24 The sociocultural and personal dimension of eating disorders

Food is considered a ‘cultural system’, and eating patterns are acknowledged as culturally shaped and socially controlled (Caplan 1997). Roland Barthes viewed food as symbolic of the entire social environment and regarded it a language or a form of communication between people (Barthes 1975). Hence, food practices have little to do with hunger or health needs than with the conditions of subjective identity and social relationships.

Food restraint, fear of fatness, and the pursuit of thinness are modern terms that are now used interchangeably to refer to the pathological dieting behaviour integral to anorexia nervosa. The anorexic syndrome was first reported in the latter part of the 19th century by William Gull (1874) in Britain and Charles Lasègue (1873) in France; both described a distinct state of self-starvation peculiar to young women and likely to be caused by a host of emotional factors. It was noted, however, that nearly half of the anorexic population exhibited symptoms of binge eating following periods of self-starvation. Russell (1979) referred to this group as having ‘bulimia nervosa’ and described it as a variant of anorexia nervosa characterized with periodic over-eating, self- induced vomiting, or purging to compensate for the effects of over-eating. Both anorexia and bulimia nervosa were later subsumed under ‘eating disorders’—a term that was introduced to acknowledge the full spectrum of eating psychopathology. The concept has been incorporated in both the American Diagnostic Manual (DSM-IV, American Psychiatric Association 1993) and the International Classification of Mental and Behavioural Disorders (ICD-10, WHO 1992).

Eating disorders are considered unique among psychiatric disorders in the degree to which social and cultural factors influence their epidemiology and development. The nature of the eating disorder syndrome and the fact that it clearly merges with the prevalent and the culturally acceptable behaviour of dieting called for an interpretation that is grounded in the culture we live in. The phenomenon was therefore understandably linked to the cultivation of a certain type of body ideal and the promotion of thinness values through media, fashion, and diet industry. Subclinical cases or partial syndrome that merge with normal dieting behaviour were generally estimated to be five times more common than the full-blown syndromes (Dancyger and Garfinkel 1995).The finding was consistent with the ‘spectrum hypothesis’ of eating disorders and ran parallel to reported steady increase in the rate of their occurrence in the latter half of the 20th century (Lucas et al. 1991).

The sociocultural model of eating disorders was further supported by the susceptibility of certain subcultural groups to develop these disorders, such as dancers, models, and athletes, where the demand for thinness is endemic (Garner and Garfinkel 1980; King and Mezey 1987; Weight and Noakes 1987).

This epidemiological research has also shown a clear and consistent ‘gender bias’ where women were found to be ten times more at risk for such disorders than men. ‘Fat’ is considered integral to women’s biology, and has the tendency to concentrate in certain areas of the woman’s body, particularly those with sexual significance like the breasts and hips. Also a threshold of body fat is an essential requisite for menstruation.

In view of this skewed distribution, feminist theorists posited that these disorders represent an answer to the dilemma women face today, being torn between old and new expectations of their gender role. The thinness ideal came to be seen as metaphorical synthesis between the old notions of attractiveness and fashionability and the new modern values of autonomy, achievement, and self-control (Orbach 1986; Malson 1998). This conflict over gender role produces in women a sense of ‘gender ambivalence’, i.e. a term used to describe the societal ambivalence of the female role and the ambiguities felt by women, particularly during periods of historical and cultural transition (Silvertein and Perlick 1995; also see Chapter 28, this volume). Even among the small proportion of men who develop such disorders, a disproportionate number have doubts or uncertainties about their sexuality and gender identity problems (Williamson 1999).

Another finding that emerged in the 1990s, was the apparent increase in the prevalence of eating disorders in proportion to the level of ‘urbanization’ in any given society (Rathner and Messner 1993; Hoek et al. 1995), This was explained on the basis of social mobility and changes within family structure with tendency towards nuclearization. Also, as cities urbanized, eating patterns, food preferences, and meal times seem to change with the inevitable rise in the rates of obesity and a subsequent increase in weight consciousness and disordered patterns of eating (Nasser and Katzman 1999).

