Clinical Psychology Review, Vol. 14, No. 7, pp.

633-661, 1994
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REVIEW OF THE EVIDENCE FOR A

SOCIOCULTURAL MODEL OF BULIMIA
NERVOSA AND AN EXPLORATION OF THE
MECHANISMS OF ACTION

Eric Stice

Arizona State University

ABSTRACT. Although numerous studies have examined the role of sociocultural pressures in
the etiology and maintenance of bulimia nervosa, a comprehensive review that synthesizes the
current knowledge is needed. The primary aim of the @sent paper was to review the available
evidence implicating sociocultural factors in the promotion of bulimia. Overall, the research sup-
ported the contention that sociocultural pressures play a role in perpetuating bulimia. The sec-
ondary aim of the paper was to propose a model that links these nebulous pressures to the actual
development of bulimic behavior This model first delineates probable carriers of these cultural
messages, including the family, peers, and the media. Second, variables thought to mediate the
relation between these societal pressures and eating pathology were examined. Internalization of
these pressures, body dissatisfaction, restrained eating, and negative affect were considered as
potential mediators. Finally, fators that possibly moa!erate the enumerated mediational pathways
were explored. Implications fw @vention and future research are discussed.

BULIMIA NERVOSA is a psychogenic disturbance in eating behavior characterized by

episodes of uncontrollable eating binges that are typically followed by self-induced
vomiting, fasting, or laxative abuse to avoid consequent weight gain (Davis, Freeman,
& Garner, 1988). Of the variables theorized to play a role in the development of
bulimia, sociocultural factors are considered paramount (Striegel-Moore, Silberstein,
& Rodin, 1986b). These sociocultural forces include the thin-ideal body image
espoused for women, the centrality of appearance in the female gender role, and the
importance of appearance for women’s societal success. According to the sociocul-
tural model of bulimia, eating disorders are a product of the increasing pressures for
women in our society to achieve an ultraslender body (Striegel-Moore et al., 1986b).
This societal obsession with weight is so widespread that a moderate degree of body

Correspondence should be addressed to Eric Stice, Department of Psychology, Box 871104,

Arizona State University, Tempe, AZ 85287-l 104.

633
634 E. Stice

dissatisfaction is now normative among women (Rodin, Silberstein, & Striegel-Moore,

1985). The sociocultural model posits that women with bulimia are simply those who
fall at the extreme end of the continuum of eating and weight concerns (Pike &
Rodin, 1991).
A comprehensive review that synthesizes the mounting evidence implicating
appearance-based sociocultural pressures in the etiology of bulimia is currently
needed. Accordingly, the first aim of this paper is to critically review this body of
research. Further, as very little is known about the mechanisms that link these ubiq-
uitous pressures to eating pathology, the second aim is to develop a model of the eti-
ology of bu1imia.l A theoretically grounded model of bulimia that elucidates prob-
able mediational pathways is crucial for the design of successful prevention and treat-
ment programs. Personality, biological, and familial variables thought to contribute
to the pathogenesis of this disorder will be discussed as they interface with sociocul-
tural pressures.

REVIEW OF THE EVIDENCE IMPLICATING SOCIOCULTURAL PRESSURES

The available research i’mplicating sociocultural pressures has been organized into
three general categories: (a) the thin-ideal body for women, (b) the centrality of
appearance in the female gender-role, (c) and the importance of appearance for soci-
etal success. Although some of the studies discussed below concern anorexia as well
as bulimia, this is because many of the earlier studies do not distinguish between these
disorders. However, it should be highlighted that anorexia and bulimia represent con-
ceptually distinct syndromes.

Evidence Regarding the Thin-Ideal Body for Women

The ShrinkingIdeal Body Image fm Women. Research suggests that over the last several
decades the weight of the ideal body image for women portrayed in the media has
decreased. Theorists have postulated that the pursuit of this thin-ideal promotes eat-
ing disorders (Garner, Garfinkel, & Olmsted, 1983a; Striegel-Moore et al., 1986b).
One study traced the dimensions of Playboy centerfolds and Miss America contes-
tants from 1959 to 1978, and found a significant decrease in the average weight-to-
height ratio of centerfolds and an average decline in the weight of contestants
(Garner, Garfinkel, Schwartz, & Thompson, 1980). Further, over the past 10 years
pageant winners had weighed less than the average contestant. During the same peri-
od there was an increase in the average weight of women, indicating that the observed
trend did not simply reflect a true decrease in the weight of females (Garner et al.,
1980). An update to this study found that pageant contestants showed a decrease in
their weight compared to the average weight for their height and age group from
1979 to 1988, but that the dimensions of centerfolds did not change (Wiseman, Gray,
Mosimann, & Ahrens, 1992). Another study found that the bust-t-waist ratio of mod-
els appearing in women’s magazines decreased steadily from 1950 to 1981
(Silverstein, Perdue, Peterson, & Kelly, 1986). They also found that actresses in the
1960s and 1970s had a smaller bust-to-waist ratio than those in the 1940s and 1950s.
Morris, Cooper, and Cooper (1989) reported an increase in the height and waist mea-
surements, but not the hip measurements, of female fashion models recruited by one
agency from 1967 to 1987. Finally, Mazur (1986) found a decrease in Miss America

lBecause the sociocultural factors examined here center on the appearance of women, bulim-
ia in males will not be addressed.
 Sociocultural InJluences on Bulimia Neruosa 635

contestants’ waist size, hip size, bust size, and weight, and a corresponding increase in
height from 1970 to 1984.
Unfortunately, as two studies failed to apply inferential tests (Mazur, 1986; Silverstein
et al., 1986), the trends they interpret may simply be random variation. However, this
limitation does not apply to all studies and the findings from investigations sampling diE
ferent referents of the ideal body converge. Thus, the evidence supports the conclusion
that images of women in the media have became thinner over the last several decades.

Increasing Number of Dieting Articles and Advertisements in Women’s Magazines.

Paralleling the shrinking ideal is an apparent increase in the number of articles and
advertisements promoting weight-loss diets in women’s magazines. Theorists contend
that the media’s focus on dieting not only propagates the thin-ideal, but actively pro
motes eatingdisordered behaviors (Rodin et al., 1985). One study found an increase
in the number of diet articles appearing in women’s magazines from 1959 to 1978
(Garner et al., 1980). A study that reviewed the same magazines from 1959 to 1988
also found an increase in the percent of articles focusing on dieting and exercise
(Wiseman et al., 1992). Finally, Snow and Harris (1986) report that number of adver-
tisements for diet products and proportion of diet articles in women’s magazines
increased significantly from 1950 to 1983. Although a visual analysis of data from
Wiseman and associates (1992) reveals that percent of diet articles actually decreased
in a linear fashion from 1978 to 1988, percentage of diet and exercise articles in the
1980s still appeared to be greater than percentage in the early 1960s. Overall, these
studies provide solid evidence that there has been an increase in number of diet arti-
cles and advertisements in women’s magazines since the late 1950s.

Zncwase in the Rates of Eating Dis&. Research suggests that there has been an
increase in rates of eating disorders over the past several decades. Correspondence
between the shrinking ideal and apparent increase in eating disorders suggests that
the thin-ideal is etiologically significant, as such an increase cannot be accounted for
by biological or personality models of eating disorders (Schwartz, Thompson, &
Johnson, 1982). Theander (1970) found an increase in the average number of cases
of anorexia at two hospitals from 1931 to 1960. Other studies examined case registers,
which ostensibly reflect all contacts with psychiatric services in a community
(Szmukler, McCance, McCrone, & Hunter, 1986). One investigation found an
increase in the rates of anorexia as reflected in psychiatric case registers for
Aberdeen, Scotland (1966-1969), Monroe County, New York (1960-1969), and
Camberwell, London (1965-1971) (Kendell, Hall, Hailey, & Babigian, 1973). Another
study found an increase in number of anorexics in the case register and hospital
records of Monroe County from 1960 to 1976 (Jones, Fox, Babigian, & Hutton, 1980).
Similarly, Szmukler and colleagues (1986) reported an increase in number of anorex-
ics in the Aberdeen case register from 1965 to 1982. However, there was no increase
in admissions for anorexia in Denmark from 1973 to 1987 (Nielson, 1990) or
Minnesota from 1935 to 1979 (Lucas, Beard, O’Fallon, & Kurland, 1988).
Regarding bulimia, there was an increase in the referral rate for this disorder at an
eating disorder center in New Zealand from 1977 to 1986 (Hall & Hay, 1991). One com-
munity study that assessed rates of bulimia in college students in 1980, and again in
1983 at a neighboring university, found that the rates of bulimia increased from 1 to
3.2% (Pyle, Halvorson, Neuman, & Mitchell, 1986). In contrast, a study that assessed
rough criteria for bulimia among high school students in 1981 and 1986 found that the
rates of bulimic behavior decreased from 4.1 to 2.0% (Johnson, Tobin, & Lipkin, 1989).
635 E. Stice

The most serious limitation of this research is that live of the studies did not use
inferential tests (Hall & Hay, 1991; Johnson et al., 1989; Kendell et al., 1973; Pyle et
al., 1986, Theander et al., 1970). Second, three studies relied on the diagnoses of
physicians and psychologists in field settings (Jones et al., 1980; Kendell et al., 1973;
Nielson, 1990), which are subject to trends brought about by increased professional
interest in eating disorders (Schwartz et al., 1982). On a conceptual level, the
observed increase may simply reflect better referral or case detection resulting from
increased awareness and acceptance of eating disorders (Hall 8c Hay, 1991). The
methodological and statistical limitations, along with the alternative explanations and
inconsistency in findings, preclude a conclusion that eating disorders have increased
in prevalence. Large scale longitudinal studies are needed before firm conclusions
may be drawn.

