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.