Eating and body image disturbances across cultures: a review

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  • European Eating Disorders ReviewEur. Eat. Disorders Rev. 14, 5465 (2006)

    Eating and Body Image DisturbancesAcross Cultures: A Review

    Nerissa L. Soh1*, Stephen W. Touyz1,2

    and Lois J. Surgenor31Discipline of Psychological Medicine, University of Sydney, Australia2School of Psychology, University of Sydney, Australia3Department of Psychological Medicine, University of Otago, New Zealand

    Objective: To critically review the literature examining theimpact of acculturation, socio-economic status, family functioningand psychological control in relation to eating and body imagedisturbances across cultures.Method: A review of the literature on eating disorders, eatingand body image disturbances, psychological control, body compo-sition, socio-economic status and family functioning on differentcultural groups.Results: Of the empirical studies undertaken, few investigated acultural groups eating pathology in both its country of origin anda Western country using the same methodology. To date, theresearch findings are mixed and it is still unclear if the presen-tation of an eating disorder differs across cultures. Acculturationhas not been consistently taken into consideration and psycholo-gical control has not been examined in relation to eating distur-bances in non-Western groups.Discussion: This review focuses on some of the methodologicallimitations of previous research and attempts to delineate thesalient issues which warrant further scientific enquiry. Copyright# 2006 John Wiley & Sons, Ltd and Eating Disorders Association.

    Keywords: body image; cross-cultural; eating disorders; psychological control

    INTRODUCTION

    Although eating disorders, and particularly anor-exia nervosa (AN), have long been identified in Wes-tern societies (Vandereycken & van Deth, 1994), inthe non-Western world such disorders have onlybeen described in the international literature sincethe late 1970s. In explanation, it is often argued thateating disorders are Western culture-bound syn-dromes and that individuals from non-Westernsocieties have some immunity to such disorders

    (Gordon, Perez, & Joiner, 2002; Lai, 2000; Nasser,1997; Timimi & Adams, 1996; Tsai, 2000; Wildes,Emergy, & Simons, 2001).

    The stereotypical AN patient is depicted as young,North-European Caucasian, female, well educatedand from the upper socio-economic class. Conven-tional wisdom dictates that it is the influence andadoption of Western values that has led to the rise ofeating disorders in the non-Western world (Rieger,Touyz, Swain, & Beumont, 2001; Weiss, 1995). Therehave been a number of reasons put forward as towhy eating disorders were thought to be rare in suchsocieties, including the following: non-Westernsocieties traditionally did not greatly value thin-ness and instead valued plumpness (Afifi-Soweid,Najem Kteily, & Shediac-Rizkallah, 2002; Buhrich,

    Copyright# 2006 John Wiley & Sons, Ltd and Eating Disorders Association.

    Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.678

    * Correspondence to: Nerissa L. Soh, Discipline of Psycholo-gical Medicine, Blackburn Building DO6, The University ofSydney NSW 2006, Australia. Tel:61 2 9515 5844. Fax:61 29515 7778. E-mail: nsoh3679@mail.usyd.edu.au

  • 1981; Lee, Leung, Lee, Yu, & Leung, 1996; Nasser,1997; Tsai, 2000); the collectivistic structure of familyand society offered some degree of protection (Lee &Lee, 1996; Tsai, 2000); and that eating disorders sim-ply were not recognised within the society and inturn, were not brought to the attention of the appro-priate clinicians (Becker, Franko, Speck, & Herzog,2003; Buhrich, 1981; Gordon et al., 2002; Silber,1986; Striegel-Moore & Smolak, 2000; Tsai, 2000).

    However, variants of eating disorders have beenknown in the non-Western world for some centuries.For example, fushokubyo, or non-eating illness,was described by Kagawa in 1718th century Japan(Nishizono-Maher, 1998; Nogami, 1997). Most of thepatients were women and the condition was thoughtto have a psychological origin. Nogami (1997) repor-ted that, before World War II, no articles on AN werefound in Psychiatria et Neurologia Japonica, the offi-cial journal of the Japan Association of Psychiatryand Neurology, and that only one case of AN inJapan was documented in 1941. The comparison ofprevalence figures for eating disorders across cul-tures is complicated by the variety of diagnosticcriteria used as well as changes in criteria over time.Nonetheless, the data suggest that while the preva-lence of eating disorders tends to be lower in non-Western countries, it has not been consistentlyreported as such (Figures 1 and 2). Furthermore,there are also differences in prevalence withincountries and communities (Fichter, Elton, Sourdi,Weyerer, & Koptagel-Ilal, 1988).