Eating LXsorders in Subnr~res with Amplijied Idetd Body Ihsswes. Research suggests
that people in subcultures where the ideal body pressures are amplified (e.g., dancers,
models, and athletes) evidence higher rates of anorexia and bulimia. It has been
argued that because these subcultures magnify the sociocultural pressures, members
are placed at an increased risk for developing eating disorders (Garner et al., 1983a).
One study examined eating pathology in dance, modeling, music, and control stu-
dents (Garner & Garfinkel, 1980). Although none of the music or control students
met criteria for anorexia, 6.5% of the dance students and 7% of the modeling stu-
dents did. A second study reported that 32% of a sample of professional ballet
dancers reported having anorexia and/or bulimia (Hamilton, Brooks-Gunn, &
Warren, 1985). Button and Whitehouse (1981) assessed eating pathology at a college
of technology and found the highest rates of disordered eating among beauty thera-
py students. Almost 10% of the beauty therapy students scored above the clinical cut-
off on the Eating Attitudes Test (EAT), a continuous measure of eating pathology
(Garner, Olmsted, Bohr, & Garfinkel, 1982). Interestingly, a study examining eating
pathology among students explicitly hypothesized that individuals at risk for develop
ing eating disorders would gravitate toward areas of study emphasizing body image
(dance, drama, and physical education) (Joseph, Wood, & Goldberg, 1982). They
found that dance and drama students evidenced higher rates of eating disorder symp-
toms than the English and physical education students. However, a study that exam-
ined the height-t~weight ratios of female college athletes in an effort to assess anorex-
ia found no evidence of the disorder (Grago, Yates, Beutler, & Arizmendi, 1985).
Although several of the investigators concluded that amplified pressures in these
fields to achieve a slender body directly promote development of eating disorders, an
alternative explanation is that people fn-edisposed to helop eating disorders may select
careers that condone a preoccupation with appearance. The fact that most dance stu-
dents report developing anorexia after beginning training (Garner SC Garfinkel,
1980) does not rule out this alternative explanation. Second, two studies did not
examine diagnostic criteria in their efforts to assess anorexia and bulimia: Hamilton
and associates (1985) simply asked dancers if they had ever had anorexia or bulimia,
and Crago and colleagues (1985) only examined height and weight data in their
effort to diagnose anorexia. Finally, two of the studies were lacking control groups
~Hamilton et al., 1985; Crago et al., 1985). Unfortunately, as all of the studies are sub-
ject to the plausible alternative explanation that people who are predisposed to devel-
op eating disorders self-select into fields that emphasize physical appearance, it is pre-
mature to conclude that these subcultures produce elevated levels of eating disorders.
At a theoretical level, it is still likely that these social milieux amplify the thin-ideal.
 SocioculturalInfluences on Bulimia Nervosa 637

One way to assess the role of self-selection biases would be to administer an eating
pathology measure to incoming dance, modeling, and control students. If self-selec-
tion processes were at work, mean differences among the three groups would be
observed. Additionally, data could then be used to control for initial levels of eating-
disordered behavior when examining the changes associated with attendance of mod-
eling or dance schools over time.

Bulimics Evidence Heightened Endorsement of the Thinldeal. In direct support of the

sociocultural model, studies suggest that bulimics show a hyperinternalization of the
thin-ideal body image. Although overconcern with body shape is a symptom of bulim-
ia, the sociocultural model posits that hyperinternalization of the thin-ideal is a pre-
requisite for the development of bulimia (Striegel-Moore et al., 1986b). Theoretically,
endorsement of the thin-ideal would be necessary before a person would purge in an
effort to manage weight. One investigation that compared the desired body size of
female bulimics and weight-matched controls found that bulimics desired to be sig-
nificantly thinner (Williamson, Kelley, Davis, Ruggiero, & Blouin, 1985). Similarly,
endorsement of the thin-ideal predicted subsequent diagnosis of bulimia (Kendler et
al., 1991). Third, bulimics scored significantly higher than controls on the drive for
thinness subscale of the Eating Disorders Inventory, a scale assessing overconcern with
dieting, preoccupation with weight, and obsession with the thin-ideal (Gamer,
Olmsted, & Polivy, 1983b; Johnson, Lewis, Love, Lewis, & Stuckey, 1984). Mintz and
Betz (1988) found that bulimics evidenced greater endorsement of sociocultural
mores regarding the desirability of thinness than chronic dieters and controls.
Another study found that importance attached to appearance (e.g., being slim and
attractive to the opposite sex) was positively related with eating disorder symptoms
(Timko, Striegel-Moore, Silberstein, & Rodin, 1987). A final study found that
endorsement of the thin-ideal stereotype was positively correlated with eating pathol-
ogy (Stice, Schupak-Neuberg, Shaw, 8c Stein, 1994).
Although three of the studies utilized college samples (Mintz 8c Betz, 1988; Stice et
al., 1994; Timko et al., 1987), these investigations were generally methodologically
strong. In addition, findings from studies employing different conceptualizations of
eating pathology converge. Thus, there appears to be solid evidence that people with
bulimia show an elevated tendency to endorse the thin-ideal. However, because these
studies were cross-sectional, questions of temporal precedence remain.

Evia’ence that Eating Dish are a CullureB~nd syndrome. Investigators have theo-
rized that eating disorders are a culture-bound syndrome, a constellation of symptoms
that is not found universally in human populations but is restricted to a particular cul-
ture (Nasser, 1988; Swartz, 1985). Gordon (1988) uses the term ethnic disurdq and
defines it as a pattern of psychopathology that is intimately related to the common
attitudes, conflicts, and strivings of a people. Often the disorder cannot be under-
stood apart from its specific culture (Swartz, 1985). As suggested by the above, the
sociocultural model of bulimia is a special case of a culture-bound syndrome. As such,
we would expect certain distributions of eating disorders along cultural lines (Nasser,
1988; Prince, 1985). Data for three logical outgrowths of the culture-bound syndrome
concept are presented below: (a) the low rates of eating disorders among ethnic
minorities, (b) the low rates of eating disorders in nonwestern countries, and (c) the
positive relation between Westernization and eating pathology.
First, if eating disorders are a product of mainstream sociocultural pressures, we
would expect rates of eating disorders to be lower among ethnic minorities. The
638 E. Stice

research on the rates of eating disorders in ethnic minorities is summarized in Table

1, which presents the total number of eating disorder cases, as well as the number and
percent of ethnic minorities. For comparison purposes, 1980 census data indicate that
19.1% of Americans are either Asian (1.5%), Black (11.7%), or Hispanic (6.4%)
(Menard 8c Moen, 1987).2 Evidence from clinical studies indicates that between 0.0
and 5.0% of eating disorder patients are ethnic minorities, with a weighted average of
2.6%. Data from community samples range from 2.7 to S.l%, with a weighted average
of 4.0% minorities. The fact that estimates from clinical samples are lower than com-
munity-generated estimates likely reflects socioeconomic status (SES) bias of clinical
populations. Additionally, a study contrasting Black and Caucasian undergraduates
found that Black females evidenced less bulimia and were less preoccupied *with
weight and food than Caucasian females (Gray, Ford, & Kelly, 1987).
The major limitation with this literature is that there were several types of selection
biases. Eight of the samples were from hospitals (Andersen & Hay, 1985; Hedblom,
Hubbard, 8c Anderson, 1981; Hsu, 1987; Jones et al., 1980; Kendell et al., 1973;
Mitchell et al., 1986; Pyle et al., 1981; Silber, 1986), two were from universities (Gray
et al., 1987; Nevo, 1985), and one was from a private practice (Garfinkel & Garner,
1982). These samples are likely to be biased regarding SES, ethnicity, and severity of
illness. Second, many of the studies rely on treatment staff to make diagnoses
(Andersen & Hay, 1985; Hedblom et al., 1981; Jones et al., 1980; Kendell et al., 1973;
Mitchell et al., 1986; Silber, 1986). This is problematic because practitioners may be
biased by the stereotype that minorities do not suffer from eating disorders (Silber,
1986). However, given the general convergence across vastly differing samples and the
fact that these limitations did not apply to all studies, evidence supports the claim that
ethnic minorities are underrepresented among eating-disordered populations.
Nonetheless, replications of this finding using epidemiological samples would pro-
vide increased confidence in this conclusion.
The second logical outgrowth of the culture-bound syndrome concept is that eat-
ing disorders should be relatively rare in nonwestern countries (Prince, 1985).
Although Buhrich (1981) found no recorded cases of anorexia in a Malaysian hospi-
tal from 1976 to 1978, he found that 30 cases had been seen by psychiatrists in private
practice since inception of their practices. Unfortunately, these data do not provide
an estimate of the overall prevalence of anorexia in this country. Raich and colleagues
(1992) found that fewer high school females in Spain (0.9%) reported bulimia than
their American counterparts (3.5%). Using a two-stage sampling procedure, one
study found that 0.4% of the females in Greek high schools met criteria for anorexia
(Fichter, Elton, Sourdi, Weyerer, & Koptagel-Ilal, 1988). Another investigation found
that 1% of the female students who visited a university health center in Cairo from
1974 to 1975 received psychiatric referrals for anorexia (Okasha, Kamel, Sadek,
Lotaif, & Bishry, 1977). H owever, this figure cannot be considered a prevalence esti-
mate because it represents only the percentage of anorexics out of the students who
visited the health center. Finally, in a two-stage epidemiological study in Japan,
Mizushima and Ishii (1983) found that only 0.04% of high school females met crite-
ria for anorexia. Because of the sampling frames of the Buhrich (1981) and Okasha
and associates (1977) studies, their findings cannot be considered prevalence esti-

