We’ve begun to scratch the surface of the vast and growing literature on cultural context and eating disorders in the previous 4 posts in this series. Of course, as I reflected the other day, there could (maybe should?) be a blog solely devoted to this topic- each time I read another study in this area, it pulls me down the rabbit hole into another related area.
In what will be the last part of this series for now, I’ll review a study by Bennett, Sharpe, Freeman, and Carson (2004) on the request of Lisa LaBorde (via Twitter). The authors wanted to learn more about the presence (or lack thereof) of eating disorders in Sub-Saharan Africa, a context that they describe as less driven by the thin-ideal. This was, they suggest, the first thorough exploration of anorexia in sub-Saharan Africa, and so might reveal more about whether and how anorexia nervosa is present in area of the world that is differently positioned on the world stage than Western societies.
THE STUDY
Bennett et al. selected 2 high schools located in the northeast of Ghana from which to draw a sample of female students between the ages of 15 and 25. The schools were both funded by the Ghanaian Education Service, though one was a mixed gender day school and the second a girls-only boarding school. The latter provided its’ students with 4 meals a day and the former did not provide any meals, so students at the day school were more dependent on their families’ resources for nourishment. Neither school was affiliated with a religion (this will come into play later on).
All young women (668) attending these schools were invited to participate; one redacted her consent after being screened. Students were screened for BMI; if a student’s BMI was below 19, they were assessed further (100 participants). Additionally, those who were below the cut off of 19 invited a friend to participate in further assessment; these invited participants became the comparison group (85 participants).
BMI for the entire (668 participant) group ranged from 15.9 to 33.8, with a median of 21.1. 100 young women had a BMI below the inclusion cut off for further assessment; 29 had a BMI below 17.5.
Further assessments included:
- Mental state assessment: information about participants’ thoughts, beliefs & behaviours related to eating
- Physical assessment: background medical history, symptom checklist (e.g., checking for worms, giardiasis, etc.)
- Eating disorders measures: Eating Attitudes Test (EAT), Bulimic Investigatory Test, Edinburgh (BITE)
Conveniently for us, the 2 measures they chose are the same measures I wrote about in the previous post about Le Grange et al.’s study. Though Bennett and colleagues note that these measures have been validated for use in cross-cultural contexts, Le Grange et al.’s work revealed that people in different contexts might have different reasons for engaging in similar behaviours; this needs to be taken into account when drawing conclusions about scores on such questionnaires as indicative of eating disorders.
Participants’ scores on the EAT did not significantly differ between the comparison group, the group with a BMI between 17.5 and 19, and the group with a BMI below 17.5; nor did participants score within clinical ranges on the BITE. Still, the authors determined that the low weight of 10 of the 29 young women whose BMI was below 17.5 could only be attributed to “morbid self starvation” (i.e., not because of physical illness).
But if this is the case, why did none score in the clinical ranges on the diagnostic tests? Again, the limitations of quantitative measurements of eating pathology come into play. The authors describe 2 case studies as well as describing the participants’ experiences in general to illustrate their orientation toward food, eating and their bodies. Among these, participants described:
- Desiring control
- Liking the sensation of hunger
- Denying feeling hungry
- Engaging in self punishment
- Associating self-starvation with control and achievement, particularly in the absence of control elsewhere in their lives
- Being perfectionistic (e.g., wanting to be successful in school)
Both case studies reflect how participants’ self-starvation was tied to religiosity and the pursuit of purity, though the authors are careful to point out that this does not mean that fasting for religious purposes is always indicative of eating disorders. They liken this distinction to the well-known adage that many people diet and relatively few actually develop eating disorders.
What does it mean for our understanding of eating disorders as culture bound?
As both the studies by Le Grange et al. and Bennett et al. reveal, individuals with eating disorders might have shared clinical presentations but different reasons for engaging in behaviours across contexts. Whereas Le Grange et al. found that their participants often engaged in what might be interpreted as eating disordered symptoms for other reasons, however, Bennett et al. found many similarities between their participants’ symptoms (including both cognitive and behavioural features) and eating disorders in other cultural contexts.