    There is a strong debate regarding whethereating disorders in non-Western patients presents

    differently when compared to eating disorderspatients of North-European backgrounds, not leastbecause of differing cultural values and family envir-onment. Much of the research into eating pathologyand body image disturbance in ethnic minoritygroups has been conducted on the African-Americangroup (Crago, Shisslak, & Estes, 1996; Wildes et al.,2001). Numerous Japanese studies were publishedafter 1970 (Nogami, 1997), albeit in the Japanese lan-guage, but otherwise relatively little work has beenundertaken in non-Western groups. Also, few studieshave investigated such groups in both their countryof origin as well as a Western country (Wildes et al.,2001) and to our knowledge, no study has yet beenundertaken on Western groups now living in anon-Western country.

    This review is organised around key questionsand issues frequently addressed in the literature.It will first focus on comparing eating and bodyimage disturbance profiles between Western andnon-Western societies, then discuss the impact ofculture and socio-economic status on the apparentemergence of eating pathology and eating disordersin non-Western society. It will then summarise thespeculated differences in the presentation of eatingdisorders, particularly between Asian and Westernpatients, and then move to suggest that core con-structs such as psychological control and accultura-tion may provide a way forward in further teasingout the relationships between eating disorders andculture. Finally, it will discuss the potential impactof differences in body composition across ethnicgroups on the management of eating disorders

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    Figure 1. Prevalence of anorexia nervosa in women1Chun et al., 1992; 2Santonastaso et al., 1996; 3Nakamura et al., 2000; 4Pyle, 1983; 5Ben-Tovim & Morton, 1990; 6Fichteret al., 1988; 7Fichter et al., 1988; 8American Psychiatric Association, 1994.

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  • and summarise the implications for research ineating and body image disturbances acrosscultures.

    EATING AND BODY IMAGEDISTURBANCES: BY GEOGRAPHY

    Studies investigating eating disorders and eatingpathology in different cultural groups have beenmostly conducted within Western nations, withmany of these studies suggesting that ethnic min-ority groups in such countries have the lower riskof eating pathology. This is possibly due to a lowerlevel of acculturation to the mainstream society,acculturation being the adoption of another cul-tures values, attitudes and society standards onexposure to them and embodies physical, biologi-cal, political, economic, cultural and psychologicalchanges in identity and attitude (Berry, 1989).Examples of such studies have found North-European Caucasian women to have greater levelsof body dissatisfaction compared to their Asianand African-American counterparts and to bemore likely to attempt to lose weight (Altabe,1998; Lowry, Galuska, Fulton, Wechsler, Kann, &Collins, 2000). Asian women who had moved tothe USA and were studying at a college were foundto have lower levels of restrained eating (16%)compared to their USA counterparts (33%) (Tsai,Hoer, & Song, 1998). Similarly, in a study of femaleuniversity students in Australia, Hong Kong-bornwomen who were more acculturated to Western

    culture were found to have more positiveeating attitudes than Australian-born women(Lake, Staiger, & Glowinski, 2000), suggesting thatthe Asian women had the lower risk of eatingpathology.

    A number of studies undertaken in Westerncountries found no difference across ethnic groups.A cross-sectional study in the USA conductedwith public school students from five differentethnic groups found that they had similar levels ofeating pathology (French et al., 1997). Similarly,Australian-born Greek- and Anglo-Australian yeareight schoolgirls showed no significant differencein their profiles for eating disorder risk factors,despite 33% of the GreekAustralian girls speakingpredominantly Greek at home (Mildred, Paxton, &Wertheim, 1995). However, other studies found thatethnic minority groups expressed greater frequen-cies of eating disturbances when compared toNorth-European Caucasians. Although Wildes(2001) meta-analysis found little difference acrossethnic groups for bulimia nervosa (BN), it found thatethnicity played a more significant role in subclinicaleating disturbances. Schoolgirls of South Asianbackground living in the UK have been foundto have significantly more unhealthy attitudes toeating than their North-European counterparts(McCourt & Waller, 1995; Mumford & Whitehouse,1988). Also in the UK, the level of acculturation inmale and female students was not associated withBulimia Investigation Test Edinburgh (BITE)scores within each sample of three different ethnicgroups: North-European, AfricanCaribbean and

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    Figure 2. Prevalence of bulimia nervosa in women1Nakamura et al., 2000; 2Santonastaso et al., 1996; 3Mumford & Whitehouse, 1988; 4Chun et al., 1992; 5Nasser, 1994;6American Psychiatric Association, 1994; 7Mumford & Whitehouse, 1988.

