Eating disorders across cultures

PSYCHIATRIC DISORDERS

Eating disorders acrossculturesMervat Nasser

AbstractThe cultivation of the body ideal and promotion of thinness values in

fashion, media and the diet industry have been repeatedly shown to

account for the increased prevalence of eating disorders. It is evident in

women in certain sub-cultures where the demand for thinness for career

advancement is endemic. There is also a correlation between eating disor-

ders and the level of modernization and urbanization characteristic of

western industrialized societies, linking it to increased social mobility,

dietary changes as well as changes within family structures. Eating disor-

ders were, therefore, thought to be unique to the ‘western culture’, an

impression that was initially substantiated by the apparent absence of

these disorders in non-western societies. However, the notion of the

culture specificity of eating disorders began to be challenged following

reports from different parts of the world when eating disorders emerged

in non-western societies. This was believed at first to be a product of

a simple identification with western cultural norms in this respect.

However, ‘westernization’ was too simplistic and needed to be broken

down to see the forces that may lie behind it. These included increased

consumerism, shift from collectivist to individualist patterns, changing

gender roles and increased alienation of the individual. Subsequently,

the individual was forced to resort to the ‘body’ as a new medium for

expressing this cultural confusion and distress. Eating disorders are an

example of such socio-pathology and needs to be seen now as a marker

of ‘transition’ and symptomatic of cultures caught in a process of change.

Keywords body language; body medium; changing gender roles;

consumerism; cultural distress; culture transition; dietary changes; diet

industry; eating disorders; endemic thinness; individual alienation;

media; social mobility; urbanization

Eating disorders: the evolution of the socio-cultural model

Starvation, vomiting and purging following binging, are all self-

inflicted body regulatory mechanisms that collectively came to

be known as eating disorders. This term encompasses its two

extremes anorexia and bulimia and all that lie between, a spec-

trum of weight/shape-focused behaviours of varying degrees of

morbidity.

Eating disorders are considered unique among psychiatric

disorders in the degree to which social and cultural factors

influence their epidemiology and development. The nature of the

eating-disorder syndrome and the fact that it clearly merges with

the prevalent and the culturally acceptable behaviour of dieting

called for an interpretation that that is grounded in the culture we

Mervat Nasser MD MPhil FRCPsych is a Consultant Psychiatrist and visiting

Senior Research Fellow at the Institute of Psychiatry (KCL), London, UK.

Conflicts of interest: none declared.

PSYCHIATRY 8:9 34

live in. The phenomenon was therefore (understandably) linked

to the cultivation of a certain type of body ideal and the

promotion of thinness values through media, fashion and the diet

industry. Subclinical cases or partial syndrome that merge with

normal dieting behaviour were generally estimated to be five

times more common than the full-blown syndromes, a finding

that was consistent with the ‘spectrum hypothesis’ of eating

disorders and ran parallel to reported steady increase in the rate

of their occurrence in the latter half of the twentieth century.

The socio-cultural model of eating disorders was further

supported by the susceptibility of certain sub-cultural groups to

develop these disorders, such as dancers, models and athletes

where the demand for thinness is endemic. This epidemiological

research has also shown a clear and consistent ‘gender bias’

where women were found to be ten times more at risk for such

disorders than men. This skewed distribution, made feminist

theorists see these disorders as metaphorical of the ‘modern

woman’s dilemma’ being torn between a desire to conform to old

traditional stereotypes of womanhood and new values related to

what the modern woman’s ought to be. This sense of ‘gender

ambivalence’ was noted to be felt by women, particularly at

times of historical and cultural change. Even among the small

proportion of men who develop such disorders, a dispropor-

tionate number of them also have doubts or uncertainties about

their gender identity.

Another finding that emerged in the 1990s was the apparent

increase in the prevalence of eating disorders in proportion to the

level of ‘urbanization’ in any given society. This was explained

on the basis of social mobility and changes within family struc-

ture with a tendency towards nuclearization. Also, as cities

urbanize, eating patterns, food preferences and meal times seem

to change, with the inevitable rise in the rates of obesity and

a subsequent increase in weight consciousness and disordered

patterns of eating.

So, within this framework, cultural, subcultural and inter-

cultural risks in the pathogenesis of eating disorders are easily

discernable. However, one of the most important aspects of the

socio-cultural argument has always been the apparent trans-

cultural variation whereby these disorders have been considered

rare or, indeed absent, in non-western societies (Box 1). This

made some regard eating disorders as a phenomenon unique to

western culture.

Eating disorders: from ‘western’ disorder to global phenomenon

The culture specificity of eating psychopathology to western

culture was initially based on an ‘epidemiologic evidence’, i.e. the

absence of sufficient published data to confirm their occurrence

in non-western cultures and societies. This was assumed to

reflect perceived differences in aesthetic standards and gender

role definitions between western and non-western societies. This

perception was, to large extent, rooted in a general tendency to

see non-western cultures as being static, isolated and remote

from forces of change that affected western societies. This was

particularly evident in the case of other women, whose roles

continued to be seen within a restricted framework of the

stereotyped and the traditional.

