Can cognitive dissonance methods developed in the West for combatting the 'thin ideal' help slow the rapidly increasing prevalence of eating disorders in non-Western cultures?

"I was bullied for being fat in every situation, in every outfit, at every celebration": A qualitative exploratory study on experiences of weight-based oppression in Qatar

Introduction

Weight-based oppression (WBO) has been documented as a widespread phenomenon in Western countries and is associated with a range of psychological, physiological, and behavioral harms. Research on weight-based oppression is largely absent from the Arab region.

Methods

We conducted a qualitative exploratory study using semi-structured in-depth interviews to examine the internalized attitudes, values, and beliefs related to body weight, and experiences of external weight-based oppression of 29 staff, faculty, and students at Qatar University.

Results

Thematic analysis revealed six major themes on the characteristics of internalized WBO, and the nature, timing, source, extent, and impact of external WBO. WBO was regarded as so common in the Arab culture as to be normative, with damaging exposure to WBO beginning in early childhood.

Conclusion

WBO in the Arab region is an important and unrecognized public health issue. Programs to reduce WBO should be developed in all sectors.

Adapting the body project to a non-western culture: a dissonance-based eating disorders prevention program for Saudi women

PURPOSE

The main aim of this study was to test the feasibility of an adapted version of the Body Project for young Saudi women as their eating and body issues are comparable to western culture and linked to internalization of westernization. The study also aims to assess predictors of attrition and preliminary effectiveness.

METHOD

The intervention was adapted to local culture in collaboration with a co-director of the Body Project Collaborative. 48 Saudi undergraduate females were recruited, mean age was 19.16 years (SD = 1.23), baseline BMI was (M = 24.42, SD = 5.46). Eating pathology, body image, and comorbidities were assessed pre and post the intervention with adapted self-report measures.

RESULTS

The Body Project is feasible for young Saudi women. Participants were willing to enrol, they found the intervention useful, understandable, and enjoyable. There was no difference between completers and non-completers. The preliminary effect sizes are similar or higher than other effectiveness trials in other cultures.

CONCLUSION

A cognitive dissonance-based eating disorders prevention can be applicable across cultures where westernization is an influence. The effectiveness is yet to be affirmed. Future research is needed to investigate effectiveness in further robust studies and a bigger sample.

EVIDENCE-BASED MEDICINE

Level IV (evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

'Dove Confident Me Indonesia: Single Session': study protocol for a randomised controlled trial to evaluate a school-based body image intervention among Indonesian adolescents

Background

Due to the prevalence and associated adverse health consequences of negative body image among adolescents globally, there is a need to develop acceptable, effective, and scalable interventions. School-based body image interventions delivered by trained teachers show promise in reducing negative body image in adolescents. However, there is currently a lack of evidenced-based body image interventions for use in low- and middle-income countries (LMICs). This paper outlines a protocol for the development and evaluation of Dove Confident Me Indonesia: Single Session, a single-session, teacher-led body image intervention for Indonesian adolescents.

Method

The effectiveness of the intervention will be evaluated using a cluster randomised controlled trial design. Due to the COVID-19 pandemic, the trial will be conducted online. Trained teachers or school guidance counsellors will deliver the intervention. Self-report questionnaires will be collected at three time points: baseline, post-intervention, and two-month follow-up. The primary outcome is body esteem. Secondary outcomes are internalisation of appearance ideals, mood, engagement in life activities, tendency to engage in appearance comparisons, and skin shade satisfaction. A minimum of 1000 participants will provide 95% power to detect small-to-medium intervention effects. To account for attrition and potential internet issues, the sample will comprise of 2000 Indonesian adolescents in grades 7–9, attending state junior high schools in Surabaya, East Java. Quantitative and qualitative data on acceptability of the intervention will also be collected from teachers and students. Additionally, fidelity of lesson implementation will be assessed. This project received ethical approval from the Universitas Indonesia and the University of the West of England. The intervention will be disseminated in junior high schools throughout Indonesia via UNICEF’s Life Skills Education (LSE) programme, which will be freely available for teachers to download.