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  • South Asian. However, South Asian subjects yieldedthe highest raw BITE scores and were more likely tokeep fasts, feel that their lives were dominated byfood, to think about food and to be compulsiveeaters, although they did not have evident concernsabout their body weight (Bhugra & Bhui, 2003). Inthe USA, HispanicAmerican women were found tohave a 9.6% prevalence of binge-eating disorder(BED), compared to 3.9% for AfricaAmericanwomen and only 1.8% for North-European Americanwomen (Fitzgibbon et al., 1998); Hispanic womenwere also significantly more dissatisfied with theirbodies than North-European women (Robinsonet al., 1996).

    Studies undertaken solely in an ethnic groupscountry of origin have also yielded mixed findings.For example the incidence of AN in Curacao wasfound to be similar to that of Western nations,despite Curacao having a culture in which it issocially acceptable to be overweight (Hoek, vanHarten, van Hoeken, & Susser, 1998). In a similarvein, there was no difference in drive for thinnessin Japanese schoolgirls before they left Japan for1 year abroad as exchange students and when theyreturned (Furukawa, 2002); however, 90% of thefemale subjects already wanted to be thinner beforethey left Japan. There was also no significant differ-ence in the drive for thinness between SingaporeanChinese schoolgirls and USA undergraduate women,although the former had a higher level of body dis-satisfaction than the female undergraduates in theUSA (Kok & Tian, 1994a). In contrast, the 16% of sec-ondary school girls in Saudi Arabia who scoredabove the screening threshold for the drive for thin-ness subscale of the Eating Disorders Inventorywere more likely to have lived in a Western countryfor at least six months and/or speak a Western lan-guage (Al-Subaie, 2000), both markers of exposure toWestern culture. Also, a preference for thinness wasassociated with speaking English at home in Singa-porean Chinese first-year undergraduate women(Wang, Ho, Anderson, & Sabry, 1999). Yet in HongKong undergraduate women, 27% wanted to weightmore than they already did, compared to just 3.1% ofUSA women (Lee et al., 1996).

    It is worth noting that when such studies makecomparisons between countries, they often do soby comparing with the research data from other stu-dies, instead of comparing with data from the samestudy using the same methodologies. However, stu-dies which do utilize the same methodology in aparticular ethnic group in both a Western and non-Western country have again produced mixedresults. For example Chinese girls in Beijing dieted

    more than Chinese girls in Sydney, although this dif-ference was not significant and their Anglo-SaxonSydney counterparts still dieted significantly morethan either group (Gunewardene, Huon, & Zheng,2001). In another study, Kenyan-South Asians stillliving in Kenya responded more positively to obesesilhouettes than Kenyan-South Asians living inBritain, the latter having similar responses to theirBritish Caucasian counterparts (Furnham & Alibhai,1983). In contrast, a study of Iranian women living inIran and in the USA revealed that, despite Westernmedia being banned in Iran since 1978 and that bylaw women must wear some form of dark, full-bodycovering that obscures body shape and size, therewere relatively few differences in eating pathologysymptoms between the two groups. Of the differ-ences present, it was the women living in Iran whowere more likely to exercise vigorously to controltheir weight or shape and more likely to desire anempty stomach (Abdollahi & Mann, 2001). Whilethe authors noted that their subjects mothers wouldhave been exposed to Western media and cultureprior to the revolution, they did not address the phe-nomenon that in Middle-Eastern societies wherewomen wear full-body coverings in public, thewomen have a great deal of interest in personalappearance and the fashions they wear beneath(Mahmoody & Hoffer, 1987; Sasson, 1992). Also sup-porting the theme of higher levels of eating and bodyimage disturbances in individuals with less accul-turation to Western society, a study of Taiwanesewomen in both Taiwan and the USA found thatthose in Taiwan not only identified significantlymore strongly with Taiwanese culture than thosein the USA, but they also exhibited significantlyhigher body dissatisfaction and eating disturbances(Tsai, Curbow, & Heinberg, 2003). In both samples,eating and body image disturbances were signifi-cantly and positively associated with greater identifi-cation withTaiwanese culture, contradicting the viewthat traditional cultural values offer protection toeating disturbances.

