The Untold Story
"I think about food constantly. I am always trying to control the calories and fat I eat, but so often I end up overeating. Then I feel guilty and vomit or take laxatives so I won't gain weight. Each time this happens I promise myself that the next day I will eat normally and stop the vomiting and laxatives. However, the next day the same thing happens. I know this is bad for my body, but I am so afraid of gaining weight."
This vignette describes the daily existence of one person seeking treatment for an eating disorder in our clinic. A second person reported, "I don't eat all day and then I come home from work and binge. I always tell myself I'm going to eat a normal dinner, but it usually turns into a binge. I have to re-buy food so no one notices all the food is gone."
Stop for a moment and try to envision these two individuals. For most people, the image of a young, middle-class, white female comes to mind. In fact, the first quote came from "Patricia," a 26-year-old African-American female, and the second from "Gabriella," a 22-year-old Latina* woman.
Recently, it has become apparent that the stereotypic image of those suffering from eating disorders may not be as valid as once thought. A primary reason why eating disorders appeared to be restricted to white women seems to be that white women were the only people with these problems who underwent study. Specialists conducted most of the early research in this area on college campuses or in hospital clinics. For reasons related to economics, access to care, and cultural attitudes toward psychological treatment, middle-class white females were the ones seeking treatment and thus the ones who became the subjects of research.
Defining eating disorders
Experts have identified three major categories of eating disorder:
Anorexia nervosa is characterized by the incessant pursuit of thinness, an intense fear of gaining weight, a distorted body image, and a refusal to maintain a normal body weight. Two types of anorexia nervosa exist. Those suffering from the so-called restricting type severely restrict their caloric intake by extreme dieting, fasting, and/or excessive exercise. Those of the so-called binge-eating purging type exhibit the same restricting behavior but also fall victim to bouts of gorging, which they follow with vomiting or abusing laxatives or diuretics in an attempt to counteract the overeating.
Bulimia nervosa consists of episodes of binge eating and purging that occur an average of twice a week for at least three months. Binge eaters devour an excessive amount of food in a brief period of time, during which they feel a general loss of control. A characteristic binge might include a pint of ice cream, a bag of chips, cookies, and large quantities of water or soda, all consumed in a short time. Again, purging behavior such as vomiting, abusing laxatives or diuretics, and/or excessive exercise occurs after the binge in an effort to get rid of the calories taken in.
Binge-eating disorder (BED) is a more recently described disorder that comprises bingeing similar to bulimia but without the purging behavior used to avoid gaining weight. As among bulimics, those experiencing BED feel a lack of control and undergo bingeing an average of twice a week.
It may come as a surprise to some that both bulimia and BED are more common than anorexia. Interestingly, prior to the 1970's, eating-disorder specialists rarely encountered bulimia, yet today it is the most commonly treated eating disorder. Many experts believe the rise in rates of bulimia has to do in part with western society's obsession with thinness and the shifting role of women in a culture that glorifies youth, physical appearance, and high achievement. Eating-disorder therapists are also treating more individuals with BED. Although doctors identified binge eating without purging as early as the 1950's, BED was not systematically studied until the 1980's. As such, the apparent increase in BED incidence may merely reflect an increase in BED identification. Among females, typical rates for bulimia are 1 to 3 percent and for anorexia 0.5 percent. The prevalence of significant binge eating among obese persons in community populations is higher, ranging from 5 to 8 percent.
As the field of eating disorders has evolved, researchers and therapists have begun seeing a number of changes. These include an increase in eating disorders among men (see One Man's Battle With Anorexia). While the vast majority of anorexics and bulimics are female, for example, a higher percentage of men are now struggling with BED. And despite the common wisdom that minority women have a kind of cultural immunity to developing eating disorders, studies indicate that minority females may be just as likely as white females to develop such debilitating problems.
"Patricia" and other African-Americans
Of all minority groups in the U.S., African-Americans have undergone the most study, yet results bear apparent contradictions.
On the one hand, much of the research suggests that even though African-American women are heavier than white women—49 percent of black females are overweight as opposed to 33 percent of white females—they are less likely to have disordered eating than white women are. In addition, African-American women are generally more satisfied with their bodies, basing their definition of attractiveness on more than simply body size. Instead, they tend to include other factors such as how a woman dresses, carries, and grooms herself. Some have considered this broader definition of beauty and greater body satisfaction at heavier weights a potential protection against eating disorders. In fact, some studies conducted in the early 1990's indicate that African-American women exhibit less restrictive eating patterns, and that, at least among those who are college students, are less likely than white women to engage in bulimic behaviors.
