Eating disturbances in white and minority female dieters

Eating Disturbances in White and MinorityFemale Dieters

Daniel le Grange,1* Arthur A. Stone,2 and Kelly D. Brownell3

1 The University of Chicago, Department of Psychiatry, Chicago, Illinois2 Department of Psychiatry and Behavioral Science, State University of New York at

Stony Brook, New York3 Department of Psychology, Yale University, New Haven, Connecticut

Accepted 14 January 1998

Abstract: Objective: This study examined disordered eating, attitudes about weight andappearance, self-esteem, weight loss, and reasons for weight regain in a sample of white,black, Asian, and Hispanic female dieters. Method: In this cross-sectional descriptive study,we scrutinized survey responses of a large number of households subscribing to ConsumerReports magazine. Females (N = 9,971) between 21 and 65 years old (M = 42.9, SD=10.4)with a mean body mass index (BMI) of 27.2 (SD = 6.2) were selected for comparisons.Results: Ethnic groups were different in terms of age, BMI, household income, and maritalstatus. Therefore, these variables were used as covariates in the analyses. More black womenwere overweight and purged compared to the other groups. Asian women valued the ben-eficial role of exercise in weight control more, while black women were more inclined toattribute weight gain to cravings and slow metabolism. The groups did not differ in terms ofbinge eating, attitudes about weight and appearance, self-esteem, the number of attempts tolose weight, and the reasons for their failures. Conclusions: This study suggests that unhealthyeating attitudes and practices may be similar for women who diet, irrespective of ethnicbackground. However, the generalizability of these findings is limited by the inherent sam-pling bias. © 1998 by John Wiley & Sons, Inc. Int J Eat Disord 24: 395–403, 1998.

Key words: minority women; dieting; eating disturbances

INTRODUCTION

Sociocultural influences in eating disturbances and the role of ethnicity in particularhave recently received considerable attention (Story et al., 1994; Striegel-Moore & Smolak,1996). Whereas eating disturbances were mainly regarded as contemporary Western cul-tural phenomena among white women, it is more apparent now that eating pathologyoccurs across a broader race distribution (Lee & Lee, 1996; Marcus, 1993). If eating dis-

*Correspondence to: Dr. le Grange, The University of Chicago, Department of Psychiatry, 5841 S. MarylandAvenue, MC 3077, Chicago, IL 60637.

© 1998 by John Wiley & Sons, Inc. CCC 0276-3478/98/040395-09

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turbances are not the exclusive domain of white women, then weight concerns andconsequent dieting may be equally prevalent among minorities who are assimilated intothe dominant culture. There is evidence supporting this contention (Abrams, Allen, &Gray, 1993), although others argue that, compared to white women, black women expe-rience less social pressure to diet and are more accepting of their body size when over-weight (Wing, Adams-Campbell, Marcus, & Janney, 1993). Also, black women are gen-erally heavier than their white counterparts. As a result, obesity is two to three times moreprevalent among black women (Kuczmarski, Flegal, Campbell, & Johnson, 1994). Thisdifference in the prevalence of weight disorders has been attributed to culturally deter-mined attitudes about weight and dieting behavior (Kumanyika, 1994).

Increasing access to majority cultural values may lead to greater sociocultural pressurestoward thinness among minorities (Wilfley & Rodin, 1995). Some research suggest thatblacks who identify with majority culture show more eating problems than those whoidentify with black culture (Abrams et al., 1993; Pumariega, Gustavson, Gustavson,Motes, & Ayers, 1994). However, only learning more about black women may not answerquestions regarding other minorities; for example, Asian women may be more similar towhite women in terms of pressures for slimness and other cultural values that promptdieting or food abuse (Davis & Katzman, in press). In clinical populations, minority eatingdisorder patients are similar to their Caucasian counterparts, both in terms of general andeating disorder pathology (Le Grange, Telch, & Agras, 1997). Few investigators, however,have surveyed prevailing pathological eating behaviors in a community sample of eth-nically diverse dieters (Warheit, Langer, Zimmerman, & Biafora, 1993). Knowledge aboutdieting is primarily derived from generalizations based on clinical samples with young-adult white females. This bias continues to have profound implications for theoreticalformulations of eating disorders (Striegel-Moore & Smolak, 1996).

The primary aim of this study was to examine attitudes about weight and appearance,disordered eating, and self-esteem in an ethnically diverse sample of dieting women. Thiswas not a population survey, but rather an examination of questionnaire responses of alarge number of white, black, Asian, and Hispanic female readers of Consumer Reportsmagazine. Our hypothesis was that white women will demonstrate significantly greatereating disturbances compared to minority women, but that obesity will be highest forblack women, that is, we predicted a main effect for ethnicity. A speculative hypothesisis that Asian women’s responses will approximate those of white women, and those ofHispanic women will approach black women’s responses.

