity of original research. Future research priorities in FEDs include conducting country-wide registry-based studies to offer real-world insights, longitudinal research to identify culturally relevant risk factors, and developing brief, culturally sensitive diagnostic instruments for FEDs in the Indian context. This will help generate locally relevant epidemiological data on FEDs and inform treatment and prevention strategies.

The Tamil version of Eating Attitudes Test-26: Reliability and factor structure among persons with schizophrenia

Background

Disordered eating behaviors (DEBs) among persons with schizophrenia (PwS) have been reported widely in the literature, with very few studies in India. Robust tools to assess DEB are needed in the vernacular language to capture symptoms of disordered eating accurately. No such tools are available in the Tamil language. Globally, the Eating Attitudes Test (EAT-26) is widely used to assess DEB among PwS.

Aim

This study aimed to translate and study the factor structure and reliability of EAT-26 among Tamil-speaking PwS.

Materials and Methods

EAT-26 was translated into Tamil following the Oxford linguistic validation process. Experts evaluated its face validity and content validity. One hundred and fifty PwS, aged between 18 and 65 years, who attended the outpatient department of a psychiatric facility, and consented to participate, completed the Tamil version of EAT-26. Test-retest reliability of EAT-26 was assessed by readministering the tool to 30 PwS after two weeks. Data were analyzed using Stata 16.1. Internal consistency and test-retest reliability were computed using Cronbach's alpha and intraclass coefficients, respectively. The factor structure of EAT-26 was explored using principal component analysis (PCA). Spearman's rho was calculated to understand the correlation between the factors.

Results

EAT-26 had an internal consistency of 0.71 and test-retest reliability of 0.896. Factor analysis revealed nine latent factors consisting of 21 of the original 26 items on EAT-26. These 21 items could explain a variance of 63.63%.

Conclusions

The Tamil version of the EAT-26 is a reliable tool to assess DEB among Tamil-speaking PwS. It can be used to screen PwS for eating disorder risk.

The 26-Item Eating Attitudes Test (EAT-26): Psychometric Properties and Factor Structure in Vegetarians and Vegans

The eating disorder screener, Eating Attitudes Test (EAT), has been used widely; however, its usability in specific dietary groups such as vegetarians and vegans remain unknown. Considering the rising popularity of vegetarianism and veganism, the current study aimed to assess the psychometric properties and theoretical assumptions of the 26-item EAT in separate groups of vegetarians (n = 278), vegans (n = 580), and omnivores (n = 413). Confirmatory factor analysis of four models from previous literature revealed inadequate fit of the data, with the exception of a 16-item four-factor model in vegetarians and vegans. Further assessment of the original three-factor model and 16-item four-factor model demonstrated poor psychometric properties. The primarily inadequate test-retest reliability discovered in this study, independent of whether a shortened version was used, raises concerns around the utility and stability of the EAT-26 in vegetarians and vegans. Future research should potentially investigate novel ways of measuring eating disorder pathology in these groups.

Adaptation and validation of the Eating Disorder Examination-Questionnaire in English among urban Indian adolescents

OBJECTIVE

Eating pathology is a salient issue in India, with clinical features reported among adults and adolescents. However, there are currently no validated measures of disordered eating in the Indian context. The present study therefore aimed to validate a culturally appropriate English language version of the Eating Disorder Examination Questionnaire (EDE-Q), a widely used measure, among adolescents in India.

METHOD

We adapted and examined the factor structure, reliability, and construct validity of the EDE-Q among an urban sample of 1,413 Indian adolescents (mean age = 13 years; 45% girls).

RESULTS

In contrast to the original four-factor model, exploratory factor analysis identified a two-factor solution for girls and boys, which was verified by confirmatory factor analysis; a "Preoccupation and Control" subscale and a "Weight and Shape Concerns" subscale. The total scale comprised 15 items for girls and 18 items for boys. Test-retest reliability and internal consistency were satisfactory for the girls' and boys' scales (Cronbach's α = .91 for both) and their comprising subscales (αs ≥ .80). Concurrent validity was established through medium-high significant correlations with measures of body image and internalization of appearance ideals. Combining items common to both versions of the scale led to a psychometrically acceptable model which was largely invariant across both genders, thus facilitating gendered comparison.

DISCUSSION

Findings indicate the reliability and validity of the EDE-Q among English-speaking urban Indian adolescents. This will facilitate further research examining the prevalence and nature of eating pathology among adolescents in India.

Eating Disorders: An Overview of Indian Research

There has been sporadic research on eating disorders in India, with no published attempt to collate and summarize the literature landscape. Hence, the present narrative review aims to summarize Indian work related to eating disorders, discern current trends, and highlight gaps in research that will provide directions for future work in the area. Electronic search using the MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles, in October 2018, using combinations of the following medical subject headings or free text terms: "eating disorders," "anorexia nervosa," "bulimia," "treatment," "epidemiology," "co-morbidity," "management," "medications," "behavioral intervention," and "psychosocial intervention." The data extracted from studies included details such as author names, year, from which of the states in India the work originated, type of intervention (for interventional studies), comparator (if any), and major outcomes. There is increasing research focused on eating disorders from India over the last decade, but it continues to be an under-researched area as evidenced by the relative paucity of original research. The cultural differences between east and west have contributed to variations in the presentation as well as challenges in the diagnosis. Hence, there is a need for the development of culturally sensitive instruments for diagnosis, as well as generating locally relevant epidemiological data about eating disorders from community and hospital settings.

