Running Head: THE INFLUENCE OF CULTURE ON EATING DISORDERS 1

The Influence of Culture on Eating Disorders

Amanda S. Rodriguez

University of North Florida

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Review . The Diagnostic and Statistical Manual of Mental Disorders (5th edition)

categorizes eating disorders into three main categories: anorexia nervosa (AN), bulimia nervosa

(BN), and eating disorder not otherwise specified (EDNOS) which captures subtypes such as,

binge-eating or night-eating disorders. Sufferers of eating disorders commonly struggle with

issues of size, shape, weight, eating, and disordered behaviors centered on eating (Goss, 2012).

It is common for diagnoses to be fluid over time, whether the disorder is presented differently, or

the patient is on their way to recovery. There is evidence to support the increasing prevalence of

eating disorders among American and Western European females between the ages of 15 and 29;

it is unclear whether the increase is due to better diagnostic practices, better detection, and an

increase in help-seeking behaviors. As for the prevalence and incidence of eating disorders in

men, little evidence and research is available to pinpoint the occurrence.

There are a variety of theories pertaining to the etiology of eating disorders, ranging from

family dynamics and genetic factors to biological dysfunction in neurotransmitters to the

sociocultural approach of thin-idealization from the media. My hypothesis supports that the

sociocultural approach is paramount in the prevalence of eating disorders in developed nations.

The focus of this paper will present a medical review of the illness and serve to analyze the

incidence of eating disorders across an array of cultures.

Onset and Duration. More females are diagnosed with an eating disorder compared to their

male counterparts; age of onset usually begins by mid- to late adolescence but can also develop

earlier or later. Early onset cases can be difficult to define if the child is young, sources of

patterns may be ambiguous to pinpoint. For example, the DSM-IV includes absence of

menstruation in the individual as part of the diagnosis for anorexia nervosa. For a young pre-

pubescent girl, it may be difficult to determine if the patient is not developmentally ready to
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menstruate or if she is preventing the onset of this function though the eating disorder. There is

literature reporting the onset of eating disorders in middle-aged women with no prior history of

an ED (Doyle, 2012).

The age of the patient presenting for treatment can influence the recommended pathway

of action. When considering an adult patient versus an adolescent patient, the adult sufferer will

likely report dealing with the illness for many years. An implication of this scenario is that the

change of a long-term habit is difficult to address, the individual may correlate the eating

disorder with their sense of self (Doyle, 2012). Medical complications from years of eating

disorder behaviors such as vomiting, starvation, and laxative abuse can be irreversible.

Treatment for adults with anorexia nervosa includes the goal of returning the patient to their pre-

morbid weight. On the other hand, children and adolescents receiving treatment for AN focus

their weight goal on height and sex norms for the patient’s age group. Parents, or other

caregivers, are typically involved with the initial referral to treatment for children and

adolescents; early-onset patients usually do not self-refer for treatment. As a result of treatment

outcome evaluation, the prognosis for children and adolescents is better; this is also correlated

with a shorter duration of the illness (Doyle, 2012).

The course of eating disorders varies from each individual and involves a combination of

factors. It is not uncommon for individuals with a history of anorexia nervosa to later develop

bulimia nervosa. For those without a history of AN, BN often has a later age of onset. In many

cases, BN is indirectly triggered by following a restrictive diet with the goal of losing weight but

quickly spirals into a vicious cycle of bingeing and vomiting with no correlation to weight loss.

The outlook for untreated eating disorders is very poor, up to 50% of individuals diagnosed with
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bulimia nervosa will continue to meet criteria for an eating disorder 5-10 years after initial onset

(Goss, 2012).

