Written by Sophie Conant
If someone were to picture a person with an eating disorder, they would most likely say a young, Caucasian female (1). However, when it comes to an accurate representation of eating disorder prevalence within the general population, this stereotype does not hold true.
What do the statistics say about ethnic diversity in eating disorders?
There is conflict in the research when looking at the overall prevalence of eating disorders with some studies suggesting relative equality among all ethnic groups (2) and others suggesting an increased prevalence in ethnic minorities (3).
Prevalence aside, there is an increasing acknowledgment that people from ethnic diversity or minorities and people of colour are far less likely to receive support for their eating disorder. One piece of research looked at bulimic behaviours in teenagers and found that black teenagers were 50% more likely to exhibit these behaviours compared to white teenagers (4). Another highlighted that people of colour with self-acknowledged eating and weight concerns were significantly less likely than white participants to have been asked by a doctor about eating disorder symptoms (4).
Individuals from both white and non-white backgrounds share the same risks for the development of an eating disorder (5), especially when we consider environmental factors such as social media use and Westernisation of food choices. The disparity between ethnicities when it comes to diagnosis and access to eating disorder treatment is influenced by a range of factors, some of which we will address here.
Barriers that prevent individuals within ethnic minority groups from accessing eating disorder treatment
1. BMI is not inclusive for all ethnicities
BMI (body mass index) is included in the assessment criteria for many eating disorder services across the world. Using BMI as a cut-off to access services poses a major barrier to receiving support for people of all backgrounds. Unfortunately, when some people are denied access based on BMI, this feeds into the belief that people are not “sick enough” (or thin enough) and can lead to stronger eating disorder behaviours developing and worsening of both physical and psychological health while waiting for alternate treatment options. The relationship between percentage body fat and BMI varies for different populations (6) which further reinforces why BMI alone should not be used in diagnosis and treatment.
Due to genetic body composition differences between ethnicities, what is deemed a “healthy” weight for people from a Caucasian background, might not be healthy for people from a non-white background. For example, research has found that individuals of a Polynesian origin had a significantly higher lean mass : fat mass ratio, at higher BMI levels, compared with those of a European origin (7). On the contrary, in Asian populations, morbidity and mortality risk has been found to occur in individuals with lower BMIs (8). This highlights that what is deemed a healthy weight, can differ based on ethnicity.
It is clear that BMI is not an inclusive measurement of weight or health as it does account for ethnicity differences. This is a clear demonstration of one of the barriers ethnic minorities have for accessing treatment for an eating disorder, and it could be suggested that different BMI ranges could be developed for different cultural backgrounds.
If you want to find out more about why the BMI is not an accurate measure, head to our blog BMI and Eating Disorders.
2. Lack of awareness
There is a lack of awareness and understanding of ethnic diversity in eating disorders amongst health professionals. Combined with racial bias, this has a significant impact on people receiving help. One study gave three case studies to a group of clinicians. These case studies were identical in every way, other than their ethnic background (white, Hispanic and African-American). The clinicians were asked to identify if the woman's eating behaviour was problematic. Despite each case study being identical, only 17% of the clinicians found the African-American woman’s behaviour to be problematic - in comparison to 44% and 41% for the white and Hispanic women (9).
This result is just one of many that demonstrates racial bias within eating disorder clinicians. Although it is not entirely clear why this is the case, one suggestion is that it could be due to a lack of confidence of being able to support the needs of an ethnic minority patient (8) and clinicians are either reluctant or slow to implement treatment.
3. Under-representation in research
Research for evidence-based treatment for eating disorders has mostly been focused on Caucasian women which could be problematic in supporting people with eating disorders in ethnic minority populations (10). In addition, clinicians might have little understanding of the cultural differences of eating practices and traditional foods.
4. Cultural differences in understanding and awareness of eating disorders
The awareness of eating disorders within ethnic minority populations may not be as high as it is in Western society, where we are becoming more and more aware of diet culture's influence. People might not be as aware of the red flags of an eating disorder, so support would not be sought.
In many cultures, food is a very important aspect of society and community. One study found that in some cases, carers of individuals struggling with their relationship with food were more inclined to hide the issue and not seek help as they were worried it would bring their family shame (10). These concerns could also cause an individual to become more effective at masking their illness and less likely to seek support.
Where to from here?
For individuals of ethnic minority origins, accessing support for an eating disorder can be difficult for a number of reasons. There are many barriers that prevent access to available treatment. It is important that clinicians develop their understanding of eating disorder manifestations within different populations, so that they can spot the red flags and implement early intervention strategies tailored towards different individual’s needs. An effort to increase eating disorder awareness in all communities is also important in helping ensure that all individuals have equal access to treatment, and therefore recovery.
If you need support or help to improve your relationship with food please reach out and connect with us by completing an enquiry form. Our specialist dietitians at the TC Nutrition clinic practice inclusivity to support you on your personal journey to heal your relationship with food.
Sophie Conant
TCN Intern
Sophie Conant is a 2nd year Dietetics student at the University of Nottingham. Her own journey to finding food freedom has given her a passion to help others to do the same. In her spare time, she enjoys yoga, climbing and cooking for friends.
REFERENCES:
[1] Gordon K, Perez M and Joiner T, 2002, The Impact of Racial Stereotypes of Eating Disorder Recognition, The international journal of eating disorders Vol. 32
[2] Marques L, Alegria M, Becker A, Chen C, Fang A, Chosak A and Diniz J, 2011, Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders, The international journal of eating disorders Vol. 44
[3] Udo T and Grilo C, 2018, Prevalence and Correlates of DSM-5–Defined Eating Disorders in a Nationally Representative Sample of US Adults, Biological Psychiatry Vol. 84
[4] National Eating Disorder Association, 2022, People, of Color and Eating Disorders, Available at: People of Color and Eating Disorders | National Eating Disorders Association [Accessed 3rd March 2022]
[5] Eating disorder hope, 2017, More Ethnic Minorities are Suffering from Eating Disorders, Available at: More Ethnic Minorities Are Suffering From Eating Disorders (eatingdisorderhope.com) [Accessed 12th March 2022]
[6] Rush E, Goedecke J, Jennings C, Micklesfield L, Dugas L, Lambert E and Plank L, 2007, BMI, fat and muscle differences in urban women of five ethnicities from two countries, International Journal of Obesity Vol. 31.8
[7] Swinburn B, Ley S, Carmichael H and Plank L, 1999, Body size and composition in Polynesians, International Journal of Obesity related Metabolic Disorders
[8] Ko G, Chan J, Woo J, Lau E, Yeung V, Chow C, Wai H, Li J, So W and Cockram C, 1997, Simple anthropometric indexes and cardiovascular risk factors in Chinese men, International Journal of Obesity
[9] Gordon, K. H., Brattole, M. M., Wingate, L. R., & Joiner, T. E., Jr. (2006). The Impact of Client Race on Clinician Detection of Eating Disorders. Behavior Therapy, 37(4), 319–325.
[10] Chowbey P, Salway S and Ismail M, 2012, Influences on diagnosis and treatment of eating disorders among minority ethnic people in the UK, Journal of Public Mental Health Vol. 11
Talia Cecchele Nutrition is a team of registered dietitians that specialise in eating disorder recovery, disordered eating, digestive issues and sports nutrition. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. We offer virtual consultations and group programs so whether you are based in London, the United Kingdom or around the world we would love to support you. To enquire about a private consultation please fill out a contact form.
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