METHOD

Participants completed a survey of subscriber households which was distributed byConsumer Reports magazine. This is one part of an annual survey of readers to evaluateconsumer products and services. 94,712 subscribers completed an evaluation of a programdesigned to reduce weight that had occurred over the past 3 years. The results of thissurvey have been published before (Consumer Reports, 1993), while the design has beendescribed elsewhere (Striegel-Moore, Wilfley, Caldwell, Needham, & Brownell, 1996).Over one third (37,222) of these respondents were willing to receive a detailed question-naire on weight and dieting history, body image, and demographic variables. Of these,21,920 persons completed and returned this questionnaire. For the present study, weexcluded participants who were pregnant or suffering with an illness affecting weight. Wealso excluded mixed race participants due to small numbers, while males were excluded

396 Le Grange, Stone, and Brownell

for purposes of separate analyses. Thus, this study comprised of a convenience sample of9,971 females between 21 and 65 years of age (M = 42.9 years, SD = 10.4). Of the total, 28%were between the ages of 21 to 35, 48% between 36–50, and 24% between 51–65. Meanbody mass index (BMI) was 27.2 (SD = 6.2) with >65% attempting to lose weight at thetime of this second survey.

Measures

Responses to the second survey were examined for the present investigation. To ad-dress our study aim, we selected only questions pertaining to disordered eating, attitudesabout weight and appearance, reasons for weight gain, and self-esteem. Questions wereprimarily developed based on prior eating pathology measures (Fairburn & Cooper,1993).

Demographic DataDemographic data included age, marital status (five categories), education (seven cat-

egories), and personal and household income (<30,000; 30–39,999; 40–49,999; 50–59,999;60–74,999; 75–99,999; >100,000). BMI was calculated based on participants’ self-reportedheight and weight.

Disordered EatingSeven questions elicited information regarding binge eating, its frequency, concomitant

loss of control and distress, and purging over the past 6 months. In addition, participantswere asked to indicate whether in the past they had ever received a physician’s diagnosisof anorexia or bulimia nervosa (AN/BN) or obesity.

Attitudes about Weight and AppearanceEight questions examined subjects’ attitudes about weight and appearance (e.g., exer-

cise is helpful to control stress or weight, weight is not a concern). Questions were ratedon a scale ranging from 1 (strongly disagree) to 5 (strongly agree).

Weight and Self-EsteemSelf-esteem was assessed using the Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1962).

In addition, participants were asked to make a subjective assessment of how self-esteemis affected by their current, past highest, and past lowest weights. Questions were ratedon a scale ranging from 1 (very dissatisfied) to 5 (very satisfied).

Reasons for Weight GainWeight loss and regain were examined, that is, times when and amount of weight lost,

and whether participants regarded themselves as yo-yo dieters. In addition, 11 variableswere examined to determine reasons for weight fluctuations (e.g., slow metabolism,stress). Questions were rated on a scale ranging from 1 (not at all important) to 5 (ex-tremely important).

RESULTS

Participant Characteristics

The ethnic breakdown of the sample was 9,227 whites (92.5%), 397 Asians (4%), 222blacks (2.2%), and 125 Hispanics (1.3%). The average household income (>$40,000) and

Eating Disturbances 397

educational attainment (at least college/ associate degree) for all groups were above themedian income and educational levels for U.S. women (US Bureau of Census, 1997).Differences on demographic variables were investigated using one-way analyses of vari-ance (ANOVAs). There was a significant difference for age [F(3, 9836) = 5.82, p < .0006],with post hoc analysis [Tukey studentized range test] showing that Hispanic women wereyounger on average than white women. There was also a significant difference for BMI[F(3, 9629) = 14.06, p < .0001], with black women being heavier than all other groups.There was a significant difference for household income [F(3, 9178) = 4.72, p < .003), withAsian and white women reporting higher incomes compared to black women. There wasalso a significant difference for marital status (x2 = 76.49, p < .0001); fewer black womenwere married compared to the other groups. There were no differences for personalincome. Although the model for educational status was significant, post hoc tests showedno differences between the groups. Demographic variables are presented in Table 1.Subsequent ANOVAs were conducted entering age, BMI, household income, and maritalstatus as covariates. Post hoc analyses were conducted using Tukey’s test and Bonferon-ni’s corrections were applied for significant pair-wise contrasts.

