Anorexia nervosa, bulimia nervosa, and binge eating disorder
African Americans struggle with eating issues too.
Although both Black and White women and men suffer from eating disorders, there are important differences in the prevalence and form of the disorders. Eating disorders include anorexia nervosa (anorexia), bulimia nervosa (bulimia), and binge eating disorder. Anorexia nervosa and bulimia nervosa are both firmly entrenched in the DSM-IV — the psychiatrist's bible of mental disorders; whereas binge eating disorder is only listed in the appendix of the DSM-IV, although it is being considered for inclusion in the DSM-5.
Although all three of these disorders involve eating, there are some important differences between them. Both anorexia and bulimia are fueled by an obsessive desire for thinness, which results in dangerous behaviors, such as repeated vomiting and/or self-starvation, to reach the person's subjective ideal. People who engage in binge eating may or may not be excessively concerned with their appearance. And although binge eating disorder is a risk factor for obesity, not all binge eaters are obese and not all obese people binge on food. People with binge eating disorder may overeat when they feel distressed; they often feel powerless to stop eating, which is why binge eating disorder is also called compulsive overeating.
Eating disorders understudied in African Americans
Little was known about disordered eating in Black people until recently. Clinically, African Americans were under represented in treatment centers and research studies about eating disorders, so it wasn't clear if they were immune from such disorders or if social and cultural factors were imposing a barrier to treatment.
The National Survey of American Life (NSAL) conducted a comprehensive nationwide study of African American and Caribbean Blacks to answer these and other important mental health questions plaguing the Black community. They interviewed a large number of adults (n = 5,191) and adolescents (n = 1,170) in their homes, using professionally trained, ethnically-matched interviewers. Their study was the first to examine the prevalence, age of onset, and gender differences in eating disorders in a nationally representative Black sample (Taylor et al., 2007).
Black-White differences uncovered
The findings matched up with previous research showing that anorexia is rare among African Americans. In fact, not a single woman in the study met criteria for anorexia in the previous 12 months, and there were no reports at all of anorexia in Caribbean adults. Interestingly, however, the age of onset for anorexia was lower for African American adults (14.9 years) compared with late adolescence as seen in a prior similar national study with primarily White participants (18.9 years), and there were no cases among African Americans occurring after age 19. These findings indicate that Black Americans are at lower risk of anorexia than their White counterparts, and Caribbean Blacks are at an even lower risk. Although when African Americans do have anorexia, the age of onset is lower and the course of the disorder is longer. The lower rates of anorexia are thought to be due to less of an emphasis on thinness in African American culture operating as a protective factor.
Lifetime prevalence rates found for bulimia in Black Americans is 1.5% for adults, which is slightly higher than the national average of 1.0%. The average age of onset is 19 years, which is the same as the general population. Thus, rates of bulimia among Blacks may not be as uncommon as once believed. This finding could be an indication that Black people do feel pressure to conform to the American ideal of thinness, contributing to the higher rate of bulimia, although not to the more extreme level that is connected to the development of anorexia.
Binge eating is not uncommon in African Americans.
Binge eating was the most prevalent eating disorder among Blacks in the NSAL, with a lifetime prevalence of 1.7%, although 5.1% had some problems with binge eating whether or not they met criteria for a disorder. Males were significantly less likely to binge than women, but may have more issues around behaviors that emphasize an athletic build. While most eating disorders had an age of onset during adolescence, binge eating had the highest age of onset (22.8), which is similar to the general population. This older age of onset may reflect less of a concern for smaller body size and may represent more of a reaction to stress. Lower incomes and stress due to racism may have an effect on the drive to binge as a coping mechanism.
As in previous research, adult women had higher prevalence of eating disorders than men in the NSAL study. There were no gender difference in eating disorders among teens, but there was a tendency for boys to exhibit more disordered eating behaviors during adolescence. There is some research that indicates this could be due to weight restrictions for sports participation, such as school football, boxing, wrestling teams, etc. Therefore, Black boys should not be considered immune to eating disorders.
Cultural understanding is critical
Taken as a whole, research shows that cultural differences must be taken into account when considering eating disorders in African Americans. Clinicians should be prepared to recognize and treat groups that may be least likely to develop an eating disorder. This will require training to work with diverse cultural groups to ensure that appropriate treatment is provided. Professionals should be educated to possible differences ing prevalence, age of onset, persistence and gender differences in eating disorders, including differences among subgroups of Black people. The social climate and subculture in which a person was raised may effect the risk and course of development of an eating disorder. Earlier and more frequent screening of eating disorders in Black communities may be a critical component to capturing cases of these disorders.
Note: This article expands and responds to the information that appeared in blog entry posted by by Dr. Marcia Herrin entitled What Does the Research Say About Ethnicity and Eating Disorders?
DSM-5 Task Force and Work Group. (2011) Proposed Draft Revisions to DSM Disorders and Criteria. Feeding and Eating Disorders. Accessed 12/29/2011. <http://www.dsm5.org/ProposedRevision/Pages/FeedingandEatingDisorders.aspx>
Henrickson, H. C., Crowther, J. H., & Harrington, E. F. (2010). Ethnic identity and maladaptive eating: expectancies about eating and thinness in African American women. Cultural Diversity and Ethnic Minority Psychology, 16, 87-93.
Jackson, J.S., et al. (2004). The national survey of American life: A study of racial, ethnic, and cultural influences on mental disorders and mental health. Int J Methods Psychiatr Res,13,196–207.
Taylor, J.Y., et al. (2007). Prevalence of Eating Disorders among Blacks in the National Survey of American Life. Int J Eat Disord, 40(Suppl), S10–S14. doi: 10.1002/eat.20451
Wonderlich, S.A., et al. (2009). The validity and clinical utility of binge eating disorder. Int J Eat Disord, 42, 687-705.