    Thus, exposure to Western culture is not irrefuta-bly associated with eating disturbances, nor withbody image issues and their associated desire forslimness which are commonly appearing variablesin aetiological models of eating disorders. However,interpretation of the results is hampered as manycross-cultural studies only take ethnicity intoaccount and do not quantitate the degree of accul-turation to Western society or the level of retentionof traditional values (Altabe, 1998; French et al.,1997; Lowry et al., 2000; McCourt & Waller, 1995).How a particular culture itself is defined is complex,

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  • spanning a wide range of characteristics beyond eth-nicity, such as language proficiency and preference,duration and place of residence, choice of clothingand food, social class, age, number of generationsspent in a specific society and preference in friends(Anderson et al., 1993; Suinn, Rickard-Figueroa,Lew, & Vigil, 1987; Triandis, Kashima, Shimada, &Villareal, 1986). Studies into eating and body imagedisturbances which have included acculturationindices incorporated items such as dominant or pre-ferred language (Abdollahi & Mann, 2001; Bhugra &Bhui, 2003; Gunewardene et al., 2001; Mildred et al.,1995; Mumford, Whitehouse, & Platts, 1991), dressand food preferences (Bhugra & Bhui, 2003;Mumford et al., 1991), country of birth (Furnham &Alibhai, 1983; Gunewardene et al., 2001; Lee et al.,1996), parental country of birth (Gunewardeneet al., 2001), duration of residence in a specific coun-try (Abdollahi & Mann, 2001; Al-Subaie, 2000; Ball &Kenardy, 2002; Furnham & Alibhai, 1983; Furukawa,2002). However, some studies did not analyse theeffect or association of these indices with bodyimage and eating disturbances (Fitzgibbon et al.,1998). Furthermore, the strength of associationbetween a particular index and the level of accul-turation requires consideration: for example theduration spent by an individual in a particularsociety is not directly proportional to the level ofadoption of that societys values (Ball & Kenardy,2002). Only a few studies had implemented a formalscale of acculturation in their methodology, such asthe Ethnic Identity Scale in Lakes study (2000) andthe Taiwanese Ethnic Identity Scale in Tsais study(2003).

    CULTURE CHANGE RATHERTHAN CULTURE BOUND

    The experience and exposure to the differencebetween two cultures, rather than a particular cul-ture itself, is also hypothesised to contribute to theaetiology of eating and body image disturbances.That is, a clash between a traditional culture andadopted culture may heighten the risk for eatingand body image disturbances in susceptible indivi-duals (Bhugra, Bhui, & Gupta, 2000; Thomas, James,& Bachmann, 2002; Tsai et al., 2003). DiNicola (1990)noted that AN could be initiated in individuals fromimmigrant families living in Western societies by achange in culture, leading him to describe AN asa culture-change syndrome. Over-identificationwith Western norms and values has also beenhypothesised as a reason for increased eating

    pathology (Furnham & Alibhai, 1983; Rathner et al.,1995).

    IMPROVED SOCIO-ECONOMIC STATUS

    Socio-economic status (SES) has long been consid-ered a risk factor for eating disorders, with womenof higher SES more likely to diet and have a lowerbody weight (Rogers, Resnick, Mitchell, & Blum,1997). In the Western world, the pressure to be slimincreases with SES (Furnham & Alibhai, 1983) andit is plausible that populations in non-Westernnations, as they become more affluent, will in turnbe more at risk of eating disorders, irrespective ofethnicity or cultural background. Previously, ANhad not been reported in ethnic minority groups inthe USA, which were at the time the less affluent sec-tors of society (Bruch, 1973). More recently, how-ever, AfricanAmerican women from higher SESbackgrounds have reported similar levels of bodydissatisfaction to North-European American women(Polivy & Herman, 2002), suggesting that body dis-satisfaction is associated with SES more powerfullythan with ethnicity.