2It would have been preferable if the ethnic composition of the samples could have been con-
trasted with the ethnic composition of the populations from which they were drawn.
Unfortunately, only one of the studies provided such data (Johnson et al., 1984), and the
small cell sizes rendered inferential tests inappropriate.
 Sociocultural Injluenceson Bulimia Neruosa 639

TABLE 1. Percentageof Ethnic Minorities Among Eating Disorder Samples

N cases N minority cases Percent of total cases

Case series
Kendell et al., 1973 62 1 (Pacific Islander) 1.6%
Jones et al., 1980 54 1 (Black) 1.8%
Pyle et al., 1981 34 0 (n/a) 0.0%
Hedblom et al., 1981 75 2 (Black) 2.7%
Garfinkel & Gamer, 1982 120 4 (Black) 3.3%
Andersen & Hay, 1985 275 8 (Black) 2.9%
Mitchell et al., 1986 275 2 (Native American) 0.7%
Silber, 1986 140 7 (Black or Hispanic) 5.0%
Hsu, 1987 175 7 (Black) 4.0%

Community samples:
Johnson et al., 1982 316 11 (not specified) 3.5%
Johnson et al., 1984 62 5 (Asian, Black or Hispanic) 8.1%
Nevo, 1985 75 5 (Asian) 2.7%

Note. Total number of diagnosed cases appears under the column labeled Ncases and the num-
ber of minority cases are provided under the column labeled Nminority cases. The ethnicity of
the minority cases are presented in parentheses. The percent of minorities in each sample is
presented under the column labeled Percent of total cases.

mates of eating disorders in those countries. However, the remaining studies are
methodologically sound and provide clear evidence that the rates of eating disorders
are lower in Greece, Japan, and Spain than in the United States.
The final testable hypothesis of the assertion that eating disorders are a culture-
bound syndrome is that increased Westernization should be associated with height-
ened eating pathology. Nasser (1986) examined the effects of Westernization on eat-
ing attitudes and behaviors by comparing female Arab students in Cairo universities
to students who had moved to London because of their parents’ professions. Clinical
interviews verified six cases of bulimia among the London group, but no cases
among the Cairo group. Interestingly, length of residence in London was not corre-
lated with eating disorder symptomatology. Another study contrasted prevalence of
anorexia among students in Greece to Greek students whose families had relocated
to Germany (Fichter et al., 1988). They found that 1.1% of the Greek female stu-
dents in Germany met criteria compared to 0.4% of the female students in Greece.
Furnham and Alibhai (1983) examined attitudes towards female figures of varying
weights among Kenyans, British Kenyans (Kenyans residing in Britain), and British
subjects. The Kenyans rated heavier figures as more attractive than did the British
Kenyans and British. Finally, one study found a significant positive correlation
between acculturation and eating pathology in a sample of Hispanic adolescents
(Pumariega, 1986).
Unfortunately, two of these studies neglected to apply inferential tests (Fichter,
et al., 1988; Nasser, 1986). Although it is theoretically likely that increased
Westernization would lead to heightened subscription to the thin-ideal and eating
pathology, because of the lack of inferential tests and the sparsity of studies direct-
ly examining this question, only a tentative conclusion can be supported by the
extent data. Large random samples are needed before firm conclusions may be
640 E. Stice

drawn. Nonetheless, the application of the culture-bound syndrome concept to eat-

ing disorders appears to be useful in exploring cultural parameters that influence
eating pathology.

Sex, Age, and .!BS’~buEiotls of Eating Disorders. The purported nonuniformity in sex,
age, and SES distributions among people with eating disorders has been interpreted
as suggesting that sociocultural factors are etiologically significant, as personality and
biological explanations of eating disorders fail to account for these unique demo
graphic distributions (Striegel-Moore et al., 198613). The available data on sex,3 age,
and SES distributions of eating disordered populations, along with the sample sizes,
are presented in Table 2.
Of those with anorexia, 80 to 100% were female, with a weighted average of 91.4%.
For bulimia, 75 to 100% were female, with a weighted average of 96.0%. Thus, the
data consistently indicate that females are overrepresented among identified cases of
eating disorders. The data also indicate that younger ages are overrepresented in dis-
tributions for age of onset and current age among anorexics and bulimics. For bulim-
ia, estimates of the average age of onset ranged from 16.5 to 20.9 years, with a weight-
ed average of 18.9. Average age of onset for anorexia ranged from 18.3 to 19.2, with
a weighted average of 18.8. It is interesting that the onset of eating disorders usually
occurs during adolescence, a developmental period with an intense focus on appear-
ance (Striegel-Moore et al., 1986b). Regarding the current age of people with bulim-
ia, ages range from 23 to 28, with a weighted average of 25.3 years. The average cur-
rent age of anorexics ranged from 21.1 to 21.7, with a weighted average of 21.3.
Finally, the five studies that provided parallel SES data are presented in Table 2.
Data indicate that between 72 and 84% of anorexics fall within social classes I to III
of the Hollingshead or Registrar General’s five-level SES classification schemes, with
a weighted average of 76.2. Regarding bulimia, the estimates indicate that between 68
and 85% of bulimics fall in the top three social classes, with a weighted average of
75.9. Although the data might appear to suggest that high SES is overrepresented
among identified cases of eating disorders, few studies applied inferential tests.*
Regarding anorexia, Szmukler and associates (1986) and Kendell and colleagues
(1973) found a significant upperclass bias in their case register samples. In contrast,
several recent epidemiological studies (Kendler et al., 1991; Rand & Kuldau, 1992;
Whitaker et al., 1990) found no relation between SES and bulimia or anorexia. It may
be that the SES bias found during the 1960s and 1970s disappeared as the thin-ideal
was embraced by people of all SES levels. However, as studies finding significant SES
effects are case registry reviews, and studies reporting nonsignificant effects were epi-
demiological studies, it is more likely that clinical samples are simply biased regard-
ing SES. In either case, there is little evidence to support a current SES bias in cases
of eating disorders.
There are several general limitations of the demographic literature that merit
attention. External validity is threatened in that eight samples were from hospitals
(Andersen & Hay, 1985; Fairburn & Cooper, 1982; Hedblom et al., 1981;Jones et
al., 1980; Kendell et al., 1973; Mitchell et al., 1986; Pyle et al., 1986; Szmukler et
al,, 1986), and two were from universities (Pope, Hudson, Yurgelun-Todd, &
Hudson, 1984b; Pyle et al., 1986). These samples are likely to be biased along a

%tudies explicitly examining only females were not included.

*As the sex and age distributions differed so markedly from expected values, the lack of
inferential tests was not deemed problematic.
 Sociocultural Injluence.s on Bulimia Nervosa 641

TABLE 2. Sex, Age, and SES Distributions of Anorexia and Bulimia Nervosa

Current Class
Ncases Females/males Age of onset age I to III

Anorexia
Kendell et al., 1973 62* 85.5%/14.5% - - 84%
Jones et al., 1980 54* 85.4%/14.6% - - -
Hedblom et al., 1981 75* 94.7%/5.3% - - 83%
Pope et al., 1984a 3 100.0%/0.0% - - -
Andersen & Hay, 1985 125* 88.3%/11.7% - 21.7m -
Szmukler et al., 1986 238* 91.7%/8.3% 19.2m 18mod 72%
Marchi & Cohen, 1990 5 80.0%/20.0% - - -
Whitaker et al., 1990 12 100.0%/0.0% - - -
Hall & Hay, 1991 170* 95.3%/4.7% 18.3m 21.1m -

Bulimia
Pyle et al., 1981 34* 100.0%/0.0% 18med 24med -
Johnson et al., 1982 316 - 18.1”’ 23.7m 68%
Fairbum & Cooper, 1982 499 - 18.4m 23.8”’ -
Pyle et al., 1986: 1980 wave 8 75.0%/25.0% - - -
Pyle et al., 1986: 1983 wave 23 100.0%/0.0% - - -
Pope et al., 1984a 36 100.0%/0.0% - - -
Pope et al., 1984b 31 - 16.5m 21.gm -
Fairbum & Cooper, 1984a 579 - 20.2m 28.1m -
Fairbum & Cooper, 1984b 35* - 19.7m 23.5m -
Mitchell et al., 1986 275* - 17.7m 24.8m 85%
Marchi & Cohen, 1990 9 88.9%/11.1% - - -
Whitaker et al., 1990 18 94.1%/5.9% - - -
Hall & Hay, 1991 126* 96.0%/4.0% 19.3m 23.0m -
Kendler et al., 1991 60 - 20.gm - -
Rand & Kuldau, 1992 23 91.3%/8.7% - - -

Note. Number of diagnosed cases appears under the column labeled Ncases. The percent of
cases for females and males, respectively, are presented under the column labeled
Females/males. The age of onset and current age of eating-disordered patients are present-
ed under the columns with those headings. The percent of cases that are in social class I, II,
or III according to the Hollingshead or Registrar General’s classification scheme are provid-
ed under the column labeled Class I to III.
* These studies are case series or case registry reviews.
mmean age.
medmedian age.
modmodal age.

