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).
Bemporad JR (1997), Cultural and historical aspects of eating disorders. Theor Med 18(4):401-420.
Bemporad JR (1996), Self-starvation through the ages: reflections on the prehistory of anorexia nervosa. Int J Eat Disord 19(3):217-237.
Bruch H (1966), Anorexia nervosa and its differential diagnosis. J Nerv Ment Dis 141:555-566.
Castillo RJ (1997), Eating disorders. In: Culture and Mental Illness: A Client-Centered Approach, Castillo RJ, ed. Pacific Grove, Calif.: Brooks/Cole Publishing Co.
Gard MC, Freeman CP (1996), The dismantling of a myth: a review of eating disorders and socioeconomic status. Int J Eat Disord 20(1):1-12.
Hsu LK (1987), Are the eating disorders becoming more common in blacks. Int J Eat Disord 6:113-124.
Hsu LK, Lee S (1993), Is weight phobia always necessary for a diagnosis of anorexia nervosa? Am J Psychiatry 150(10):1466-1471.
Miller MN, Verhegge RD, Miller BE, Pumariega A (in press), Assessment of risk of eating disorders in among adolescents in Appalachia. J Am Acad Child Adolesc Psychiatry.
Nassar M (1988), Eating disorders: the cultural dimension. Soc Psychiatry Psychiatr Epidemiol 23:184-187.
Pate JE, Pumariega AJ, Hester C, Garner DM (1992), Cross-cultural patterns in eating disorders: a review. J Am Acad Child Adolesc Psychiatry 31(5):802-809. See comments.
Prince R (1983), Is anorexia nervosa a culture-bound syndrome? Transcultural Psychiatric Research Review 20:299-300.
Pumariega AJ (1986), Acculturation and eating attitudes in adolescent girls: a comparative and correlational study. J Am Acad Child Psychiatry 25(2):276-279.
Pumariega AJ, Gustavson CR, Gustavson JC et al. (1994), Eating attitudes in African-American women: the Essence eating disorders survey. Eating Disorders 2(1):5-16.
Ritenbaugh C, Shisslak C, Prince R (1992), Eating disorders: a cross-cultural review in regard to DSM-IV. In: Cultural Proposals for DSM-IV. Mezzich JE, Kleinman A, Farega H et al., eds. Submitted to the DSM-IV Task Force by the NIMH Group on Culture and Diagnosis. Pittsburgh: University of Pittsburgh.
Robinson TN, Killen JD, Litt IF et al. (1996), Ethnicity and body dissatisfaction: are Hispanic and Asian girls at increased risk for eating disorders? J Adolesc Health 19(6):384-393. See comments.
Rowland CV (1970), Anorexia and obesity. Int Psychiatry Clin 7(1):37-137.
Russell GFM (1997), The history of bulimia nervosa. In: Handbook of Treatment for Eating Disorders, Garner DM, Garfinkel PE, eds. New York: Guilford Press.