Exploring challenges and lessons learned in cross-cultural environmental education research

The field of environmental education (EE) has been criticized for scarcity of research findings that can be used to compare the approaches and outcomes of various interventions and contexts. This is particularly problematic for EE programs that are implemented across multi-cultural settings because very little academic attention has been devoted to cross-cultural EE research methods. Intending to address this gap, we set out to develop and pilot a pre/post survey in Costa Rica that could help us investigate the impacts of a bird-focused curriculum on Latin American children's knowledge, attitudes, behavioral intentions, and behaviors toward birds and the natural world. This article describes the challenges encountered and subsequent adaptations made throughout our ongoing, iterative survey development process, in order to appropriately address language, sociocultural context, audience, and research-to-practice tensions. We present key lessons learned, including the importance of having strong local partners, the need to create a realistic research timetable that accounts for unique challenges involved in undertaking cross-cultural EE research, and the limitations of quantitative methods in this sort of research.

Cross-Cultural Translation

Translating questionnaires for cross-cultural research is fraught with methodological pitfalls that threaten research validity. Some flaws are difficult to detect, leading to the erroneous conclusion that cultural differences are substantive when, in fact, they stem from semantic inconsistencies. We describe the process of translation and validation of the Hebrew version of an American questionnaire for cross-cultural comparisons of medical students' attitudes toward preventive medical services. The results provide evidence to support the validity of the Hebrew instrument for cross-cultural comparisons. Although it is always possible to contend that differences in cross-cultural comparisons result from metiodological flaws rather than actual differences, we believe that the arduous step-by-step process of validation described here reduces that possibility to an acceptable minimum.

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.

Cross-cultural child and adolescent psychiatry research in developing countries

Mental disorders are currently a major source of morbidity among children and youth globally. The bulk of the epidemiological data about childhood mental health morbidity currently comes from the industrialized countries which paradoxically host a small (about 20%) proportion of global children and youth population. As the world seek to generate more data on the mental health of the teeming children and youth population in low- and middle-income countries (LMICs), cross-cultural issues need be considered. This consideration is imperative for reasons which include the high level of ethno-diversity in LMICs; the contextual issues in the conceptualization of normal (and abnormal) childhood across cultures, the cross-cultural nuances in risk and protective factors, and the plurality of nature and expression of childhood psychopathology. As much as it is imperative to do so, advancing cross-cultural child and adolescent research in LMICs will need to overcome challenges such as inclusive sampling and cultural validation of instruments developed in the industrialized countries of the West. Funding, technical resources, and publication bias are other potential challenges. These issues are appraised in this narrative review and some ways forward are proffered.

A comparison of eating disorder patients in India and Australia

BACKGROUND

Eating disorders (EDs) are an emerging concern in India. There are few studies comparing clinical samples in western and nonwestern settings.

AIM

The aim was to compare females aged 16-26 years being treated for an ED in India (outpatients n = 30) and Australia (outpatients n = 30, inpatients n = 30).

MATERIALS AND METHODS

Samples were matched by age and body mass index, and had similar diagnostic profiles. Demographic information and history of eating and exercise problems were assessed. All patients completed the quality-of-life for EDs (QOL EDs) questionnaire.

RESULTS

Indians felt they overate and binge ate more often than Australians; frequencies of food restriction, vomiting, and laxative use were similar. Indians were less aware of ED feelings, such as, "fear of losing control over food or eating" and "being preoccupied with food, eating or their body." Indians felt eating and exercise had less impact on their relationships and social life but more impact on their medical health. No differences were found in the global quality-of-life, body weight, eating behaviors, psychological feelings, and exercise subscores for the three groups.

CONCLUSION

Indian and Australian patients are similar but may differ in preoccupation and control of their ED-related feelings.

Prevalence of child and adolescent psychiatric disorders in India: a systematic review and meta-analysis

BACKGROUND

The importance of epidemiological studies lies in recognition of cases that do not come to treatment settings. The increasing focus on child adolescent mental health in India points to the necessity of epidemiological studies on children. Although there are a few such studies done in different parts of India in different socio-cultural settings, data from those cannot be generalized to the entire country. This need can be served by meta-analysis. There has been no meta-analysis reported from India for the child and adolescent psychiatric epidemiology.

AIM

To review and do the meta-analysis of epidemiological studies on child and adolescent psychiatric disorder from India.

METHODS

Sixteen community based studies on 14594 children and adolescents; and seven school based studies on 5687 children and adolescents, reporting prevalence of child and adolescent psychiatric disorder were analyzed and overall prevalence was calculated.

RESULTS

The prevalence rate of child and adolescent psychiatric disorders in the community has been found to be 6.46% (95% confidence interval 6.08% - 6.88%) and in the school it has been found to be 23.33% (95% confidence interval 22.25% - 24.45%).

CONCLUSIONS

This is the first meta-analysis determining the epidemiology of child and adolescent psychiatric disorders in India. It has been found that the reporting systems of psychiatric disorders in children are inadequate.

Translation and linguistic validation of Korean version of short form of pelvic floor distress inventory-20, pelvic floor impact questionnaire-7

The short forms of pelvic floor distress inventory (PFDI) and pelvic floor impact questionnaire (PFIQ) are useful disease specific questionnaires evaluating symptoms, quality of life for pelvic floor disorders. The purpose is to develop linguistic validation of the PFDI-20 and PFIQ-7 questionnaires. Three types of Korean version of questionnaires have been used in four locations of University Hospitals in Korea. Each version of questionnaires was developed by forward translation and back-translation by bilingual translators and was verified by the patients with pelvic floor disorder and healthy persons. For harmonization of 3 types of questionnaires, four authors reviewed, discussed all discrepancies, incorporated and produced a new version. The multi-step processes of translation and linguistic validation of the Korean version of PFDI-20 and PFIQ-7 questionnaire were completed. Further process of validation of Korean version of these questionnaires is required.

