7  Eating Problems in Special Populations

Cultural Considerations

Anne E. Becker, M.D., Ph.D., S.M.

Clinical effectiveness in multicultural and cross-cultural settings in general warrants sensitivity to variations in illness experience and symptom reporting as well as expectations, values, and preferences that drive risk, presentation, help seeking, and therapeutic engagement in health care delivery. Attunement to culturally and socially patterned characteristics of clinical presentation is essential to an informed and accurate mental health assessment, given the importance of the psychiatric interview and patient report of experiential symptoms to the diagnostic formulation. Understanding cultural variation is especially germane to identifying, evaluating, and managing feeding and eating disorders, given the dimensional nature of many core symptoms, the salience of cultural contextual factors in ascertaining diagnostic criteria, and the critical importance of decisions to seek help and disclose symptoms. Video 5, “Cultural considerations in the assessment of eating problems,” highlights cultural factors.

Epidemiology of Eating Disorders Across Social Contexts

Historical and cross-cultural data support that anorexia nervosa (AN) and bulimia nervosa (BN) are mental disorders associated with the sociocultural contexts of modernization. After sentinel case reports of AN in the nineteenth century, aesthetic ideals and valuation of thinness emerged in the United States and other historically Western cultural regions in the twentieth century, and the documented prevalence of AN rose concomitantly (Brumberg 1988). By the late twentieth century, the presence of AN and BN was recognized in North America, Europe, Australia, and New Zealand, whereas eating disorders were viewed as relatively rare outside postindustrialized, Westernized societies. In this respect, the argument that eating disorders are “culture bound” to the West or to Western cultures has been made (e.g., Keel and Klump 2003; Swartz 1985).

The Global Burden of Disease Study demonstrates, however, that the health burdens associated with eating disorders, as measured both in disability-adjusted life years and in years lived with disability, have shown steep percentage increases globally over the past two decades (Murray et al. 2012; Vos et al. 2012). Given that the prevalence of AN and BN does not appear have increased in Europe, the United States, and other high-income regions over the past few decades (Smink et al. 2012), these data support the possibility that eating disorders may be increasingly prevalent in low- and middle-income countries. Transnational migration and widespread participation in the global economy have resulted in similarly widespread exposure to ideas, values, and products originating in historically Western societies. Cross-cultural epidemiological data, moreover, support the association of eating disorders with some of these Western cultural exposures, even across socially diverse populations. These exposures occur, for example, through acculturation associated with both migration and in-country rapid social and economic development (e.g., Becker 2004; Becker et al. 2002, 2010a; Nasser et al. 2001). Furthermore, emerging communication platforms—including televised and other media—that enable the rapid and broad global distribution of ideas, images, and products may foster accelerated distribution of cultural exposures that elevate risk for disordered eating (Becker et al. 2011; Gerbasi et al. 2014; Grabe et al. 2008; Levine and Murnen 2009).

Within the United States, eating disorders are also more broadly distributed across sociodemographic strata than previously understood. Epidemiological data collected in representative community-based samples of the U.S. population indicate that eating disorders occur across each major census group residing in the United States (Alegria et al. 2007; Nicdao et al. 2007; Striegel-Moore et al. 2011; Taylor et al. 2013). Although clinicians should be aware of sociodemographic variation in patterns of eating disorder presentation, they should also understand that it is neither possible nor advisable to summarize clinical features that “typify” eating disorders within a particular ethnic, racial, or social group. For example, there is substantial heterogeneity within any one of the major census groups, relating to country of origin and postmigration generation. In addition, cultural exposures arise not only from the family’s country or ethnic heritage of origin but also from the so-called host or dominant culture, global culture (accessed through the media and Internet), and other immigrant communities.