A case-control study assessed in France in 2011 evaluated the characteristics of the

suicides attempted by individuals diagnosed with an eating disorder. The researchers inform us

on the current suicidality rate; compared to other eating disorders, anorexia nervosa has the

highest rate of completed suicide. In regards to attempting suicide, anorexia nervosa and bulimia

nervosa have similar rates. Anorexia nervosa patients are more likely to make more serious and

severe suicide attempts. Compared to bulimia nervosa patients, anorexia nervosa patients report a

higher desire to die and have a higher intent on following through with the attempt. The feelings

of social isolation and being a burden to others, along with an acquired pain tolerance constitute

the factors that generally influence suicide. The strongest correlation between eating disorders

and suicide attempts is comorbidity, especially with a mood disorder. Literature suggests bipolar

disorder patients have a higher risk of completed suicide, compared to unipolar depressive

patients. Interestingly, based on the study’s results, anorexia nervosa patients had a higher rate of

bipolar disorder, while bulimia nervosa patients had a higher rate of major depressive disorder;

this would provide explanation for the increased severity of suicide attempts for anorexia

nervosa patients (Guillaume, 2011).

Physical Effects. Below the surface of the expression of the symptoms of eating disorders,

is an array of deficiencies and physical effects that can be potentially deadly, or impeding at the

least. The stance that eating disorders are a more recent phenomenon supports why doctors are

not medically trained to examine the body for signs this spectrum of disorders (Birmingham,

2012).
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An early sign of self-induced vomiting is enlarged parotid glands as well as a small

wounded area of the back of the knuckles of the dominant hand. A key diagnostic factor along

with significant weight loss is low blood pressure and a slow heart rate; the heart rate can

fluctuate when changing body position from laying to standing (Birmingham, 2012). Most

humans are euthermic, meaning the body is able to maintain a constant temperature despite the

external changes; an individual with anorexia nervosa will exhibit temperature that reflects the

outside environment. For example, if the patient has been in the cold, her body will have a low

temperature as well. More physical effects include the growth of lanugo hair, which is fine hair

that can be found growing on the back and abdomen of the individual. The patient may have

slightly yellowed skin that is absent in the whites of the eyes; this is caused by low metabolic

rate resulting from malnourishment. Many of these symptoms will diminish during the recovery

process but in more severe cases, the effects may affect the individual abidingly (Birmingham,

2012).

A long-term effect of low metabolic rate is arrhythmia, or irregular heartbeats. Chronic

illness can cause severe osteoporosis. This condition can also develop from deficiencies in

potassium and magnesium. Lack of these ions, along with phosphorus can cause other issues

such as muscle weakness and cramps, decreased memory, heart failure, decreased vision, etc.

Not as commonly, nutrient deficiencies can result in confusion and loss of short-term memory,

dry skin, anemia and fatigue, among other abnormal functions (Russell, 2012).

Behavioral Symptoms.In order to cope with the overwhelming anxiety of negative body

image and lack of impulse control, behaviors such as purging and overexericse are exhibited

following a binge eating session. Despite excessive behavior and preoccupation with thoughts,

language and avoidance of family meals, the individual suffering from the eating disorder will
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exhibit intense participation in the preparation and cooking of food. The individual will have

difficulty identifying hunger and satiety. An individual suffering from a restrictive-type eating

disorder will likely disguise their binge episodes (pg 109, Russell, 2012). Decreases in hormone

levels, such as estrogen and testosterone can decrease libido in men and women. Along with the

obsessive rituals preformed around food, other psychopathologies can be diagnosed, such as

major depression, substance abuse, and borderline personality disorders; these comorbidities can

mimic or trigger an eating disorder (Russell, 2012 pg 102).

An individual with anorexia nervosa may apply a variety of techniques to evaluate their

body size or weight, such as frequent weighing, obsessive measuring of body parts, and

persistent use of a mirror to check body areas of “fat”. Weight loss is viewed as an immense

achievement and a sign of self-discipline; the self-esteem of affected individuals depends of the

perception of their physical body. It is not uncommon for individuals to be oblivious to the

severity of possible medical complications as a result of their malnourished state DSM-5

(Russell, 2012). (pg. 340)

Other common cognitive features include worry about eating in public, a strong desire to

control the environment, inflexible thinking, and overly restrained emotional expression. On the

other hand, individuals with the binge-eating/purging type of anorexia have higher rates of

impulsivity; they are also more likely to abuse substances. Some individuals experience

significant social isolation along with failure to complete an academic or career goal, while

others have the ability to remain active in social and professional scenarios (Russell, 2012).