Discussion

This paper presents Dove Confident Me Indonesia: Single Session, a culturally adapted school-based intervention designed to improve Indonesian adolescents’ body image. It details the plan for evaluation, highlighting the strengths and limitations of the proposed study design. It will be informative for others aiming to adapt evidence-based school curricula to promote well-being among adolescents in LMICs.

Trial registration

NCT04665557. Registered 11th December 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11770-0.

Bonding With Parents, Body Image, and Sociocultural Attitudes Toward Appearance as Predictors of Eating Disorders Among Young Girls

A more holistic approach to treatment and prevention focuses on identifying the multiple risk and protective factors for eating disorders. However, there is a lack of research verifying the nature of the relationship between patterns of bonding with parents, sociocultural attitudes toward appearance, body image, and their role in developing or preventing eating disorders. The main aim of the study was to verify whether there is a specific set of risk or/vs. protective factors/measures for behaviors and dispositions related to the development of eating disorders. The study group consisted of 134 young Polish females (M = 14.92; SD = 1.349), with an average body mass index. The variables were measured using the Parental Bonding Instrument, the Sociocultural Attitudes Toward Appearance Questionnaire-3, The Multidimensional Body-Self Relations Questionnaire, and the Eating Disorder Inventory 3. Stepwise regression analysis was applied. Statistical analysis showed that bonding with parents (including maternal overprotection), body image (including overweight pre-occupation, fitness evaluation, health orientation, and self-classified weight), and sociocultural attitudes toward appearance (such as searching for information, pressures, and internalization) are predictors of eating disorder risks. On the other hand, maternal and paternal care (aspects of patterns of bonding with parents), positive fitness evaluation, positive appearance evaluation, and satisfaction with one's body were found to be the most significant protective factors. The results may improve prevention and intervention aimed at increasing protective factors.

The Associations Between Breastfeeding Duration and Body Dissatisfaction, Ethnicity, and Obesity Among Mexican Women, a Cross-Sectional Study, ENSANUT 2012

Introduction: Body image dissatisfaction (BID) has been inversely associated with breastfeeding initiation particularly among women with obesity. However, less is known on BID and the association with maintaining breastfeeding in Mexico, where breastfeeding rate is decreasing across ethnic subgroups. Therefore, we explore this gap of knowledge in diverse ethnic subgroups across levels of maternal weight status. Methods: Data were derived from the Mexican National Health and Nutrition Survey (Encuesta Nacional de Salud y Nutrición [ENSANUT] 2012), and 10,466 women aged 20-49 years were included. Breastfeeding (<6 months versus ≥6 months) of the last child, BID (Stunkard Figure Rating Scale), anthropometric (body mass index, BMI), sociodemographics, and biological variables were collected. Crude and adjusted target associations and effect modifiers were assessed using weighted-logistic regression models. Results: Overall, 72.4% of ever breastfeeding mothers breastfed a minimum of 6 months, 22% were indigenous, 74% were dissatisfied with their body image (BID >0), and 37% had obesity (BMI ≥30 kg/m²). In the multivariable analysis, for each one-unit increase in the BID score, the adjusted odds of breastfeeding (≥6 months) decreased by 6% (odds ratio [OR] = 0.94, 95% confidence interval [CI]: 0.89-0.99). After stratifications, only among women with obesity, a greater BID score was associated with lower odds of breastfeeding duration by 24% (OR = 0.76, 95% CI: 0.64-0.89) in indigenous and by 10% (OR = 0.90, 95% CI: 0.82-0.98) in non-indigenous women. Conclusions: Mexican women with a higher BID score reported lower odds of breastfeeding duration (≥6 months). Body image concerns should be integrated into a health promotion curriculum to mitigate their negative effect particularly in certain segments of the populations, such as women with obesity and among indigenous women.

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.

Understanding the healthcare experiences and needs of African immigrants in the United States: a scoping review

BACKGROUND

Africans immigrants in the United States are the least-studied immigrant group, despite the research and policy efforts to address health disparities within immigrant communities. Although their healthcare experiences and needs are unique, they are often included in the "black" category, along with other phenotypically-similar groups. This process makes utilizing research data to make critical healthcare decisions specifically targeting African immigrants, difficult. The purpose of this Scoping Review was to examine extant information about African immigrant health in the U.S., in order to develop lines of inquiry using the identified knowledge-gaps.