It may be that the only valid assumption relating ethnicity to eating disorders for clinical assessment is that any individual could be at risk, regardless of ethnic, racial, or social background. Clinicians should be aware that although eating disorders may present in conventional ways across diverse populations (Shaw et al. 2004), disclosure and presentation of symptoms may vary across sociodemographic groups. For this reason, implementation of the DSM-5 Cultural Formulation Interview (American Psychiatric Association 2013a) and its additional supplementary modules (American Psychiatric Association 2013b) can be especially helpful in eliciting the patient’s understanding and experience of symptoms as well as his or her preferences and expectations about treatment. Because of lay and clinical stereotyping of AN as a disease associated with affluence and white ethnicity, ethnic minority patients are at risk of a double stigma attached to having an eating disorder (Becker et al. 2010b). Stigma, moreover, may have different kinds of impact for different health care consumers. For example, in China, Tong et al. (2014) reported a 39% refusal rate for an interview among study participants who were likely to meet diagnostic criteria on the basis of screening; they suggested that this may have been driven by concerns about stigma and shame (Tong et al. 2014).

Cultural Patterning and Other Contextual Influences on Diagnostic Assessment

Evidence of culture-specific phenotypes and patterning of symptoms (Franko et al. 2007; Lee et al. 2010; Pike and Mizushima 2005; Striegel-Moore et al. 2011; Thomas et al. 2011) suggests that cultural factors may have more of a dimensional than categorical role in influencing the kind and presentation of symptoms. For example, in Fiji, the use of traditional herbal purgatives has been identified as a weight management behavior among adolescent girls. Individuals with this behavior—along with those reporting more familiar and conventional purging behaviors—have greater eating psychopathology than individuals who do not engage in purging; in addition, and perhaps more unexpectedly, the use of traditional herbal purgatives appears to be associated with greater distress and impairment than is the more familiar and conventional bulimia-like purging behavior (Thomas et al. 2011).

Lee and colleagues have extensively documented another example of a culture-specific phenotype of AN. They described a variant of AN among the Hong Kong Chinese distinguished by an absence of “fear of fatness,” a characteristic that has been regarded as a core diagnostic feature of AN. This presentation, termed non-fat-phobic AN, characterized a sizable proportion of individuals presenting to a tertiary psychiatric clinic in this Hong Kong setting in the mid-1980s (Lee et al. 2010). Notably, these patients provided a different—but culturally salient—rationale for their dietary restriction and failure to gain weight (Lee 1995, 1996; Lee et al. 2001). Additional studies identified non-fat-phobic AN in other Asian study populations, including in Japan, Singapore, and China (e.g., Pike and Borovoy 2004). Non-fat-phobic AN has also been documented in the United States (Becker et al. 2009b).

The phenomenological diversity of feeding and eating disorders is reflected in the substantial proportion of cases that are assigned to the residual category even after the publication of revised criteria in DSM-5 (Machado et al. 2013; Nakai et al. 2013). Wide cultural variability in dietary patterns and variability in body size and weight ideals and their salience across the life course (Becker 1995) amplify this diversity further and may contribute to the absence of clinical detection of an eating disorder, which is frequent in primary care settings. Other major challenges in the diagnostic assessment of feeding and eating disorders include the dimensionality of key symptoms that lie on a continuum with socially normative dietary patterns and weight concerns. Intrinsic to several of these criteria is their relativity to cultural context. For instance, ascertainment of Criterion D for BN requires a judgment about whether the influence of shape and weight on an individual’s self-evaluation is “undue.” Likewise, Criterion A for both BN and binge-eating disorder operationalizes a binge episode in relation to an amount that most individuals “would eat in a similar period of time under similar circumstances” (American Psychiatric Association 2013a, pp. 345, 350). As a result, clinical assessment requires understanding of the prevailing social norms within the patient’s cultural milieu. In the absence of observable behaviors or collateral history that can inform ascertainment of cognitive symptoms intrinsic to the feeding and eating disorders, their assessment relies on patient report, which can be affected by maturity, insight, and willingness to disclose (Becker et al. 2005, 2009a). Furthermore, whether a patient is able or willing to formulate or provide information about the departure from these norms may also be governed by cultural style. Additional related symptoms such as “marked distress” or “feeling uncomfortably full” (American Psychiatric Association 2013a, p. 350) also require interpretation of subjective experience, which may be informed by socialization to culturally grounded standards and expectations. Collateral information from other sources is also likely filtered through a cultural lens.