Risk Factors. A greater understanding of the risk factors that predict the onset of eating

disorders will contribute to determining possible etiologies for each disorder, as well as inform

content for preventative programs. According to a nine-year study conducted by the Oregon
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Research Institute, negative affect and impaired psychological functioning predicted each

subtype of eating disorders. Negative affect increases the risk for binge eating and compensatory

behaviors in order to gain control; these types of behaviors reduce the overwhelming anxiety

surrounding body weight. For others, this risk factor can manifest in the reduction of appetite,

resulting in unhealthy weight loss. This study was the first of its kind to note impaired

psychological functioning as a theory for eating disorder etiology. Maladaptive cognitive

operations can contribute to the negative affect and social withdrawal at the onset of any eating

disorder. Further, these faulty mechanisms increase risk for binge eating, compensatory

behavior, and under nutrition. Receiving mental health care may be a risk factor for comorbid

psychopathology.

Surprisingly, although low BMI, negative affect, and functional impairment predicted the

onset of anorexia nervosa, the risk factors relating to sociocultural pressures for thinness

influencing body dissatisfaction did not predict the eating disorder. This finding shed light on the

importance of healthy body weight throughout childhood development as well as engaging in

normal eating practices. The evidence predicted that lifetime diagnoses of anorexia nervosa are

correlated with low birth weight, eating conflict, meal struggles, and unpleasant meals up

through the age of 6 (Stice et al., 2017). From this, I summarize that in regards to developing

anorexia nervosa, the cause may be due in part to childhood development and mental

functioning, in distinction to the absence of cultural influence.

Medical Diagnosis. In patients who are presented disordering eating behaviors, it is important

to assess nutritional status to guide treatment. A nutritional assessment will include four

measures: anthropometry, biochemistry, clinical symptoms, and dietary behaviors (Russell,

2012).
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According to the Diagnostic Statistical Manual IV, the criteria for anorexia nervosa

includes a BMI of 17.5 or less, this measure is taken from the patients’ height and weight ratio.

On the other hand, individuals suffering from bulimia nervosa or binge eating disorder will

present ranging from slightly underweight to overweight. It is relevant to note the BMI measure

is an imperfect guide and can be misinterpreted if the individual engages in heavy exercise. For

children, BMI charts are less appropriate; usually percentile growth charts are referenced.

Biochemical tests measure sodium, potassium, phosphate, and blood glucose levels; a

urinalysis test quantifying osmolality and specific gravity is useful to assess hydration. Low

levels of these nutrients indicate acute malnutrition and contribute to the assessment of risk for

developing refeeding syndrome (Russell, 2012)

Other than the weight loss, low body temperature, heart rate and blood pressure, as

mentioned before, patients of eating disorders frequently experience constipation and gastric

bloating. They can also experience loss of dental enamel, damage to the gums, sore throat, and

enlarged salivary glands, which indicate excessive vomiting. Amenorrhea, the cessation of

regular menstruation, can increase the risk for developing osteoporosis. Body fat levels will drop

as a result of excessive dieting and exercise; this may eventually cause estrogen production to

fall. Estrogen is essential for regular menstruation and bone strength. In males, significant weight

loss can lower testosterone production; it also affects bone density and muscle mass (Russell

2012).

The relevant health professional will acquire information regarding the patients’ daily

food intake in order to assess the nutritional content of their diet. Excluding an entire food group

indicates the individual is emaciated. Vegetarianism is a socially accepted method of reducing

calorie and fat intake; it should be approached skepticism if the family of the young adult is not
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also vegetarian. As well as food intake and behaviors surrounding it, clinicians should also

inquire about the patient’s fluid intake. The motivation for excessive or restrictive drinking

demonstrates the concept of feeling full and decreasing appetite. On the other end of the

spectrum, restrictive types may reduce fluid intake to avoiding full and maintain control and the

sense of feeling empty. Addressing and correcting these behaviors centered around food and

nutritional status are the challenge of treating and aiding recovery in eating disorder patients

(Russell, 2012)

Clinical Diagnosis. Due to its secretive nature, many parents and friends of an eating disorder

sufferer may not even be aware of it. The individual is likely to socially withdraw and deny or

avoid confrontation about the subject. Adolescents and adults may be more likely to self-refer

themselves to treatment or attempt an extreme behavior to call for help. Parents, or other

caregivers, are typically involved with the initial referral to treatment for children and younger

adolescents; early-onset patients usually do not self-refer for treatment. As a result of treatment

outcome evaluation, the prognosis for children and adolescents is better; this is also correlated

with a shorter duration of the illness (Doyle, 2012). As mentioned before, there are a series of

medical examinations that can be tested to show quantitative indication of the presence of an

eating disorder. However, unless the physician has the medical knowledge of the physical

indicators, the defining laboratory tests may not be collected.