number of dimensions, including severity, education, and income. Second, gener-

alizability of the estimates and statistical power of the analyses are compromised by
the small number of cases in several studies (Marchi & Cohen, 1990; Pope,
Hudson, & Yurgelun-Todd, 1984a; Pyle et al., 1981, 1986; Rand & Kuldau, 1992;
Whitaker et al., 1990). Despite the limitations, the fact that none of the problems
applies to all of the studies and the magnitude of the nonuniformity in the distri-
butions support the contention that eating disorders are overrepresented among
females and younger ages. However, the data do not support the contention that
there is an SES bias.
642 E. Stice

Evjdence Regarding the Centraiity of Appearance in the Female Gender Role

The centrality of appearance in the female gender role is the second sociocultural fac-
tor thought to promote eating disorders. Theorists contend that being concerned
with appearance and making efforts to enhance and preserve one’s beauty are central
features of the female gender role (Brownmiller, 1984). It is thought that this perva
sive focus on appearance contributes to the development and maintenance of eating
pathology (Striegel-Moore et al., 1986b). Several lines of evidence suggest that
appearance is a central facet of the female gender role. The most direct indication is
that endorsement of the female gender role is correlated with afIirmation of the ideal-
body stereotype. Studies have found that self-report of feminini~ was positively relat-
ed to importance attached to appearance (e.g., fitness and slimness) (Pliner, Chaiken,
& Flett, 1990; Timko et al., 1987). Similarly, Stice and associates (1994) found a sig-
nificant positive relation between affirmation of the female gender role and endorse-
ment of the ideal-body stereotype.
Second, attractive women are perceived as more feminine. One study that had col-
lege students rate pictures of people varying in attractiveness found that as females
increased in attractiveness they were attributed more positive female traits (Gillen &
Sherman, 1980). A similar study found that attractive females were rated as more fem-
inine than less attractive women (Gillen, 1981). Heilman and Saruwatari (1979) had
students judge attractive and unattractive bogus job applicants, and also found that
attractive females were rated as more feminine. Finally, Heilman and Stopneck (1985)
found that business workers rated femaie executives who were attractive as signifi-
cantly more feminine than unattractive ones. Interestingly, none of these findings dif-
fered according to sex of rater.
Third, there is evidence that perceived femininity is related to body dimensions.
Undergraduates rated ectomorphic (thin) silhouettes as significantly more feminine
than either mesomorphic (muscular) or endomorphic (corpulent) silhouettes (Guy,
Rankin, & Norvell, 1980). Indeed, the most frequently selected ideal body type for
females was the ectomorph. Finally, there is evidence that eating behavior is directly
related to perceived femininity. Subjects that read food diaries rated female targets
who ate smaller meals as more feminine, attractive, and concerned about their
appearance than female targets who ate larger meals (Chaiken & Pliner, 1987).
Additionally, two experiments on eating behavior found that for females, the amount
eaten was negatively related to both their own and their male partner’s ratings of their
femininity (Mori, Chaiken, & Pliner, 1987; Pliner & Chaiken, 1990). Unfortunately,
generalizability is limited because all of the studies except Heilman and Stopneck
(1985) relied on college student samples. However, no other methodological prob-
lem was present across a significant number of studies. Thus, available evidence sug-
gests that appearance is in fact a central component to the female gender role.

Evidence Regarding the Importance of Appearance for Women’s Societal Success

The final sociocultural factor thought to contribute to eating pathology is the impor-
tance of appearance for women’s societal success (Striegel-Moore et al., 198613).
Theoretically, this factor reinforces and perpetuates a preoccupation with appearance
by rewarding attractiveness in women. This force likely combines with the thin-ideal
and the centrality of appearance in the female gender-role to promote an obsession
with weight and appearance in a subset of women. A large body of literature has
found that attractive people are perceived as possessing more socialiy desirable traits
and positive life outcomes than less attractive people. As two comprehensive meta-
 Sociocultural h@ences on Bulimia Nervosa 643

analytic reviews of this area have recently been completed (Eagly, Ashmore,
Makhijani, & Longo, 1991; Feingold, 19921, I will briefly summarize their findings
rather than review this literature here. The majority of studies assessed physical attrac-
tiveness stereotypes by requesting subjects to form judgments of targets depicted in
photographs who varied in attractiveness. For example, a study that had undergradu-
ates evaluate pictures of children and adults possessing various levels of attractiveness
found that the most positive social characteristics were consistently ascribed to the
most attractive targets (Moore, Graziano, & Millar, 1987). Overall, meta-analytic
results indicate that attractive females are perceived as more sociable, dominant, men-
tally healthy, intelligent, and socially skilled than their less attractive counterparts
(Feingold, 1992). Similarly, although studies with female and male targets were not
analyzed separately, Eagly and associate’s (1991) meta-analysis indicated that attrac-
tive people were judged to be more socially competent, adjusted, potent, and intel-
lectually competent, and to possess more integrity.
Not only are attractive people per&ued as possessing more socially desirable traits,
but evidence suggests that attractive people may actually possess many of these char-
acteristics. Feingold (1992) performed a meta-analysis on studies that examined the
relation between self-reported characteristics, which should not be biased by level of
attractiveness, and both self-report and judges’ ratings of attractiveness. Females
rated as attractive by judges were more dominant, mentally healthy, socially skilled,
popular, academically successful, had higher selfesteem, and were less socially anx-
ious. Similarly, self-report of attractiveness was positively related to dominance, socia-
bility, mental health, selfesteem, popularity, and negatively related to social anxiety.
Further support for actual differences in traits due to attractiveness comes from a
study that was able to elicit evaluations of people’s social skills that were not conta-
minated by perceived attractiveness (Goldman & Lewis, 1977). Subjects who had
only interacted via phone perceived attractive women (judged by self-report and
observer rating) as more socially skilled and likable. Thus, in addition to the fact that
attractiveness plays a major role in the impressions that people form about females,
there also appear to be actual differences between attractive and unattractive people
in these socially desirable characteristics. It is likely that the differential treatment
directed at attractive people influences the development of many of these traits (e.g.,
social skills).
Finally, research also suggests that attractiveness is important in the employment
realm. In an experiment in which personnel directors rated resume packages, those
which included a photo of an attractive applicant were perceived to be more quali-
lied, less in need of therapeutic guidance, and as possessing higher employment
potential than those containing an unattractive photo (Cash, Gillen, & Burns, 1977).
A second experiment, where resume packages including pictures of attractive and
unattractive applicants were rated by undergraduates, found that attractive people
were recommended for hire more frequently, judged as more qualified, and their rec-
ommended salaries were significantly higher (Heilman & Saruwatari, 1979). However,
for managerial positions, attractive females were judged as less qualified and were rec-
ommended for hire less often. In a similar experiment, although attractive male exec-
utives were rated as more capable, likable, potent, and as possessing more integrity
than unattractive males, attractive female executives were seen as less capable and as
possessing less integrity (Heilman & Stopneck, 1985).
Despite the fact that the majority of these studies relied on university samples,
there is solid evidence that attractiveness is related to societal success. Attractive
females are not only perceived as possessing more socially desirable traits, such as
644 E. Stice

social skills, mental health, and intelligence, but they actually appear to possess high-
er levels of many of these characteristics compared to less attractive women.
Additionally, for jobs other than upperechelon positions, attractiveness proved bene-
ficial for women. This last finding suggests that the effects of attractiveness in the
employment realm might by moderated by job category.

Summary of the Evidence for the Sociocultural Model of Bulimia

This review of the evidence advanced to support the sociocultural model of bulimia
has yielded somewhat mixed conclusions. Regarding ideal body image for women,
research supports the conclusions that the ideal has become increasingly thin and
that there has been a corresponding increase of the numbers of diet articles and
advertisements in women’s magazines. There also is convincing evidence that bulim-
its show a hypexinternalization of the thin-ideal, that appearance is a central compo
nent of the female gender role, and that attractiveness is important for women’s soci-
etal success. Further, while data support the conclusion that eating disorders are not
uniformly distributed across sex and age, data do not confirm the SES bias. Similarly,
the extant research provided only partial support for the contention that eating dis-
orders are a culture-bound syndrome. Specifically, although there is evidence that
ethnic minorities are underrepresented among eating-disordered populations, and
that the prevalence of eating disorders are lower in non-Western countries, the
research only warrants a tentative conclusion that increased Westernization is associ-
ated with heightened eating pathology. However, because of the plausible alternative
explanations, it is deemed premature to conclude that there has been an increase in
the rates of eating disorders, or that subcultures with amplified ideal body image stan-
dards cause increased eating pathology. Overall, several lines of evidence that have
been advanced to support the sociocultural model of bulimia appear justified given
the existent data. Although not all of the contentions are adequately validated by the
available research, enough evidence exists to justify the claim that sociocultural fac-
tors are related to the promotion of bulimia. Further studies will be needed to assess
the plausibility of the contentions lacking sufftcient empirical validation.

