Taken as a whole, the world data on child and adolescent eating dis- orders reveals six principle trends, although there are almost always excep- tions to these trends.
1. Generally, the eating disorders described here do not emerge in a society or subset of a society until there is more than sub- sistence food intake.
2. Sex differences are found in eating-disordered attitudes and behaviors, with females reporting more disordered attitudes and behaviors than males.
3. Eating-disordered behavior seems to be particularly salient among adolescents and appears to often emerge first in a society among this group.
4- Upward mobility seems to place young women at risk for eating disorders across contexts, although the disorders occur among those from across the range of socioeconomic backgrounds.
5. Urban contexts appear to place children and adolescents at increased risk of both obesity and eating disorders when com- pared with rural.
6. Cultural change appears to be associated with eating pathology, although the pathways between these phenomena appear to be multiple, complex, and hold key exceptions.
A less well-studied trend established in some contexts includes the rela- tionship of individual and group trauma or violence with disturbed eating.
Given that the first two of these trends are already well established in the cross-cultural literature, the following discussion focuses on the others.
Adolescence
Although not every society in the world has a life period considered adolescence, this time often seen as a transition between childhood and adulthood is becoming more widespread and is lasting longer ( W H O , 2003).
Adolescence, a period of enormous neurological change in places where it has been studied (Spear, 2000), is an important time for mental health issues generally ( W H O , 2003), with many disorders emerging, intensifying, and becoming predictive of adult outcomes at that time. In developed Western
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nations, eating disorders have been found to be most prevalent during ado- lescence w i t h b o t h physiological and psychological factors appearing to be involved i n this pattern. Puberty and its significant gain of body fat for ado- lescent girls are thought to be a possible trigger factor for eating disorders i n places where a t h i n body ideal reigns. I n t w i n studies, puberty has been found to be related to significant increases i n genetic influence o n disor- dered eating ( K l u m p , Perkins, Alexandra Burt, M c G u e , & Iacono, 2007).
These findings are i n addition to the neural plasticity implicated generally i n adolescent psychopathology (Spear, 2000). Concurrently, the normative developmental changes of Western adolescence such as becoming more capable of abstract thought, more dependent o n peers, more attuned to the social world and social comparison, and having increasing indepen- dence can contribute to body image dissatisfaction and disordered eating.
Moreover, adolescents are often the first i n a developing society to adopt new technologies and transnational media that may impact disordered eating (Anderson-Fye, 2004). I t is perhaps t h e n no surprise that the global expansion of adolescence coincides w i t h the cross-cultural expansion of eating disorders. However, the empirical data o n the explanatory models of this relationship are l i m i t e d .
Social developmental goals of adolescence may also vary significantly cross-culturally. For example, individuation and identity formation are con- sidered key goals among U.S. adolescents, and weakness i n these areas has been linked w i t h disordered eating (Strong & H u o n , 1998). I n societies that are more collectivistic and communally focused, assumption of f u l l adult roles may lead to different sorts of adolescent achievements. I t is not k n o w n how such variable developmental goals would relate to the development of body image and eating disorders. Nascent correlational data indicate that culturally specific developmental goals are relevant to intracultural variation o n disordered eating. For example, among adolescent females, i t was the upwardly mobile girls who had lived outside of the country and had personal goals conflicting w i t h those considered " t r a d i t i o n a l " who reported eating- disordered symptoms i n Curacao (Katzman, Hermans, Van Hoeken, & Hoek, 2004). I n contrast, immigrant Asian girls who were less acculturated (Jen- nings et al., 2005) and classified as more traditional ( M u m f o r d , Whitehouse,
& Platts, 1991) i n Australia and Britain, respectively, reported more disor- dered eating attitudes. I n the U n i t e d A r a b Emirates, i t was girls who watched more Western television programming and reported significant family con- flict who scored higher o n measures of eating pathology (Eapen et al., 2006).
Even subcultural context can affect eating disorder risk as was found by type of school i n Israel, w i t h those o n a kibbutz reporting the least amount of eating pathology and those i n a secular boarding school the most (Latzer &
Tzischinsky, 2003). T h e actual mechanisms and pathways by w h i c h such variables take effect are still relatively u n k n o w n around the world and would benefit from more in-depth ethnographic and ethnopsychological study.
A n additional problem with the apparent finding that eating concerns are most salient among adolescents cross-culturally is the typical cross-cul- tural sampling technique. Secondary schools and colleges/universities are most often targeted for nonclinical sampling in developing and non-Western nations. Sampling younger children is more difficult for a nonclinical sample, and therefore less is known about this group. Moreover, the tension between reliability and validity of measures is a constant problem for any cross-cul- tural psychiatric work as discussed above regarding the South African data, and the impact of these problems on the current body of data drawn heavily from adolescents is unknown.
