How Do Eating Disorders Change Between Cultures?

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When we think of eating disorders, we usually associate them with Western perceptions of an ‘ideal’ body. For a feminine body, Western ideals typically promote an unrealistically small shape. For masculine bodies, they idealise leanness and muscularity. 

However, research into eating disorders around the world shows that disordered eating isn’t isolated to the Western world. Western ideals have now spread to many other regions, apparently bringing with them body dissatisfaction and other issues that underlie eating disorders.

But more than this, experts have pointed out that patterns of disordered eating existed in many of these cultures even before the arrival of Western values – but with slightly different symptomology. Specifically, people tended not to explicitly express over-concern about their shape and weight or a fear of gaining weight but justified their eating behaviours with other reasons.

This blog offers some information on the different patterns of disordered eating that are connected to cultures in Asia and Africa. It also touches on how these have changed in recent years with the spread of Western media beauty ideals to more regions of the world.

Disordered Eating Behaviours in Africa

Studies on eating disorders in Africa seem to paint a cohesive picture. While there are fewer cases of eating disorders that share all the main characteristics that are typical of disordered eating in the West, the prevalence of eating disorders (with slightly different forms) is about the same. 

Four studies that looked into the prevalence of formal diagnoses of eating disorders among women in different African countries found, taken together, that rates of bulimia nervosa were around 0.87%, while rates of unspecified eating disorders were around 4.45%.

These numbers are not dissimilar to other places in the world. In the US, for example, the prevalence of bulimia among women is around 1.5%, while the prevalence of unspecified eating disorders in adults is about 4.78%.

Notably, these studies found no cases of anorexia nervosa according to the DSM-4 criteria (which were relevant at the time the studies took place). While there were several cases of women with a very low body weight who restricted their diet, these women did not express an intense fear of gaining weight.

Instead, they said that their disordered eating behaviours were driven by religious fasting. They also showed other characteristics commonly found in women’s anorexia, including self-control, enjoyment of hunger, denial of hunger, and self-punishment. 

These women seem to have had eating disorders that were very similar to anorexia nervosa but without an emphasis on shape and weight. It seems that rather than eating disorders developing from Western beauty ideals, it may be only one specific form that’s connected in this way. Disordered eating behaviours that restrict and control eating may be more widespread across different cultures, underpinned by various reasons, such as religious motivations or self-punishment.

Interestingly, the DSM-5 criteria for anorexia nervosa are broader than those of DSM-4. The DSM-5 now includes a criterion of ‘persistent behaviour that interferes with weight gain, even when already at a significantly low weight’. Under the new criteria, some of the women from the previous studies may have met the criteria for a formal diagnosis.

Pica in African Societies

Pica is an eating disorder where someone deliberately eats non-food items. This might involve eating things like paint or clay or eating food raw that is usually eaten cooked.

In some parts of Africa, it’s relatively common to eat soft stones, dirt, clay, and uncooked foods – especially when women are pregnant. Some people choose to eat these things because they believe they are medically beneficial, ideas embedded in their culture. Others may eat them for different cultural reasons.

The criteria for a diagnosis of pica require that these eating behaviours are not part of a culturally accepted habit or social norm. This that many of the people who show pica-like behaviours would not be diagnosed as having the disorder. Of course, there may be others whose behaviours are not rooted in cultural practice and would meet the criteria for the disorder.

Eating Disorders in Hong Kong and India

As with some African countries, early studies in Hong Kong and India also showed the presence of eating disorders without an emphasis on shape and weight.

In Hong Kong in the 1990s, people with eating disorders usually described how pains or discomfort in their body caused them to restrict the food that they ate. They often spoke about bloating, stomach pain, or a lack of appetite. 

In India, two studies in the mid-1990s found that both young men and women showed signs of disordered eating, but again without a fear of gaining weight or a preoccupation with their body size.

Nonetheless, they described many other familiar symptoms of eating disorders, such as persistent vomiting, refusal to eat, weight loss, and discomfort in their bodies.

The Rise and Change of Eating Disorders in Asian Countries

While in the 1990s, eating disorders in Hong Kong seemed to be driven by things other than shape and weight, this quickly began to change.

As Western media – and with it Western values – spread and intensified in Asian countries, more and more cases of body dissatisfaction and a desire for a smaller body shape were identified. Reports of eating disorders without a preoccupation with shape and weight have steadily decreased, and those underpinned by shape and weight concerns have increased. 

In India, the presence and forms of eating disorders have always been diverse, especially given the country’s size and huge cultural variations within its borders.

While anorexia nervosa without concerns for shape and weight did exist, they were always less common than typical anorexia. As with Hong Kong, these cases are becoming increasingly rare, and instances of anorexia that resemble Western eating disorders have become more common.

Other Asian countries have also seen a dramatic increase in eating disorders in the past three decades. Before the 1990s, eating disorders were rare in many Asian countries, with the exception of Japan where disordered eating had been common since the 1970s. But by the end of the century, this had changed.

Now, rates of eating disorders in many Asian countries are the same as in the West, and levels of body dissatisfaction are just as concerning, if not more so.

Interestingly, the order that eating disorders reached each Asian country is in line with the way economic transformation spread across the region.

As countries became more developed, they tended to see higher rates of eating disorders. Those that went through processes of industrialisation, growth, and urbanisation later were the last to report a rise in eating disorders.

During these industrialisation processes, foreign investment from Western countries and the arrival of Western companies brought Western media and culture to Asian countries, and with it the ‘thin body ideal’. Many experts understand this process of Westernisation as the driving force behind the rise of eating disorders in Asia today.

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FAQ

What Are the DSM-4 and DSM-5?

DSM stands for Diagnostic and Statistical Manual for Mental Disorders. It’s a handbook written by the American Psychiatric Association (APA) that mental health professionals use to diagnose different mental health disorders. While other handbooks exist, in many parts of the world the DSM is the authoritative guide to diagnosing.

As our understanding of mental health disorders improves, the DSM is also updated to reflect our new knowledge. The DSM-4 was published in 1994 and the DSM-5 in 2013. Currently, scientists and other experts are working on the formation of the DSM-6, which is not expected to be released until at least 2025.

Fiona - The Wave Clinic

Fiona Yassin is the founder and clinical director at The Wave Clinic. She is a U.K. and International registered Psychotherapist and Accredited Clinical Supervisor (U.K. and UNCG).

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