We’ve begun to scratch the surface of the vast and growing literature on cultural context and eating disorders in the previous 4 posts in this series. Of course, as I reflected the other day, there could (maybe should?) be a blog solely devoted to this topic- each time I read another study in this area, it pulls me down the rabbit hole into another related area.
In what will be the last part of this series for now, I’ll review a study by Bennett, Sharpe, Freeman, and Carson (2004) on the request of Lisa LaBorde (via Twitter). The authors wanted to learn more about the presence (or lack thereof) of eating disorders in Sub-Saharan Africa, a context that they describe as less driven by the thin-ideal. This was, they suggest, the first thorough exploration of anorexia in sub-Saharan Africa, and so might reveal more about whether and how anorexia nervosa is present in area of the world that is differently positioned on the world stage than Western societies.
Bennett et al. selected 2 high schools located in the northeast of Ghana from which to draw a sample of female students between the ages of 15 and 25. The schools were both funded by the Ghanaian Education Service, though one was a mixed gender day school and the second a girls-only boarding school. The latter provided its’ students with 4 meals a day and the former did not provide any meals, so students at the day school were more dependent on their families’ resources for nourishment. Neither school was affiliated with a religion (this will come into play later on).
All young women (668) attending these schools were invited to participate; one redacted her consent after being screened. Students were screened for BMI; if a student’s BMI was below 19, they were assessed further (100 participants). Additionally, those who were below the cut off of 19 invited a friend to participate in further assessment; these invited participants became the comparison group (85 participants).
BMI for the entire (668 participant) group ranged from 15.9 to 33.8, with a median of 21.1. 100 young women had a BMI below the inclusion cut off for further assessment; 29 had a BMI below 17.5.
Further assessments included:
- Mental state assessment: information about participants’ thoughts, beliefs & behaviours related to eating
- Physical assessment: background medical history, symptom checklist (e.g., checking for worms, giardiasis, etc.)
- Eating disorders measures: Eating Attitudes Test (EAT), Bulimic Investigatory Test, Edinburgh (BITE)
Conveniently for us, the 2 measures they chose are the same measures I wrote about in the previous post about Le Grange et al.’s study. Though Bennett and colleagues note that these measures have been validated for use in cross-cultural contexts, Le Grange et al.’s work revealed that people in different contexts might have different reasons for engaging in similar behaviours; this needs to be taken into account when drawing conclusions about scores on such questionnaires as indicative of eating disorders.
Participants’ scores on the EAT did not significantly differ between the comparison group, the group with a BMI between 17.5 and 19, and the group with a BMI below 17.5; nor did participants score within clinical ranges on the BITE. Still, the authors determined that the low weight of 10 of the 29 young women whose BMI was below 17.5 could only be attributed to “morbid self starvation” (i.e., not because of physical illness).
But if this is the case, why did none score in the clinical ranges on the diagnostic tests? Again, the limitations of quantitative measurements of eating pathology come into play. The authors describe 2 case studies as well as describing the participants’ experiences in general to illustrate their orientation toward food, eating and their bodies. Among these, participants described:
- Desiring control
- Liking the sensation of hunger
- Denying feeling hungry
- Engaging in self punishment
- Associating self-starvation with control and achievement, particularly in the absence of control elsewhere in their lives
- Being perfectionistic (e.g., wanting to be successful in school)
Both case studies reflect how participants’ self-starvation was tied to religiosity and the pursuit of purity, though the authors are careful to point out that this does not mean that fasting for religious purposes is always indicative of eating disorders. They liken this distinction to the well-known adage that many people diet and relatively few actually develop eating disorders.
What does it mean for our understanding of eating disorders as culture bound?
As both the studies by Le Grange et al. and Bennett et al. reveal, individuals with eating disorders might have shared clinical presentations but different reasons for engaging in behaviours across contexts. Whereas Le Grange et al. found that their participants often engaged in what might be interpreted as eating disordered symptoms for other reasons, however, Bennett et al. found many similarities between their participants’ symptoms (including both cognitive and behavioural features) and eating disorders in other cultural contexts.
In this case, Bennett et al. make the argument that rather than seeing preoccupation with weight and shape as a central feature of eating disorders, seeing self-starvation itself as the central feature of eating disorders might be more conducive to appropriate cross-cultural comparisons. This argument is not new, and even seems somewhat self-evident. Looking back at work by researchers like Sing Lee who have studied eating disorders in other cultures in the absence of thin-ideal internalization/fear of fatness, we can see how this makes a lot of sense.
What might be a more interesting question is: if eating disorders can be disentangled from preoccupation with thinness (or at least if this is seen as often coming after other driving factors), how have they come to be so closely tied to thin-ideal internalization in popular descriptions?
Despite the differences in Le Grange et al. and Bennett et al.’s findings, when both looked at eating disorders in Africa, both studies also clearly demonstrate the need to get at the heart of why participants are engaging in the behaviours rather than making assumptions about reasons based on questionnaire responses alone. I like this a lot for obvious reasons (I’m a qualitative researcher) but also for the reason that it continues to add complexity and richness of experience to what can sometimes become a push for numbers and figures, one-size-fits-all treatment approaches and streamlined diagnoses.
Thinking particularly about the Ghanaian perspective presented here and the South African context presented in Le Grange et al.’s study, we an also begin to think about what a context of economic scarcity does for interpretations of eating disordered behaviours. What implications does scarcity have on, for example:
- How restriction is socially interpreted (i.e., Could it be seen as selfish? As borne of necessity? As adaptive? As indicative of physical illness? As tied to religion?) and what might that do for the individual’s experiences?
- Are there enough resources to make binging and purging possible, and how that might play out in terms of symptom presentation? Though both of these studies looked at anorexia, we could look more in-depth at the meaning of binging and purging and how this is tied to economic scarcity
These questions and more also underline the importance of seeing “culture” as more than just “media.” It might be indicative of our Western point of view that the first thing that tends to jump to mind when someone says “culture” tends to be that barrage of images to which we are exposed each day.
Bennett, D., Sharpe, M., Freeman, C., & Carson, A. (2004). Anorexia nervosa among female secondary school students in Ghana. The British Journal of Psychiatry, 185, 312-7 PMID: 15458991