According to the most recent edition of the Diagnostic and Statistical Manual for Mental

Disorders, anorexia nervosa is diagnosed based on the following criteria: restriction of energy

intake that leads to significantly low body weight for the individual in regards to age, sex,

development, and physical health. Despite the significantly low body weight, the individual has

intense fears of gaining weight or engages in persistent behavior that interferes with weight gain.
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The individual exhibits a disturbed perception of their own body weight or shape; they may also

fail to recognize the seriousness of their low body weight. This diagnosis splits into two subtypes

– the restricting type and the binge-eating/purging type. To be assigned the restrictive type of

anorexia nervosa, the individual presents weight loss through extreme dieting, fasting, and/or

excessive exercise within the last 3 months. During that same amount of time, the binge/purge

type will engage in compensatory behaviors such as self-induced vomiting, misuse or laxatives,

diuretics, or enemas following a binge-eating episode. Some individuals may not necessarily

binge a large meal, but will purge after consuming a small amount of food. The level of severity

is determined by accounting for the BMI, ranging from 17 (mild) to less than 15 (extreme). The

CDC and WHO employ a consensus of a BMI of 18.5 as the lower limit of normal body weight.

Many individuals may also be dealing with depressive symptoms; this may be another

explanation for the decreased interest in sex. Eating disorder sufferers are likely to be

preoccupied with thoughts of food, or engage in obsessive-compulsive features such as

collecting recipes or hoarding food. Until the individuals exhibit obsessions/compulsions

unrelated to food or weight, an additional diagnosis of obsessive-compulsive disorder is not

necessary.

Bulimia nervosa is diagnosed based on the criteria that an individual is engaging in

recurrent episodes of binge eating following by the inappropriate behavior to prevent weight

gain, along with the influence of body shape and weight that determines the individual’s self-

worth. The severity of the diagnosis is evaluated by the number of episodes of compensatory

behavior per week, ranging from 1-3 (mild) to greater than 14 (extreme); these behaviors must

occur at least once per week for 3 months in order to qualify for the diagnosis. The excessive

food consumption occurs during a discrete period of time and it characterized with a sense of
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lack of control over what and how much is ingested. Individuals diagnosed with BN are typically

between the normal weight and overweight range.

Binge-eating disorder occurs in normal/overweight and obese individuals. The binge-

episodes, unlike bulimia nervosa, are not followed by compensatory behaviors. Characterized by

lack of control and feelings of distress, binge-eating disorder brings feelings of shame and guilt

to the individual. Remission is higher for binge-eating disorder than bulimia and anorexia.

Treatment. The course for the disordered eating behavior can vary depending on the age of

onset, the individual may experience recovery or will exhibit a fluctuating pattern of weight gain

and relapse over several years. Inpatient hospitalization is utilized as needed for an emergent

situation. In this type of treatment, the patient is stabilized medically and psychologically in

order to be discharged to a less intensive program. Outpatient programs include partial

hospitalization program (PHP) or intensive outpatient program (IOP) and are typically less

intensive and costly than inpatient care (Russell, 2012). According to the National Institute for

Clinical Excellence in the United Kingdom (NICE, 2004), cognitive behavioral and interpersonal

psychotherapy was most effective when used to treat adults with bulimia nervosa and binge

eating disorders. Clinicians have found cognitive behavioral therapy also works well for

adolescents aged 12-18 (pg.221). For young people, NICE guidelines recommend family

involvement for the member recovering from the eating disorder. As the treatment proceeds, the

patient gradually gains control over decisions about food and exercise (Doyle, 2012).

