18 - Cultural perspectives on eating disorders

Summary

Summary Evidence suggests that both the presentation and prevalence of eating disorders has changed across history and cultures. This challenges earlier conceptualisations of these disorders as culture-bound syndromes, and raises important questions about aetiology. Culture may play a role in shaping the presentation as well as possibly affecting the prevalence of eating disorders. Although the evidence base is limited, current evidence of the pathoplastic role of culture in shaping the presentation of eating disorders and the pathofacilitative role of culture in the aetiology of the condition are discussed. The role of gender is similarly explored. Finally, the importance of cultural sensitivity in the development of future diagnostic criteria, treatment and service provision is discussed.

Eating disorders constitute a range of conditions associated with abnormal eating behaviour, with related cognitive, emotional, behavioural and physiological components. Anorexia nervosa and bulimia nervosa are the two most well-described eating disorders. Although a medical conceptualisation of anorexia nervosa goes back to the last quarter of the 19th century, bulimia nervosa was first described as a ‘variant’ of anorexia nervosa only three decades ago (Russell, 1979). Anorexia nervosa and bulimia nervosa remain the most commonly studied eating disorders, but the majority of people presenting for treatment in the UK do not meet the diagnostic criteria for these disorders and are classified as ‘eating disorder not otherwise specified’ (EDNOS) (Fairburn & Bohn, 2005). Prevalence of the different forms of eating disorders vary across cultures, e.g. among African–Caribbean and Latino people in the USA binge eating disorder was found to be the most common diagnosis (Hudson et al, 2007).

Eating disorders were once thought to affect only young women in affluent Western societies. This led to the suggestion that anorexia nervosa may be a culture-bound syndrome of the West (Prince, 1983). This notion was later challenged by the demonstration that eating disorders are not confined to one particular culture or socioeconomic class (Hoek et al, 2003). Eating disorders may therefore be culturally reactive rather than culture-bound phenomena (Caradas et al, 2001), and their expression may be influenced by gender and culture (Reiger, 2007). Cultural plasticity presents a challenge in understanding and diagnosing eating disorders for the forthcoming fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (Striegel-Moore & Wonderlich, 2007).