    Across Asia, there is also support for an associa-tion between SES and eating pathology. Comparingthree socio-economic zones in China, Lee and Lee(2000) found that although the BMI values weresimilar, schoolgirls in the more affluent Hong Kongzone had the greater body dissatisfaction and eatingdisturbance. Only 17.6% of the Hong Kong subjectswanted to weigh more than they already did, com-pared to 33.7% of the subjects in the rural Hunanzone. However, 44.3% of the Hunan subjects wantedto weigh less than they already did, compared to74.3% of Hong Kong subjects (Lee & Lee, 2000). Itis worth noting that Hong Kong has had a greaterlevel of exposure to Western culture than the othertwo regions, although the Chinese language is themain medium for communication in all three zones.In Singapore, which has an even higher level of Wes-tern cultural influence and uses English as the teach-ing medium, eating disorder patients tend to comefrom professional backgrounds (Ung, Lee, & Kua,1997). But there is also a suggestion that SES has aneffect independent of cultural exposure: Taiwan isan Asian society of high SES but has had less expo-sure to Western culture than Hong Kong, yet 51.4%of their female college students perceived them-selves as overweight or obese when only 16.2%actually were (Wong & Huang, 1999). In addition,65.5% of 1014 year old Taiwanese girls wanted to

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  • be thinner and 38% had attempted to lose weight(Wong, Bennink, Wang, & Yamamoto, 2000).

    But wealth itself does not automatically mean anincreased prevalence of eating disorders (Nasser,1997). The treasured ideal of slimness has percolatedthrough all levels of society via the media (Polivy& Herman, 2002), lending further credence to thehypothesis that eating pathology is no longerrestricted to the higher SES (Fear, Bulik, & Sullivan,1996). Feasibly, once a certain level of affluence hasbeen achieved in a particular society, the associationof high SES with eating disorders may no longerhold, owing to globalisation and a blurring of theboundaries between the socio-economic classes incontemporary times.

    DIFFERENCES IN PRESENTATION:BODY IMAGE, WEIGHT CONCERNAND FEAR OF FATNESS

    A repeated theme in research is that eating disordersmay present differently in patients with a non-Western background due to factors such as differingcultural values, family structure and body composi-tion. Prominent among these arguments is whetherfear of fatness or weight concern should be inclu-ded as criteria for a diagnosis of an eating disorder.Some authors have highlighted that the originalaccounts of AN by Gull (1973) and Lase`gue (1973)made no mention of weight concern (Lee, 1993;Palmer, 1993; Rieger et al., 2001). Palmer (1993) com-mented that concern about shape and weight are notnecessarily present in Western cases. Polivy andHerman (2002) also noted that while it is difficultto imagine an eating disorder developing withoutbody dissatisfaction, there are many individualswho are dissatisfied with their bodies and yet nevergo on to develop an eating disorder.

    Traditional Indian, Chinese and Arabic cultureshave been cited as examples where at the very leastthinness was not emphasised as a requirement forfeminine beauty (Khandelwal, Sharan, & Saxena,1995; Nasser, 1988). The preference for plumpnesswas thought to protect against eating disordersin such communities. However, several lines ofthought suggest that the degree to which womenin non-Western societies admire a plump figurehas been exaggerated by Western observers. First,historically the non-medical literature suggests thatalthough a certain degree of fullness in the body mayhave been traditionally desirable, being fat wasnot universally admired across all traditional non-

    Western societies. Nogami (1997) described womenbeing depicted as slender in Ukiyoe prints, a form ofart characteristic of early 17th to late 19th centuryJapan. The heroine Lin Dai Yu in the 18th centuryChinese literary classic Dream of the Red Mansionhas been cited as an example of a slender ideal forChinese women (Kok & Tian, 1994a) and in addition,the description of an ideal for Chinese femininebeauty at the turn of the 20th century includedslender figure and sloping shoulders (Chang, 1991;pp. 3031). Second, body image dissatisfaction maynot be as critical a risk factor for eating disorders insome groups of non-Western women (Lake et al.,2000). Rieger et als (2001) retrospective analysisof 14 Asian patients treated for eating disorders inAustralia found that all 14 showed weight concern.In Singapore, 90% of eating disorder cases showedfear of fatness and 84% displayed disturbances inbody image (Ung et al., 1997), but a retrospectivestudy of AN patients in Hong Kong showed thatonly 41% displayed fear of fatness (Lee, Ho, &Hsu, 1993). In a review of five AN patients in India,only one showed concern regarding being over-weight, as well as conscious dieting and exercising(Khandewal et al., 1995). The other four did not dis-play body image disturbance, fear of maintaining anormal weight, a desire for thinness or a history ofpre-occupation with foodall hallmarks of ANbut at the same time these patients were not discon-tent with their emaciated weights. All five patientshad lost at least 25% of their premorbid weight, fourhad amenorrhoea and three had spontaneous vomit-ing. The authors considered that fear of fatness maybe a common but inessential feature of anorexianervosa, a theme supported by Fairburn and collea-gues (Fairburn, Shafran, & Cooper, 1998).

