Sociocultural Influences and Eating Disorders Around the Globe

Highlights of the 2002 International Conference on Eating Disorders

The Academy for Eating Disorders’ annual conference took on a global flavor in Boston this year. Nine hundred clinicians from the U.S. and abroad had a choice of hundreds of reports and presentations, plenary sessions, dozens of seminars, two satellite symposia and a clinical teaching day.

In a plenary session moderated by Dr. Daniel le Grange, assistant professor of psychiatry and director of the Eating Disorders Program, University of Chicago, four panelists took the audience on a trip around the globe to examine the effects of culture and gender on eating disorders.

South Africa:
Youth at increasing risk

Dr. Christopher P. Szabo predicts that the unique and complex social and political transformation taking place in South Africa will lead to an increased risk of eating disorders. As urbanization continues, Dr. Szabo said, the current trickle of cases of eating disorders reported in South Africa “will turn into a flood.” Dr. Szabo is currently the only academic mental health professional in South Africa working with people with eating disorders, and was a member of the group that reported the first 3 cases of eating disorders in black African females in 1995. He is associate professor of psychiatry at the University of Witwatersrand and director of the Adolescent and Eating Disorders Unit at the H. Moross Centre, Johannesburg.

In South Africa, few data are available about any of the eating disorders, he said. What is known is that the tremendous migration of people from rural areas to urban settings has brought a clash of new and old sociocultural trends. For example, he reported that while there are efforts to get black women to lose weight to prevent heart disease and diabetes, many black women are very resistant to participate in weight loss programs because in the black community weight loss is associated with HIV and AIDS.

Dr. Szabo feels that South Africa is currently in a latent phase, where the incidence of eating disorders appears to be lower in blacks than in non-black populations. Although in his own experience he has seen very few cases of eating disorders among blacks, the stigma of having “a white man’s disease” may keep some black Africans from seeking help. For example, he reported a case of a young black girl being treated for an eating disorder who was verbally attacked by black nursing staff. The staff asked her how she could suffer from a ‘white man’s disease.’ This prejudice was echoed by the girl’s family. The girl remained in treatment and is now recovering.

“The important message,” said Dr. Szabo, “is that eating disorders can affect everyone.” He added, “Everyone, especially in an urban setting, is at risk.”

Fiji: TV strikes with a vengeance

Anthropologist and eating disorders expert Anne E. Becker, MD, PhD, told the audience that television has had a tremendous and often negative impact upon the Fijian society. She noted that her studies add a little more to the mounting pile of evidence of the very insidious and very profoundly adverse effects of media imagery on the body image of young women.

Dr. Becker, who is director of the Adult Eating and Weight Disorders Program at Massachusetts General Hospital, and a professor of medical anthropology and psychiatry at Harvard Medical School, said that more than three-fourths of Fijians in a recent study reported that television teaches them what to do and not to do; more than 75% of subjects wanted to look more like television characters.

Her data suggest that the prevalence of disordered eating attitudes and behaviors is increasing among ethnic Fijian schoolgirls, and this trend appears to be associated with prolonged television exposure. “Data thus far suggest that there is a very clear and explicit relationship between what they see modeled on TV and their fantasy that if they can achieve the body, they can achieve that lifestyle as well,” she said.

Fijian youth are also at increasing risk because their society is entering a cash economy for the first time and there is virtually no experience with this way of life, Dr. Becker said. Young people cannot look to their traditional avenues to know how to navigate the changing environment and their elders have no idea what to tell them. So, they turn to television characters instead. Dr. Becker added, “I am personally disheartened to see that 2000 years of tradition has been so easily undermined by just a few years of exposure to televised images.” In additional to TV, young women are now feeling pressure to enter the work world, particularly the tourist industry as hostesses and flight attendants; women who are selected for these jobs are thinner and fairer-skinned.

Disordered eating is only one of the problems that has arisen in the context of television, she said. Ten-year prospective data show that the prevalence of overweight and obesity has risen from about 66% to 84% among Fijian women. Television has also brought ads for high-fat Western foods, which are prestige foods in Fiji. On Fiji, Dr. Becker notes few psychiatric services or psychotropic medications are available through the Public Health Service. Thus, while the adverse effects of western media have reached the island, effective means for counteracting the effects have not.