Upward Mobility
Contrary to initial reports of eating disorders as a pathology of the elite, A N , BN, and BED have been found among those from all class backgrounds (Anderson-Fye & Becker, 2003), although in some areas such as southeast Brazil higher SES is still associated with increased risk for symptoms of eating disorders (Moya et al., 2006). Although the diversity of class backgrounds is also represented in the cross-cultural data, the pattern of upward mobility in the data is striking. Upward mobility—regardless of socioeconomic status—
has been associated with disordered eating among ethnic minority groups in the United States (Yates, 1989) and Afro-Caribbeans in Britain (Soomro, Crisp, Lynch, Tran, & Joughin, 1995). Nascent cases of eating-disordered symptomatology were associated with processes involved in upward mobility among young women in Belize (Anderson-Fye, 2004), Fiji (Becker, 2004), and Zimbabwe (Buchan & Gregory, 1984). Social comparison theory has been offered as one process by which the thin body becomes idealized in cases of upward mobility (Anderson-Fye & Becker, 2003). The thin female body has been written about as a carrier of multiple social meanings, and cross-culturally, it may be considered a possible route into transnational systems and values.
Urban Contexts
On the whole, eating disorders have been found among children and adolescents in urban contexts with greater frequency than among those in rural contexts. Additionally, processes of urbanization via social change or migration appear to be linked to higher rates of at least some types of eating- disordered behavior such as bulimic symptoms (Hoek et a l , 1995). Urban settings cross-culturally are thought to foster more exposure to Western media and technologies that are implicated in eating disorders. In Western nations, adolescents exposed to higher levels of mainstream media report worse body image and eating attitudes compared with those with less exposure (Stice, Maxfield, & Wells, 2003). Studies in non-Western nations have also linked
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Western media exposure with more pathological body image and eating atti- tudes (Becker et al., 2002; Eapen et al., 2006; Shroff & Thompson, 2004).
Children in urban settings have been found to be more sedentary than those in rural settings such as in Mexico (Yamamoto-Kimura et a l , 2006) and the South Pacific (Fukuyama et al., 2005), leading to greater concerns about obesity and weight management among urban school-age children.
The paradox of simultaneous continued malnutrition and increasing rates of overweight and obesity among children and adolescents in urban areas is of increasing concern in many developing nations.
In contrast, some studies have found rates of disordered eating attitudes to be similar between rural and urban high school students, particularly in Western developed nations (Jonat & Birmingham, 2004). One recent study found higher rates of disordered eating among adolescents in rural Mexico than among their peers in Mexico City (Bojorquez & Unikel, 2004).
Another found higher EAT-26 scores among female Indian university stu- dents in rural areas compared with those in urban (Sjostedt, Schumaker, &
Nathawat, 1998). Noncomparative studies in rural communities have estab- lished that eating concerns can be present in these areas as well (Becker, 2004). These discrepant data may be pointing to a new trend or to the need to more closely study type of eating and body image pathology prevalent in the different settings as well as differential pathways to the development of the disorders. Regardless, they are evidence that even adolescents in rural areas in developing nations are not immune to developing eating concerns and disorders, particularly as globalization continues to expand its reach.
Cultural Change and Acculturation
Two key routes of cultural change are immigration and globalization.
Both processes have been associated with an increase in body image and eating concerns among adolescents. Studies with children in these situa- tions have focused predominantly on obesity. A few interesting studies have compared young women in a country of origin with their counterparts who immigrate to a new, usually Western and more developed nation. These studies have reported mixed results. Some of these studies have found the emigres to report greater rates of eating-disordered attitudes and behaviors.
For example, Arab female undergraduates living in London were found to exhibit more bulimic tendencies compared with a matched sample in Cairo (Nasser, 1986). Similarly Greek adolescents in Germany were found to have more anorexic syndromes compared with those in Greece, though other symptomatology was higher among those in their native country (Fichter, Weyerer, Sourdi, & Sourdi, 1983). However, over a 20-year period, the differ- ences between the latter samples were found to be greatly reduced, with both samples reporting bulimic syndromes (Fichter, Quadflieg, Georgopoulou, Xepapadakos, & Fthenakis, 2005). Another subset of these comparative
studies has found equivalent rates of eating-disordered attitudes between the immigrants and those who remained i n the country of origin. A n example of this type of study includes Iranian late adolescents and Iranian immigrants i n Los Angeles, where exposure to Westernization and acculturation did not appear to place young women at greater risk for disordered eating ( A b d o l l a h i
& M a n n , 2001).