A THEORETICAL MODEL LINKING SOCIOCULTURAL PRESSURES TO

BULIMIA NERVOSA

Given the premise that sociocultural pressures are related to bulimia, the next logi-
cal question concerns the mechanisms by which these forces ultimately produce
bulimia. The central limitation of the sociocultural model is that it fails to specify
how these pervasive factors lead to bulimia in only a subset of women. In the sections
below, a sociocultural model of bulimia will be proposed with a specific focus on
these neglected mechanisms of action. First, the messengers of these sociocultural
pressures will be examined. Evidence for family, peer, and media influences will be
discussed, as all of these institutions are probable carriers of the sociocultural mes-
sages. The second task will be to elucidate the mechanisms that link these manifes-
tations of sociocultural pressures to actual disordered eating. Internalization of the
pressures, body dissatisfaction, restrained eating, and depression will be examined as
potential mediators. The third question focuses on which women in particular will
be adversely affected by these sociocultural pressures. Although all women are pre-
sumably exposed to these detrimental messages, only a minority develop bulimia.
Thus, the third question relates to variables that moderate the proposed mediation-
al linkages. Because of the complexity of the model, potential moderators will be dis-
cussed as each mediational path is presented. A graphical representation of the
model is depicted in Fig. 1
Throughout this section, I critically review the available empirical support for these
proposed mechanisms. However, it should be acknowledged that because of the
paucity of research, this model-building effort is exploratory in nature. Additionally,
in keeping with the sociocultural position that eating pathology occurs along a con-
tinuum, studies focusing on bulimic symptomatology, restrained eating, and binge
eating were included. Finally, it is important to note that within this paper I use the
definitions of mediator and moderator presented in Baron and Kenny (1986). Briefly,
a mediator is a variable that accounts for the relation between two variables. A mod-
erator, in contrast, is a variable that affects the direction and/or strength of the rela-
tion between two variables.

Transmitters of the Sociocultural Pressures

Families, peers, and the mass media may all play important roles in the transmission
of sociocultural pressures to women. Theoretically, sociocultural pressures are mani-
fest in proximal social institutions, which in turn lead individuals to internalize these
messages. Drawing from Kandel’s (1980) work on socialization of substance use, influ-
ences of families, peers, and the media in perpetuating bulimia may be broken down
into two distinct mechanisms: social reinforcement and imitation. Social reinforce-
ment is the phenomenon wherein youth internalize definitions and exhibit behaviors
and values that are approved of by respected people in their en~ronmen~. In con-
trast, imitation refers to the process where new behaviors are learned simply by
observing others perform them. Regarding the former process, several studies suggest
that family, peers, and the media serve to socially reinforce attitudes conducive to eat-
ing pathology.

Family hjhnces. As the primary socialization agent, the family is in a unique position
to impart sociocultural messages to young females. Families of eating-disordered
youth are thought to be hyperconscious of weight and appearance, and thus perpet-
uate these sociocultural pressures (Pike & Rodin, 1991). In a case series of buiimics,
Pyle, Mitchell, and Eckert (1981) found that dieting episodes associated with the
onset of bulimic behaviors “frequently followed suggestions by a family member to
lose weight” (p. 61), although they provide no data on the frequency of this occur-
rence. Of the bulimics in a larger case series, 53% reported that they had initiated
bulimic behavior following pressure from their family to lose weight (Mitchell,
Hatsukami, Pyle, & Eckert, 1986). Similarly, Irving (1990) found that women with
high levels of bulimic symptoms report a greater amount of pressure to be thin com-
ing from their family, friends, and the media than did symptom-free women.
Unfortunately, as the disaggregated data were not presented, there is no way of sepa-
rating perceived pressure from family versus that from peers and the media.
Another study found that restrained eaters recalled their parents as more focused
on dieting and physical attractiveness than controls did (Costanzo & Woody, 1985).
Further, restrained eaters indicate that their parents more often manipulated their
eating and were more likely to regard weight as a salient basis for evaluation. In an
examination of familial correlates of overweight in children, Costanzo and Woody
(1984) found that parental restraint regarding their daughter’s eating was positively
related to her weight. Pike and Rodin (1991) found that mothers of eating-disordered
adolescents wanted their daughters to lose more weight than mothers of controls,
646 E. Stice

Family
inflwznces

Internalization
of pressures 1

FIGURE 1. A model of the sociocultural influences on the etiology of bulimia ner-

vosa. Note: Proposed mediators are family influences, peer influences, media influ-
ences, internalization of pressures, body dissatisfaction, restrained eating, and nega-
tive affect. Proposed moderators are self-esteem, identity confusion, weight, coping
skills, impulsivity, and family, peer, and media modeling.
 Sociocultural Injluences on Bulimia Neruosa 647

Further, the difference between mothers’ and daughters’ ratings of the daughters’
attractiveness was significantly greater for the mothers of the eating-disorder group
than for the controls, with mothers of eating-disordered daughters reporting that
their daughters were significantly less attractive than the daughters rated themselves.
However, one study comparing mothers of compulsive eaters to control mothers
found no significant differences in body satisfaction or eating pathology (Attie &
BrooksGunn, 1989).
One problem with three of these studies was that they fail to control for daughters’
weight when assessing the relation between pressure to lose weight from parents and
daughters’ eating pathology (Irving, 1990; Mitchell et al., 1986; Pyle et al., 1981).
Indeed, Irving (1990) found a positive relation between weight and bulimic sympto
matology. If daughters’ weight influences both pressure from parents to lose weight
and eating pathology, then the observed relation between parental pressure and eat-
ing disorder symptoms would be spurious. Pike and Rodin (1991) addressed this ques-
tion by statistically controlling for daughters’ weight when examining the relation
between parental pressures and daughters’ eating pathology. Although they still
found a relation between parental pressure to lose weight and eating pathology, the
obtained F dropped from 19.7 to 6.1, indicating that the majority of variance was
accounted for by the daughters’ weight. Thus, studies should control for subjects’
weight when examining the relation between environmental pressures and eating
pathology, to rule out this third variable explanation. Nonetheless, the Pike and
Rodin (1991) findings still indicate that the family’s perpetuation of the thin-ideal is
related to eating pathology.
Other methodological problems include use of retrospective reports (Costanzo
& Woody, 1985; Mitchell et al., 1986; Pyle et al., 1981) and sampling biases
(Costanzo SC Woody, 1985; Irving, 1990; Mitchell et al., 1986; Pyle et al., 1981).
Although there are limitations with these studies, collectively they are methodolog-
ically sound and provide convincing evidence that parents propagate the sociocul-
tural messages of thinness.
It is interesting to speculate about what variables might affect the magnitude of the
sociocultural messages emanating from the family. Perhaps being overweight causes
people to experience amplified versions of these pressures. Surprisingly, there is
almost no research addressing this question. As cited above, Costanzo and Woody
(1984) found that parental restraint of their daughter’s food intake was positively
related to their daughter’s weight, suggesting that overweight is associated with more
intense pressure to restrict food consumption. Lack of research on this topic is unset-
tling given that weight may be an important determinant of the magnitude of socio
cultural pressures.

Peer ZnjZuences. Investigators have also argued that peers play an important role in the
promotion of eating disorders by perpetuating the thin-ideal (Crandall, 1988;
Cordon, 1988). Although frequency was not reported, Pyle and associates (1981)
found that suggestions from friends to lose weight were often followed by dieting
episodes associated with the onset of bulimia. Forty-five percent of the bulimics from
another case series said that they had initiated binging and purging following pres
sure from a friend to lose weight (Mitchell et al., 1986). As noted previously, Irving
(1990) found that perceived pressure to be thin coming from family, peers, and the
media was positively related to bulimic symptomatology. One interesting study exam-
ined the relation of social networks to binge eating in two sororities over a one-year
period (Crandall, 1988). Although binging was positively related to popularity in one
sorority, the two variables were uncorrelated in the second. Crandall also found that
a sorority member’s binge eating was correlated with the bingeeating level of her
friends, and that this effect increased in magnitude as friendships grew more cohesive
over the year. However, as noted by Crandall, the findings may not generalize to
bulimia nervosa <asthis study focused on binge eating.
Regarding limitations, generalization is impeded because the samples were from
case series (Mitchell et al., 1986,
Pyle et al., 198 I ) and universities (Crandall, 1988;
Irving, 1990). Additionally, three of the investigations employed retrospective reports
and did not control for actual weight when appropriate (Irving, 1990; Mitchell et al.,
1986, Pyle et al., 1981). Although these studies are suggestive, methodological Iimi-
tations and the paucity of studies directly assessing peer propagation of sociocultural
pressures precfude any firm conclusions. Nevertheless, these findings are encourag-
ing and highlight the need for further research in this area. Longitudinal studies of
peer influences would be particularly powerful. As with parenting influences, over-
weight may increase the magnitude of the sociocult,ural pressures emanating from
the peer group.