The associations of sociocultural attitudes towards appearance with body dissatisfaction and eating behaviors in Hong Kong adolescents

OBJECTIVES

Western culture has great influences on body dissatisfaction and related eating behaviors in adolescents. This study aimed to assess the sociocultural influences on eating attitudes and motivations among Hong Kong Chinese adolescents.

METHODS

In 2007, 909 adolescents (mean age = 14.7 years, 55.3% boys) completed a survey with Stunkard's Figure Rating Scale (FRS), Motivation for Eating Scale (MFES), Eating Attitudes Test (EAT), Revised Restraint Scale (RRS), and Sociocultural Attitudes Towards Appearance Scale (SATAQ). In addition, their body mass index (BMI) was objectively measured.

RESULTS

Our results indicated that Hong Kong adolescents, particularly girls exhibited a remarked level of body dissatisfaction, external, emotional, restrained and disordered eating behaviors. Hierarchical regression analyses indicated that age, sex and BMI were the most common contributing factors to individual eating styles. SATAQ significantly accounted for an additional variance of body dissatisfaction (2%), physical eating (2%), external eating (1%), emotional eating (3%), restrained eating (5%), and disordered eating (5%).

CONCLUSIONS

In Hong Kong, the sociocultural influences on body image and eating disturbance were supported.

Translation of the Quality of Life for Eating Disorders questionnaire into Hindi

OBJECTIVE

The Quality of Life for Eating Disorders questionnaire was translated into Hindi (QOL ED-H) using the forward-backward translation procedure for use with Indian females.

METHOD

A total of ninety-five females were recruited from two secondary schools and one tertiary college from Delhi, India. They were aged between 14 and 37 years, ranging from low to high socioeconomic status communities. A psychologist and teacher produced a preliminary Hindi version, which was back-translated by the psychologist and a journalist and any disparity was checked. The Hindi and English versions were administered one week apart to the same participants, the order being randomised.

RESULTS

Repeated measures analysis revealed no significant differences in QOL ED scores (global and subscores) between the Hindi and English versions, when controlled for age.

CONCLUSION

The QOL ED-H can be used to assess eating and exercise disordered thinking, feeling, behaviours, psychological feelings and daily living in Indian females of all SES groups.

Belief and behavior aspects of the EAT-26: The case of schoolgirls in Belize

This study investigates components of eating attitudes in a sample of Belizean schoolgirls and argues for separate analysis of eating beliefs and eating behaviors using the EAT-26 in populations undergoing rapid cultural change. The EAT-26 was utilized in a novel manner, preserving the ethnographic and empirical distinction between belief and behavior components of eating attitudes. Participants included a sample of secondary schoolgirls (n = 80) undergoing acculturative stress. Participants reported more disordered eating beliefs than behaviors. Respondents having higher belief scores than behavior scores were more likely to prefer thinner body build and to be concerned about boys' assessments of their bodies. Girls with higher behavior scores were less likely to report eating when hungry and stopping when full. In conclusion, discriminant validity was found between attitudinal and behavioral aspects of the EAT-26 as evidenced by face validity and patterns in predicting body image preference and desired weight change. Such a distinction has implications for assessing risk for disordered eating among populations undergoing acculturative stress. Among such populations, while behavioral symptoms might be absent or present in subclinical levels, disordered beliefs associated with psychological distress or potential precursors to eating-disordered behavior might be detected and should be investigated further.

Eating attitudes and body dissatisfaction in adolescents: Cross-cultural study

AIMS

Sociocultural factors are thought to be important in the pathogenesis of eating disorders. However, there have been few studies comparing eating behavior among various cultural populations. The aim of the present study is to compare attitudes towards bodyweight and shape, and desire for thinness in Japanese male and female subjects with those in people from other countries and of different ethnic origin.

METHODS

The subjects were 411 Japanese, 130 Indian, 135 Omani, 113 Euro-American and 196 Filipino adolescents. The Eating Attitude Test-26 and the Drive for Thinness subscale of the Eating Disorder Inventory-2 were used to assess eating attitudes and fat phobia.

RESULTS

Subjects from India, Oman and the Philippines demonstrated eating attitudes that were similar to or worse than subjects from Western countries and Japan, although their desire for thinness was not as strong. The relationship between body mass index and eating attitudes or fat phobia in Indian, Omani and Filipino subjects differed from that in subjects from Western countries and Japan. In addition, both males and females showed disturbed eating attitudes in the Indian, Omani, and Filipino subjects.

CONCLUSION

There are differences in eating attitudes and the drive for thinness among different cultural groups.

Culture and eating disorders classification

OBJECTIVE

This paper discusses cultural considerations for classification of eating disorders.

METHOD

The literature on epidemiology and phenomenology of eating disorders in culturally diverse populations was selectively reviewed to identify methodologic challenges in classification and characterization of prevalence and phenomenology.

RESULTS

Prevalence of eating disorders among culturally diverse populations is incompletely characterized. Few studies address the epidemiology of eating disorders or provide qualitative data on variation in presentation in these populations. Unrecognized cultural diversity may result in misclassification of cases.

CONCLUSION

Development of culturally valid assessments, ethnographic data on indigenous nosologic correlates and idioms of distress, and attention to phenomenologic diversity may have critical impact on understanding clinical presentations and risk factors that may be culturally particular. A flexible classificatory system for the eating disorders may help to encompass their culturally based phenomenologic diversity, facilitate culturally sensitive and strategic prevention strategies, and reduce ethnic disparities in access to care for them.