Treatment usually progresses in a series of states, throughout the program; the individual

completes self-monitoring reports to assess progress. Time is spent evaluating motivations and

fears regarding change, this is where cognitive restructuring is implemented. Detached

mindfulness is introduced to interrupt unhelpful thinking; its goal is to bring a different

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perspective on the negative thoughts and symptoms. Along with this practice, techniques to

encourage flexibility in the patients’ schema are applied. A successful method for treating

anorexia nervosa has not yet been determined (Doyle, 2012).

Eating disorders require a multidimensional approach, meaning collaborative and

coordinated care for the patient. Experienced dietitians are key members of the eating disorder

treatment team, their role is to educate team members in key nutrition principles and basic

science, along with the education of family members regarding normal eating habits and

allowing the patient to eat more and enjoy their food while settling for a normal weight. The

dietitian has the skills to provide an assessment of the patient’s nutritional status and evaluate the

risk of refeeding syndromes with the appropriate dietary prescription. The treatment team

members should be cautious when discussing sensitive topics while providing a unified message.

(Russell, 2012)

Refeeding Syndrome is a medical emergency that results from refeeding an emaciated

patient; it causes disturbances in electrolytes, vitamins and minerals, and bone and muscle

homeostasis. The syndrome requires balanced re-nutrition acquired gradually and replacing

electrolytes and minerals (Russell, 2012). Clinically, it produces symptoms of confusion, chest

pain, and even heart failure; slowing the rate of refeeding can prevent these effects. Treatment

guidelines for anorexia nervosa recommend average inpatient weight gain between 0.5 and 2

kg/week. Eating disorder protocol for refeeding utilize a multidisciplinary team in an inpatient

hospitalization setting, which incorporates behaviorally based programs with the goal of

achieving rapid weight gain and normalizing eating behaviors and cognitions in eating disorder

patients. The refeeding is administered orally, starting with 1,200-1,500 kCal per day and

gradually increasing the daily caloric input to 3,500-4,000. Family therapy, cognitive-behavioral
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therapy, along with treatment for medical or psychiatric comorbidities are integrated during the

patient’s refeeding program. During the transition into a partial hospital, social eating skills and

nutritional counseling are the main focus (Redgrave, 2011).

Prevention. Through assessing the reduction of risk factors and taking preventative

approaches, the decrease incidence of eating disorders can be achieved. Parents are essential role

models that communicate their attitudes and behaviors concerning food, body weight, and shape;

they display this expression in front of their children. Parents also hold significant influence on

verbally directing their child’s actions, as well as messages about the child’s appearance or

weight. By encouraging value-based judgment rather than appearance-based judgment, the child

will be able to develop resilience against peer comments. Parents also have the ability to filter

the media content viewed by the child, in order to avoid subliminal messages about the emphasis

of thinness in the media (Hart et al. 2015).

Prevention programs have aimed to reduce negative body image by assessing cognitive

evaluation, the investment in one’s body parts, and the resulting associated affect. By stimulating

mediators of change, such as educating the youth about unrealistic norms of thinness and media

literacy, enlightening children about natural body weight, and conducting dialogue about social

pressures and setting new peer norms in groups. Another important factor in developing

prevention programs is evaluating the relationship between media exposure and internalization

of a thin ideal (Piran, 2015).

Positive body image is making its way as an emerging methodology in the field of eating

disorders. It aims to emphasize the psychological processes to creating a positive mindset of

inhabiting the body. The core of this approach focuses on the acceptance of the body and its

unique “imperfections”, along with attending the body’s needs and promoting self-care.
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Interventions that involve being comfortable in one’s body with agency and appropriate care

may contribute to the prevention of eating disorders. Due to the social position of thin-

idealization in the media, a public health approach may be more effective than intervening at the

individual level (Piran, 2015).

Ecological approaches to prevention programs target school communities. Although the

early school years are centered on the family of origin as the most principal source of

information, prevention programs are lacking a parent involvement component (Hart et al.,

2015).

Reaction. My own interest in my academic career of nutrition and naturopathic medicine

largely encompass a cultural approach to medicine, the same curiosity has been apparent in the

topic of researching eating disorders. I chose this topic to personally discover the numerous

views of etiology of eating disorders. I decided to concentrate on eating disorders in order to

integrate the illness by providing a nutritional and psychological approach. As far as I know, I

have not personally dealt with an individual with an eating disorder, although I have read and

watched case-studies centered on patient’s with eating disorders.