METHODS

Literature published in the English language between 1980 and 2016 were reviewed in five stages: (1) identification of the question and (b) relevant studies, (c) screening, (d) data extraction and synthesis, and (e) results. Databases used included EBSCO, ProQuest, PubMed, and Google Scholar (hand-search). The articles were reviewed according to title and abstract, and studies deemed relevant were reviewed as full-text articles. Data was extracted from the selected articles using the inductive approach, which was based on the comprehensive reading and interpretive analysis of the organically emerging themes. Finally, the results from the selected articles were presented in a narrative format.

RESULTS

Culture, religion, and spirituality were identified as intertwined key contributors to the healthcare experiences of African immigrants. In addition, lack of culturally-competent healthcare, distrust, and complexity, of the U.S. health system, and the exorbitant cost of care, were identified as major healthcare access barriers.

CONCLUSION

Knowledge about African immigrant health in the U.S. is scarce, with available literature mainly focusing on databases, which make it difficult to identify African immigrants. To our knowledge, this is the first Scoping Review pertaining to the healthcare experiences and needs of African immigrants in the U.S.

"Our daily life was mainly comprised of eating and sitting:" a qualitative analysis of adolescents' experiences of inpatient eating disorder treatment in China

BACKGROUND

Some individuals with Eating Disorders (EDs) require hospitalization to stabilize and improve life-threatening physical complications. The experiences of those receiving inpatient treatment for EDs are well-documented in western samples, but less is known about the experiences of those in China, the world's most populous country in which the incidence of EDs may be increasing.

METHODS

This qualitative study aimed to use Interpretative Phenomenological Analysis to understand the experiences of four adolescents receiving inpatient treatment for EDs in China. Individual, semi-structured interviews were conducted.

RESULTS

Four themes emerged from the data: perceptions of the treatment received, peer influences during admission, the impact of treatment on wellbeing and participants' sense of self.

CONCLUSIONS

This is the first published study on the experience of Chinese participants with EDs. Their experiences share commonalities with those reported by participants in Western studies and also illuminate differences in how EDs are understood and managed in inpatient settings in China. Cross-cultural collaborations will be important to share knowledge and practice.

Eating symptomatology and general psychopathology in patients with anorexia nervosa from China, UK and Spain: A cross-cultural study examining the role of social attitudes

Cultural studies exploring differences in the manifestation of anorexia nervosa (AN) have primarily focus on Western and non-Western cultures. However, no study so far has considered the role that social attitudes (i.e. Collectivist vs. Individualist cultural values) have in the clinical manifestations of eating disorders, including AN patients. With this in mind, the aim of this study is to compare eating and general psychopathology in a large sample of individuals diagnosed with AN from China, Spain, and United Kingdom (UK), in order to study the differences according to belonging to Western or non-Western country, or the country's Individualist Index (IDV). The total sample comprised on 544 adults with a diagnosis of AN recruited from People´s Republic of China (n = 72), UK (n = 117), and Spain (n = 355). Assessment measures included the Eating Disorders Inventory and the Symptom Checklist-90-Revised. Our results show significant differences in most of the eating and psychopathological indices between the three countries. Patients from Western societies (Spain and UK) share more similarities regarding psychopathological expression of AN than the non-Western country (China). While Western countries show higher levels of body dissatisfaction, somatization and overall psychopathology, Chinese patients tend to deny or minimize depression, anxiety and other psychopathological symptoms. Besides, the IDV shows cultural differences in the interpersonal sensitivity scale, being AN patients from UK (the more individualistic society) who presented with higher levels of interpersonal sensitivity (i.e. discomfort during interpersonal interactions and more negative expectations concerning interpersonal behavior). In conclusion, our findings suggest that psychopathological expression of AN is better explained by Western/Eastern influence than by individualist/collectivist values. Although the diagnosis for the eating disorder may be the same, differences in the psychopathology comorbid to the eating disorders may suggest the need for treatments to be modified according to the culture.

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.