In this case, Bennett et al. make the argument that rather than seeing preoccupation with weight and shape as a central feature of eating disorders, seeing self-starvation itself as the central feature of eating disorders might be more conducive to appropriate cross-cultural comparisons. This argument is not new, and even seems somewhat self-evident. Looking back at work by researchers like Sing Lee who have studied eating disorders in other cultures in the absence of thin-ideal internalization/fear of fatness, we can see how this makes a lot of sense.
What might be a more interesting question is: if eating disorders can be disentangled from preoccupation with thinness (or at least if this is seen as often coming after other driving factors), how have they come to be so closely tied to thin-ideal internalization in popular descriptions?
Despite the differences in Le Grange et al. and Bennett et al.’s findings, when both looked at eating disorders in Africa, both studies also clearly demonstrate the need to get at the heart of why participants are engaging in the behaviours rather than making assumptions about reasons based on questionnaire responses alone. I like this a lot for obvious reasons (I’m a qualitative researcher) but also for the reason that it continues to add complexity and richness of experience to what can sometimes become a push for numbers and figures, one-size-fits-all treatment approaches and streamlined diagnoses.
Thinking particularly about the Ghanaian perspective presented here and the South African context presented in Le Grange et al.’s study, we an also begin to think about what a context of economic scarcity does for interpretations of eating disordered behaviours. What implications does scarcity have on, for example:
- How restriction is socially interpreted (i.e., Could it be seen as selfish? As borne of necessity? As adaptive? As indicative of physical illness? As tied to religion?) and what might that do for the individual’s experiences?
- Are there enough resources to make binging and purging possible, and how that might play out in terms of symptom presentation? Though both of these studies looked at anorexia, we could look more in-depth at the meaning of binging and purging and how this is tied to economic scarcity
These questions and more also underline the importance of seeing “culture” as more than just “media.” It might be indicative of our Western point of view that the first thing that tends to jump to mind when someone says “culture” tends to be that barrage of images to which we are exposed each day.
References
Bennett, D., Sharpe, M., Freeman, C., & Carson, A. (2004). Anorexia nervosa among female secondary school students in Ghana. The British Journal of Psychiatry, 185, 312-7 PMID: 15458991
Speaking for myself all of the described orientations towards eating apply to me to a certain degree. So all this demonstrates is that anorexia is a mental disorder. The precise triggers and behaviours don’t matter. Some people seem predisposed towards it.
But I also question the criteria used for what is and what is not a healthy weight. Generally we say a BMI under 18.5 is underweight. Why? When did it get decided that this was the criteria? My BMI is around [Edited to remove number] and my health is perfect. I simply don’t like food and find the feeling of it in my stomache unpleasant.
Most people my age are disgustingly overweight to my eye. Fat hangs off them. It actually makes me feel nauseous to be near them.
I never have and never will seek out help for what I realise is an unusual preoccupation with weight. It terrifies me to think I might look like them, I would be beyond miserable.
I would argue that the precise triggers and behaviours do matter, particularly for understanding how best to treat & support people. I’m unsatisfied with saying we don’t know; I think this makes it seem like there is no way to better meet people’s needs and lumps what are individual and complex symptoms & behaviours & experiences under a single umbrella.
The authors justified their BMI choice on the notion that 18.5 is the cutoff for underweight, and wanted to access a segment of the population who might be experiencing symptoms but be above this cutoff so went with 19. There are many, many flaws with the use of BMI. However, if we’re looking at statistics, only a very small proportion of the population has a BMI of below 18.5 without artificially manipulating it to be that low. Which isn’t to say it’s impossible, but less common. I will critique the BMI until I’m blue in the face, but I don’t think that you need to call people “disgusting” whose weight is higher or use your experiences to shame those whose body weights are higher. It is, of course, your prerogative to seek or not seek help, but I would caution against judging those who do seek to gain weight in order to be well.
Further I would never encourage those whose health is compromised from seeking treatment. I merely wanted to point out that the science behind what is underweight and what is not is pretty thin. In fact, there is mounting evidence to suggest that health and life expectancies are better for those with what are traditionally considered to be “underweight”.
As I’m sure you are aware not all anorexics and certainly not all bulimics are underweight. Both conditions can be unhealthy but using BMI as a diagnostic criteria is bad science. Fasting and starving are one set of behaviours, binging and purging are another. They also have different health outcomes.
