Prevalence of Eating Disorders: A Comparison of Western and Non-Western Countries

Mariko Makino, MD, PhD; Koji Tsuboi, MD, PhD; Lorraine Dennerstein, AO MBBS, PhD, DPM, FRANZCP

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Discussion

More female subjects suffered from eating disorders and had abnormal eating attitudes than male subjects in 11 countries reported here. The prevalence rate in non-Western countries was lower than in Western countries, although it has gradually increased. There is evidence from many studies that gender[50] and sociocultural influences play a role in this increase.[51,52]

DiNicola[50] has argued that a necessary connection between eating disorders and culture exists and can be identified as a cultural change syndrome that emerges under conditions of rapid economic and sociocultural change. DiNicola also suggested that cultural changes occur in 2 broad ways: cultural evolution and human migration. Thus, anorexia nervosa may be more prevalent during times of cultural change and confusion for immigrants and individuals in rapidly developing countries.

Tsai[53] has suggested that a component of cultural change, such as generation conflict or the disintegration of extended family networks, indiscriminately affects the development of eating disorders and that girls in Asian countries, for example, are at risk as many are growing up in rapidly Westernizing urban centers or migrating to the West.

Sociocultural change includes westernization or modernization and urbanization.[54] Tsai[53] suggested that westernization or modernization is defined as "a historical shift driven by technological development in social and family structure where personal status is determined less by kinship and more by contractual and individualized roles. With greater geographical and social mobility and less ascription of identity through caste, kinship, or gender, greater value is placed on self-determination, achievement motivation and future orientation."

In Japan, some surveys were conducted to assess the effects of westernization.[55,56] Kuboki's survey of increasing anorexia nervosa during the period 1985-1992 indicated that the increased prevalence rate paralleled modernization in Japan.[22] Kiriike and colleagues[57] found that body mass index was decreased in females from 21.5 in 1960 to 20.5 in 1995. He suggested this phenomenon reflected the tendency of young females to diet and of their having employment.

The higher prevalence is also associated with urbanization or population density.[58] In Japan, Nadaoka[55] reported that most eating disorder patients came from medium-sized cities (population: 60,000 to 250,000) compared with small and rural districts. He also indicated that more anorexia nervosa sufferers were found in urban areas.

By contrast, a recent Iranian survey reported that women in Teheran who were more interested in Western culture were more likely to be satisfied with their body shape and suggests that the hypothesis of cultural effects on eating disorders may be limited.[28]

In the early 1990s, Lee[26] suggested that the reason there were so few anorexia sufferers in Hong Kong was that the Chinese were thinner, they did not admire thinness as beauty, obesity was thought to be a symbol of wealth, and there was no tendency of dieting among young girls. In 2001, Lee[59] interestingly reported that 3% to 10% of women in Hong Kong were suffering from some form of eating disorder. Lee also suggests that "fat phobia" was no longer bound to specific Western localities and instead may be conceived as being grounded in the transnational culture of "modernity" characterized by an internationalized socioeconomic stratum now found in many rapidly urbanizing parts of the world. The results of a recent Fijian survey demonstrated that key indicators of disordered eating among Fijian adolescent girls were significantly more prevalent after exposure to television.[60]

In conclusion, a limited number of studies have been conducted in non-Western countries. However, survey findings indicate that the number of subjects with eating disorders or abnormal eating attitudes is increasing in non-Western countries. This may support the westernization hypothesis. It is important to understand how eating and body image problems present differently in different cultures and to identify potential risk factors for abnormal eating attitudes in order to determine the need for treatment, prevention, and education. Further studies are needed to document the prevalence of abnormal attitudes to eating and eating disorders in non-Western countries as well as Western countries.

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