the existing criteria within the DSM IV culturally relevant to our diverse
As our society is bombarded with the
images of manufactured beauty and “thinness”, conversations increasingly
center on dieting and body dissatisfaction.
The media advertises weight loss products in the form of pills, drinks,
surgery, fitness equipment and support groups to mold individuals into the
proposed ideal form. This evidence
alone suggests a strong case for the possibility of a pathological fear of fat.
Is this fear, however, the driving force behind all cases of anorexia
nervosa and bulimia? According to the DSM IV, the fear of gaining weight is
essential for these diagnoses to be made. Strong
arguments have been made both in favor and against modifying the existing
criteria to allow for the diagnosis and treatment of individuals, regardless of
whether or not a ‘fat phobia’ is present.
Is it culturally insensitive to retain this particular criterion, a fear
of gaining weight, if a patient has not been exposed to the same cultural
pressures and orientation towards being thin?
Although western culture is thought to be the dominant culture, because
of power and economics, non-western cultures make up eighty percent of the world’s
population (Lee, 1995). Many of
these ‘sub-dominant’ cultures are present in the melting pot of the modern
United States. Are these non-Westernized individuals being denied the necessary
treatments and interventions merely because a fear of gaining weight is not
expressed? Such a strong focus on
body dissatisfaction may cause one to overlook or disregard the pressures of
societal systems, such as immigration or poverty, on the mental and physical
well being of an individual. If ‘fat
phobia’ is indeed a culturally constructed definition of anorexia nervosa, it
lacks a strong psychological and biological foundation, and is therefore
questionable in the eyes of many researchers and clinicians.
To observe the impact of culture on attitudes towards eating
and perception of body shape, Lake, Staiger and
Glowinski (1999) conducted a study using 140 female students from 2 Australian
universities. The students were
divided into 2 groups – those who were born in Australia (98) and those who
were born in Hong Kong (42). The
Students born in Hong Kong were further divided into 2 groups – a weak Chinese
ethnic identity group (Western acculturized) and a strong Chinese ethnic
identity group (Traditional) using the Ethnic Identity Scale (EIS).
All subjects were given the Eating Attitudes Test (EAT), a commonly used
and well-validated measure (Garner et. al 1979; Garner et. al 1982), to assess
attitudes towards eating. The Figure Rating Scale (FRS), used in similar
research due to its high test-retest reliability (Thompson et. al, 1991), was
used to determine perception of body shape.
The scores from these tests were then compared with the subjects’
The results showed significantly higher scores on the EAT (indicating
more negative attitudes toward eating) in the traditional Hong Kong born
subjects than that of their acculturized counterparts, while the acculturized
Hong Kong born subjects’ scores were significantly lower than those of the
Australian born subjects. In other
words, between groups (Hong Kong born v. Australian born) there was no
significant difference, but within-group (based on level of ethnic identity)
significant differences were present. In addition, the FRS scores indicated a
greater level of body dissatisfaction among the Australian born subjects.
The fact that greater body image distortion, in the absence of eating
attitude differences, was present in the Australian born women, it may be
inferred that body image is not a crucial factor contributing to eating
disorders in Hong Kong born women. It
is not a ‘drive for thinness’ that leads to their eating pathology. Perhaps
Hong Kong born subjects have not embraced ‘Western body figure preferences’.
These results support existing literature, which states that ‘attitudes
toward eating and perceptions of one’s own body shape are influenced by
cultural factors’ (Furnham et.al, 1994; Hill et. al, 1995).
The authors of this study believe that the criteria for eating disorders
should be more flexible in order to account for these cultural variations.
Based upon these results alone, can a decision be made as to whether or
not diagnostic changes are necessary? The
measures that were used to obtain data for this study, despite their validity
and reliability to date, are ‘Western’ questionnaires. Whether these questionnaires can be applied to non-Western
cultures has not been shown (King et. al, 1989). Therefore, to search for a more culturally sensitive
definition of eating disorders, a more culturally appropriate scale for aiding
in the search is needed.
Lending the perspective of Eastern culture, researchers from the Chinese
University of Hong Kong conducted a study in their country.
The study was aimed at exposing and explaining the non fat phobic segment
of anorexia nervosa. It is their
belief that anorexia nervosa may be conceptualized without ‘invoking the
explanatory construct of fat phobia exclusively’ (Lee et. al, 1993).
In this study, the subjects were 70 eating disordered patients (69
female; 1 male) with a mean age of 24 years.
To be included in the study, subjects had to meet the following criteria:
(1) weight loss of 15% or more of weight expected for height; (2) the weight
loss or maintenance of low body weight had to be induced by a restriction of
food intake, which may have been accompanied by (a) excessive exercise, (b)
self-induced vomiting, (c) self-induced purging, or (d) use of appetite
suppressants and/or diuretics; (3) in response to others’ attempts to make
him/her increase food intake, the patient used complaints such as fear of
fatness, abdominal bloating, loss of appetite, no hunger, or distaste for food,
to resist such attempts; (4) amenorrhoea in female or loss of libido in male;
and (5) no other known disorder accounted for the weight loss.
When the researchers examined reasons for food refusal, fat phobia did
not emerge as a prevalent explanation. In
fact, only 29 patients (41.4 %) exhibited fat phobia at the onset or during the
course of their illness. 41
patients (58.6 %) gave other reasons, such as stomach bloating (N=21), no
appetite (N=11), fear of food (N=1), or no explanation at all (N=8).
The proportion of non fat phobic patients to fat phobic patients is
thought to be even higher than what these numbers portray, because the former
may seek other forms of treatment (i.e. medical care rather than psychiatric
If such a large number of eating disordered patients lack a fear of fat,
how are they to be categorized and treated.
Without a clinical diagnosis, which necessitates a fear of gaining
weight, treatment becomes more complicated and uncertain.
Shouldn’t the terms ‘anorexia nervosa’ and ‘bulimia nervosa’ be
expanded in order to accommodate the non fat phobic patients?
answer is still unclear. Perhaps
the absence of fat phobia in these patients can be explained by insufficient
methodologies concerning the gathering of necessary data.
Human error can result in simply overlooking the presence of a phobia,
and imperfect questioning can allow for a phobia to remain concealed.
If a fear of fat does indeed prevail, there is no need to change the
Habermas, from the Institute for Medical Psychology in Berlin, is a proponent of
keeping the existing specific psychological criterion of fat phobia in the DSM
IV. He believes that this criterion creates a group of patients
with sufficient similarity (Habermas, 1994).
To expand the diagnostic criteria would be detrimental to the patient
population. A broad category for anorexia nervosa allows for food refusal of any
type - be it a display of religious beliefs, of defiance, a political statement
or any other non fat phobic behavior.
The existing definition of anorexia nervosa allows a doctor or clinician
to clearly define the problem and treat it accordingly.
a compromise can be made between the two schools of thought, without completely
abolishing or completely adhering to the fear of fat criterion. Lee and his
colleagues suggest the addition of a fat phobic - non fat phobic subtype
distinction within the existing diagnosis of anorexia nervosa (1993).
Regardless of the DSM IV’s diagnostic flexibilities, research
flexibility is needed to further understand and explore the nature of eating
disorders. The most critical
element to keep in mind is the need for treatment.
However we decide to categorize them, eating disorders are disabling and
can even be fatal. Treatments such as nutritional education, psychotherapy,
medication, and various interventions will continue to illuminate the details
and underlying causes that are still unknown.
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