Validation of the eating disorder diagnostic scale for use with Hong Kong adolescents

OBJECTIVE

We examined the psychometric properties of the Eating Disorder Diagnostic Scale (EDDS) in a community sample of Hong Kong school children.

METHOD

Participants (359 boys and 387 girls), aged 12 to 19 years, were assessed on the EDDS on two occasions, one month apart. Factor structure, internal consistency, test-retest reliability, and validity against the Eating Disorders Examination-Questionnaire (EDE-Q) and Center for Epidemiological Studies-Depression (CES-D) were investigated.

RESULTS

Four groupings emerged on exploratory factor analysis: body dissatisfaction, bingeing behaviors, bingeing frequency, and frequency of compensatory behaviors. Items loaded on the same factors for boys and girls. Internal consistency for these factors was acceptable. Test-retest reliability was high for body dissatisfaction factor but weak to moderate for other factors and for diagnoses. High concurrent validity with the EDE-Q, and correlation with the CES-D was shown.

CONCLUSION

We offer preliminary reliability and validity evidence to support the further development of the EDDS as a screening instrument to assess eating disturbances in Hong Kong youth.

Rural/urban differences in the distribution of eating disorder symptoms among adolescents from community samples

OBJECTIVE

Rural/urban differences in the prevalence of mental disorders have often been reported in the last 30 years, among others in the distribution of eating disorder symptoms and suicide rates. The role of sex, age and socioeconomic status in the differences by place of residence has often been neglected in past studies.

METHOD

Two independent community samples of students (mean age=17.4 years, SD=1.4), taken from among those attending high school in an urban district (Cagliari; n=817) and in a rural one (Carbonia; n=507) of south Sardinia, Italy, were invited to fill in the Eating Attitudes Test (EAT), the Bulimic Investigatory Test of Edinburgh (BITE), the Body Attitudes Test (BAT) and the revised Hopkins Symptom checklist (SCL-90-R).

RESULTS

Female students scored higher than male students on all inventories. In male participants, the scores on the EAT were higher in the urban than in the rural sample. Conversely, in both male and female students the rural sample reported higher scores on the BITE symptoms subscale. When the comparison was confined to the fraction of those who scored higher than the suggested cut-off on the EAT and the BITE, students in the urban sample outnumbered those in the rural sample. No other differences were found. Socioeconomic status and age did not influence the differences in the reporting of eating disorder symptoms by place of residence.

CONCLUSIONS

Although caution is required when reading the findings drawn from self-report instruments, it is evident that the factors influencing the distribution of eating disorder symptoms and their psychological correlates by place of residence are far more complex than currently thought.

Facets of acculturation and their diverse relations to body shape concern in Fiji

OBJECTIVE

The present study examines the relation between acculturation and body shape concern in Fiji--a society undergoing rapid social change.

METHOD

Data were from two cohorts of ethnic Fijian girls and women collected in 1998 (n = 115). A factor analysis was performed to identify dimensions of acculturation. The association of these with body shape concern was examined with linear regression.

RESULTS

Three dimensions of acculturation were identified. Multiple linear regression models demonstrated that each of these dimensions of acculturation had a unique relation to body shape concern. The adjusted R(2) for the fully adjusted model relating acculturation to body concern was 0.63, indicating a substantial degree of shared variation between measures of body shape concern and measures of acculturation.

CONCLUSION

Acculturation may have a strong impact on body shape concern in Fiji. However, acculturation is a multidimensional construct and does not likely have a monolithic relation to body shape concern.

Incidence, prevalence and mortality of anorexia nervosa and other eating disorders

PURPOSE OF REVIEW

The purpose of this review is to evaluate the recent literature on the incidence and prevalence of and mortality associated with eating disorders.

RECENT FINDINGS

General-practice studies show that the overall incidence rates of anorexia nervosa remained stable during the 1990s, compared with the 1980s. Some evidence suggests that the occurrence of bulimia nervosa is decreasing. Anorexia nervosa is a common disorder among young white females, but is extremely rare among black females. Recent studies confirm previous findings of the high mortality rate within the anorexia nervosa population.

SUMMARY

The incidence of anorexia nervosa is around eight per 100,000 persons per year. An upward trend has been observed in the incidence of anorexia nervosa in the past century till the 1970s. The most substantial increase was among females aged 15-24 years, for whom a significant increase was observed from 1935 to 1999. The average prevalence rates for anorexia nervosa and bulimia nervosa among young females are 0.3 and 1%, respectively. Only a minority of people with eating disorders, especially with bulimia nervosa, are treated in mental healthcare.

Partial eating disorders among adolescents: a review

PURPOSE

Many adolescents do not fulfill all the DSM-IV criteria's for anorexia nervosa and bulimia, but do nevertheless suffer from partial eating disorders (EDs). This review focuses on the definition, epidemiology and clinical aspects of these disorders.

METHODS

Search on Medline & PsycINFO, review of websites, screening of bibliographies of articles and book chapters.

RESULTS

There is still no consensus on the definition of these disorders, which cover a wide range of severity. Affected adolescents often suffer from physical and psychological problems owing to co-morbidity or as a consequence of their eating patterns: chronic constipation, dyspeptic symptoms, nausea, abdominal pain, fatigue, headaches, hypotension, menstrual dysfunction as well as dysthymia, depressive and anxiety disorders, or substance misuse and abuse. In comparison with those who are unaffected, adolescents with partial ED are at higher risk of evolving into full ED. However, most of them evolve into spontaneous remission. Adolescents with partial ED engaged, over a period of several months, in potentially unhealthy weight-control practices, suffering from intense fear of gaining weight and a disturbed body weight/image should be offered therapeutic support.