So, within this framework, cultural, subcultural, and intracultural risks in the pathogenesis of eating disorders are easily discernable. The apparent absence of these disorders in non-Western cultures and societies; added—at first—another support and made some regard the phenomenon of eating disorders as exclusively bound to the Western culture (Prince 1983) (see Box 24.1).

The culture-boundedness/specificity of eating pathology stood first on the assumption that societal mandates regarding thinness were rooted in Western cultural values and conflicts. The theory of culture-boundedness was based on the scarcity of these disorders as judged by the few published reports in this respect. This was thought to reflect perceived differences in aesthetic standards between West and non-West. In contrast to the Western ideal of thinness, non-Western societies were seen to favour plumpness and associate with it positive attributes of wealth,

fertility, and femininity. The fact that the majority of these societies also belong to Third World economies, made them appear protected from developing a disorder commonly associated with wealth and affluence. Also, the role of women in non-Western societies continued to be seen within a restricted framework of the stereotyped and the traditional, and therefore considered immune from the challenges of modernity that women in the West face (Nasser 1997, 2000).

In spite of these considerations, there is now an increasing body of evidence that challenges the rarity of these disorders in non-Western cultures and societies. Research among different ethnicities living in the United Kingdom (UK) and United States (US) showed the presence of these disorders in such groups. Also a surge of publications in the 1990s, from different countries in the world suggests that eating disorders are increasingly becoming a global phenomenon. Most of these studies aimed to explore the impact of immigration, acculturation, and overall cultural change in the pathogenesis of these disorders.

The experience of women from other ethnicities and cultures with disordered eating behaviours has accumulated after the publication of several case reports in both the UK and the US (Jones et al. 1980; Andersen and Hay 1985; Thomas and Szmukler 1985; Hsu 1987;  Lacey and Dolan 1988). These authors observed the psychological problems of those girls who were reported to have high aspirations and clear achievement orientation. They were also described as being conflicted over their ‘racial identity’ with a powerful urge to fit into the host society, hoping for integration through conforming to the prevailing ideal of thinness/beauty. Hence, immigration and acculturation were regarded in a great number of these studies to be behind the immigrants’ susceptibility to developing weight concerns. A correlation was found between the level of acculturation and morbid concern over weight (Smith and Krejci 1991; Davis and Katzman 1998). Dieting behaviour was found to be equal among black and white females in the US (Gray et al. 1987), and dysfunctional eating patterns were found to be more prevalent in the African-Caribbean population in Britain than their white counterparts (Reiss 1996).

In some of these cases, the desire to fit into a culturally desirable weight was not only a licence to approval/acceptance but also served the need of the immigrants to correct a negative stereotyped image of their race (Davis and Katzman 1999). The issue of ‘racial identity’ and its relationship to eating disorders was further studied among black South African women after the fall of the apartheid regime, where the reported increase of eating disorders following the political change was linked to a sense of shifting identity and altered self-conception among those South African females (Szabo et al. 1995; Le Grange et al. 1998).

From these reports and studies it is clear that women from minority groups—contrary to the initial assumption—could be at a higher risk of developing eating psychopathology than originally assumed. The following are the risk factors encountered in these groups:

The majority of research into eating disorders across cultures was modelled on community surveys carried out in the West. Most of these studies were structured around a recurring binary hypothesis aiming to identify if eating psychopathology did exist in non-Western societies or not, as well as the relationship between exposure to Western cultural norms and values and increased vulnerability to such disorders. Some of the earliest studies were carried out in Egypt (Nasser 1986, 1994; Dolan et al. 1990), Greece (Fichter et al. 1983), and Turkey (Fichter et al. 1988), where high rate of disordered eating behaviour was found among those who appeared to be more influenced by the idealized Western cultural norms in this respect.