Finally, a few studies have reported higher rates of eating pathology among young women i n their native contexts compared w i t h emigres. Ko and C o h e n (1998) found higher EAT-26 scores among Korean college students i n Seoul t h a n among Korean A m e r i c a n students from a variety of colleges i n the U n i t e d States. I n a similar study that also tested effect of generation, Korean and first-generation Korean A m e r i c a n female students were found to have higher EAT-26 scores t h a n second-generation Korean Americans (Jackson, Keel, & Lee, 2006) p o i n t i n g to the importance of native factors and not just westernization i n disordered eating. Similarly, Taiwanese young women were found to have higher rates of body dissatisfaction and disordered eating than their Taiwanese A m e r i c a n peers (Tsai et al., 2003), and late adolescent T h a i women reported higher rates of eating-disordered attitudes and behaviors than their Asian Australian or W h i t e Australian counterparts (Jennings et a l , 2006), These studies reporting higher rates of disordered eating among young women i n A s i a n cultures when compared w i t h those who immigrate to Western societies indicate the need for closer ethnographic investigation into the cultural or globalization factors involved i n these results.
A related set of studies compares immigrant schoolgirls to native-born girls i n Western nations. Many of these studies find higher rates of disordered eating symptoms among the immigrant girls including A s i a n schoolgirls i n England ( M u m f o r d et al., 1991). Studies w i t h Latina girls i n the U n i t e d States where immigration status was not necessarily tracked also indicate that they have increased risk for some types of eating-disordered behaviors (see chap. 8, this volume). A study w i t h older women (mean age = 29.1) indicated that second-generation Mexican A m e r i c a n women have increased risk of eating-disordered behaviors compared w i t h newer immigrants, and that risk was associated w i t h increased acculturation (Chamorro & Flores- Ortiz, 2000).
Regarding globalization, mixed results have also been reported. I n addition to m e n t i o n i n g the effects of globalization i n some of the survey studies i n w h i c h native young women have higher rates of disordered eating t h a n emigres, a handful of detailed ethnographic studies have been conducted examining the effects of globalization among adolescent girls including those conducted i n Fiji (Becker, 2004) and Belize (Anderson-Fye, 2004).
These contrasting studies, where, w i t h respect to disordered eating, adoles- cents were relatively quickly influenced by Western television programming i n the former study and surprisingly immune to a host of globalization
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effects including Western television i n the latter, p o i n t to the importance of meaning-centered work i n trying to understand patterns and processes of influence of globalization o n eating disordered attitudes and behaviors.
Taken as a whole, these cross-cultural and intracultural comparative studies raise interesting questions about the processes by w h i c h cultural contexts and cultural change affect eating disorders risk, particularly among m i d - to late-adolescents. Many studies implicate westernization per se as a risk factor for the development of eating disorders, yet other studies do n o t support this hypothesis. Some scholars suggest more broad social risk factors such as the cultural conflict created i n postindustrial societies (Appels, 1986), although recent empirical work i n nonindustrial societies calls that theory i n t o question as well. A l t h o u g h some cultural factors related to globalization that contribute to eating disorders such as t h i n body ideals, exposure to transnational media, social transition, and modernization have been found to be compelling i n the cross-cultural data, additional work is needed to understand exactly w h i c h factors become salient and interact i n local contexts to explain divergent data. A promising approach to the study of cultural emergence of eating disorders, particularly among adoles- cents who are acutely attuned to changing social contexts, may be to parse out more specific social dynamics. For example, i n examining risk for eating disorders i n east Asia, Lee (1996) described the social factors of food abun- dance, changing weight norms, affluence, and transitioning social roles for women as contributing to risk for eating disorders i n young women. Specific stressors involved i n cultural change—whether that change is a result of glo- balization or migration—are another promising area i n w h i c h to continue more meaning-centered analysis.
C O N C L U S I O N
T h e cross-cultural data regarding eating disorders i n children and adolescents are n o t only important for understanding global mental health issues, but also raise many interesting questions about the nature, etiology, variation, and measurement of eating disorders. Because sociocultural factors are well-established contributors to the individual development and societal expansion of eating disorders (Anderson-Fye & Becker, 2003), the cross-cul- tural data provide a unique lens through w h i c h to examine these factors i n particular, although genetic, psychological, and other factors may also even- tually benefit by cross-cultural comparisons. I n theincreasingly multicultural receiving contexts of immigration such as the U n i t e d States, understanding the factors involved i n the etiology of eating disorders for those experiencing migration is important to diagnosis, successful treatment, and ultimately prevention of eating disorders. Moreover, because preliminary data indicate
that varying phenomenology, body image constructs, and routes to disor- dered eating may be culturally or subculturally specific, knowledge about particular populations may aid clinicians- Similarly, culturally appropriate models of healing are important to eating disorders recovery, especially when working with children, adolescents, and their families (Dancyger et al., 2002). Although the global data are not comprehensive, and the trends that are established almost always have notable exceptions, there are some strong models for how to proceed in this research. Namely, the combination of epidemiological and qualitative or ethnographic materials appears to be particularly promising to ensure both reliable and valid studies.
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