    This is not to say that fear of fatness is notexpressed in non-Western settings and patients. Aprevalence study of first-year medical students inChina found that 78.1% of the female studentsexpressed a fear of being fat, compared to 42.5% ofmale subjects (Chun et al., 1992). Also, in Romania,33 cases of eating disorders reported from 19901993 were found to be similar to those reported in lit-erature, despite occurring in a context outside ofWestern cultural influence (Joja, 2001). A review offive Arab AN patients also found that weight con-cern, expressed in terms of body image and fear offatness (concern regarding looking ugly and beingoverweight) was present in four of the five patients(Abou-Saleh, Youmis, & Karim, 1998).

    It is conceivable that while weight concern in theform of fear of fatness is not necessary for an eatingdisorder to develop and/or be maintained, it is more

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  • likely to be expressed in patients who have hadgreater exposure to Western culture and society.

    DIFFERENCES IN PRESENTATION:FAMILY STRUCTURE ANDENVIRONMENT

    From at least the 19th century, it has been speculatedthat disturbed family functioning is associated withAN (Weiss, 1995). AN patients have been typicallydepicted as emerging from cohesive and overprotec-tive family environments (French et al., 1997;Minuchin, Rosman, & Baker, 1978), while familiesof BN patients have been depicted as poorly orga-nised and non-cohesive (Vandereycken, 1995). Inboth North-European and African-American ado-lescent schoolgirls, a low level of family connected-ness has been associated with frequency of dieting(French et al., 1997), supporting the BN family struc-ture described above.

    However, a review of the literature regarding par-ental care and protection and family environment, inCaucasian and other ethnic groups, has not pro-vided consistent conclusions. A study into womenwith a chronic eating disorder (AN, BN or eating dis-orders not otherwise specified) found that their per-ceived level of maternal care to be significantlylower than that of partially recovered, fully recov-ered and control women. Their level of paternal carewas also perceived as significantly lower than that ofwomen fully recovered from an eating disorder andcontrol women (Bulik, Sullivan, Fear, & Pickering,2000). The authors put forward two interpretations:that the chronic nature of the eating disorder itselfhas a detrimental effect on the family structure aswell as causing bias in the persons perception ofher parents; or that the absence of adequate parentalcare truly contributes to the chronicity of the con-dition. Hodges, Cochrane, and Brewerton (1998)found that AN, BN and binge-eating disorder(BED) subjects perceived their family environmentto be less cohesive and supportive than normalpopulation subjects. However, the authors foundthat BED subjects perceived a significantly higherlevel of control in the family than did normal sub-jects and a trend for this high level of control wasnoted for AN and BN subjects as well. In contrast,Harding and Lachenmeyer (1986) found that familyenvironment factors did not contribute significantlyto eating disturbance levels in AN patients. Like-wise, Kent and Clopton (1002) found no differenceacross BN, subclinical BN or control undergraduatewomen in terms of family cohesion and control

    or levels of paternal and maternal care or over-protection.

    Few studies have examined parental overprotec-tion issues cross-culturally, let alone explored suchissues in eating disorder populations. McCourtand Waller (1995) found that South Asian school-girls in the UK had a significantly higher level ofperceived maternal overprotection than their North-European counterparts. The South Asian samplehad significantly unhealthier eating attitudes, uponwhich their perception of maternal overcontrol had asignificant effect (McCourt & Waller, 1995). How-ever, none of the studies discussed so far investi-gated the participants preferred familyenvironments.