In Israel, where both Arab and Jewish school girls were examined, the Kibbutz women were found to have the highest risk for eating morbidity followed by the Arab Muslims (Apter et al. 1994). The effect of combined religious influence and exposure to Western culture values was later explored in a number of studies with evidence of equal or higher rates of disordered eating behaviour in Muslim women in the UAE and Iran (Abou-Saleh et al. 1998; Nabakht and Dezkhan 2000).

Studies of the eating disorders in Asian groups, was initially part and parcel of studies carried out on ‘Asian’ immigrants in the UK or in other countries in the West. The Asians constitute the largest immigrant population in the UK and comprise Indians, Pakistanis, and Bangladeshis. The most notable of these studies is the one conducted by Mumford and Whitehouse (1988) on Asian schoolgirls in Bradford which showed Asian girls to have higher risk to eating disorders than the Caucasian group, particularly girls from traditional/Islamic backgrounds. However, in another study conducted in Lahore, Pakistan, the girls who were most Westernized appeared to be more at risk of developing an eating disorder (Mumford et al. 1991).More cases of bulimic behaviour were also found among Asian schoolgirls than Caucasians in further studies conducted on mixed population of school girls in the UK (Ahmed et al. 1994; McCourt and Waller 1995).

Cultural variations on how ‘Asian’ is defined between the US and UK, suggest that studies of Asian populations in these countries actually differ in the types of samples they are examining. While in the UK, these investigations typically involve individuals who are ethnically south Asian (i.e. from India, Pakistan, and Sri Lanka, etc.), in the US the term ‘Asian American’ refers to East Asian and South Asian countries. When Asian women attending American schools in the United States were compared to those in Hong Kong, the former group showed evidence of increased vulnerability to abnormal eating behaviours (Davis and Katzman 1998). Also, disordered eating patterns and body dissatisfaction were, on the whole, reported to be on the increase in Hong Kong (Katzman 1995; Lee and Lee 1996). It was argued however, that the over-reliance on the ‘fear of fatness’ as a diagnostic criterion in eating psychopathology could have led to an overall underestimation of the magnitude of these problems in societies like China, India, and Japan (Katzman and Lee 1997). They added that the weight/thinness-focused approach to the eating disorder phenomenon failed to take into account the cultural meaning of ‘self-starvation’ in a society like China, for instance, where the food denial is symbolic of loss of voice in a social world perceived to be oppressive (Lee 2001). The same was argued in a survey of eating disorders in Singapore (Pok and Tian 1994).

On the other hand, Japan reported an increased tendency towards anorexic behaviours since the Second World War, attributed to changes in traditional family structure in the post-war period (Ishikawa 1965). This was followed by several studies which confirmed this trend (Suematsu et al. 1985; Kamata et al. 1987; Mukai et al. 1994). The level of urbanization was found to affect this incidence with higher rates of these disorders in cities than in rural areas of Japan (Ohzeki et al. 1990).

A similar situation was found in Latin America with eating disorders emerging as a significant problem in urban areas in particular. Cases of anorexia nervosa were reported in Chile and Brazil (Pumarino and Vivanco 1982; Nunes et al. 1991), and in Argentina an ‘epidemic of eating disorders’ in Buenos Aries was reported in the 1990s and was related to ambiguities and conflicting cross-currents regarding national and that of female identity in particular (Meehan and Katzman 2001)

However, one of the most interesting findings of transcultural research in the field of eating disorders was the emergence of eating psychopathology in Eastern Europe following the politico-economic change. Eating disorders that were largely unreported in Eastern Europe before the collapse of the communist regimes began to appear in eastern European literature. High rates of abnormal eating attitudes as measured by the Eating Attitude Test Questionnaire (EAT) were reported in Hungary, Poland, and the Czech Republic (Szabo and Tury 1991; Krch 1994; Rathner et al. 1995; Warczyk- Bisaga and Dolan 1996) and for detailed review of this published research refer to Nasser (1997), Nasser and Katzman (1999) and Gordon (2001) (Fig. 24.1).