During a lecture from Psychology of Abnormal Behavior, a video was presented on four

young girls and their families struggling with the adolescent’s eating disorder and behaviors.

Prior to viewing the case studies, I was not aware of the family dynamic approach to

investigating the etiology of an eating disorder. The common trait of feeling inadequate and not

having the necessary emotional support from their families deteriorated each of the girls’ self-

esteem. I found it interesting how despite living in the same home, the parents failed to notice

any abnormality in their daughter’s behavior. I understand teenagers can be a bit rebellious at

times and may have the habit of demanding much private time, but I see lack of involvement
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from the parents as a significant factor. Another hardship I noticed was the repeated enrollment

in treatment programs, but difficulty in maintaining recovery. I think the treatment approaches

required a multi-faceted integrative approach in order to be more successful. The individual’s

status seemed to improve while they were still in treatment, but as soon as the patient returned

home, the disordered behaviors became apparent again.

Since the 1980s, the awareness of eating disorders as a psychopathology has become

more prevalent, it has been evident that eating disorders are unique in the fact that their

development and possibly even their etiology is highly influenced by social and cultural factors.

The incidence of eating disorders has appeared to increase in developed countries such as the

United States, the United Kingdom, and many Western European countries since the 1960’s. As

high fashion and media become more accessible in the 1970’s and 1980’s, the epidemic

continued to escalate. Interestingly, bulimia nervosa was fairly obscure and exotic until the

1980’s, when it was agreed that BN was more common than anorexia nervosa. Although, the

percentage of individuals who exceed the healthy standard of weight are highly increasing since

the 20th century, obesity is still highly stigmatized which results in the increasing drive for

thinness. Research studies have indicated extreme dieting is a common precursor to developing

eating disorders, especially bulimia nervosa (Gordon, 2001 pg 1).

The exposure of Western European and American culture provides evidence that

anxieties pertaining to self-doubt and weight control practices are the driving force for thin body

ideal. South Africa’s political transition from the apartheid government to political democracy

has brought immense change for the black population. The apartheid policies served to enforce

separation of people based on racial classification, the liberation of these policies was marked by

a shift in depreciating ethnic barriers, racial integration in schools, and affirmative action in the
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workplace. The country’s transformation into healing the sociopolitical attitudes allowed for the

creation of a new national identity. The Western image is reflected on the sociopolitical

empowerment of women in South Africa, based on the advertising of corporate apparel, which

deviates from the traditional “primitive” dressings. The woman’s emancipation takes place in the

urbanization of South Africa by participating in business creation and interest in fitness.

Although it is evident among black South African males that fatness is desired and praised, the

present-day South African woman is content with demonstrating achievement through discipline

and self-control. It is not surprising that eating disorders are becoming more apparent in the

general population (Szabo et al., 2001).

The differing economic configurations of Northern and Southern Italy resulted in two

different Italian societies with different value systems. The Northern region developed

abundance in land, economy, and currency while the Southern region was founded on poverty

and rural traditions. In the modern era, eating disorders in Italy follow a similar path as the rest

of Europe. The prevalence rate of eating disorders in the southern region resembles that of other

Western European countries, the lowest rate originated in the northern territory of Italy. An

investigation revealed while females in the south were less sensitive to mass media outlooks in

regard to body ideals, they still exhibited lower self-esteem, a high degree of emotional

confusion, and maturational fears.

Again, here we see increased levels of urbanization and modernization shaping

significant changes in lifestyle, traditional family structure, and gender roles. The clash of values

in desire for independence and parental control expose conflict in adolescents. This cultural

distance between values influenced by media and parental values compose a woman’s

vulnerability to developing an eating disorder (Ruggerio, 2001).

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In conclusion, varying influences in political, economic, social, and developmental

factors can explain the emergence of eating disorders throughout cultures. The factor of mass

media may not play the significant role in predicting the onset of an eating disorder. I have

enjoyed delving deeper into the understanding of the complexity of this set of illnesses. I believe

the multicultural approach allowed me to see the similarities in presentation compared to

American models.
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