Eating Disorders in Asia
Eating disorders in the United States and other Western countries draw much attention. However, it is wrong to assume that because Western civilizations receive the majority of attention and research, eating disorders are isolated to Western civilizations. Bearing that in mind, the first major goal of this paper is to determine the prevalence of eating disorders among women in Asian societies. Then, the causes for eating disorders among non-Western women can be compared with the causes among individuals in Western societies. This comparison also includes differences in eating behaviors and views on body image and how the culture shapes these qualities.
Eating Disorders among Asian Women
A study was done in Taiwan using 843 schoolgirls, age 10 to 14 (Wong et al., 2000). The researchers administered a questionnaire that collected data regarding body-weight perception, body-weight satisfaction, desired body weight and attempts at intentional weight loss. The girls Body Mass Indexes were calculated, and they were classified as obese, overweight, acceptable weight, underweight, or severely underweight. The distribution fell in a bell-shaped curve, with 8.1% of the students classified as severely underweight, 10.4% underweight, 64.3% acceptable weight, 10.8% overweight, and 6.4% obese. Regardless of their actual weight, a high percentage of students in each category perceived themselves to be in a higher weight category than they actually were.
Approximately 65% of the students in the study, including girls in both underweight categories, wanted to be thinner. The researchers came to the conclusion that dissatisfaction with body weight occurs in women in all weight categories. Thirty-eight percent of the subjects had intentionally tried to lose weight, once again including 12.5% of underweight individuals and 35.2% of acceptable weight individuals. The desire for lower body weight also increased with age. The ten-year olds wished to weigh an average of 1.6 kg less, while the fourteen-year olds wanted to weigh about 4.5 kg less than they did. This indicates an increased dissatisfaction with weight as the girls enter into puberty around ages 13 and 14. The authors of the study felt that a longitudinal follow-up study was necessary to determine if eating disorders became a problem for these schoolgirls later in their teens.
A study of female Japanese high school students attempted to estimate the prevalence of eating problems and identify factors associated with these problems (Nakamura, 1999). They distributed questionnaires to 3,032 female high school students in Japan and calculated their BMI. The questionnaire consisted of sections related to demographic characteristics, behaviors and symptoms related to eating problems, risk factors for eating problems and a version of the Eating Attitudes Test. The subjects were asked to rate their self-perception of their body weight as very light, light, average, heavy, or very heavy. Their actual BMIs were also classified according to these categories.
The researchers found that 57.5% of the students had dieted for less than a month, 11.3% had dieted for a month or more, 8.7% had fasted for less than three days, and 1.7% had fasted for more than three days. Approximately 6% of the females had performed strenuous exercise to lose weight, 9.6% took laxatives, 4.8% used diet pills, and 1.4% used diuretics. Seventeen percent of the individuals in the study reported amenorrhea and 5.4% had an EAT score equal to or greater than 20, which is indicative of eating problems. They found that older age, higher BMI, distorted body image, obsessive-compulsive tendency, and familial issues related to eating problems. Out of these issues, distorted body image was found to be the most important factor associated with eating problems.
Another study conducted by Wong and Huang examined the concerns about obesity, weight and dieting among Taiwanese female college students (Wong 1999). There are only a few cases of eating disorders reported each year in Taiwan, and the actual prevalence is unknown. The authors believe that the small number of reported cases stems from the inadequate knowledge of symptoms of eating disorders and proper eating behavior. Data was collected using a questionnaire that measured 1,057 female students’ concerns and behaviors related to body weight, knowledge of general nutrition, attitudes toward nutrition, and their nutritional practices. Their weight and BMI was also computed and they were classified as severely underweight, underweight, acceptable, overweight, and obese.
Results showed that the students perceived themselves as being heavier than they were, regardless of their weight category. There were also approximately a quarter of both severely underweight and underweight individuals that indicated they were either on a diet or exercised to lose weight. There were only two subjects that took medication or purged to lose weight. The study found that 51.4% of the students perceived themselves as overweight or obese, while only 16.2% of the subjects actually were. The researchers discuss how dissatisfaction with body weight is a well-known risk factor leading to eating disorders and that risk factors leading to eating disorders are high in Taiwanese college females. According to the authors, the existing and potential problem of eating disorders in Taiwan ought to be attracting the attention of physicians, psychologist, dieticians and educators.
Cross-Cultural Comparisons of Eating Disorders
The effect of culture on eating disorders is a concern that many people have. Many studies have shown that the incidence of eating disorders tends to increase in non-Western women who enter Western society. It has also been found that Chinese women share an ideal of slimness with Western women, but it does not necessarily lead to dieting and eating disorders. One study on cultural effects on eating disorders examined Hong-Kong- and Australian-born women attending Australian universities (Lake 2000). Before they did the study, they noted that the DSM-IV makes reference to the fact that in non-Western individuals, disturbed perceptions of body image might not be shown and food restriction may not be to lose weight. The main purpose of their study was to examine the effect of cultural influences on the development of negative attitudes toward eating and unhappiness with body image. Both of these factors have been associated with the development of eating disorders.
The researchers sampled 140 female college students, 98 born in Australia, 43 born in Hong-Kong. The Hong-Kong group was divided into two subgroups using the Ethnic Identity Scale. This separated them into weak Chinese ethnic identity and strong Chinese ethnic identity groups. The subjects completed the Eating Attitudes Test, the Figure Rating Scale, and a demographics questionnaire. The Australian- and Hong-Kong-born groups had no significant differences in eating attitudes. Within the Hong-Kong-born group, the traditional Chinese subjects had higher EAT scores than the acculturated Chinese subjects, indicating more negative eating attitudes. The Australian-born subjects reported greater body image dissatisfaction than either of the Hong-Kong-born groups, which had similar body image perceptions.