Curacao: Shape, weight concerns affected by education, travel abroad

Eating disorders should be viewed as a marker of cultural change rather than as a function of or a response to thin ideals, according to Hans W. Hoek, MD, PhD, professor at the Hague Psychiatric Institute, the Netherlands, and professor of epidemiology, Columbia, University. Although eating disorders are currently rare in Curacao, the daily arrival of cruise ships is bringing western influences to the island, he said.

Curacao offers the perfect “living lab” to study eating disorders in a non-white, changing society, according to Dr. Hoek. The population is 79% black, 30% Creole, or mixed race, 7% white and 1% Asian, he said. The people of Curacao have been fairly thoroughly studied, and the health data are fairly complete, unlike the situation described in South Africa.

Weight and shape are not of concern to most women of Curacao, he said, and a general health survey showed that most females, even those who were obese, were happy about their body weight and shape. As for body mass index (BMI), he added, men in Curacao weigh a little less than blacks and whites in the US. For women, however, the average BMI is 2 points higher than the average BMI for white women in the US. He pointed out that this is a 13-lb difference, and that health-care professionals are much more concerned about treating obesity than detecting and treating eating disorders.

Tourism and television do have an impact upon the island’s society. Dr. Hoek added that those who are educated abroad have much more concern about weight and shape than those who haven’t traveled abroad. AN does not seem to occur among the black population, and this group has a high tolerance for overweight. However, in a second group, those educated abroad and from a higher socioeconomic level, the incidence of eating disorders is similar to that of the U.S. and the Netherlands.

Dr. Hoek concluded, “One would expect eating disorders to occur in societies where there is at least a subset of individuals who may be struggling with two cultures, due to educational or immigration opportunities, or a subgroup that is being exposed to modernizing influences.”

Rhode Island: Body image disorders in men

Body image concerns are relatively common and actually quite disturbing to men, according to Katherine A. Phillips, MD, associate professor of psychiatry at Brown University School of Medicine and director of the Body Dysmorphic Disorder Program at Butler Hospital, Providence, RI. Body image concerns are commonly reported in women, but when it comes to body image, men are really a neglected gender, she said. Very little attention is paid to their concerns and very little research has been done in this area.

She told the audience that body dysmorphic disorder (BDD), a preoccupation with an imagined defect in appearance, is being increasingly reported among men. If a slight physical anomaly is present, even if it is not apparent to anyone else, the individual becomes obsessed about changing it or hiding it. The defect they perceive is either something that can’t be seen by others, or is very minimal. About 1 to 2% of the population is affected. BDD can coexist with anorexia nervosa and other eating disorders.

Dr. Phillips then described one of the newer forms of BDD, muscle dysmorphia, a condition almost exclusively reported in men. Muscle dysmorphia is a pathological concern that one’s body is not lean and muscular. This preoccupation with size and strength causes problems in functioning or distress, she said, in which an individual often gives up important activities because of a compulsive need to maintain his diet and workout schedule, and avoids situations where his body is exposed to others or endures them only with much distress and anxiety. While BDD has been known for more than a century, muscle dysmorphia has really been discussed and recognized only for the past few years and is not yet included in the Diagnostic and Statistical Manual of Mental Disorders.

Dr. Phillips asked the audience to consider the possible influence of sociocultural messages, media messages, and even action toys upon men’s body image. In the same way that Barbie dolls send messages to girls, action toys may be having an effect on boys, she said. Studies are showing that action figures are dramatically increasing in size and muscularity and provide an exaggerated model of fitness (often attainable only with steroids) for young boys. Women’s magazines are also including a increasingly high number of unrealistically thin and muscular men. During the past 35 years, the number of photographs of undressed men has skyrocketed, while the percentage of undressed women hasn’t changed much, she said. She added that during this time the average male centerfold in Playgirl magazine lost 12 lb of fat and put on 27 lb of muscle.

Dr. Phillips concluded that there is much to learn about treating muscle dysmorphia. For BDD, however, cognitive behavioral therapy can be very effective, and other approaches such as cognitive restructuring, exposure treatment and response prevention can be helpful for stopping the excessive and repetitive behaviors so common to BDD. SSRIs given at slightly higher dosages than are used for depression can be quite effective as well, she said.

Dr. Phillips told the audience that the first step in intervening in the disturbing trend of increasing body image problems among men is to recognize that sociocultural messages do exist and that men are getting messages similar to those that women have received for a very long time. These messages may contribute to body image dissatisfaction. Steroids are available and may be contributing to the rise of muscle dysmorphia. “We need to start educating boys and men about these influences, and to study them,” she said.