Media Znjhwnce~. Theorists have also argued that the mass media is a pervasive per-
petuator of the importance of attractiveness and the thin-ideal (Garner & Garfinkel,
1980; Gordon, 1988). As detailed above, research has found that the number of diet
articles and advertisements in women’s magazines has increased over the last several
decades (Garner et al., I980; Snow & Harris, 1985; Wiseman et al., 1992). Further,
Andersen and DiDomenico (1992) found that women’s magazines contained IO.5
times as many advertisements and articles promoting weight loss than men’s maga-
zines; the same sex ratio reported for eating disorders. A qualitative study found that
of the women who read fashion and beauty magazines, 46.5% said their feelings of
self-esteem and confidence were undermined and 68% said they felt worse about
their looks after reading these magazines (Then, 1992).
Stice and colleagues (1994) Iassessed the relation of exposure to television pro-
grams and magazines containing ideal body content to eating pathology, and
explored mediating mechanisms. They found a positive direct effect of media expo-
sure on eating disorder symptomatology. They also found that media consumption
was related to increased gender-role stereotype endorsement and heightened sub-
scription to the thin-ideal. Endorsement of the thin-ideal led to body dissatisfaction,
which was in turn related to eating pathology. Further, a study that exposed under-
graduates to slides of thin, average, and heavy models found that exposure to thin
models led to lower self-esteem and decreased weight satisfaction (Irving, 1990). As
noted previously, Irving also found that perceived pressure from media, family, and
peers to lose weight predicted bulimic symptomatology. Stice and Shaw (1994)
exposed undergraduates to pictures of models from women’s magazines and found
that exposure to thin models, versus average-sized models or control photos contain-
ing no people, resulted in increased feelings of depression, guilt, shame, insecurity,
stress, and body dissatisfaction.
Regarding the limitations of this literature, four of the studies used university sam-
ples (Irving, 1990; Stice et al., 1994; Stice & Shaw, 1994; Then, I992), and one had a
response rate of 25% (Then, 1992). Although there are probfems with this literature,
convergence of
experimental, correlational, and qualitative studies suggests that the
media plays a role in propagating the thin-ideal and attitudes associated with eating
pathology. Nonetheless, more extensive research addressing this question would be
of utility.
 Sociocultural Influences on Bulimia Neroosa 649

Media tars and Moderators of the Effects of Sociocuhal Pressures

Yl%e~e~~~~ Role OMITS of ~~ ZdeaIs.The most obvious prerequi-

site for these sociocultural pressures to adversely affect eating behavior is that they
must be internalized. If a woman does not subscribe to these pressures, it is unlikely
that they would negatively impact her eating behavior. Consistent with this, Striegel-
Moore and associates (1986b) propose that women who have most deeply internal-
ized the sociocultural mores about attractiveness are at greatest risk for developing
bulimia. In support, research has found that bulimics evidence signi~candy greater
endorsement of sociocultural pressures regarding thinness and attractiveness than
controls (Garner et al., 1983b; Johnson et al., 1984; Mintz 8c Be& 1988; Williamson et
al., 1985). Further, eating pathology is positively correlated with importance attached
to appearance (Timko et al., 1987) and endorsement of the thin-ideal (Stice et al.,
1994; Stice & Shaw, 1994). Despite the fact that these studies have methodological lim-
itations (reviewed above), not all of the studies suffered from these problems and
there was convergence across studies using different conceptualizations of eating
pathology. Thus, there is indirect evidence that internalization of such stereotypes
may mediate the adverse effects of sociocultural pressures.

7% ~0~~~ Roles of ~~~ and IWiry G.+siun. It is important to consider

what factors might moderate the degree of internalization of these sociocultural
ideals. Although there has been little research in this area, some suggestive findings
exist. It may be that people with low self-esteem are more likely to subscribe to cul-
turally prescribed ideals in an effort to gain social acceptance and heightened esteem.
This is consistent with Striegel-Moore, McAvay, and Rodin’s (1986a) contention that
low self-esteem might make women more vulnerable to external social pressures.
Although there are no known empirical tests of this proposed interaction, indirect
support for this hypothesis is provided by studies indicating that bulimic women have
lower self-esteem than controls (Dykens & Gerrard, 1986; Katzman & Wolchik, 1984;
Kendler et al., 1991; Mintz & Betz, 1988; Shisslak, Pazda, & Crago, 1990). While three
of these studies relied on university samples (Dykens & Gerrard, 1986, Katzman &
Wolchik, 1984; Mintz & Betz, 1988), these studies were methodolo~c~ly sound and
provide strong evidence that bulimics have lower selfesteem. Additional support for
this assertion comes from a meta-analytic review indicating that people with lower self-
esteem are more susceptible to interpersonal influence than people with higher self-
esteem (Rhodes & Wood, 1992).
In a more speculative mode, identity confusion may influence degree of internal-
ization of sociocultural pressures. Identity confusion refers to a weak or disturbed
sense of self-identity (Schupak-Neuberg & Nemeroff, 1993). Theoretically, people
lacking a firm sense of self may turn to culturally defined ideals in an effort to gain a
sense of identity. Johnson and Canners (1987) argue that changing gender roles
might contribute to identity confusion. However, there have been no tests of this pro-
posed interaction. Indirect support for this hypothesis is provided by a study finding
that bulimics evidence greater identity confusion and instability in selfconcept than
controls and binge eaters (Schupak-Neuberg & Nemeroff, 1993). Unfortunately,
instability of self-concept was confounded with unreliability of measurement, as the
former was indexed by the instability of subject generated self-concept descriptors
over a two-week period. Although this study suggests that bulimics evidence identity
deficits, it is premature to conclude that identity confusion leads to heightened inter-
nalization of the sociocultural pressures.
650 E Slice

The Mediating Role of Body ~~~~~ Internalization of sociocultural pressures is

thought to produce body dissatisfaction in some proportion of women. Theoretically,
a woman would not be dissatisfied with her body unless she had internalized some
ideal referent. This assertion is consonant with Crisp’s (1984) view that poor body
image is a risk factor for the development of eating problems. In support, body dis-
satisfaction has been shown to be correlated with bulimia (Dykens & Gerrard, 1986;
Katzman & Wolchik, 1984; Mintz & Betz, 1988) and eating disorder symptoms (Attie
& Brooks-Gunn, 1989; Stice et al., 1994; Stice & Shaw, 1994). Body dissatisfaction also
prospectively predicted eating pathology over a two-year period (Attie & Brooks-
Gunn, 1989). Further, decreased satisfaction with weight and attractiveness was asso-
ciated with increased eating pathology over a one-year period (Striegel-Moore,
Silberstein, Frensch, & Rodin, 1988). In a direct test of this mediational link, Stice and
associates (1994) found that body dissatisfaction mediated the relation between en-
dorsement of the thin-ideal and eating pathology. Although five of these studies used
college samples (Katzman & Wolchik, 1984; Mintz & Betz, 1988; Stice et al., 1994;
Stice & Shaw, 1994; Striegel-Moore et al., 1988)) they were generally methodological-
ly sound. Further, the longitudinal findings provide particularly compelling evidence
of this relation. Thus, there is relatively solid evidence that body dissatisfaction medi-
ates the effects of sociocultural pressures.

The Moderating Role of WG@& It is further proposed that weight may interact with
internalized ideals to produce body dissatisfaction. Theoretically, being overweight
would not produce body dissatisfaction unless the thin-ideal was internalized. This
assertion is consistent with Halmi, Falk, and Schwartz’s (1981) conclusion that bulim-
ia is more likely to develop in individuals who have been overweight. Unfortunately,
no known test of this interaction has been reported in the literature. Indirect evi-
dence for this hypothesis is provided by studies finding that weight is a strong predic-
tor of body satisfaction. Body mass (measured by confederates) was negatively related
to self-report of attractiveness (Klesges, 1983) and positively related to body dissatis-
faction and the discrepancy between current and ideal body size (Strien, 1989).
Similarly, self-report of body mass predicted body dissatisfaction (Stice & Shaw, 1994)
and the discrepancy between current and ideal weight (Drewnowski & Yee, 198’7).
Finally, dissatisfaction with weight was positively related to overall body dissatisfaction
and the difference between current and ideal body size (Silberstein, Striegel-Moore,
Timko, & Rodin, 1988). Although four studies used undergraduates as subjects
(Drewnowski & Yee, 1987; Klesges, 1983; Silberstein et al., 1988; Stice & Shaw, 1994),
this literature suggests that weight is an important determinant of body satisfaction,
Further indirect support for the role of weight in the development of eating pathol-
ogy is provided by studies finding high rates of premorbid obesity among bulimics.
Numerous studies have found that bulimics have a history of being over recornmend-
ed weight (Fairburn 8c Cooper, 1982, 1984a; Johnson, Stuckey, Lewis, & Schwartz,
1982; Mitchell, Hatsukami, Eckert, & Pyle, 1985). Further, Patton (1988) found that
weight prospectively differentiated between nondieters, dieters, and eating-disordered
adolescent females, with increased weight being positively related to diagnoses. In con-
trast, one epidemiological study failed to find a relation between previous heaviest
weight and risk for bulimia (Kendler et al., 1991). Urlfortunately, because of the scarci-
ty of controlled studies and the overreliance on retrospective reports, only a tentative
conclusion that a history of overweight is related t,o bulimia is warranted.
Although there are no direct tests of the hypothesis that weight interacts with inter-
nalized ideals to produce body dissatisfaction, it is theoretically likely that such a rela-
tion exists. It is clear that overweight is a major determinant of body dissatisfaction
among women. However, overweight would not produce dissatisfaction unless the
thin-ideal was used as the referent. It is likely that overweight is a central, if not some-
what neglected, variable that may contribute to the risk of developing bulimia. It is
also important to acknowledge, within the context of this sociocultural model, that
genes appear to play a relatively strong role in determining weight (Brownell, 1991).