Disordered Eating

Forty-one percent of participants were overweight (BMI >27), while 25% reported aphysician’s diagnosis of obesity. Black women had the highest percentage of overweight(59%) as opposed to Hispanic (42%), white (40%), and Asian women (39%) (x2 = 38.62, p< .001).

Forty-one percent answered affirmatively to binge eating during the past 6 months. Themean number of binge episodes was similar for the four groups, averaging 12.7 (SD =16.7). To make a classification of binge eating disorder (BED) according to the 4th ed. ofthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American PsychiatricAssociation, 1994), we examined participants who indicated binge eating more than twiceper week during the 6 months preceding the survey, with loss of control during suchepisodes, and no purging. There were no differences between the groups with 13% meet-ing BED criteria. In terms of a broad definition of purging (self-induced vomiting, laxa-tive, or diuretic abuse), 12% indicated purging in the previous 6 months. Black women

Table 1. Subject characteristics: M (SD)

White(n = 9,227)

Black(n = 222)

Asian(n = 397)

Hispanic(n = 125) Fb p

Age 43.1 (10.4) 42.1 (10.1) 42.0 (9.8) 39.7 (11.1) 5.82 .0006Educationa 4.8 (1.1) 4.9 (1.2) 4.9 (1.1) 4.6 (1.2) 3.22 .0001Personal incomea 2.2 (1.7) 2.4 (1.6) 2.3 (1.7) 2.1 (1.4) 1.54 .20Household incomea 4.0 (1.9) 3.6 (1.9) 4.1 (1.9) 3.6 (1.9) 4.72 .003Height (in.) 64.9 (3.1) 64.9 (2.8) 64.7 (2.7) 63.9 (2.8) 4.94 .002Weight (lb) 162.6 (37.9) 178.5 (45.3) 157.9 (34.9) 158.5 (36.3) 15.31 .0001BMI 27.2 (6.2) 29.8 (7.3) 26.6 (5.8) 27.4 (5.62) 14.06 .0001

Note: Education: 1 = Junior high school or less; 2 = some high school; 3 = high school graduate or equivalent;4 = college/associate degree; 5 = completed college; 6 = Masters degree; 7 = doctoral/professionaldegree. Personal and household income: 1 = <30,000; 2 = 30,000–39,999; 3 = 40,000–49,999; 4 = 50,000–59,999; 5 = 60,000–74,999; 6 = 75,000–99,999; 7 = 100,000. BMI = body mass index.

aEducation, personal and household income were treated as continuous variables for purposes of data analyses.bOne-way analysis of variance.


reported the highest percentage of purging (19), followed by Hispanic (17), white (12), andAsian (10) women (x2 = 12.46, p < .006). Logistic regression, with four covariates, showedblack versus white women (x2 = 11.5, p < .0007), younger women (x2 = 87.06, p < .001), anddivorced versus married women (x2 = 7.9, p < .005) to be most likely to purge. This surveydid not allow detailed analysis of purging, for example, whether one group inducedvomiting or laxative abuse more than another.

Seven percent of women sampled had a BMI < 20, that is, 9% Asian, 8% Hispanic, 7%white, and 4% black. Participants were asked to indicate whether they had ever beendiagnosed in the past with an eating disorder. Fisher’s exact test revealed no significantdifferences in rates of AN or BN among the four groups, irrespective of whether anomnibus test or a contrast of groups with each other was performed. One hundred onesubjects (1%) indicated a diagnosis of AN; 98 white (1.1%) and 3 Asian women (0.8%)answered affirmatively, no black or Hispanic female indicated a diagnosis of AN. Onehundred sixty-four females (1.6%) reported a history of BN. Four black females (1.8%), 154white women (1.7%), 5 Asian women (1.3%), and 1 Hispanic woman (0.8%) indicated adiagnosis of BN.

Attitudes about Weight and Appearance

Using analyses of covariance (ANCOVAs), eight questions pertaining to attitudes aboutweight and appearance were examined. There were main effects for ethnicity in terms ofexercise being helpful to control stress [F(3,8645) = 5.0, p < .0018], weight [F(3,8628) = 3.99,p < .0076], and overeating [F(3,8637) = 2.53, p < .05]. Post hoc analyses revealed that thedifferences were between white and Asian women, with the latter valuing the beneficialrole of exercise more than white women. There were no main effects for yo-yo dieting,eating less for weight control purposes, amount of weight concern, and the degree towhich they believe that weight regain following weight loss is the result of factors beyondtheir control. Main effects are shown in Table 2. There was a significant interaction foryo-yo dieting and BMI [F(3,8535) = 3.27, p < .0202]. The effect of BMI on yo-yo dieting forwhite women (B = .067) was significantly different than for Hispanic women (B = −.003;p < .0036). There was an interaction for current dieting and BMI [F(3,8561) = 4.89, p <.0021], showing a stronger relationship for Hispanic women (B = −.082) compared to

