Eating disorders in the South Asian Community

By: Shruti Shankar Ram

​While the culture in the United States has come a long way in terms of normalizing and destigmatizing mental illness, particularly with respect to depression and anxiety, there are still a lot of misconceptions and stereotypes surrounding other mental illnesses, such as eating disorders and obsessive-compulsive disorder. Eating disorders, and mental illness in general, is still a taboo topic in a lot of communities, specifically among people of color.
 
As an Indian-American, I have witnessed the culture surrounding mental illness within my community. Rather than being seen as a real illness that warrants the same attention and level of care as a physical ailment, mental illness is often dismissed and not legitimized. Even when one’s mental illness is acknowledged, their family might try to explain it by giving it a biological cause, such as rationalizing it as a thyroid dysfunction. Due to a myriad of sociocultural factors, South-Asians face unique barriers to seeking treatment for eating disorders.    
 
One issue is that eating disorders are still stereotyped as an issue that only affects young, affluent, White women. In reality, eating disorders affect people of all genders, ethnic groups and ages (Marques et al., 2011).
 
While extensive research on eating disorders has been conducted in European-American populations, and some research has been conducted in African, Latin-American, and Hispanic populations, eating disorder research has been historically sparse in Asian populations (Soh & Walter, 2013). Research has suggested that referrals to eating disorder services from South-Asian populations are under-represented (Abbas et al., 2010), despite evidence suggesting that rates of disordered-eating behaviors are similar to the rest of the population (Wales et al., 2017). Studies have also shown that there is a high prevalence of disordered eating behaviors in minority populations in general (Solmi et al., 2014), and research in South-Asian populations have suggested that the incidence of certain eating disorders, specifically bulimia nervosa, is higher in South-Asian populations than White populations (Mumford et al., 1991).
 
Eating disorders are particularly relevant in the South-Asian community due to role that food plays in the culture. Any large gathering of family or friends usually involves a lot of sugary, fatty food, and people are encouraged to socialize and eat, and those that do not partake are seen as asocial. However, it is also a common occurrence in the South-Asian community to have various relatives or family friends comment on various aspects of one’s life, including one’s physical appearance. In the Indian community, being light-skinned and thin are seen as not just sufficient, but necessary to be considered attractive, if you are a woman. Societal pressure in the form of comments or suggestions are often made if a woman does not match this ideal body type, conditioning individuals to go to extremes pursuing this ideal. Research has found that this is a common theme in the South-Asian community that can prime individuals to develop disordered eating habits and behaviors (Wales et al., 2017). Much of this pressure is faced by young women and adolescent girls, as patriarchal norms dictate that they are expected to look attractive to find an ideal husband. Men in the South-Asian community also face the same societal pressures, but generally to a lesser extent. Older women often note that they do not face the same pressures after marriage, though some pressures still exist. This dual pressure to eat in social settings and yet maintain a thin figure may be one reason why there is a higher than average prevalence of bulimia nervosa in South-Asian women, and why anorexia nervosa might not be as common (Mumford et al., 1991; Abbas et al., 2010). Klump and Keel (2003) also provide other explanations on cultural differences in eating disorders, and their research has found that bulimia nervosa has greater variability cross-culturally than other eating disorders, such as anorexia nervosa.
 
Additionally, women who are part of the South-Asian diaspora, but who live in the Western world face experience many conflicting messages about food and weight, as they are exposed to more traditional South-Asian influences from their family, as well as being exposed to various Western disordered eating triggers such as peer pressure, pictures of thin celebrities and pro-anorexia websites.
 
Not only do South-Asians face unique sociocultural pressures that may contribute towards disordered eating, but they also face barriers to seeking treatment. One of the biggest barriers to accessing services is lack of knowledge – while younger South-Asians tend to be more aware and exposed to ideas about mental illness, they may be dismissed by elder family members or friends. The lack of communication and understanding of the seriousness of eating disorders can keep younger South-Asians from accessing care, particularly if they are dependent on family members to assist with paying for treatment (Wales et al., 2017). This goes along with the general stigma surrounding mental illness in the South-Asian community – seeking treatment involves acknowledging the mental illness, and many South-Asians do not want to admit that there is a “problem” in their family or community.
 
While South Asian populations face these unique barriers to accessing care for eating disorders, progress is still being made. Mental health is being discussed in a serious way in South-Asian media, such as in Bollywood movies, reshaping the way it is viewed by the general population. However, increasing eating disorder research on this understudied population is important, as it could contribute towards reducing barriers to treatment and improving quality of care to the South-Asian population. Moreover, eating disorders may present differently in Eastern populations versus Western populations, so more research needs to be done to parse out if such differences exist. Additionally, normalizing topics within these communities is essential, as stigma can keep South-Asians from accessing mental health services, even when readily available.
 
References
 
Abbas, S., Damani, S., Malik, I., Button, E., Aldridge, S., & Palmer, R. L. (2010). A comparative study of South Asian and non‐Asian referrals to an eating disorders service in Leicester, UK. European Eating Disorders Review, 18(5), 404-409.
 
Keel, P. K., & Klump, K. L. (2003). Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychological bulletin, 129(5), 747.
 
Marques, L., Alegria, M., Becker, A. E., Chen, C. N., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44(5), 412-420.
 
Mumford, D.B., Whitehouse, A.M., & Platts, M. (1991), Sociocultural correlates of eating disorders among Asian schoolgirls in Bradford. The British Journal of Psychiatry, 158(2), 222-228.
 
Soh, N.L. & Walter, G. (2013), Publications on cross-cultural aspects of eating disorders. Journal of Eating Disorders, 1(1), 1-4.
 
Solmi, F., Hatch, S.L., Hotopf, M., Treasure, J. and Micali, N. (2014), Prevalence and correlates of disordered eating in a general population sample: the South East London community (SELCoH) study. Social Psychiatry and Psychiatric Epidemiology, 49(8), 1335-1346.
 
Wales, J., Brewin, N., Raghavan, R., & Arcelus, J. (2017). Exploring barriers to South Asian help-seeking for eating disorders. Mental Health Review Journal, 22(1), 40-50. doi:10.1108/MHRJ-09-2016-001