    Although the traditional picture of an AN family isone of rigidity and enmeshment, some studies thatinvestigated eating pathology and ideal family func-tioning found interesting discrepancies betweenperceptions of family members. Dare, le Grange,Eisler, and Rutherford (1994) investigated familycohesion and adaptability in AN and BN adolescentoutpatients and their families, finding that the par-ents viewed their families as flexible and separated.This was in contrast to the patients themselves, whosaw their families as less cohesive than their parentsdid but more structured than their fathers perceived.However, the family structures identified by bothparents and patients as their ideal were similar, witha desire for greater cohesion and flexibility. Theauthors found that the relationship between adapt-ability and cohesion showed little uniformity acrossfamilies and when they investigated the differencebetween the perceived and ideal scores, they foundthat most of the families showed a sense of isolationand constraint. A similar finding was made in astudy of Singaporean schoolgirls: in this non-clinicalsample, there was a preference for families to bestructured and connected, irrespective of whetherthe subjects had a low or high drive for thinness.Thus the subjects desired more flexibility and morecohesion than they currently perceived theirfamilies to have (Kok & Tian, 1994b).

    Given the cross-sectional and retrospective natureof the above studies, as well as that of as others (Blair,Freeman, & Cull, 1995; Brookings & Wilson, 1994),caution needs to be exercised in extrapolating theirfindings or concluding that family cohesion andrigidity are aetiological factors in eating disorders.At least, however, such results do not universallysupport the classic family models proposed byMinuchin (1978), but nor do they reveal consistentsupport for a particular family structure for eatingdisorders, eating disturbances or ethnic groups.

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  • Furthermore, the empirical research has been con-ducted on eating disorder as well as communitypopulation samples. It is worth noting that even ifa certain type of family structure or functioning werecommonly found in eating disorder families, it doesnot indicate that it is part of the conditions aetiology(Dare et al., 1994). Also, families are not necessarilypathological, even if their functioning is at anextreme, as long as their members all expect andsupport such a pattern (Olson, 2000). As Tsai(2000) notes, What is perceived as parental overcon-trol in one culture may be construed differently inanother. High levels of cohesion and overprotectionare the norm in Asia and are seen as desirable (Bhu-gra et al., 2000; Kok & Tian, 1994a), yet the incidenceof AN is low. It is still debated whether or not the col-lectivistic nature of Asian families and societiesreduces or increases the risk of eating disorders(Lee & Lee, 1996; Tsai, 2000), but the above studiessuggest that the level of satisfaction with the per-ceived family environment, and patterns preferredby different members of the family, should be exam-ined more closely in relation to body image andeating disturbances.

    DIFFERENCES IN PRESENTATION:PSYCHOLOGICAL CONTROL

    It has been hypothesised that an individuals needfor control over their body is an essential featurein the development of an eating disorder (Polivy &Herman, 2002), and for example that an extremeneed to control eating is necessary to maintain AN(Fairburn et al., 1998). AN may be considered a dis-order originating from control issues, such as lackof control over the individuals life and emotions, afight or extreme need for self-control, or controlwithin a family setting (Surgenor, Horn, Plumridge,& Hudson, 2002). Fairburn and colleagues (1998)hypothesised that the AN patients initial need forgeneral self-control soon becomes dominated bythe need to have control over eating and that controlof eating is chosen as the means of control because itprovides direct, tangible evidence of self-control.They highlight that dietary restriction has connota-tions of being in control and that this is encouragedin Western society.

    As noted recently (Surgenor et al., 2002), the pre-sumed close relationship between AN (and eatingdisorders in general) and issues of psychologicalcontrol has not been tested in non-Western popula-tions, which may deem quite different control stylesand mechanisms as pathological. Fairburn et al.

    (1998) took the link further and hypothesised thateating disorder cases which do not display shapeand weight concern would more likely be found innon-Western countries and that the disorder wouldmore probably be driven by matters of self-control.

    Importantly in such speculations, it should benoted that the meaning and expression of controlvary across countries and cultures. For exampleWestern cultures emphasise primary or internalcontrol while Japanese culture emphasises second-ary or external control. European Americans andthose of higher SES report more internal controlwhile the Japanese report more external control;Hispanic cultures also commonly hold externallocus of control beliefs, which may be stronger inthose of a lower SES (Marks, 1998). Chinese studentsstudying in Australia and Asian-Australian migrantstudents were also more likely to endorse an exter-nal locus of control than Anglo-Saxon Australianstudents (Leung, 2001). Levels of acculturation alsoaffect the perception of control: first generation Japa-nese students in the USA have been found to scoremore externally in their control while third or latergeneration students were more internally orientated(Marks, 1998).