I’m not sure what it is about my comment that leads you to believe I’m a fan of the BMI; I was noting how the authors used it in the study. I dislike the BMI. It is possible that the authors’ awareness of the fact that not everyone with an eating disorder is underweight drove their decision to have a friend not in that group participate.
I should add that my social setting could not be more different than these young ladies.
Maybe it’s everyone else, the vast majority of over indulgent, obese, calorie addicted people who are the problem while people like myself actually have a more healthy attitude towards food. My friends panic at the thought of missing a meal, I couldn’t care less. So who really has the more important problem? It’s pretty rare to die in North America from eating too little but common place to die from over eating.
You seem to be equating morals and bodies. You can’t know much (anything) about how a person eats/doesn’t eat/exercises/behaves by looking at their body size. Nor can you tell anything about whether they are a productive and healthy human being. It is dangerous and rude to draw conclusions that people are “calorie addicted” from a set of observations you’ve made. This is weight stigma, which in and of itself has highly negative consequences for peoples’ health.
Excess weight to the point of obesity should be stygmatized. That’s how we successfully reduced the rates of smoking. Addiction is addiction and if you don’t change the attitudes of society towards it the situation will not improve. I was expressing freely my highly biased viewpoints, after all I am anorexic and view things differently from most. I don’t approve of shaming people, addiction is a social problem and needs to be dealt with as such. Addicts are not immoral, I never said so but they are addicts and it is a serious life threatening condition. It would not be unfair to refer to it as an epidemic.
Your statement ” you can’t know anything about how a person eats/ exercises etc. or draw conclusions about their health is just wrong. The health consequences of obesity and morbid obesity are well documented.
There is no evidence that stigmatizing promotes healthy relationships with exercise or eating; in fact, there is evidence to the contrary, for example:
Rice (2007): http://www.sciencedirect.com/science/article/pii/S0277539507000179
Puhl & Heuer (2010): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866597/
Annis et al. (2004): http://www.sciencedirect.com/science/article/pii/S1740144504000270
Herndon (2005): http://www.tandfonline.com/doi/abs/10.1080/10350330500154634
Vartanian & Shaprow (2008): http://hpq.sagepub.com/content/13/1/131.short
And more.
You can’t assume that everyone who is in a larger body is addicted to food. Referring to obesity as an epidemic is commonplace but can be harmful.
“Excess weight to the point of obesity should be stygmatized. That’s how we successfully reduced the rates of smoking.” Is it really through stigma? Or is it through programs that help individuals quit smoking?
Also, “Your statement ” you can’t know anything about how a person eats/ exercises etc. or draw conclusions about their health is just wrong. The health consequences of obesity and morbid obesity are well documented” is a non-sequitur. The consequences of obesity have nothing to do with the notion that you know how someone eats or how much they exercise because they are obese (or because they are at any weight, for that matter). They may be obese and eat well and exercise well, or they may be obese and not. Someone might be slim and eat well and exercise well, or they may be slim and eat poorly and not exercise.
I like common sense. You can tell a lot about someone’s lifestyle merely by looking at them. Note, I used words like obese and morbidly obese. No person carrying that amount of weight is healthy nor do they have a healthy diet. Sorry, healthy foods simply aren’t sufficiently calorie dense.
ANDREA
You are obviously a fan of BMI and thin phobic or you would not have taken the time to delete my personal BMIi of [low BMI value removed by Tetyana]. In fact all of your writings reflect a thin phobic bias. No need to reply but feel free to exercise your prejudice by once again deleting a report of good health.
I would encourage you to read the Heath at Every Size literature, though I don’t believe you would be open to the perspective so perhaps it is best to let it alone and accept that I won’t change your mind. I do suggest that you avoid taking a stigmatizing approach that can alienate those whose bodies are not like yours. I would like to clarify that the deletion of your BMI in the comment was because the inclusion of your personal BMI has nothing to do with the argument you were making. In terms of your accusation that I am thin phobic, I am not, however I don’t believe any argument I would make would convince you otherwise. In all of my work I try to emphasize the need to not place one type of body size on a pedestal above any other.