Notwithstanding the debate about culture and its definitions,

there is now increasing evidence that challenges the notion of the

7 � 2009 Elsevier Ltd. All rights reserved.


western boundedness and shows these disorders to be no longer

confined to one particular culture. Recent research from the

Middle East, the Far East, South America and Africa, all indicate

that eating disorders are now emerging in these societies with

similar or even higher rates to those reported in the West

(Figure 1, Box 2). The majority of this research was modelled on

community surveys carried out in the West where the Eating

Attitude Test Questionnaire (EAT) was the main instrument. The

EAT, is a self-report questionnaire that was originally devised to

elicit abnormalities in eating attitudes and measure a broad range

of symptoms characteristic of anorexia nervosa. Doubts were

understandably raised about the validity of the EAT in different

cultural settings and its susceptibility to cultural misinterpreta-

tion, and yet the EAT proved helpful at least in allowing

preliminary comparisons across cultures.

Percentage of dieting/abnormal eating attitudesworldwide

Countries

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Figure 1

Eating disorders e the socio-cultural model

C Culture specificity: assumed to be bound to ‘western’ culture

C Nature of psychopathology: symbolic of notions of thinness

cherished and promoted by the western culture

C Continuum of morbidity: merges with culturally acceptable

behaviours

C Reported increase over the past 50 years possibly in response

to increased emphasis on the ‘thinness ideal’

C Gender specific: women at risk by reason of gender

ambivalence

C Subcultural variations: more prevalent in dancers, models and

athletes where demand for thinness is endemic.

C Intra-cultural variations: possibly more prevalent in urban than

rural areas

Box 1

PSYCHIATRY 8:9 34

Identification with western norms in relation to body weight

and image was initially offered as an explanation for this

worldwide emergence of eating psychopathology, and in the

majority of these studies a correlation was found between eating

disorders in those societies and the level of their exposure to

western cultural norms in this respect.

The media was considered to play the main role in spreading

this ‘body ideal’ and in homogenizing perceptions worldwide in

this respect.

However, the effect of exposure to western culture combined

with the presence of strong religious values in some populations

and societies proved to be more significant particularly among

the Muslim Asian population in the UK as well as Muslim women

in the Gulf region and Iran. This showed that what is at stake

here is the issue of conflicted cultural values rather than the

simple exposure to different cultural norms.

Another major finding in this respect was the emergence of

eating psychopathology in Eastern Europe following the politico-

economic changes. Eating disorders were largely unreported in

Eastern Europe before the collapse of the communist regimes and

only began to appear in eastern European literature in the

nineties with reported high rates of abnormal eating attitudes in

Hungary, Poland and the Czech Republic. This was largely

attributed to the transition from state-controlled economy to

Countries reporting eating disorders

Argentina*

Australiaþ

Belgium

Brazil*

Canada

Chile

China*

Czech Republic

Denmarkþ

Egypt

France

Germany

Hong Kong*

Hungary

India*

Iranþ,*

Israelþ

Italy

Japan

Mexico*

the Netherlands

New Zealandþ

Nigeria

Norway

Poland

Portugal*

Singapore*

South Africa

(blacks)*

South Africa

(whites)þ

South Korea*

former Soviet

Union

Swedenþ

Switzerlandþ

Turkey*

United Arab

Emirates*

United Kingdomþ

United Statesþ

þ Formal epidemiological studies carried out.

* First reports since 1990.

Reproduced, with permission, from Gordon R. Eating disorders

East and West: a culture-bound syndrome unbound. In: Nasser

et al, eds. Eating disorders and cultures in transition. London:

Brunner-Routledge, 2001. p. 1e24.

Box 2



markets that undermined the collective social structure and

resulted in the disappearance of some of the social networks that

provided women with protection in their education, employment

and childcare rights. This resulted in greater ‘gender ambiva-

lence’ increasing the vulnerability of those women to eating

disorders (Box 2).

Eating disorders: the case of ethnic minority groups

The prevalence studies shown in Figure 1 went hand in hand with

studies of ethnic minorities in USA and UK. An increase in the

prevalence of eating disorders among black, Native Americans

and Hispanic communities in the USA was reported. Similar

results were also obtained among the Asian and the African-

Caribbean immigrant populations in the UK. The Asian pop-

ulation constitutes the largest immigrant population in the UK

and comprises Indians, Pakistanis and Bangladeshis. In the

majority of these studies, more cases of bulimic behaviour were

found among Asian schoolgirls than in their Caucasians

counterparts.

Cultural variations on how ‘Asian’ is defined between the US

and UK suggest that studies of Asian populations in these

countries actually differ in the types of samples they are exam-

ining. In the UK, these investigations typically involve individ-

uals who are ethnically south Asian (i.e. from India, Pakistan,

and Sri Lanka, etc.); in the US, the term ‘Asian American’ refers

to East Asian and South Asian countries. When Asian women

attending American schools in the US were compared with those

in Hong Kong, the former group showed evidence of increased

vulnerability to abnormal eating behaviours. It was argued,

however, that the over-reliance on the ‘fear of fatness’ as

a diagnostic criterion in eating psychopathology could have led

to a general underestimation of the magnitude of these problems

in societies like China, India and Japan.