    Such different expressions of and preferencesregarding psychological control has been explainedby recourse to various cultural traditions and values.For example the agrarian heritage of the Chineseis seen as lending itself to collectivism, whereas thehunting and herding heritage of Europeans favoursautonomy and a looser social structure (Ji, Peng,& Nisbett, 2000). The East Asian individual doesnot view things in isolation and a sense of personalcontrol is less important to an East Asian individualthan to a Western individual. The East Asianindividual aims to conform to the reality whilethe Western individual tries to make the realityconform to him (Ji et al., 2000). Chan (1989) exam-ined locus of control in Hong Kong Chinese under-graduate students, who are considered moreWesternised in their values. This group was foundto be more externally oriented than those from avariety of Western countries. In Hong Kong, successis linked to various geomancy factors such as time ofan individuals birth, location of ancestors gravesand the layout of the house. Thus, in Hong Kongsociety, there is an emphasis on external controlwhere an individual should work hard on their pre-sent task and fate would take care of the rest(Leung, Salili, & Baber, 1986).

    In sum, psychological control is clearly importantin understanding eating disorders, but as suggestedby Surgenor et al. (2002), it may be that the degree of

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  • deviation from the control profile norm of a particu-lar culture has more of an association with eatingdisorders than the absolute profile itself. In the sameway that constructs of psychological control differacross cultures, the traditional associations betweensuch constructs and eating disorders may functiondifferently in these cultures.

    DIFFERENCES IN PRESENTATION:BODY COMPOSITION

    It is now recognised that universal cut-off points forbody mass index (BMI) values are not suitable foruse across all ethnic groups. Italian women havehigher body fat percentages than Danish womenfor the same BMI (De Lorenzo, Andreoli, Testolin,Oriani, & Svendsen, 2000) and Chinese women havealso been found to have higher body fat percentages(Deurenberg, Yap, & van Staveren, 1998; Ko et al.,2001). Compared to the World Health Organiza-tions cut-off points of 25 BMI points and over foroverweight and 30 and over for obese (World HealthOrganization, 2000), new lower cut-off values of 23for overweight and 26 for obese have been sugges-ted for Hong Kong Chinese (Ko et al., 2001).In Singapore, a cut-off of 27 for obesity was pro-posed (Deurenberg-Yap, Schmidt, van Staveren, &Deurenberg, 2000). To our knowledge, cut-off pointsto define what is underweight in different ethnicgroups have not yet been established. Ethnic differ-ences in body composition may be of clinical signi-ficance in managing eating disorder patients ofdifferent ethnic backgrounds in that modified wei-ght and BMI targets may need to be implemented.

    SUMMARY AND RESEARCHIMPLICATIONS

    The aetiology of eating disorders is still not wellunderstood and there are relatively few prospectivestudies reported in the literature. Only a handful ofstudies have examined patients diagnosed with aneating disorder while others have rather investi-gated subclinical levels of eating pathology. Com-mon notions that acculturation to Western cultureinduces eating pathology and body image distur-bances in non-Western societies is further compli-cated by cultural differences in family environmentand the encroaching similarity of socio-economiclevels. Classic features of eating disorders, such asbody image dissatisfaction, affluence, high familycohesion and rigidity and weight concern, are not

    universally present in Western patients, let alonenon-Western ones, and eating disorders were notunknown in the non-Western world, nor was a slimstature in women necessarily unfavoured thesesocieties.

    Most of the studies on eating pathology and bodyimage disturbances in non-Western subjects havebeen undertaken in Western nations rather thanthe country of origin, and often the degree to whichan individual had retained their traditional culturalvalues or absorbed the mainstream Western socie-tys values were not considered. Few studies mea-sured the level of acculturation and the methodsused have not been consistent across the literature.Also, few studies have been conducted in both aWestern and non-Western nation using the sameset of assessment tools. Psychological control pro-files in the non-Western individual have not beeninvestigated in relation to eating disturbances andthe differences in body composition across ethnicgroups warrants examination in regard to clinicalmanagement. Further scientific enquiry into theseareas is strongly encouraged and will hopefully con-tribute to understanding and managing eating dis-orders, which are now increasingly recognised inindividuals of different cultural backgrounds.

    ACKNOWLEDGEMENT

    The late Pierre Beumont, Professor of PsychologicalMedicine at The University of Sydney, was an activecontributor to this paper prior to his untimely deathin October 2003.

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