Culture and Eating Disorders: A Singaporean Perspective — Part 1

Some previous posts on this blog have explored whether eating disorders might (or might not) be considered culture-bound, or in other words specific to or presenting specifically in certain cultures. If you consider eating disorders to be “culture bound,” they would present primarily in Western cultures, with non-Western cultures ‘receiving’ eating disorder pathology through Westernization. In this post, I explore eating disorders in the Singaporean context to continue to unpack the relationship between culture and eating disorders. Singapore is an interesting place in which to look at eating disorders (not just because I live there) because it complicates the idea of “culture-boundedness.”

Studies have been conducted in Asia; primarily in Hong Kong and to a lesser extent Japan. Most notably, Lee (1991) found non-fat-phobic presentations in Hong Kong supported by Ngai, Lee & Lee (2000) (see this post for more on the Ngai study). Singapore is like Hong Kong in its rapid economic development, coupled with a competitive and individualistic culture that places high value on academic achievement. However, the two broad studies on anorexia nervosa here, Lee et al. (2005) and Kuek et al. (2015), quite strongly contradict Lee (1991)’s findings. They are largely descriptive, but show that many Singaporean patients did experience body image issues as a key part of their illness.

THE STUDIES

Both studies reported patients’ self-identified precipitating factors for their anorexia – 58.7% of patients in the 2005 study and 84.9% of patients in the 2015 study identified specific factors triggering their eating disorder.

In the 2005 study the following percentages of participants said these factors triggered their illness:

• Comments or teasing (26.9% )
• Being in a Trim and Fit program for overweight students (5.6%)
• ‘Health reasons’ (3.2%)
• Stress (11.9%)

In 2015:

• Comments and teasing (31.7%)
• Stress (24.7%)
• Dieting (14.8%)
• Being overweight (7.7%)

In other words, the typical Singaporean patient appears quite similar to the classic Western presentation as laid out in the DSM:

• Female (> 90% in both samples)
• Low body weight (mean BMI at presentation was 15.56 in 2005 and 14.43 in 2015)
• Placing ‘undue influence on body weight or shape’ (DSM-IV).

One concern raised by Kuek et al. (2015) was that cases have become significantly more severe since 2005: the mean BMI decreased between studies, as did the mean duration of illness (from 2.17 to 1.39 years), indicating a more rapid onset and decline. In fact, 1/3 of cases from 2003-10 presented as inpatient, but bear in mind that

• Their treatment centers may have been handling less severe/ complex cases on an outpatient basis
• The lack of residential and PHP programs means that anyone too unstable for outpatient would have jumped straight to inpatient.

It also suggests that, if Western patterns resemble Singapore’s, only this most visible population of sufferers is being identified. An older patient with mixed restrictive and bingeing patterns will be much more likely to fly under the radar without the visible signs of rapid weight changes (or possibly diagnosed as OSFED, on which no-one seems to have done a study). I’ll talk about this in relation to another study, but it’s worth noting that 9 out of 19 male patients said that their pre-morbid overweight status triggered their ED. Another explanation for such a low presenting BMI might simply be that young Chinese women in particular tend to be small-built and hence reach a critical weight much more easily (unfortunately, the studies do not mention any numbers on weight changes).

The 2015 study has less detail than the 2005 one in breaking down the profile of cases, which is a pity because the 2005 findings highlighted some interesting trends that I would have wanted to see confirmed or altered in the more recent study:

1. Binge/purge subtype patients tended to have older onset, higher BMI and levels of psychopathology, impulsivity and emotional distress – in other words, more similar to bulimia patients. However, the authors of the 2015 study reported a higher age of onset (16.34 versus 15.5 in 2005) and a lower percentage of B/P subtype cases, contradicting this correlation. On the other hand, maybe the bulimic behaviors just didn’t have time to develop at time of presentation (see this very old post).
2. Another finding was that anorexia is not only highly gendered, but highly associated with same-sex environments: out of 95 participants in 2005 who reported their schools, 47.3% came from girls’ schools (which make up only 8.5% of schools in Singapore). These schools also tend to be more competitive, so it is unclear what factor is at work here, but anecdotally, these schools remain hotspots for eating disorders.
3. The peak age of onset is around 15 years old, but there is a smaller spike around 12 years old – around the time students take their national exams and are streamed into secondary schools by academic ability. The study did not break down precipitating factors by early and late onset, but I’d want to know whether body image concerns were as prevalent for this younger age group or if it tended to present in ‘atypical’ non-fat-phobic ways.

WHAT IT MEANS

So, what does this tell us about culture and eating disorders, if anything? There is just not enough evidence to tell at the moment. Data on the ground in individual countries is very thin, given the insufficient numbers of cases and the fragmented provision of ED services and specialist treatment. A few suggestions, however:

1. Cultural factors always influence the presentation and treatment of eating disorders – but to say that eating disorders are tied to a certain kind of culture is, I would argue, so broad as to be meaningless. The differences between Singapore and Hong Kong patients contradict the idea that there can be a typical ‘Western’ and ‘Asian’ eating disorder patient, or that eating disorders outside of the West solely come about as a by-product of globalization.

2. It’s important to explore cultural differences – just at the right unit of analysis. One good example in this is the apparent under-representation of Malays in the sample. There are a few plausible factors that could be at work:

• Protective elements of Malay culture (attitudes towards food and weight)
• Stigma preventing treatment-seeking
• Different presentations – perhaps falling more into the bulimia and OSFED diagnoses
• Socio-economic barriers to accessing treatment

Isolating these various cultural influences at a more detailed level could be helpful in developing more targeted prevention and early intervention programs.

3. Another approach might be to see, as Tsai (2000) suggests, eating disorders as a product of cultural change rather than cultural-boundedness. Eating disorders rose sharply in the late 1990s and early 2000s, which coincides with a period of social fragmentation and economic difficulty in Singapore. In fact, the incidence of psychiatric disorders in general rose by an even greater percentage. Just as stress on the individual can trigger EDs, general social strain can prompt higher levels of illness. Mark Fisher’s great work in Capitalist Realism argues for this interpretation, more specifically the impact of neoliberalism and its individualistic culture. One of Singapore’s core principles of governance – ‘work for reward, reward for work’ – ties in perfectly with the anorexic drive to individual bodily perfection.

4. For Singapore at least, I think the big question is what culture is doing the “bounding”. If we look at Singapore as a typical Asian society, then it challenges the idea of eating disorders as a typically Western disease. On the other hand, Singapore has deeply assimilated Western culture, which may suggest that exposure to the latter correlates to an increase in culture-bound disorders. Much about Singaporean culture remains ambiguous in this regard: for instance, many celebrities openly patronize slimming centres and even admit to having plastic surgery, which reflects what I think is a more Asian norm of being upfront about discussing physical appearance. On the other hand, all this ‘body work’ aspires towards a deeply Westernized ideal. The notion of culture hence remains very slippery and hard to pin down in a manner that can be generalized to other countries.

[Full disclosure: I know one of the authors of the 2005 study.]

References 

Kuek, A., Utpala, R., & Lee, H.Y. (2015). The clinical profile of patients with anorexia nervosa in Singapore: a follow-up descriptive study. Singapore Medical Journal, 56 (6), 324-8 PMID: 26106239

Lee, H.Y., Lee, E.L., Pathy, P., & Chan, Y.H. (2005). Anorexia nervosa in Singapore: an eight-year retrospective study. Singapore Medical Journal, 46 (6), 275-81 PMID: 15902355