Culture has been identified as one of the etiological factors leading to the development of eating disorders. Rates of these disorders appear to vary among different cultures and to change across time as cultures evolve. Additionally, eating disorders appear to be more widespread among contemporary cultural groups than was previously believed. Anorexia nervosa has been recognized as a medical disorder since the late 19th century, and there is evidence that rates of this disorder have increased significantly over the last few decades. Bulimia nervosa was only first identified in 1979, and there has been some speculation that it may represent a new disorder rather than one that was previously overlooked (Russell, 1997).
However, historical accounts suggest that eating disorders may have existed for centuries, with wide variations in rates. Long before the 19th century, for example, various forms of self-starvation have been described (Bemporad, 1996). The exact forms of these disorders and apparent motivations behind the abnormal eating behaviors have varied.
The fact that disordered eating behaviors have been documented throughout most of history calls into question the assertion that eating disorders are a product of current social pressures. Scrutiny of historical patterns has led to the suggestion that these behaviors have flourished during affluent periods in more egalitarian societies (Bemporad, 1997).It seems likely that the sociocultural factors that have occurred across time and across different contemporary societies play a role in the development of these disorders.
Sociocultural Comparisons Within America
Several studies have identified sociocultural factors within American society that are associated with the development of eating disorders. Traditionally, eating disorders have been associated with Caucasian upper-socioeconomic groups, with a "conspicuous absence of Negro patients" (Bruch, 1966). However, a study by Rowland (1970) found more lower- and middle-class patients with eating disorders within a sample that consisted primarily of Italians (with a high percentage of Catholics) and Jews. Rowland suggested that Jewish, Catholic and Italian cultural origins may lead to a higher risk of developing an eating disorder due to cultural attitudes about the importance of food.
More recent evidence suggests that the pre-valence of anorexia nervosa among African-Americans is higher than previously thought and is rising. A survey of readers of a popular African-American fashion magazine (Table) found levels of abnormal eating attitudes and body dissatisfaction that were at least as high as a similar survey of Caucasian women, with a significant negative correlation between body dissatisfaction and a strong black identity (Pumariega et al., 1994). It has been hypothesized that thinness is gaining more value within the African-American culture, just as it has in the Caucasian culture (Hsu, 1987).
Other American ethnic groups also may have higher levels of eating disorders than previously recognized (Pate et al., 1992). A recent study of early adolescent girls found that Hispanic and Asian-American girls showed greater body dissatisfaction than white girls (Robinson et al., 1996). Furthermore, another recent study has reported levels of disordered eating attitudes among rural Appalachian adolescents that are comparable to urban rates (Miller et al., in press). Cultural beliefs that may have protected ethnic groups against eating disorders may be eroding as adolescents acculturate to mainstream American culture (Pumariega, 1986).
The notion that eating disorders are associated with upper socioeconomic status (SES) also has been challenged. Association between anorexia nervosa and upper SES has been poorly demonstrated, and bulimia nervosa may actually have an opposite relationship with SES. In fact, several recent studies have shown that bulimia nervosa was more common in lower SES groups. Thus, any association between wealth and eating disorders requires further study (Gard and Freeman, 1996).
Eating Disorders in Other Countries
Outside the United States, eating disorders have been considered to be much rarer. Across cultures, variations occur in the ideals of beauty. In many non-Western societies, plumpness is considered attractive and desirable, and may be associated with prosperity, fertility, success and economic security (Nassar, 1988). In such cultures, eating disorders are found much less commonly than in Western nations. However, in recent years, cases have been identified in nonindustrialized or premodern populations (Ritenbaugh et al., 1992).
Cultures in which female social roles are restricted appear to have lower rates of eating disorders, reminiscent of the lower rates observed during historical eras in which women lacked choices. For example, some modern affluent Muslim societies limit the social behavior of women according to male dictates; in such societies, eating disorders are virtually unknown. This supports the notion that freedom for women, as well as affluence, are sociocultural factors that may predispose to the development of eating disorders (Bemporad, 1997).
Cross-cultural comparisons of eating disorder cases that have been identified have yielded some important findings. In Hong Kong and India, one of the fundamental characteristics of anorexia nervosa is lacking. In these countries, anorexia is not accompanied by a "fear of fatness" or a desire to be thin; instead, anorexic individuals in these countries have been reported to be motivated by the desire to fast for religious purposes or by eccentric nutritional ideas (Castillo, 1997).
Such religious ideation behind anorexic behavior also was found in the descriptions of saints from the Middle Ages in Western culture, when spiritual purity, rather than thinness, was the ideal (Bemporad, 1996). Thus, the fear of fatness that is required for the diagnosis of anorexia nervosa in the Diagnostic and Statistical Manual, Fourth Edition (American Psychiatric Association) may be a culturally dependent feature (Hsu and Lee, 1993).
Anorexia nervosa has been described as a possible "culture-bound syndrome," with roots in Western cultural values and conflicts (Prince, 1983). Eating disorders may, in fact, be more prevalent within various cultural groups than previously recognized, as such Western values are becoming more widely accepted. 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. In addition, cultural factors such as affluence and freedom of choice for women may play a role in the development of these disorders (Bemporad, 1997). Further research of the cultural factors influencing the development of eating disorders is needed.
Dr. Miller is an associate professor at James H. Quillen College of Medicine, East Tennessee State University, and is director of the university psychiatry clinic.
Dr. Pumariega is professor and chair of the department of psychiatry at the James H. Quillen College of Medicine, East Tennessee State University.