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EDs Across Cultures - Increasing in Prevalence & Awareness?

Moving beyond culture: creating an environment for prevention & better treatment

I have the wonderful good fortune as I write to be at a Film Festival in France - Festival International du Film Fantastique de Gerardmer, now celebrating its 20th year. I am the guest of the Cinematographer and the Director of an Independent Film that was accepted in the competition. Removing myself from the world of eating disorders for a week is never possible. Since eating disorders are an international issue, one is never far from conversation, observation or awareness of their presence or their devastating effects.

As a general rule, Europeans eat more sensibly. The mantra to our American eating disorder patients regarding the recovery process is, “No food is off limits” – seemingly an apparent rule of thumb in Europe. Diets more balanced in fat, protein and carbohydrates tend to be standard fare. European restaurants and supermarkets are not likely to offer super size meals or big gulp beverages. Yet, eating disorders exist in Europe as well. In fact, the country with the highest prevalence of female anorexia was Austria (1.55 per cent,) followed by France (1.42 per cent, although some reports state the prevalence rate in France to be as high as 5.7%,) the lowest prevalence was in Northern Ireland and the Netherlands. (London School of Economics. March 2012.) By comparison, approximately 1 in 54 or 1.84% or 5 million people in the United States have eating disorders. Some research indicates that the prevalence in the USA is significantly higher, but is underreported, misdiagnosed or diagnosed under a medical or psychological condition that may or may not be eating disorder related i.e. electrolyte imbalance, cardiac arrhythmia, and depression. (Prevalence refers to the estimated population of people who are living with eating disorders at any given time.)

Those of us in the mental health field understand and generally accept more now a day that culture, whether it is American or any other culture, does not cause eating disorders but rather provides the container (atmosphere, conduit & catalyst) for eating disorders to flourish. We also understand and accept that eating disorders flourish in homes where eating is normal and food is neither restricted nor excessive. Eating disorders also exist in countries that have limited economic resources i.e. Poland has estimated more than 700,000 people with eating disorders from a population of roughly 39 million. Turkey has estimated more than 1 million people with eating disorders from a population of roughly 69 million. ( 2012.) Eating disorders cut across geographic lines.

There are certain universalities in eating disorders wherever the person originates or lives currently. Causes of eating disorders are complex, yet despite this there are symptomatic and psychological similarities among cultures. Sometimes these similarities make it easy to blame the culture as the cause; if everyone wherever you go wants to have the western idealized body, then culture must be to blame. Western media and merchandising of the culture at first blush seems like the culprit.

Often cited as the “smoking gun” that culture is to blame is the increase in incidence of eating disorders in the Fiji Islands in 1996 following the introduction of satellite TV – American television programs like “90210” slammed the ideal image of women in to the psyches of Fiji women and men. Initially, this was proof that culture must therefore cause eating disorders - as the culture became westernized the incidence of eating disorders in Fiji increased. Many in the field now embrace a more integrated approach to the understanding of eating disorder causality. An accepted understanding currently is that the westernizing of the Fiji Islands in terms of perception of women’s bodies and body image provided the incentive and the environment for eating disorders to flourish – no different for America and other western cultures. Individuals in Fiji who developed eating disorders were as likely as their American counterparts, to have a myriad of factors that dominated or existed prior to the development of their disorder. Predisposing depression and anxiety, familial strife, relationship difficulties, abuse and psychological vulnerabilities were as apparent in women in Fiji as in other cultures.

I am currently working on a documentary about the causes of eating disorders - Many eating disorder documentaries tend to explore the behavior and symptoms of people with eating disorders and sometimes explore the recovery process. This film explores the underbelly of eating disorders – what contributes to the causes, how is the individual affected and what effect does the eating disorder have on family and relationships. The film is intended to provide a deeper understanding about contributing factors. How does biology play a role? How do the disorders address anxiety and depression? What role do relationships play in contributing to cause or in maintaining symptoms? How have childhood issues contributed? How are anger and sexuality connected to eating disorders? Are eating disorders a voice or vehicle for how a person feels or what they are unable to express verbally? Is the media responsible and if so how?

So, when in France…Why not take advantage of the opportunity in being among an international mix of people and ask them what they thought about eating disorders in France or in their culture of origin. What I heard was surprising on the one hand, but reassuring on the other. It does indeed seem, at least among the people I interviewed, that there is an understanding of the impact of culture and the media on how people feel about their bodies and the tie to self-worth, but most people interviewed, including those already interviewed back home in NYC, did not blame the culture for the proliferation of eating disorders. Most interviewed expressed that there was a “cause beneath the cause,” and that there were other factors which made someone develop an eating disorder.

Helping people get beyond a general or, might I say, “simplistic” understanding of the causes of eating disorders is the work ahead. It seems we may be indeed on that road. A deeper, fuller and richer understanding of what causes them will have the most impact in their prevention and in tailoring sound treatment. This is good for all cultures.


Judy Scheel, Ph.D., LCSW

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