The Mediating Role of Restrained Eating. Despite the fact that studies have documented
the relation of body dissatisfaction to bulimia, the mediating mechanisms between
these variables have not yet been clearly identified. It is theorized that there are two
pathways from body dissatisfaction to bulimia: a r&r&t pathway and an uffect-read-
tion pathway. First, body dissatisfaction may produce bulimia through restrained eat-
ing (Polivy & Herman, 1985). Theoretically, body dissatisfaction results in dietary
restraint because of the belief that restrained eating will lead to weight-loss. Not sur-
prisingly, research indicates that body dissatisfaction is positively related to dietary
restraint. Dissatisfaction with appearance (Hawkins & Clement, 1984) and body shape
(Strien, 1989) have both been found to be positively related to restrictive dieting.
Similarly, Dykens and Gerrard (1986) found that repeat dieters were less satisfied with
their bodies than nondieting controls. Finally, perceived amount overweight and
body dissatisfaction were positively correlated with frequency of dieting (Drewnowski
& Yee, 1987). Interestingly, frequency of dieting showed a noticeably weaker correla-
tion with actual weight than perceived amount overweight (?- = 0.19 vs. r = 0.33 respec-
tively). Although these studies used undergraduate samples, no other limitation is
present across all studies. Thus, there is moderately strong evidence that body dissat-
isfaction is associated with dietary restraint.
Unfortunately for the restrained eater, not only has research indicated that dieting
is an ineffective approach to losing weight (e.g., Heatherton, Polivy, & Herman,
1991), but it has also suggested that restrained eating leads to binge eating and the
onset of bulimia (Polivy & Herman, 1985, 1987). Restrained eating is thought to result
in hinging because of both physiological (carbohydrate cravings) and cognitive mech-
anisms (cognitively produced disinhibition). According to Polivy and Herman (1985),
dieting promotes a cognitively regulated eating style that renders the person more
susceptible to disinhibition and consequent binging.
Several lines of evidence converge to implicate dieting in the etiology of bulimia.
First, studies indicate that the majority of bulimics began binging foliowing a period of
self-induced dieting (Fairbum & Cooper, 1984b; Hall & Hay, 1991; Johnson et al., 1982;
Lacey, Coker, & Birtchnell, 1986; Mitchell et al., 1986). For example, 84.6% of the
bulimics in a case series reported that the onset of bulimia occurred during a period of
self-imposed dieting (Mitchell et al., 1986). Hawkins and Clement (1984) also found a
positive correlation between dieting and binge eating. Second, dieting prospectively
predicted bulimic symptomatology over a two-year period (Marchi & Cohen, 1990).
Similarly, the odds of developing an eating disorder over a one-year period were 2.5
times higher for dieting adolescent females than for nondieting females (Patton,
1988).5 Third, a significant proportion of initially restrictive anorexia nervosa patients
begin binging and purging as their illness progresses (Garflnkel & Garner, 1984; Hall
& Hay, 1991). Fourth, many bulimics report that they diet (Kendler et al., 1991), and
frequently skip meals and fast between binges (Davis et al., 1988; Mitchell et al., 1985;
Weiss & Ebert, 1983). For instance, not oniy did bulimics report consuming significantly

5This odds ratio was computed using data presented in Table I from Patton (1988)
fewer meals per day than weight-matched controls, but they were more calorie-deprived
prior to binge episodes than controls at the equivalent time of day (Davis et al., 1988).
Finally, laboratory studies have found that dietary restraint increases the likelihood of
binge eating (for a review see Polivy & Herman, 1985). Although the studies examin-
ing historic dieting in bulimics lack nonbulimia control groups and rely on retrospec-
tive data, the experiments, matchedcontrol studies, and longitudinal findings provide
solid support for the restraint pathway from body dissatisfaction to bulimia.
Binge eating is considered etiologically significant because it is thought to initiate
the cycle of bulimia in at-risk individuals (Hawkins & Clement, 1984; Marchi &
Cohen, 1990). Specifically, as binge eating induces negative affect and increased body
dissatisfaction, it is often followed by a purge. Purging is likely to be highly reinforc-
ing because it provides relief from the negative affect and fears of weightgain.
Because of these mechanisms, this cycle may become deeply ingrained in the person’s
behavioral repertoire (Hawkins & Clement, 1984).

The Mediating Role of Negatiue Afj2ct. In addition to the restraint pathway from body
dissatisfaction to bulimia, it is proposed that some women develop bulimia via an
affect-regulation pathway. Specifically, it is posited that body dissatisfaction produces
negative affect, which in turn leads to bulimia. McCarthy (1990) similarly hypothe-
sized that body dissatisfaction contributes to depression. Negative affect, in turn, the-
oretically results in bulimia because of the belief that binge eating regulates mood
state (Hawkins & Clement, 1984). As for the link from body dissatisfaction to negative
affect, research with both adolescents and adults has found a positive relation
between body dissatisfaction and depression (Fabian & Thompson, 1989; Stice &
Shaw, 1994).
Restrained eating may also produce negative affect, and thus contribute to bulim-
ia. McCarthy (1990) proposed that dieting leads to depression because of its ineffec-
tiveness in controlling weight. Failure in a domain considered to be under one’s voli-
tion is thought to result in feelings of helplessness and depression (McCarthy, 1990).
In support of the path from dieting to depression, one study found that repeat dieters
scored higher on the depression scale of the Minnesota Multiphasic Personality
Inventory (MMPI) than nondieting controls (Dykens & Gerrard, 1986). Further, diet-
ing and weight concerns are positively related to general feelings of personal failure
among both high school (Kagan & Squires, 1983) and college students (Kagan &
Squires, 1984). However, given that eating disturbance is a symptom of depression, a
mood disorder may actually cause overeating and the accompanying diet efforts.
A central link of the affect-regulation pathway is the relation between depression
and bulimia. Studies using standardized measures (Dykens & Cerrard, 1986, Katzman
& Wolchik, 1984; Weiss & Ebert, 1983; Williamson et al., 1985) and clinical interviews
(Kendler et al., 1991) have clearly documented that bulimics evidence more depres-
sion than controls . Additionally, research has found a positive correlation between
depression and bulimic symptomatology (Hawkins & Clement, 1984; Pertschuk,
Collins, Kreisberg, & Fager, 1986; Stice & Shaw, 1994). Epidemiological research indi-
cates that the majority of patients with both bulimia and major depression (71%)
report onset of depression before bulimia (Kendler et al., 1991). These studies are
methodologically strong, with no one limitation applying to all studies.
The relation between depression and bulimia centers around the use of binge eat-
ing to regulate affect. It has been proposed that binging reduces feelings of depres-
sion via distraction (Hawkins & Clement, 1984; Heatherton & Baumeister, 1991). In
support, 71% of the bulimics from a case series reported that they generally felt
 Socioculturalinfluences on Bulimia Nervosa 653

unhappy prior to binge eating (Pyle et al., 1981). Similarly, bulimics reported signifi-
cantly more negative affect prior to binge episodes than binge eaters and controls
(prior to normal eating) (Lingswiler, Crowther, & Stephens, 1989). Bulimics also
reported more negative moods in the hour prior to binges compared to their moods
before consuming a snack or meal (Davis et al., 1988). Convergent evidence is pro-
vided by laboratory studies showing that induced negative affect triggers overeating
among restrained eaters but not among controls (Ruderman, 1985; Schotte, Cools, &
McNally, 1990). Finally, bulimics also report that binging is associated with a perceived
decrease in depression (Steinberg, Tobin, &Johnson, 1990), and that they pul’ge to
regulate negative affect (Schupak-Neuberg & Nemeroff, 1993).
Interestingly, while bulimics appear to believe that binging and purging manage
negative affect, some findings suggest that these behaviors may actually increase neg-
ative moods (Elmore & de Castro, 1990; Johnson & Larson, 1982; Rosen, Leitenberg,
Fisher, & Khazam, 1986). For example, a study that randomly assessed affect among
bulimics found that immediately preceding a binge bulimics felt more irritable and
inadequate; however, they also found that during the binge negative mood increased,
with subjects reporting heightened inadequacy, guilt, and shame (Johnson & Larson,
1982). Similarly, when bulimics completed food diaries every time they ate or drank,
data indicate that they felt significantly more depressed following a binge-purge cycle
than preceding it (Elmore & de Castro, 1990).
Although many of the above studies are subject to sampling biases, the findings col-
lectively suggest that negative affect plays a role in precipitating binge eating.
Research consistently indicates that negative affect is associated with binging and that
bulimics believe that binging and purging regulates these negative mood states.6
However, there is evidence suggesting that binging and purging may actually increase
negative affect. Future research on the affect-regulation pathway should examine the
factors involved in both the initiation and maintenance of binge eating, and should
apply a microlevel analysis of these processes.