A Clinical Approach to Eating Problems Across Culturally and Socially Diverse Patient Populations

DSM-5 has replaced the older term “culture-bound syndrome” with several new terms that better frame and capture the multiple cultural dimensions that influence experience, presentation, and help seeking (American Psychiatric Association 2013a, p. 758). Definitions are summarized in Table 7–1 with some corresponding examples. A culturally informed approach to assessment of feeding and eating disorders in multicultural clinical settings will benefit from referencing relevant cultural syndromes, idioms of distress, and cultural explanations with regard to the disordered eating and comorbid psychiatric symptoms and disorders, including anxiety and depressive disorders. However, because these cultural influences are neither temporally fixed nor uniform within any particular social group, a process-based approach to cross-cultural diagnostic formulation—such as is set forth in the Cultural Formulation Interview (CFI) in DSM-5—has optimal clinical utility. The CFI can also be accessed at www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Cultural.

Video 5 demonstrates cultural factors in the assessment of individuals with eating problems.

images Video Illustration 5: Cultural considerations in the assessment of eating problems (6:10)

Overcoming Social and Cultural Barriers to Treatment

Eating disorders are serious mental disorders, yet nearly half of individuals with an eating disorder in the United States do not receive specialty care for this problem (Hudson et al. 2007). Available evidence, moreover, points to ethnic disparities in care access for an eating disorder in the United States (Marques et al. 2011). Factors associated with both clinicians and health consumers likely contribute to suboptimal care access. For example, consumer demand for care may be low in certain ethnic groups, and clinician recognition of and response to patients with a feeding or eating disorder may also vary across patient ethnicity. Community-based epidemiological survey data demonstrate that service utilization for an eating disorder is significantly lower among African Americans, Latinos, and Asian Americans than among non-Hispanic white populations in the United States (Marques et al. 2011). One study, controlling for severity of symptoms, found that clinicians in a college-based screening program were less likely to refer Latino participants than non-Latino white participants, when controlling for severity of symptoms (Becker et al. 2003). A qualitative study showed that some health consumers experience ethnicity-based stereotyping by clinicians specific to their eating or weight complaints (Becker et al. 2010b). Clinician bias related to other psychiatric diagnoses has also been reported (Good 1992-1993). Unfortunately, these clinician and health consumer factors can both reinforce reluctance to seek care and reify the impression that feeding and eating disorders are uncommon among ethnic minorities. It is advisable, therefore, for clinicians to consider whether patient distrust may adversely affect a patient’s willingness to engage in care. The CFI includes a probe question (question 16) that clinicians can use to address this sensitive issue in a respectful way along with other social and cultural barriers to help seeking. The CFI Supplementary Module 8 (“Patient-Clinician Relationship”) provides additional guidance for addressing factors in the patient-clinician relationship that might undermine care. This module can be accessed in its entirety online (see American Psychiatric Association 2013b). Table 7–2 excerpts five relevant questions that clinicians can ask a patient to expand on CFI question 16.

TABLE 7–1. Cultural dimensions of illness experience, expression, and expectations relevant to mental health assessment
Cultural concept DSM-5 definition Examples relevant to disordered eating

Cultural syndromes

“[C]lusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience”

Macake (Fijian)–a loss of appetite associated with rhinorrhea, fever, oral candidiasis, which can cause dangerous weight loss (Becker 1995)

Cultural idioms of distress

“[W]ays of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns”

Non-fat-phobic anorexia nervosa among Hong Kong Chinese–in lieu of concerns about fatness or weight gain, patients provide an alternative rationale for dietary restriction, such as fullness or other gastrointestinal symptoms, which is culturally salient (Lee et al. 2001)

Cultural explanations or perceived causes

“[L]abels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress”

Macake (Fijian)–often perceived to be caused by social neglect that leads to a diet that is of poor quality or otherwise inadequate (Becker 1995)

Note. Definitions are excerpted from American Psychiatric Association 2013a, p. 758. Used with permission. Copyright © 2013 American Psychiatric Association.