I’m sure I won’t change your mind either. But mostly I prefer to focus on health. So, in my mind ther area wide range of body types that can be healthy, some appeal to me personally and some do not. At both ends of the bell curve however there are body types that are clearly unhealthy. I merely find it ironic that in a society with an obesity epidemic we continue to study a rare condition based on criteria with questionable scientific criteria.
If my memory serves you yourself were diagnosed as anorexic. After decades of living as a trans woman and anorexic I’m beginning to wonder if these are psychiatric conditions at all.
I chose my words poorly when I saif stygmatized. Smoking rates were reduced because the practice became socially unacceptable, hence the stygma. I was merely suggesting that the same shift needs to happen to promote a reasonable range of healthy body weights.
Hi Amber,
The deletion of the BMI reference is in accordance with my comment policy. I asked Andrea to delete the BMI reference and yours is not the only comment that I’ve moderated in the past. My comment policy hasn’t changed since I began the blog in 2012. It is available here: https://scienceofeds.org/comment-policy/.
Regards,
Tetyana
The study is fascinating in its finding that 10 out of a sample of 668 girls in this part of Ghana appeared to have anorexia. These statistics are completely in line with the theory that around 1% of people – more women than men – are (genetically) susceptible to developing anorexia, and that this holds true across all cultures. As we know, there is a massive tendency for people to confuse dieting and anorexia and believe that it is solely a Western problem linked to idealisation of slimness. Such misunderstandings can be caused when statistics published for “Eating disorders” show that they are becoming more and more common in the West. If anorexia is considered alone (and not together with bulimia, ednos, BED etc.) there is considerably less growth in prevalence, and most of that is probably down to increased understanding and diagnosis. If the statistics pointing to 1% genetic susceptibiilty across all cultures were to be widely communicated it would improve the discourse on anorexia immensely.
What theory are you talking about regarding the idea that 1% of people are genetically susceptible to develop AN? I’ve never heard of such a theory.
Just to add: Given that the prevalence of AN is roughly 1% or so, I’d suspect a lot more are susceptible to developing AN (since not all who are susceptible will develop it, presumably, anyway).
Putting together the lifetime prevalence for anorexia of around 1% (higher for women, lower for men) with all the research pointing to high rates of heritability and adding in various hypotheses about genetic causes…
but, true, actual susceptibility may be a bit higher: only actualised cases can be analysed. (I’m not a scientist, so please excuse any inaccurate wording).
My point was that I have seen quite a few studies like this suggesting that anorexia (defined in this study as low weight caused by “morbid self-starvation”) has a fairly constant prevalence across time and cultures. And that is noteworthy (heartening, even, if that’s not the wrong word) because it’s not what the media constantly claim – that numbers have risen exponentially in recent times and that it’s solely a problem in the West because we are all so vain and self-absorbed etc, etc, etc.
I am partially recovered from anorexia. I’m especially interested in the concept of confabulation (ie post-hoc rationalisations for engaging in self-starvation). Cultural studies unearth any number of these stories – each one created by an individual psyche – but maybe the pathway is generally the same?
You wrote: “that is noteworthy (heartening, even, if that’s not the wrong word) because it’s not what the media constantly claim – that numbers have risen exponentially in recent times and that it’s solely a problem in the West because we are all so vain and self-absorbed etc, etc,”
Yes, I agree. It sounds a bit odd to say it is heartening, indeed, but I think I know what you’re getting at- for some reason the kind of media-obsessed & vanity rhetoric somehow continues despite the strong evidence to the contrary, and I think it would be interesting to look at why that is. Is it just the easiest “cause” for people to latch onto? You also make a good point about the potential for rationalization after the fact. I wonder if there are any studies about this… I assume it would be quite difficult to explore, empirically. Now I need to go look for such studies…
Referring me to a prejudicial policy that you consistently enforce is an oxymoron. It’s clear to me now that this whole site is a thinly disguised mechanism for promoting your cultural and ideological stereotypes. I would compare it to the “scientific” proofs offered by those who support the theory of creationism. It looks like science and sounds like science but since it proceeds on the basis of an axiom which is accepted but unproven it is not science.