The researchers found no difference between the groups in eating attitudes, but there were significant differences in body shape perceptions between the Australian-born and Hong-Kong-born individuals. Hong-Kong-born women had little body dissatisfaction when compared with Australian-born women. The traditional Chinese women, those who had strong ethnic identity, were more influenced by Western values than the acculturated group. Their eating attitudes are body image perception was most similar to Australian-born women, which the authors feel supports the "culture clash argument." The traditional group was more influenced by Western values than the acculturated group. A possible explanation for this is that traditional Chinese women feel in conflict with their family values when trying to emulate Western independence. Since the Australian and Hong Kong groups showed similar attitudes toward eating, but different body image perceptions, the authors thought that body image might not be a strong factor contributing to eating disorders in Hong-Kong-born women. This is consistent with the DSM-VI reference that disturbed body image in non-Western eating disorder patients may not be obvious. This implies that the absence of this factor in a non-Western individual may not rule out an eating disorder if other symptoms are present.
Emotional eating is another factor associated with eating disorders since eating problems are often related to mood. A study done by Waller compared emotional eating and bulimic attitudes among women in Japan and the United Kingdom (Waller 1999). It is not well-known whether or not emotional eating exists among Japanese women or if it is associated with eating disorders, since the rules for emotional expression differ in non-Western cultures. Japanese women are found to be reluctant to express emotion and that they are poor at recognizing negative emotions through faces and body movements. The study examined three groups of women: Japanese living in Japan, Japanese living in the U.K., and British in the U.K. Ninety women were given the Emotional Eating Scale and the Eating Disorders Inventory. The EES measures the use of eating to cope with negative mood and asks people to rate the strength of their urge to eat while they are experiencing certain emotions.
British women had more restrictive eating attitudes than either Japanese group. The Japanese women living in Japan had low levels of self-esteem and Japanese women were less comfortable with their development. Japanese women living in the U.K. showed similar patterns of linkage between emotional eating and levels of bulimic attitudes with British women. British women were heavier and had less healthy eating habits than the Japanese women. The Japanese women living in the U.K. were similar to the British women, with emotional eating relating strongly to bulimic attitudes. The authors concluded that emotional eating is not necessarily a psychopathological problem, since its presence in non-Western culture did not coexist with disturbed eating attitudes, as in Western cultures. This study supports the belief that acculturation affects eating attitudes. Japanese women living in the U.K. demonstrated a behavioral pattern more similar to British women than the Japanese women living in Japan.
A study by Lippincott compared the attitudes toward eating between women in Pennsylvania and South Korea. They studied 226 college women, 111 in Pennsylvania and 115 in South Korea. The two groups had similar percentages of individuals with scores that would indicate eating disorders. Twenty-one percent of the U.S. college students had scores suggesting symptomatology of eating disorders, higher than 20 on the EAT, and 18% of South Korean students had these high scores also. The two groups had similar attitudes toward eating and body size as well. The authors believed that the mass media exposure of Western ideals of thinness to non-Western cultures could be a possible reason for the increase in eating disorders among individuals in non-Western society. This gains credibility when compared to the traditional belief in Asian cultures that thinness represents ill health and fatness represents affluence. Some reports state that fatness is no longer valued by Asian, female college students and that they feared becoming fat.
Different age groups have different ideas about eating behaviors and body image. The study done on Taiwanese elementary school students showed an increase in body image and weight dissatisfaction over the period between ages ten and fourteen. In high school students, eating problems were found to increase. The study examining Taiwanese college students found that risk factors leading to eating disorders were fairly common. They misperceived their body weight, overestimated body fatness and had inappropriate body images. The studies indicated that body dissatisfaction increased through puberty and into college years.
More longitudinal studies need to be done in order to determine possible causal factors in eating disorders among women in Asia. Many studies discussed a need for a review of the DSM VI criteria for eating disorders to account for cultural differences to help with diagnosis. The low number of reported cases of eating disorders is probably related to inadequate diagnosing tools. The effects of culture can be seen as a strong influence in the presence of body image dissatisfaction among Asians living in non-Western societies in the numerous cross-cultural studies. There was little discrepancy between the findings of the studies, leading me to believe that they were executed well and their conclusions were valid. It is almost impossible to determine if culture can cause eating disorders, so studies examining behaviors cross-culturally is the best indicator of cultural beliefs. The increase of eating disorders in non-Western societies after the introduction of Western ideas, fashion and media, supports the belief that culture plays an important role in the development of eating disorders, since their prevalence in Western societies is high.
Lake, A., Staiger, P., & Glowinski, H. (2000). Effect of Western Culture on Women’s Attitudes to Eating and Perceptions of Body Shape. International Journal of Eating Disorders, 27, 83-89.
Lippincott, J. & Hwang, H. (1999). On Cultural Similarities in Attitudes Toward Eating of Women Students in Pennsylvania and South Korea. Psychological Reports, 85, 701-702.
Nakamura, K. et al. (1999). Eating Problems in Female Japanese High School Students: A Prevalence Study. International Journal of Eating Disorders, 26, 91-95.
Waller, G., Matoba, M. (1999). Emotional Eating and Eating Psychopathology in Nonclinical Groups: A Cross-Cultural Comparison of Women in Japan and the United Kingdom. International Journal of Eating Disorders, 26, 333-340.
Wong, Y., Bennink, M., Wang, M., & Yamamoto, S. (2000). Overconcern about thinness in 10- to 14- year old schoolgirls in Taiwan. Journal of the American Dietetic Association, 100 (2), 234-236.
Wong, Y., Huang, Y. (1999). Obesity Concerns, Weight Satisfaction and Characteristics of Female Dieters: A Study on Female Taiwanese College Students. Journal of the American College of Nutrition, 18 (2), 194-199.
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