The authors of these studies linked the susceptibility of the

immigrant population to eating disorders to their high aspirations

and achievement orientation, and more importantly to their

conflict over ‘racial identity’. It was noted that many of them felt

a strong need to correct a negative and traditionally stereotyped

racial image and had a powerful urge to fit into the host society

through conforming to the prevailing ideal of thinness/beauty.

A correlation was found between the level of acculturation

and morbid concern over weight. Dieting behaviour was found to

be equal among black and white females in the USA and

dysfunctional eating patterns were found to be more prevalent in

the African-Caribbean population in Britain than their white

counterparts. The issue of ‘racial identity’ and its relationship to

eating disorders was also studied among black South African

women after the fall of the apartheid regime, where the reported

increase of eating disorders following the political change was

linked to a sense of shifting identity and altered self-conception

among those South African females.

This shows that contrary to all initial assumptions immigrants

could be at a higher risk of developing eating psychopathology

than the native population (see Box 3).

Transitional cultural forces and the issue of acculturative stress

From what has been advanced so far, it is clear that disordered

forms of eating behaviour are grounded in the global culture of

PSYCHIATRY 8:9 34

modernity which characterizes many rapidly urbanizing parts of

the world today. These changes are bound to influence life and

dietary patterns, with a likely increase in the rates of obesity fol-

lowed by weight consciousness and disordered eating patterns.

These behaviours also reflect the tensions and conflicts of the

current cultural transition where a number of deregulatory forces

are in play, including markets and media with their power of

standardizing the aesthetic ideal and the marketing of this ideal

worldwide. Media and information technologies are also great

unifying powers that have the potential to dilute cultural speci-

ficity and undermine national boundaries, thus posing a threat to

cultural identity. Under these transitional circumstances, any

individual who has insufficient adaptive resources to support

adjustment to this new cultural environment is bound to suffer an

‘acculturative stress’, where the body becomes the platform of its

expression manifesting in eating disorders or any of its equivalents

or permeations. This clearly shows that eating disorders are far

from being just a simple compliance wild a Western cosmetic ideal

but a psychosocial pathology symptomatic of social transition,

where the body becomes a dominant means by which the tension

and crises of society are thematized (Box 4).

Transnational approaches to treatment and prevention

As one examines the movement of eating disorders from indi-

vidual neurosis to cultural marker of distress, caused by transi-

tional and conflicting cultural forces, it becomes increasingly

important to identify ways of operationalizing treatment and

prevention strategies.

Immigrants/ethnic minority groups: vulnerabilityfactors

C Confused and disturbed racial/cultural identity

C A strong need to correct a negative and traditionally stereo-

typed racial image

C Strong need to fit into the host society by conforming to the

prevailing aesthetic standard

C Desire for success, achievement and the fulfilment of higher

aspirations

Box 3

Transitional/de-regulatory ‘cultural’ forces

C The marketing of a standard aesthetic ideal through universal

media

C Life-style changes e change in work/dietary habits and

increased rates of obesity

C Increased levels of urbanization, migration and immigration

C Worldwide confusion over gender role definitions

C Revision of traditional national boundaries through universal

media and information networks

Box 4



The link between power and knowledge production has been

explored in a number of preventative strategies. For example, in

the participatory model empowering knowledge is constructed

through dialogue, self-inquiry and reflection based on life experi-

ences. Electronic connections may provide a new way of achieving

connectedness; linked by computer technology, individual

sufferers may be able to overcome their social and political isola-

tion and gain new insights into formulae for success and survival.

Other models of prevention can be employed, again through

producing computer programs or other types of mass media

geared towards the enhancement of self-esteem, teaching coping

skills and promoting positive cognitions related to negotiations of

power and control and to the significance of the individual in

relation to the environment.

Similar techniques are currently being used in the manage-

ment of eating disorders focusing on psycho-education and

self-help cognitive strategies as well as interactive web-based

multi-media therapeutic programmes that are likely to make

specialist therapies available to many more people who

PSYCHIATRY 8:9 350

traditionally would have been unable to access such help.

Recognition of these new mechanisms is likely to stimulate

research devoted to a transnational perspective for the preven-

tion and management of eating disorders. A

FURTHER READING

Nasser M. Culture and weight consciousness. London, New York:

Routledge, 1997.

Nasser M, Katzman M, Gordon R. Eating disorders and cultures in tran-

sition. London, New York: Brunner-Routledge, Taylor & Francis Group,

2001. p. 1e24.

Nasser M, Katzman M. Socio-cultural theories of eating disorders. In:

Treasure J, Schmidt U, van Furth E, eds. Handbook of eating disorders.

London: Wiley & Sons, 2003. p. 139e51.

Nasser M. Culture and eating disorders. In: Bhugra D, Bhui K, eds. Text-

book of cultural psychiatry. Cambridge, UK: Cambridge University

Press, 2007. p. 292e301.

� 2009 Elsevier Ltd. All rights reserved.

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Eating disorders across cultures