The overall picture is not so clear, however. Take, for example, Patricia's story. Patricia's struggle with daily bingeing followed by vomiting and laxative abuse is not unique. Nearly 8 percent of the women we see in our clinic are African-American, and our clinical observations parallel research studies reporting that African-American women are just as likely to abuse laxatives as white women are. Data from a recent large, community-based study give more reason for concern. The results indicate that more African-American women than white women report using laxatives, diuretics, and fasting to avoid weight gain.
The study of eating disorders in minority populations in the U.S. remains in its infancy.
Much research is now focused on identifying factors that affect the onset of eating disorders among African-American women. It seems that eating disorders may relate to the degree to which African-American women have assimilated into the dominant American social milieu—that is, how much they have adopted the values and behaviors of the prevailing culture. Not surprisingly, African-American women who are the most assimilated equate thinness with beauty and place great importance on physical attractiveness. It is these typically younger, more educated, and perfection-seeking women who are most at risk of succumbing to eating disorders.
Patricia fits this profile. Recently graduated from law school, she moved to Chicago to take a position with a large law firm. Each day she strives to do her job perfectly, eat three low-calorie, low-fat meals, avoid all sweets, exercise for at least an hour, and lose weight. Some days she is successful, but many days she cannot maintain the rigid standards she has set for herself and ends up bingeing and then purging. She feels quite alone with her eating disorder, believing that her eating troubles are not the kind of problems that her friends or family could possibly understand.
"Gabriella" and other Latinas
As the fastest-growing minority population in the U.S., Latinas have been increasingly included in studies of disordered eating. Like African-American women, Latina women were thought to bear cultural immunities to eating disorders because they have a preference for a larger body size, place less emphasis on physical appearance, and generally pride themselves on a stable family structure.
Studies are now challenging this belief. Research suggests that white and Latina women have similar attitudes about dieting and weight control. Further, prevalence studies of eating disorders indicate similar rates for white and Latina girls and women, particularly when considering bulimia and BED. As with African-Americans, it appears that eating disorders among Latinas may be related to acculturation. Thus, as Latina women attempt to conform to the majority culture, their values change to incorporate an emphasis on thinness, which places them at higher risk for bingeing, purging, and overly restrictive dieting.
Consider Gabriella. She is a young Mexican woman whose parents moved to the U.S. when she was just a child. While her mother and father continue to speak Spanish at home and place a high value on maintaining their Mexican traditions, Gabriella wants nothing more than to fit in with her friends at school. She chooses to speak only English, looks to mainstream fashion magazines to guide her clothing and make-up choices, and wants desperately to have a fashion-model figure. In an attempt to lose weight, Gabriella has made a vow to herself to eat only one meal a day—dinner—but on her return home from school, she is rarely able to endure her hunger until dinnertime. She often loses control and ends up "eating whatever I can get my hands on." Frantic to keep her problem hidden from her family, she races to the store to replace all the food she has eaten.
Disordered eating behavior among minority women often goes unnoticed until it reaches dangerous levels.
Gabriella says that although she has heard her "Anglo" friends talk about eating problems, she has never heard of anything like this in the Latina community. Like Patricia, she feels isolated. "Yeah, sure, I want to fit in with mainstream America," she says, "but I hate what this bingeing is doing to my life."
Despite an apparent rise in such problems among Latina women, it is difficult to assess the status of eating disorders among them for three reasons. First, little research has been conducted on this group. Second, the few studies that have been done are somewhat flawed. Many studies, for example, have based their conclusions on very small groups of women or on groups comprised only of clinic patients. Finally, most studies have neglected to consider the role that factors like acculturation or country of origin (e.g., Mexico, Puerto Rico, Cuba) might have on the prevalence, type, or severity of eating disorders.
As with all minority groups, not enough is known about eating disorders among Asian-American women. Available research, which has focused on adolescents or college students, appears to indicate that eating disorders are less prevalent in Asian-American females than in white females. Asian-American women report less binge eating, weight concerns, dieting, and body dissatisfaction. But to come to any firm conclusions about eating disorders within this ethnic group, researchers need to gather more information across different ages, levels of acculturation, and Asian subgroups (e.g., Japanese, Chinese, Indian).
Among Native American populations, the scant available information suggests that aberrant eating patterns more often strike heavier individuals and that purging behaviors such as vomiting and laxative abuse are used to control weight. Research has also noted that younger women with higher levels of education, as well as those who have moved off reservations and are assimilating into western culture, are at increased risk.
Stemming the trend
The study of eating disorders in minority populations in the U.S. remains in its infancy. Yet as the stories of Patricia and Gabriella reveal, minority women with eating disorders experience the same feelings of shame, isolation, pain, and struggle as their white counterparts. Sadly, clinical anecdotes suggest that disordered eating behavior among minority women often goes unnoticed until it reaches dangerous levels. Only stepped-up research and efforts to increase awareness of the dangers can begin to stem this disturbing trend.