27~~ Moderating Role of So&I Learning. As restrained eating is very normative (Rodin
et al., 1985), but only a small percentage of women develop bulimia, a crucial ques-
tion concerns what variables moderate the link from restraint to bulimia. Social learn-
ing, coping skills, and impulsivity were examined as potential moderators. As dis-
cussed above, families, peers, and the media may not only promote bulimia by rein-
forcing sociocultural pressures, but they might also directly model eating-disordered
behavior. As young women would not likely emulate dieting and purging behaviors in
their environment unless they wished to lose weight or prevent weight gain, modeling
and instruction effects were considered moderators of the relation between restraint
and bulimia. It is felt that presence of these influences would facilitate movement
from innocuous restrained eating to bulimic symptomatology.
Pike and Rodin (1991) found that mothers of eatingdisordered daughters scored
significantly higher on a measure of eating pathology than control mothers. Further,
of the mothers who had dieted, those of the eating-disordered girls reported that they
began dieting at a younger age than control mothers. A second study found that fre-
quency of dieting in siblings and fathers was higher for restrained eaters than for con-
trols (Costanzo & Woody, 1985). Similarly, Patton (1988) found frequency of dieting

6It is important to note that negative affect is atmost certainly influenced by variables other than
body dissatisfaction and dietary restraint (e.g., at~butional style), and that the sect-re~lation
mechanism would apply equally well to negative mood states produced by these other factors.
654 E. Slice

in family members significantly discriminated between nondieters, dieters, and eat-

ing-disordered adolescent females. Finally, 11% of the bulimics in a case review
reported that they began vomiting following a suggestion from a family member that
they should vomit if feeling nauseous (Chiodo & Latimer, 1983). However, in all cases
the patient had not informed the relative that she was feeling nauseous because of
binge eating. While two of these studies relied on retrospective report (Chiodo SC
Latimer, 1983; Costanzo & Woody, 1985) and one suffered from sampling bias
(Costanzo & Woody, 1985), none of these problems was present across all investiga-
tions. Overall, these findings support the contention that families instruct and model
eating pathology.
There is also evidence for peer modeling and instruction effects. In one case
review, 37% of the bulimics reported learning to vomit from a friend (Chiodo &
Latimer, 1983). One woman reported that upon joining a sorority, a member
explained which bathroom was used by the sorority for vomiting following parties
where excessive food and alcohol was consumed. Nasser (1986) found that three of
six identified bulimics reported that they learned to abuse laxatives from another
bulimic. Finally, one study found that most college women who purged had another
self-induced vomiter as their “closest friend,” whereas normal eaters had often never
heard of one (Schwartz et al., 1982). Despite the use of retrospective reports (Chiodo
& Latimer, 1983; Nasser, 1986) and the small sample in Nasser (1986), these findings
suggest that peers model eating-disordered behavior. However, additional research on
peer influences is needed to bolster this conclusion.
Finally, there is evidence that the mass media serves to model and instruct people
in eatingdisordered behavior. One study found that 26.6% of a large bulimic sample
indicated they had learned to vomit as a means of weight control from the media
(Fairburn & Cooper, 1982). Similarly, 19% of the bulimics from a case review admitted
getting the idea to vomit from magazine articles (Chiodo & Latimer, 1983). Finally, a
study examining sources of knowledge of eating disorders among a community sample
of females found that although most subjects reported that knowledge gleaned from
the media helped them avoid eatingdisordered behavior, 2.5% reported that upon
hearing about these disorders they decided to use vomiting for weight control pur-
poses (Murray, Touyz, & Beumont, 1990). Despite a reliance on retrospective reports
(Chiodo & Latimer, 1983; Fairburn & Cooper, 1982), no limitation is present across all
of these studies. Additionally, the vastly different sampling methods inspire confidence
in the conclusion that some females acquire bulimic behaviors from the media.

Z%e ~0~~~ RoEe of Coping Sk& Coping skills may interact with restrained eating,
as well as depression, to produce bulimia. Hawkins and Clement (1984) postulate that
inadequate coping skills constitute a risk factor for bulimia. It is proposed that defi-
cient coping skills interact with restrained eating to produce bulimia, in that women
with more adaptive coping abilities would likely manage the urges to binge resulting
from dietary restraint. Coping-skill models have been successfully applied to addictive
behaviors and posit that relapse results from ineffective coping in tempting situations
(Shiffman, 1984). Support for this assertion is provided by a study that found coping
skills moderated the relation between dieting and overeating, with subjects who
reported using a coping strategy in response to an overeat.ing temptation showing a
lower relapse rate (Grilo, Shiffman, & Wing, 1989). Deficient coping skills may also
interact with depression to produce bulimic behavior. Women with more effective
coping mechanisms would likely deal with their negative affect in a more adaptive
fashion (e.g., seek social support). Unfortunately, there is no known research that has
examined these hypothesized interactions with respect to bulimia. Nonetheless, it
seems useful to postulate that inadequate coping skills play a role in the ultimate
expression of bulimia in the hope that it will generate research in this area.

The Mo&r&ing ROL of Z~@.sitity. Finally, impulsivity may moderate the relation
between restrained earing and bulimic behaviors, in that impulsive people would be
more likely to both binge in response to triggers and purge after hinging. Similarly,
Striegel-Moore and associates (1986b) posit that women with poor impulse control
are at risk for bulimia. Although there are no known tests of this interaction, research
suggests that bulimics are more impulsive than controls. Pyle and associates (1981)
found that bulimics had clinically elevated scores on the psychopathic deviant scale of
the MMPI, which they interpreted as reflecting impulsive. Bulimics also evidence
imputsive behaviors such as stealing, substance use, and self-abusive behaviors. Rates
of theft range from 58 to 64% in clinical samples (Mitchell et al., 1986; Pyle et al.,
1981), and from 13.3 to 27.8% in college samples (Pyle et al., 1986). In one controlled
study, bulimics reported significantly more stealing (67%) than controls (14%) (Weiss
& Ebert, 1983). Among a case series of bulimics, 23% had received treatment for
chemical dependency and 15% reported using alcohol on a daily basis (Pyle et al.,
1981). Weiss and Ebert (1983) found that bulimics used significantly more marijuana,
cocaine, amphetamines, and barbiturates than controls. In a large case series, 34.4%
of the butimics reported that they had tried to physically hurt themselves (e.g., cut
themseIves) {Mitchell et al., 1986). Finally, the rate of suicide attempts was signifi-
cantly higher among bulimics (40%) than controls (O%} (Weiss SC Ebert, 1983).
Unfortunately~ none of these studies directfy assessed the construct of impulsivity. The
psychopathic deviant scale is not a pure measure of imp&iv&y, as elevated scores may
result from other factors (e-g., antisocial behavior). Addition~iy, only one study incor-
porated a control group. Overall, this research only provides suggestive evidence that
bulimics show heightened impulsivity.

Summary and Conclusions

In summary, the above mode1 proposes that socioculturaf pressures, as transmitted by

family, peers, and the media, promote an internalization of these ideals. Low self-
esteem and identity confusion are thought to increase the likelihood of internaliza-
tion of these pressures. Further, it is hypothesized that internalizing these ideals
results in body dissatisfaction because of the unrealistically thin standard. Weight is
posited to moderate this effect, with the reiation between internalized ideals and body
dissatisfaction being stronger among heavier women. According to the first linkage in
the dual pathway model, body dissatisfaction leads to dietary restraint, which in turn
increases the chances of binge eating and bulimia. Modeling of bulimic behaviors by
family, peers, and the media is theorized to increase the likelihood of moving from
restrained eating to bulimia. Similarly, coping skills deficits and impulsivity are postu-
lated to interact with restraint to produce bulimic behavior. fn the second pathway,
body dissatisfaction and restrained eating are thought to produce bulimia via negative
affect. Theoretically, negative affect leads to bulimia because of the belief that bing-
ing and purging regulates affective state. Finally, deficits in coping skills are thought
to increase the likelihood that negative affect will lead to bulimic behavior.
A major limitation of the proposed mode1 is that it rests aImost entirely on cross-
sectional correlational data. Thus, the direction of effects for many of the links have
not been adequately verified. Second, this model does not fully incorporate other
656 E. Stice

variables that are thought to be related to the development of bulimia, such as per-
sonality and biological influences. Future work should more broadly integrate the
effects of sociocultural pressures with these other factors in an effort to produce a
more comprehensive model of bulimia nervosa. Finally, this model focuses solely on
the etiology of bulimia among females. It is likely that somewhat different processes
are involved in the development of bulimia in males.
Several implications for the design of prevention programs emerge from this
review. First, prevention efforts should attempt to decrease internalization of socio-
cultural pressures. Programs might achieve this aim through enhancing self-esteem,
highlighting the incongruence between biology and the thin-ideal, and stressing the
health risks associated with the pursuit of this body type. Second, programs might bol-
ster body satisfaction as it appears to be a key factor in the etiology of bulimia.
Prevention efforts should also educate adolescents about the negative consequences
of restrictive dieting. Finally, programs could teach adolescents more adaptive coping
skills, in an effort to minimize the chances that bulimic symptomatology would devel-
op out of restrictive dieting and negative affect.
Future research will need to further validate the mediational links proposed in the
present model. Additionally, the hypothesized moderators are generally lacking
empirical validation. Longitudinal studies of high-risk populations would be useful for
demonstrating temporal precedence. Experimental preventive inte~entions
designed to decrease identified risk factors would also provide a particularly powerful
test of the proposed linkages. Finally, the adequacy of the overall model in predicting
bulimic symptomatology should be assessed. In general, researchers in the area of eat-
ing disorders should take advantage of more sophisticated methodologies (e.g.,
multiple reporters) and analytic techniques (e.g., structural equation modeling).
Utilization of these powerful research technologies would greatly enhance our under-
standing of the etiology of bulimia nervosa.
Overall, this review concludes that there is evidence of sociocultural influences in
the promotion of bulimia nervosa. However, as illustrated in the later sections of this
review, the knowledge base concerning linkages between sociocultural pressures and
the expression of bulimia is lacking. Elucidation of the mechanisms of action for these
sociocultural influences would not only enhance our undemanding of the etiology of
bulimia, but would also optimize our ability to prevent and treat this disorder.

A~k~ow~dg~ts - This article is an outgrowth of the author’s comprehensive paper for the
PhD requirements at Arizona State University. This project was supported in part by a Research
Development Grant from Arizona State University. I would like to thank Carol Nemeroff,
Heather Shaw, Rick Stein, and Sharlene Wolchik for their valued input regarding this article.

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