A variety of additional cultural and social factors influence patterns of help seeking for mental disorders. For example, the stigma frequently associated with mental disorders may present a barrier to care if there are perceived intolerable social costs to the patient or family. Likewise, patients and their caregivers may experience the therapeutic benefits of care in nonclinical settings as superior or preferable. Family and social factors that either enable or undermine adherence can be elicited using the CFI Supplementary Module 3 (“Social Network”). Example questions from this module are included in Table 7–2, and the module can be accessed in its entirety online (see American Psychiatric Association 2013b).

Many individuals with an eating disorder are initially reluctant to disclose their symptoms to a clinician but may be willing to admit to symptoms when asked directly (Becker et al. 2005). Self-report assessments, such as the Eating Disorder Examination Questionnaire (EDE-Q Fairburn and Beglin 1994) and the SCOFF questionnaire (Morgan et al. 1999), which have demonstrated validity in several languages and study populations, may be useful in promoting case identification when used alongside clinician-based assessment. For example, they can augment a clinical interview or prime a conversation about disordered eating symptoms. Because the item content in these measures may not tap all relevant domains in all cultural settings, clinicians working with populations in multiethnic settings or regions outside of Europe, North America, Australia, and New Zealand should consider supplementing these screeners—as well as clinical interviews—with questions assessing local dietary and weight management behaviors. In addition to inquiring about conventional symptoms, clinicians should consider asking patients about use of complementary and alternative medicines and products, including over-the-counter natural supplements. Because use of natural supplements and traditional purgatives varies across ethnicities (Kelly et al. 2006) and may be regarded as normative in some social milieus, and may also be common among individuals with BN (Roerig et al. 2003), clinicians should inquire directly about usage and probe further for misuse that reflects eating disorder psychopathology.

TABLE 7–2. Excerpted questions from Cultural Formulation Interview (CFI) supplementary modules addressing the patient-clinician relationship and the patient’s social network

Patient-Clinician Relationship (related to CFI question 16)

QUESTIONS FOR THE PATIENT:

  1. What kind of experiences have you had with clinicians in the past? What was most helpful to you?
  2. Have you had difficulties with clinicians in the past? What did you find difficult or unhelpful?
  3. Now let’s talk about the help that you would like to get here. Some people prefer clinicians of a similar background (for example, age, race, religion, or some other characteristic) because they think it may be easier to understand each other. Do you have any preference or ideas about what kind of clinician might understand you best?
  4. Sometimes differences among patients and clinicians make it difficult for them to understand each other. Do you have any concerns about this? If so, in what way? [RELATED TO CFI Q#16.]
  5. What patients expect from their clinicians is important. As we move forward in your care, how can we best work together?

Social Network (related to CFI questions 5, 6, 12, 15)

INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: I would like to know more about how your family, friends, colleagues, co-workers, and other important people in your life have had an impact on your [PROBLEM].

Composition of the individual’s social network

2. Is there anyone in particular whom you trust and can talk with about your [PROBLEM]? Who? Anyone else?

Social network understanding of problem

4. What ideas do your family and friends have about the nature of your [PROBLEM]? How do they understand your [PROBLEM]?

Social network response to problem

6. What advice have family members and friends given you about your [PROBLEM]?

Social network as a stress/buffer

9. What have your family, friends, and other people in your life done to make your [PROBLEM] better or easier for you to deal with? (IF UNCLEAR: How has that made your [PROBLEM] better?)

11. What have your family, friends, and other people in your life done to make your [PROBLEM] worse or harder for you to deal with? (IF UNCLEAR: How has that made your [PROBLEM] worse?)

Social network in treatment

15. How would involving family or friends make a difference in your treatment?

Source. Excerpted from American Psychiatric Association 2013b. Used with permission. Copyright © 2013 American Psychiatric Association.