Table 2. Attitudes about weight and appearance: main effects [M (SD)]

White(n = 9,227)

Black(n = 222)

Asian(n = 397)

Hispanic(n = 125)

Fa

df = 3 p

1. Yo-yo dieting 3.36 (1.4) 3.24 (1.5) 3.24 (1.4) 3.47 (1.3) 3.49 .0152. Restrain to control weight 3.68 (1.2) 3.51 (1.3) 3.75 (1.1) 3.78 (1.2) 1.48 .223. Severe dieting 3.69 (1.2) 3.68 (1.2) 3.69 (1.2) 3.73 (1.2) 0.35 .794. Exercise to control stress 3.95 (1.0)* 3.97 (1.1) 4.17 (0.9)* 3.97 (1.0) 5.00 .0025. Exercise to control weight 3.52 (1.1)** 3.54 (1.1) 3.69 (1.0)** 3.47 (1.1) 2.53 .056. Compulsive exercising 1.61 (0.9)*** 1.70 (1.0) 1.76 (1.0)*** 1.71 (1.1) 3.99 .0087. Weight is no concern 2.05 (0.9) 2.00 (0.9) 2.15 (0.9) 1.94 (0.9) 1.34 .268. Lack of control 2.21 (0.9) 2.27 (1.0) 2.26 (0.9) 2.28 (1.0) 0.97 .41

Note: 1 = yo-yo dieting; 2 = restricting eating to control weight; 3 = have to eat much less to control weight;4 = exercise to control stress; 5 = exercise reduces overeating; 6 = compulsive exercising; 7 = weight isnot a concern; 8 = weight regain, following a loss, is due to factors beyond one’s control.

aAnalyses of covariance controlling for age, body mass index, household income, and marital status.*p > .0002; **p > .0096; ***p > .0087.


white respondents (B = −.016; p < .002). Finally, there was an interaction for weightconcerns and BMI [F(3,8581) = 3.47, p < .0155]. This also showed a stronger relationshipfor white women (B = −.027) than for Hispanic women (B = .012; p < .018).

Weight and Self-Esteem

No significant differences between ethnic groups existed on RSE scores. Using a moresubjective assessment of self-esteem, participants were asked to rate their satisfaction withself-esteem in terms of current, highest, and lowest weight during the past year. Therewas an interaction for self-esteem at highest weight and age [F(3,8448) = 2.95, p < .0315],with white women (B = .013) showing a stronger relationship than Asian women (B =−.003; p < .016). There were, however, no main effects for the groups, rather, mean ratingsof esteem were highest at lowest weight, and lowest at highest weight.

Reasons for Losing and Regaining Weight

There were no differences between the ethnic groups in answer to the question: Howmany times have you lost 5–9 lb intentionally? Participants indicated that they have made,on average, 9–10 such attempts in the past year. There were no differences betweengroups when asked to indicate how many times they have attempted to lose between10–19, 20–49, 50–99, or 100 lb or more. There was also no difference among the fourgroups in terms of weight cycling (losing/ regaining 10 lb at a time within the past 5years).

Eleven variables which may explain past weight gain were examined. There were maineffects for ethnicity for slow metabolism [F(3,8525) = 2.72, p < .04] and carbohydratecravings [F(3,8508) = 3.01, p < .02]. Post hoc analyses revealed that black women weremore inclined than white and Asian women to attribute weight gain to these variables.There were no main effects for attributing weight gain to either genetics, stress, depres-sion, low self-esteem, avoiding social or sexual situations, lack of willpower, weightcycling, lack of exercise, or enjoying food. There was an interaction for lack of willpowerand BMI [F(3,8491) = 2.82, p < .0377], showing a stronger effect for Hispanic women (B =.064) compared to white women (B = .009; p < .0148). There was also an interaction for lackof exercise and BMI [F(3,8490) = 3.52, p < .0143], showing a stronger relationship for white(B = .027) versus Asian women (B = 0.0; p < .0171).

DISCUSSION

This descriptive investigation examined eating disturbances in one of the largest com-munity samples of white and minority female dieters collected to date. This informationis important as there is a dearth of research regarding eating disturbances in nonclinicalsamples. Results were mixed in that differences between the groups were demonstratedfor several variables, especially for Hispanic women, suggesting variability among theethnic groups surveyed. However, a similar number of variables yielded no differences,an outcome perhaps indicating homogeneity among readers of Consumer Reports maga-zine or highlighting sampling biases.