The proof is in the pudding. Your moderation substituted a fact with a judgement – the word low. Are you a doctor, do you have access to my health records? No, of course not, but still you display a clearly negative attitude towards my body type. I can’t say what led you to this conclusion but let me offer a thought. Body weight is not in and of itself a sign of unhealthy behaviour and true anorexia is over diagnosed by an army of pseudo intellectuals who make a living from their so called studies. A lot like what has been done to trans people.
It’s sad and depressing for me to realise how many make a living off convincing others that their behaviours are conditions in desperate need of treatment. Of course these various conditions as laid out in tedious detail in the DSM all represent small, normal variations in human behaviour that social norms dictate. Now we even go to other countries to enforce our notions on others.
It’s like a religion. Just take it on faith. As a scientist with three degrees I don’t take things on faith, I need proof, something sorely lacking here.
Enough said but perhaps you and your compadres should rethink the basis for your entire line of thinking. In bio sciences and chemistry ( my particular areas of expertise) we would say ” go back to formula” which means to re-examine the fundamental concepts on which any research was based. It’s hard, but science demands perfection.
All of you here should think long and hard about this but I doubt you will.
I appreciate the feedback; however, if you do not like the content on the website or the comment policy/moderation, you do not need to read or comment.
“Are there enough resources to make binging and purging possible, and how that might play out in terms of symptom presentation?”
I remember during my worst years fantasising about being in a situation where I physically didn’t have access to food. I tried to create the scenario for myself through various methods. I became ingenious at finding ways to get food, and my brain went into overdrive thinking of ways to get food. Often I’d eat things we don’t normally consider to be food. I’d draw the conclusion that in scenarios like this we’d see more pica like behaviour.
I’m unsure how you’d study this ethically thoug, rather than relying on self reported incident!
Thanks for sharing your experiences. I think that’s a really interesting point, but I agree that it would be near impossible to study ethically, with humans at least (and if studied with animals the conclusions wouldn’t necessarily be translatable). Mostly you just wouldn’t be able to put people in conditions of scarcity and ask what binging strategies they use; I suppose you could select groups who already live in scarcity and have them do some kind of event behaviour monitoring where they indicate what the binge was comprised of; I’m not sure how feasible it would be, but I do think that more research needs to integrate economic analysis for sure, however that is done.
“I’d draw the conclusion that in scenarios like this we’d see more pica like behaviour”!! This is an interesting point! I hadn’t thought of that.
I think it IS possible to study ethically, but perhaps not to the extent you are thinking of. (I.e., look at people in urban areas where food is easy to get vs. food deserts where it is harder, or where there’s like one tiny store, so buying tons of food is very suspicious).
Thanks for writing the series on culture. I myself am a black anorexic who is currently in inpatient for anorexia. I’m 42 and my issues started at 14. There are some articles that may be of interest to the readers.
Eating disorders in South Africa: an inter-ethnic comparison of admission data
http://www.samj.org.za/index.php/samj/article/download/368/870
Eating disorders in black South African females
http://archive.samj.org.za/1995%20VOL%2085%20Jan-Dec/Articles/06%20June/2.8%20EATING%20DISORDERS%20IN%20BLACK%20SOUTH%20AFRICAN%20FEMALES.A%20SERIES%20OF%20CASES,%20C.P.Szabo,%20M.Berk,%20E.Tlou,.pdf
Anorexia nervosa in two Nigerians
http://www.ncbi.nlm.nih.gov/pubmed/3232532
Anorexia nervosa in a developing country
http://www.ncbi.nlm.nih.gov/pubmed/7272625
Anorexia nervosa in a black Zimbabwean
http://connection.ebscohost.com/c/articles/24830801/anorexia-nervosa-black-zimbabwean
It has been pointed out to me in inpatient by a bank non regular staff just how rare i am as they said that they don’t see black people being admitted. That made me feel like a bit of a freak. I’m black british African and grew up in the UK and went to Nigeria for the first time at 25; I have a first cousin who struggles with her eating and she was well below a BMI 17.5 the last time i saw her and she has never visted the West. She is not AN, i think if she lived in the West then that could contribute as a trigger in developing anorexia nervosa.