CONCLUSION

Future research should focus on the exact delineation of various subtypes of clinical presentations in partial ED and on evidence-based treatment and follow-up of these various situations.

Eating disorders in Asian populations: a critique of current approaches to the study of culture, ethnicity, and eating disorders

There is increasing evidence that eating disorders are present among ethnically diverse populations, and researchers have suggested that investigations in this area may inform the field's understanding of how sociocultural factors are related to the development of eating disorders. Although it is generally accepted that sociocultural factors are key in eating disorder etiology, knowledge on how best to study these influences in diverse groups is still limited. In this article, the authors review how the research literature has explored relationships among culture, ethnicity, and eating disorders in Asian populations and critically examine strategies that have been used to investigate these issues across 1 ethnic/racial group. The methodological challenges encountered in these approaches are identified and considered in the provision of recommendations for future endeavors to improve the field's understanding of how culture is related to eating disorders.

A preliminary study of EAT and BITE scores for one school year in Bermuda: increased early anorexic measures related to socio-economic factors

BACKGROUND

Bermuda is a unique heterogeneous ethnic population in which it is possible to study the interaction of ethnicity, culture, gender and economic factors that influence abnormal eating attitudes.

METHOD

A cross-sectional survey of 836 adolescents, one total school year in Bermuda. The BITE and EAT self-report questionnaires were administered in a classroom setting. The analysis was for caseness and for total scores. Caseness represents possible developing anorexic or bulimic eating disorder pathology for this non-adult population.

RESULTS

7.3% fulfilled EAT caseness, 0.24% fulfilled BITE caseness. There was no gender or ethnic difference for caseness. Multivariate analysis for EAT caseness found Odds Ratios of 2.89 (95% CI 1.37, 6.11) for Manual maternal job status.

CONCLUSION

Despite the limitation of a questionnaire analysis, lower socioeconomic status increases the risk of possible eating disorder pathology in this adolescent population. Developing anorexic eating attitudes were more prevalent compared to bulimic attitudes for schoolchildren in this unique cultural setting.

Disordered eating attitudes: an emerging health problem among Mediterranean adolescents

Aim of the present study was to investigate eating attitudes in a group of Mediterranean high school students. One hundred and twenty high school students participated in this survey. The Eating Attitudes Test (EAT-26) was used for evaluating symptoms and attitudes associated with disordered eating. Body composition and dietary intake were also assessed. Using the cut-off point of 20 in the total EAT, 13 females (20.3%) and 4 males (7.3%) exhibited disordered eating behavior. Overweight students had significantly higher scores in the dieting scale than those in the normal BMI range. Percent fat mass was positively related to the total EAT (r=0.326, p<0.001) and the dieting scale (r=0.489, p<0.001). Waist/hip ratio was negatively related to total EAT and its scales. In conclusion, a significant percentage of students in this urban Mediterranean adolescent population found to have abnormal eating attitudes. This finding may be partly explained by the effect of cultural transition.

The Sociocultural Internalization of Appearance Questionnaire - Adolescents (SIAQ-A): psychometric analysis and normative data for three countries

A brief measure of internalization of societal norms regarding appearance was developed and validated on six early adolescent female samples (mean ages 11.7-13.3) from three countries (US, Australia, India; total n = 2210). Internal consistency levels were uniformly high in all samples, ranging from 0.83 to 0.92. Convergent validity estimates were high in all samples. Level of internalization was significantly positively correlated with levels of body dissatisfaction and restriction for all samples. Internalization was also significantly positively correlated with bulimic behaviors and negatively correlated with levels of self-esteem for the four samples that included these variables. The findings indicate that the Sociocultural Internalization of Appearance Questionnaire - Adolescents (SIAQ-A) may be used to further explore a media influence cross-culturally, allowing for the investigation of the role of internalization as a potential risk factor for body image problems and eating disturbances in different contexts.

Review of the prevalence and incidence of eating disorders

OBJECTIVE

To review the literature on the incidence and prevalence of eating disorders.

METHODS

We searched Medline using several key terms relating to epidemiology and eating disorders and we checked the reference lists of the articles that we found. Special attention has been paid to methodologic problems affecting the selection of populations under study and the identification of cases.

RESULTS

An average prevalence rate for anorexia nervosa of 0.3% was found for young females. The prevalence rates for bulimia nervosa were 1% and 0.1% for young women and young men, respectively. The estimated prevalence of binge eating disorder is at least 1%. The incidence of anorexia nervosa is 8 cases per 100,000 population per year and the incidence of bulimia nervosa is 12 cases per 100,000 population per year. The incidence of anorexia nervosa increased over the past century, until the 1970s.

DISCUSSION

Only a minority of people who meet stringent diagnostic criteria for eating disorders are seen in mental health care.

Prevalence of bulimic behaviours and eating attitudes in schoolgirls from Trinidad and Barbados

We investigated eating attitudes and the prevalence of bulimic disorders in a group of 362 schoolgirls from the islands of Trinidad and Barbados using key questions from the Bulimia Investigatory Test, Edinburgh (BITE) and additional questions for the exploration of eating attitudes and dieting practices. A random sample of 92 girls were interviewed using the DSM-III-R Bulimia Diagnostic Interview. Only three subjects (0.8%) scored over the cut-off point on the BITE. None of the interviewees was diagnosed as having bulimia nervosa. Two hundred and forty-five girls (67.7%) reported being terrified of becoming fat and fat-fear was associated with higher Body Mass Index, dieting and exercising for losing weight. Girls of African origin were found to have a more unusual eating pattern and more concerns about their eating habits. The prevalence of bulimic disorders in Caribbean schoolgirls is still very low, but they are a population at increasing risk since they share the western ideals of slimness and engage in dieting behaviours.