It is important, however, to mention that several doubts were raised about the validity of using the EAT in different cultural settings, particularly its susceptibility to cultural misinterpretation (King and Bhugra 1989). Despite those concerns the use of EAT in these studies proved to be helpful in facilitating research and allowing possible comparisons to be made between cultures in this respect (Nasser 1995, Nasser 1999).

From what has been advanced so far, it is possible to argue that countries in the grip of cultural changes as well as immigrants and minority groups on the fringe of mainstream cultures, are at certain risk for developing disordered forms of eating.

Immigration and increased migration to the cities is a common feature of today’s world; this is normally accompanied with increased social mobility as well as changes within family structures. Following urbanization there is a notable change in individual lifestyle, particularly with reference to work and dietary habits. The urbanized world is also increasingly becoming more ‘uniform’ by reason of several globalizing forces, including mass media, information technologies, and the adoption of market economy. Market forces, in turn leads to the standardization of an aesthetic ideal and the marketing of this ideal.

The transition in some countries from State-controlled economy to markets has arguably undermined the collective social structure and resulted in the disappearance of some of the social networks that provided women with protection in their education, employment, and childcare rights. This is seen to be behind the ‘gender ambivalence’ felt by women of former socialist regimes, in addition to increased consumerism and material aspirations.(Catina and Joja 2001; Nasser and Katzman 2003). It was suggested that the increase in commercialism and the changing gender roles, coupled with the depletion of State-offered benefits (such as education, employment, and healthcare), may result in the commodification of the human body and its modification to fit with the global standardizations of beauty, marketability, and adaptability (Rathner 2001).

Another dimension to the ‘change in culture’ is the emergence of ‘online cultures’, reflected in a change of how an individual relates to one’s own nation as a geographic entity which carries with it a threat to the sense of national identity (Morley and Robins 1995; Nasser and Katzman 1999, 2003).

There is no doubt that there are inherent advantages in the potentially unlimited choices, but to negotiate these choices the individual needs to learn how to reformulate an identity amidst an influx of visual information and images. However, at times of change or when ‘identity definition or redefinition’ is called for, the individual was noted to have a tendency to shift the locus of power to the body and reformulate the new identity in bodily terms. This results in various forms of ‘body control’, including eating disorders which make them, in turn, symptomatic of the ‘transition’ in culture and not culture per se (Nasser and DiNicola 2001). This means that the underlying sociocultural dynamics of eating psychopathology lies in ‘cultural change’. This can be broken down to the following forces:

As one examines the movement of eating disorders from individual neurosis to cultural marker of distress, caused by transitional and conflicting cultural forces, it becomes increasingly important to identify ways of operationalizing treatment and prevention strategies. By organizing our research and clinical questions around ways of assisting women in self-determination, control, and connection rather than simply documenting media and weight insults, we may be able to progress beyond the limitations of our current strategies and provide alternatives for women struggling with eating disorders as a ‘answer’ to complex personal, social, and personal problems. Nasser and Katzman (1999) suggested that the prevention of eating problems will be enhanced by the provision of new social supports and the careful work of providing new ways of belonging at the work and school level. They also recommended a shift in emphasis towards competencies rather than pathology in prevention and treatment strategies.

However, the question remains as to how to generate dialogue and engage individuals who share the same predicament worldwide? Perhaps the answer lies in taking advantages of the existing information technology. Electronic connections may provide a new way of achieving female connectedness, one in which women may be able to help other women whom they would not have been able to access in the past. Linked by computer technology, women may be able to overcome their social and political isolation and gain new insights into formulae for success and survival (Nasser 1999).

Similar techniques are currently being used in the management of eating disorders, focusing on psychoeducation and self-help cognitive strategies. These interactive web-based multimedia programmes are likely to make specialist therapies available to many more people who traditionally would have been unable to access such help. Recognition of these new mechanisms is likely to stimulate research devoted to a transnational perspective for the prevention and management of eating disorders.