Although little is known about the global epidemiology of the feeding and eating disorders, avoidant/restrictive food intake disorder and rumination disorder, there are numerous prevalence studies of pica eating. For example, in some African regions, geophagia is prevalent among schoolchildren (e.g., near or exceeding 75% in Zambia [Nchito et al. 2004] and Western Kenya [Geissler et al. 1998a]) as well as among women attending antenatal clinics (e.g., approximately half of women sampled in Kenya [Geissler et al. 1998b]). Pica eating in these regions often falls within local social norms (e.g., in Western Kenya, Zambia, and Dar es Salaam [Geissler et al. 1999; Kawai et al. 2009; Nchito et al. 2004]). For example, in some regions, local vendors sometimes sell earth for consumption. Consequently, clinicians not only should consider assessing for pica eating in migrant populations in which pica eating is prevalent but also should evaluate whether or not it is socially normative if intervention is indicated.

In assessing AN, clinicians should probe for persistent dietary restriction or compensatory behaviors that prevent weight gain even if the presence of intense fear of weight gain or fatness is not apparent. When these behaviors are present, the patient’s rationale should be evaluated. If present, unconventional rationales for dietary restriction, such as gastrointestinal (GI) discomfort, which are commonly seen in Chinese patients (Lee et al. 2012) and which persist in undermining weight gain despite appropriate intervention, should be considered and assessed.

Clinicians should be aware that social structural barriers, such as poverty or limited knowledge of English, may impede access to treatment settings and also influence clinical presentation. The differential diagnosis for AN should encompass nutritional deficits due to food insecurity. The U.S. Department of Agriculture reports that 14.5% of U.S. households were food insecure in 2012. In addition, 7 million American households (5.7%) experienced very low food security (operationalized by disruption of eating patterns and reduction of food intake by at least one household member because of poverty). Nearly half of these households with very low food security reported weight loss due to inadequate money for food (Coleman-Jensen et al. 2013). Clinicians may find the questions used to assess household food security as part of the Current Population Survey (item content available at www.ers.usda.gov/media/1183208/err-155.pdf; Coleman-Jensen et al. 2013) to be a useful guide for assessing food insecurity; they should also ask about the specific impact of food insecurity, if any, on the identified patient. Household characteristics associated with food insecurity in the United States include those with children and headed by a single adult, those at or below the poverty line, and those with identified as black or Hispanic (Coleman-Jensen et al. 2013). Although the relationship between food insecurity and disordered eating is not yet well understood, neither poverty nor presence of hunger excludes the possibility of an eating disorder, because both can be simultaneously present.

Physical Assessment

Physical examination is crucial to excluding medical causes of signs and symptoms and planning nutritional, medical, pharmacological, and psychosocial management. Psychoeducation for the patient and his or her family, when appropriate, about the physical health impacts of disordered eating may be especially helpful if they are unfamiliar with eating disorders and their associated risks. In addition to a comprehensive physical and laboratory examination to evaluate general health, clinicians should consider and evaluate additional possible health and psychosocial exposures among patients who have recently emigrated from or traveled to their country of origin. A patient’s weight and height should be measured and assessed against international standards for body mass index (BMI) and BMI centiles, as well as in the context of population-specific benchmarks, growth history, and family history. For example, clinicians should be aware that the relationship among BMI, adiposity, and health risk varies across some Asian, white, and Pacific Islander populations (Duncan et al. 2009; Rush et al. 2009; WHO Expert Consultation 2004).

Although GI symptoms are common complaints among patients with feeding or eating disorders, these symptoms may have no discernible physiological correlate. Moreover, if a GI symptom or another somatic complaint is a culturally preferred idiom for distress, then some patient populations may present with these complaints with greater frequency than others. In addition to considering and ruling out GI disorders and conditions (Becker and Baker 2010), clinicians should consider and exclude helminthic and other parasitic infections that can affect appetite and weight (Stephenson 1994) and that differentially affect certain populations in the United States (Hotez 2008).

Conclusion

Eating disorders have broad global distribution and occur across diverse social and cultural contexts. Given sociocultural variation in help seeking for, and the presentation and experience of, mental disorders, it is important for clinicians to consider the potential influence of the cultural and social contexts in which symptoms have developed in the diagnostic assessment of an eating disorder. Clinicians, moreover, should be mindful of social barriers to treatment in framing recommendations and formulating a care management plan. The DSM-5 Cultural Formulation Interview can be a helpful supplemental tool in evaluating social and cultural factors germane to the diagnosis and treatment of an eating disorder.

Key Clinical Points

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