A survey of anorexia nervosa using the Arabic version of the EAT-26 and "gold standard" interviews among Omani adolescents

OBJECTIVE

The purpose of this study was to assess the validity of the Eating Attitude Test (EAT) in identifying the presence and severity of eating pathology in male and female Omani urban adolescents and to establish cut-off scores that matched those of anorexia identified by gold standard interviews without fear of fatness criteria.

METHODS

Both females (n=126) and males (n=136) were screened using the Arabic version of the EAT-26 and interviewed using a semi-structured, Composite International Diagnostic Interview (CIDI) in order to investigate the relationship between false positives and false negatives at various EAT-26 cut-off points. A receiver operating characteristics (ROC) curve was calculated to discriminate the power of the EAT-26 for every possible threshold score.

RESULTS

The EAT-26 identified 29% of the subjects as probable anorexic cases as against 9.5% identified during the structured interview based on the anorexia gold standard (32% males and 68% females). The sensitivity and specificity of the EAT-26 were respectively 24% and 69.6%. When using the ROC curve, a cut-off score of 10 gave the best compromise between sensitivity (64%) and specificity (38%).

DISCUSSION

Although the EAT-26 is the most widely used screening instrument in cross-cultural studies, it does not appear to be reliable in identifying probable cases of anorexia among Omani adolescents. The use of a gold standard interview without fat phobia criteria indicated that the rate of anorexia nervosa may be more prevalent among males than previously estimated. This intriguingly high preponderance of males is discussed in terms of prevailing demographic trends in Oman.

An exploration of eating disorders in a Georgian sample

BACKGROUND

There is debate as to whether eating disorders may be culture-bound. However, accumulating evidence suggests that eating disorders may be found outside of the West, although the precise form of the eating disorder may differ.

AIMS

There were two aims of this study: (1) to translate and establish the psychometric properties of standard questionnaires to measure eating pathology in a Georgian sample; (2) to use these measures to determine whether cases of eating disorders exist in Georgia.

METHODS

We held focus groups of various health professionals to establish how eating disorders present in Georgia and to identify groups perceived to be at high risk of having an eating disorder. We obtained translated versions of a number of standardized questionnaires (measuring eating and general psychopathology) from 245 women from these identified high risk groups and a subsample were given a structured clinical interview.

RESULTS

We estimated from the responses to the questionnaires, that as many as 5% may have clinically significant bulimia nervosa, 7% fell in the weight range for anorexia nervosa with a further 7% in the weight range for obesity. We interviewed a sample of the high scoring group which confirmed the presence of clinically significant eating pathology in the majority of those identified as possible cases.

CONCLUSIONS

The results of this study suggest there may be women in Georgia with significant eating problems.

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.

Presence and severity of anorexia and bulimia among male and female Omani and non-Omani adolescents

OBJECTIVE

The population of Oman is a heterogeneous mix of nationalities providing a natural setting for studying the cross-cultural differences in the presence and severity of eating disorders as well as an opportunity for evaluating the performance of measurement instruments for these disorders.

METHOD

Disordered eating screening instruments (the Eating Attitude Test and the Bulimic Investigatory Test) were administered to Omani teenagers, non-Omani teenagers, and Omani adults.

RESULTS

On the Eating Attitude Test, 33% of Omani teenagers (29.4% females and 36.4% males) and 9% of non-Omani teenagers (7.5% of males and 10.6% females) showed a propensity for anorexic-like behavior. On the Bulimic Investigatory Test, 12.3% of Omani teenagers showed a propensity for binge eating or bulimia (13.7% females and 10.9% males). Among the non-Omani teenagers, 18.4% showed a tendency toward bulimia, with females showing a slightly greater tendency than males. In contrast, barely 2% of Omani adults showed either a presence of or a severity of disorderly behavior with food.

CONCLUSION

Omani teenagers scored significantly higher than other ethnic groups and Omani adults. This finding is discussed in the light of emerging evidence from many parts of the world suggesting that cultural transition, compounded by demographic constraints, plays a significant role in abnormal eating attitudes.

An ethnic comparison of eating attitudes and associated body image concerns in adolescent South African schoolgirls

OBJECTIVE

The purpose of this study was to investigate whether differences exist in eating attitudes and body shape concerns amongst adolescent schoolgirls representing South Africa's ethnically and culturally diverse population currently undergoing epidemiological transition.

METHOD

A questionnaire survey, including the Eating Attitudes Test, Body Shape Questionnaire and a Body Silhouette Chart, was administered to 228 South African schoolgirls (60 black, 83 mixed race and 85 white) aged 15-18 years from five secondary schools in the greater Cape Town area.

RESULTS

Black girls had significantly higher mean BMI values (24.1 (3.3)) than either white (21.9 (3.0)) or mixed race girls (22.1 (3.7)) (P < 0.05). Controlling for differences in BMI, white subjects scored significantly higher on the Body Shape Questionnaire than did mixed race or black subjects, whereas no ethnic differences were found for Eating Attitude Test scores. A comparable percentage (mean = 18.8%) of black, mixed race and white girls had scores indicative of eating disorder pathology on the Eating Attitudes Test, while a higher percentage of white, compared to mixed race and black, girls had abnormal scores on the Body Shape Questionnaire (33%, 26% and 20%, respectively; P < 0.05). The ideal body size desired by white girls was significantly smaller than that of the mixed race or black samples. Dissatisfaction with present body size was significantly higher in white, compared to black or mixed race girls (P < 0.001).