Forty percent of respondents were overweight. Black women were the heaviest, but notto the same degree as reported in population studies (Kumanyika, 1994), leading us toquestion the representativeness of black women in our study. Forty-one percent of par-


ticipants reported binge eating episodes in the 6 months preceding the survey, while 12%reported binge eating more than twice weekly. There were no differences in binge eatingepisodes, loss of control, or distress among the groups. Although not based on a formaldiagnosis, 13% met research criteria for BED. It needs to be borne in mind that oursampling strategy favored identification of eating disorders in which dieting plays a role.Therefore, our findings may underestimate true prevalence of binge eating among blackwomen who are not dieters and thus excluded from this survey. Compared to bingeeating, a smaller number of participants (12%) indicated episodes of purging. Significantlymore black women reported purging compared to the other groups. This lends tentativesupport to previous findings that more minority women suffer from eating disturbancesthan previously suspected (Le Grange, Telch, & Tibbs, 1998; Warheit et al., 1993).

A small number of participants (7%) were underweight (BMI <20). Equal numbers ofwhite, Asian, and Hispanic women had low BMIs, whereas a significantly smaller numberof black women were underweight. A physician’s diagnosis of AN was absent amongblack and Hispanic females, while present in 1% in the other two groups. This was notsurprising as AN in minorities is rare (Striegel-Moore & Smolak, 1996), although differ-ences in health care utilization or questions physicians ask women of color could accountfor our findings. BN was reported at a similar rate (1.5%), with all four groups equallylikely to report a physician confirmed diagnosis, providing tentative support to the pro-posal that black women may suffer from eating disturbances more than previously sus-pected.

Examination of attitudes regarding weight and appearance revealed few differencesamong the groups. Asian women felt more strongly than others that exercise helps controlstress in their lives and that they are less likely to overeat when they exercise regularly.This is not entirely surprising, as Asian communities have long emphasized martial artsas part of a daily ritual to enhance health and productivity (Weiser, Kutz, Kutz, & Weiser,1995). On the other hand, blacks have been found to exercise less frequently and are lessfit physically (Wing et al., 1989) than their white counterparts. Future work should in-vestigate race differences in terms of attitudes regarding the implementation of exerciseas a therapeutic component in weight loss programs.

Weight loss attempts were similar for the four groups, with considerable numbersengaging in potentially unhealthful behaviors. Weight cycling was more common amongblack than among either white or Asian women. Weight gain was attributed to a varietyof factors. Black and Hispanic women were more inclined to highlight slow metabolism,carbohydrate craving, depression, and low self-esteem than did white and Asian women.However, there were no differences among the groups on the perceived role played bygenetics, stress, lack of willpower or exercise, and enjoyment in food.

Despite the fact that black women were the heaviest, RSE scores were similar for allgroups, lending support to the suggestion that black women are more accepting of bodysize when overweight (Kumanyika, Wilson, & Guilford-Davenport, 1993). Subjective as-sessment of self-esteem in relation to weight also yielded no differences among thegroups, whether at present, lowest, or highest weight. Self-esteem varied with weight, inthat self-esteem was highest at lowest weight and lowest at highest weight. Not surpris-ingly, black womens’ self-esteem was least affected when weight was at its highest level.

The primary limitation of our study concerns the representativeness of the sample. Allparticipants were dieters from Consumer Reports subscriber households with relativelyhigh income and education levels. The self-selected nature of our study group may havemasked ethnic differences typically present in more representative samples. It is thereforepremature to conclude whether similarities among the groups were due to the fact that,


as ethnic differences diminish over time, minorities may internalize body image idealsakin to the majority culture. Notwithstanding, this study contributes to what little isknown about eating disturbances in community samples representing dieters from dif-ferent ethnic backgrounds. Our findings underscore previous well-known differences inthe presentation of weight disorders across race. However, this study also demonstratesa degree of confluence in eating disturbance between women from comparable socioeco-nomic backgrounds, although representing different ethnic groups. In other words, onceblack women become dieters, they may be more similar to white women than different.However, the relationship among ethnicity, dieting, and socioeconomic status in a com-munity sample should be addressed more systematically in future research. Likewise,future research should compare representative ethnic groups and include a measure ofacculturation.

The authors thank the Consumers Union and the staff of Consumer Reports magazine fortheir role in designing the survey and collecting the data. We also thank the FetzerInstitute, which provided support for distributing the survey and data analysis. Theinterpretation of the data reflects the work of the authors and does not necessarily rep-resent positions of the Consumers Union or the Fetzer Institute. We would also like tothank Steven Grossman, MS, for support in the statistical analyses.

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Eating disturbances in white and minority female dieters