CONCLUSION

These findings suggest that the prevalence of abnormal eating attitudes is equally common in South African schoolgirls from different ethnic backgrounds. White girls exhibit greater body image concerns and body image dissatisfaction than mixed race or black individuals. These findings reinforce the notion that eating disorders are culture-reactive rather than culture-bound phenomena and provide insight into the extent of eating-related problems and body image issues in developing societies.

Weight-related body image concerns among 18-24-year-old women in Canada and India: an empirical comparative study

OBJECTIVE

Sociocultural factors are important in the pathogenesis of eating disorders. We examined some core (DSM IV) features of eating disorders, i.e., drive for thinness and dissatisfaction with the weight of the abdomen, hips, and thighs among women in Canada and India.

METHODS

A total of 65 Canadian (mean+/-S.D. age: 21.4+/-2.0 years) and 47 Indian (mean+/-S.D. age: 18.7+/-4.1 years) women completed the Drive for Thinness (DT) and Body Dissatisfaction (BD) subscales of the Eating Disorder Inventory (EDI) and in addition rated the degree to which they believed all major regions of their body were overweight.

RESULTS

After the effects of body mass index (BMI) were partialled out statistically, the DT (EDI) and BD (EDI) scores were not significantly different between the two countries. In both groups, concerns about the weight of the abdomen, hips, thighs, and legs loaded on a factor that essentially described the 'body dissatisfaction' construct. After the effects of BMI were partialled out, however, the factor scores from this factor correlated with BD (EDI) in the Canadian but not the Indian sample.

DISCUSSION

In contrast to the Canadian women, the Indian women did not overestimate the 'fatness' of their abdomen, hips, thighs, and legs. Among the Indian women, concerns about the weight of the upper torso (i.e., face, neck, shoulders, and chest) emerged as a distinct body image construct. In conclusion, after the effect of BMI was controlled for statistically, the Canadian and Indian women scored similarly on some of the core features of eating disorders, as measured by the DT (EDI) and BD (EDI) subscales, however, the nature of the underlying body image construct was different between the two groups.

Cross-Cultural Research on Anorexia Nervosa: Assumptions Regarding the Role of Body Weight

OBJECTIVE

To critically examine two assumptions guiding cross-cultural research on the weight concerns of anorexia nervosa: (1) that weight concerns are specific to contemporary, Western manifestations of the disorder and (2) that the dissemination of Western values regarding thinness is primarily responsible for the development of anorexia nervosa in non-Western contexts.

METHOD

A review of theoretical and empirical literature on cross-cultural aspects of anorexia nervosa and the medical records of 14 Asian patients treated for eating disorders in Sydney, Australia.

RESULTS AND DISCUSSION

Regarding the first assumption: It is argued that weight concerns when defined as weight loss that is positively valued (rather than a fat phobia) is a defining characteristic of anorexia nervosa and is not limited to contemporary, Western cases of the disorder. Regarding the second assumption: It is argued that the occurrence of anorexia nervosa in non-Western contexts cannot be solely attributed to the acceptance of Western thinness ideals because values and practices intrinsic to non-Western cultures are also likely to be etiologically relevant.

The eating attitudes test: twenty-five years later

This manuscript reviews the literature involved with the Eating Attitudes Test (EAT), first developed in the late 1970s as a self-report, indicative of the symptoms of eating disorders. The EAT has good psychometric properties of reliability and validity, and reasonable sensitivity and specificity for the eating disorders, but very low positive predictive value because eating disorders are relatively uncommon. In addition they exist on a continuum, because of denial and social desirability, the results of a self-report instrument may be affected. A very large literature has documented the use of the EAT in a variety of cultures. It is used to screen eating disturbances in general as the first part of a two-part diagnostic screen, as an ability to compare across groups and to measure change between groups and over time.

Culture and eating disorders: a historical and cross-cultural review

Cultural beliefs and attitudes have been identified as significant contributing factors in the development of eating disorders. Rates of these disorders appear to vary among different racial/ethnic and national groups, and they also change across time as cultures evolve. Eating disorders are, in fact, more prevalent within various cultural groups than previously recognized, both within American ethnic minorities and those in other countries. This review examines evidence for the role of culture as an etiological factor for the development of eating disorders. Historical and cross-cultural experiences suggest that cultural change itself may be associated with increased vulnerability to eating disorders, especially when values about physical aesthetics are involved. Such change may occur across time within a given society, or on an individual level, as when an immigrant moves into a new culture. Further research into the cultural factors that promote the development of eating disorders is much needed. Understanding how cultural forces contribute to the development of disorders is needed so that preventive interventions can be created.

A cross-cultural study of parental conflict and eating disorders in a non-clinical sample

Previous British studies have found that EAT scores of second generation British Asian schoolgirls are higher than those of White schoolgirls (Furnham & Husain, 1999; McCourt & Waller, 1995; Mumford et al., 1991), and that these scores are positively associated with parental over-protection (Furnham & Hussain, 1999). This study looked at the relationship between parental conflict and parental overprotection and EAT scores in three cultures. The three groups, all of late adolescent females, were British Caucasians (N=116), immigrant British Asians from Pakistan (N= 118), and Pakistanis tested in Pakistan (N=114). A 22 item conflict questionnaire was constructed and administered to 355 participants, along with the PBI, EAT-26, and Body Shape Belief Scale (BSBS). It was predicted that the British Asians would have higher EAT, parental protection and conflict scores than the other two groups. It was also predicted that EAT scores would be highly correlated with conflict scores. All hypotheses were supported, and over-protection scores were noticeably highest in the British Asian group. They also had a significant amount of more conflict with parents than any of the other cultural groups. EAT scores were associated with conflict and over-protection. Results are discussed in terms of the literature in the field.

Disordered eating in three communities of China: a comparative study of female high school students in hong kong, Shenzhen, and rural hunan

OBJECTIVE

To examine disordered eating and its psychological correlates among female high school students in three Chinese communities that lay on a gradient of socioeconomic development in China.

METHOD

796 Chinese students from Hong Kong, Shenzhen, and rural Hunan completed a demographic and weight data sheet, the Eating Attitudes Test (EAT-26), a Body Dissatisfaction Scale (BDS), the Beck Depression Inventory (BDI), and the Rosenberg Self-Esteem Scale (RSES).

RESULTS

Compared to students in Hunan and to a lesser extent students in Shenzhen, students from Hong Kong were slimmer, but desired a lower body mass index (BMI), reported more body dissatisfaction, exhibited a more typical EAT-26 factor structure, scored higher on the "fat concern and dieting" factor, and constituted more EAT-26 high scorers. Multiple regression analyses indicated that BDS was the most significant predictor of fat concern at each site, but this effect was strongest in Hong Kong. Hunan students had significantly higher BDI scores but lower fat concern than Shenzhen and Hong Kong students.

DISCUSSION

The consistent gradient of fat concern across the three communities gives credence to the view that societal modernization fosters disordered eating in women, possibly via the gendered social constraints that accompany it. It is also expressive of the marked socioeconomic heterogeneity within China nowadays. The predictable rising rate of eating disorders that follows global change will pose a growing public health challenge to Asian countries.

Effect of Western culture on women's attitudes to eating and perceptions of body shape

OBJECTIVE

The current study investigated the effect of culture on two factors implicated in the development of eating disorders, negative attitudes toward eating and dissatisfaction with body shape.

METHOD

Hong Kong-born and Australian-born women from two Australian universities were surveyed using the Eating Attitudes Test (EAT) and the Figure Rating Scale (FRS).

RESULTS

Results showed no difference between the groups in eating attitudes, but significant differences in body shape perceptions, with the Australian-born reporting greater dissatisfaction. Hong Kong-born subjects were separated into two groups based on their level of Chinese identity (Western acculturized and traditional). Their EAT and FRS scores were compared to the Australian-born, with Western acculturized Hong Kong-born subjects reporting significantly lower EAT and FRS scores than the Australian-born, whereas the more traditional Hong Kong-born subjects reported equivalent scores.

DISCUSSION

Main implications center around the need for a cross-culturally sensitive definition of eating disorders, the effect of level of ethnic identity on eating attitudes and body image, and the importance of developing culturally appropriate measures.

Eating problems in female Japanese high school students: a prevalence study

OBJECTIVES

This study was conducted to estimate the prevalence of eating problems and to identify factors associated with the eating problems among Japanese high school girls.

METHODS

This study used a cross-sectional design. The study population was 3,032 female students attending three high schools in Fukushima, Japan. The 26-item version of the Eating Attitudes Test (EAT-26) was administered to assess eating problems. Inquiries were also made regarding possible risk factors for the eating problems.

RESULTS

Of the 2,685 subjects, 5.4% had a total EAT-26 score above the cutoff point (20 < or =). Logistic regression analysis demonstrated that older age, higher body mass index, a distorted body image, obsessive-compulsive tendency, and some familial issues were independently related to the eating problems.

DISCUSSION

The prevalence of eating problems in the Japanese female population was low compared with reports from Western countries. In addition, distorted body image was suggested to have the greatest influence on eating problems.

Eating disorders in Japan: finding the right context

Eating disorders have traditionally been described as a typically 'Western' illness. Cases that occur outside Western countries are often regarded as atypical. Peculiarities are thus emphasized. However, eating disorders are now prevalent in Japan, among non-Western immigrants in Europe, and in other societies. The author focuses on the universality of the background of eating disorders and looks at them as 'culture change syndromes'. Change in the family and in women's roles are the central themes. The majority of the subjects experienced very little emotional relationship with their parents when they were children. It is misleading to say that eating disorder patients lack femininity and that they should be encouraged to be more feminine, more passive. Gender issues concerning treatment settings such as the doctor-patient relationship, the doctor-nurse relationship influence the treatment process. Typical anorexics described in a 1788 Japanese document are briefly presented in order to challenge further the idea of eating disorders as a Western illness.

Intraethnic comparison of eating attitudes in native Koreans and Korean Americans using a Korean translation of the eating attitudes test

Although Asian samples have been studied using the Eating Attitudes Test (EAT-26), the literature lacks data on Korean samples. Furthermore, although cross-cultural studies of eating disorders have been done, intraethnic studies are lacking. This study concerns an intraethnic Korean comparison of eating attitudes. The EAT-26 was translated into Korean and validated by back-translation and by a preliminary study on 32 bilingual (Korean and English-speaking) Korean women. The validated Korean translation was completed by a sample of 195 native South Koreans (NKs) and the original version by a sample of 39 Korean Americans (KAs). EAT-26 scores seemed to indicate that the NKs had more disordered eating attitudes. Furthermore, the KAs appear to be a low-risk sample for eating disorders. Implications for further research are discussed.