Representation Matters: Eating Disorders among Arab, Middle Eastern, and North African (A-MENA) Identities

Written by Ayah Aldebyan, EAT Lab Study Coordinator

There has been an increase in the representation of diverse and marginalized identities in research. However, much progress is still needed, especially in the inclusion of Arab, Middle Eastern, and North African (A-MENA) identities. A-MENA identities have historically been categorized as white, making this group an invisible minority [3]. This has led to their underrepresentation in research and many undocumented health disparities [2]. This is an important issue in psychological research, especially in the study of eating disorders. Given the high morbidity and mortality rates associated with eating disorders, the lack of understanding and prevalence rates in A-MENA populations presents challenges to improving outcomes for this group. However, the US Census recently added the Middle Eastern as a racial category which could increase research among A-MENA populations in the coming years. This new categorization can increase research and awareness on specific health disparities and barriers A-MENA groups face leading to better prevention and treatments [1]. 
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Current Challenges: Research on eating disorders has primarily focused on skinny, white, affluent girls (SWAG) populations. Most diagnostic assessments for eating disorders have also been developed using samples of White American females. Due to research and diagnostic assessments primarily using white female samples, many diverse groups, such as A-MENA populations, are underrepresented in the eating disorder field. Since eating disorders among A-MENA groups tend to appear as physical symptoms such as nausea and stomach aches rather than psychological, assessment measures need to be created to reflect these differences [9] A-MENA groups experience barriers to accessing mental health services, such as shame and stigma [6]. More representation and discussions of A-MENA identities in eating disorder research can help decrease feelings of shame and encourage seeking treatment [4]. Having conversations about eating disorders and mental health among A-MENA populations can improve treatment seeking behaviors and in turn improve research [4]. 
Minority groups face barriers in seeking and accessing mental health services due to stigma, cultural factors, negative perceptions of treatment and mental health professionals, language barriers, and lack of awareness of available services [8]. Despite A-MENA groups experiencing these similar barriers, Arabs visit mental health professionals less frequently compared to other ethnic groups [8]. A-MENA women are at risk for eating disorders due to factors like body dissatisfaction, social media influence, and Western body image ideals. These sociocultural factors suggest there are similar pressures and risks for developing eating disorder behaviors and symptoms among A-MENA women in the United States. Similar to males in Western cultures, A-MENA males may want to appear muscular [10] mainly because of traditional masculine norms. These cultural norms lead to similar feelings of avoiding support from family and friends due to the fear of appearing weak [8]. 

The Role of Mental Health Professionals: Mental health professionals may neglect to properly screen and provide resources for eating disorders among those from marginalized identities [6]. More representation of A-MENA identities in research can lead to a better understanding of these disorders among mental health providers. Mental health professionals rely on research to inform their practice and improve treatments. The lack of diverse identities in eating disorder research can make it difficult to generalize treatment options across different populations and becomes harder when they do not fit into the same race category. Data and research can serve as sources of validation for some, yet for others it excludes and invalidates their perspectives and experiences. When diverse groups are left out of research or grouped under a different racial identity, their experiences are not validated and acknowledged. The census change recognizing Middle Eastern and North African (MENA) identity as a distinct category is beneficial for both research and practice. When mental health professionals acknowledge their patients' ethnic backgrounds, it can improve patient communication and, in turn, increase treatment-seeking behavior [11]. 

Steps Towards Inclusion: Some simple steps can be taken to make sure that research is inclusive such as including more racial and ethnic identities in demographic questions, increasing conversations about mental health among minorities to decrease shame, including more diverse samples in studies when possible, conducting more qualitative research especially when sampling from diverse identities, and collaborating with researchers from diverse backgrounds. Future studies could benefit from advisory boards that include individuals with lived experiences from diverse backgrounds. Their input would help ensure the research is culturally sensitive. 
Experiences of discrimination, hate crimes, and prejudice are stressors known to result in negative mental and physical health outcomes [5]. These experiences can increase the risk of developing eating disorders and other health concerns among A-MENA groups [8]. When working with marginalized identities, it is important to assess for instances of racism and discrimination. Currently, the Eating Anxiety Treatment (EAT) Lab conducts a study called Pioneer, which collects this type of information to better personalize treatment and understand the unique experiences of underrepresented identities. This new census change will allow research to better understand how these experiences impact different groups and improve long-term health outcomes. 
Even though research has gotten better with increasing diversity and conversations about this topic, we still have a long way to go. There is a crucial need for a societal change in how we view eating disorders, including a shift in perceptions about who can be affected by them. 

References 

1. Abboud, S. (2023). Inclusion of the MENA category in the U.S. Census: Will MENA individuals and their health disparities be finally visible? Survey Practice, 16(1). https://doi.org/10.29115/SP-2023-0028
2. Abboud, S., Chebli, P., & Rabelais, E. (2019). The Contested Whiteness of Arab Identityin the United States: Implications for Health Disparities Research. American Journal of Public Health, 109(11), 1580–1583. https://doi.org/10.2105/AJPH.2019.305285 
3. Abuelezam, N. N., El-Sayed, A. M., & Galea, S. (2018)1. The health of Arab Americans in the United States: An updated comprehensive literature review. Frontiers in Public Health, 6, 262. https://doi.org/10.3389/fpubh.2018.002623 
4. Ahad, A. A., Sanchez-Gonzalez, M., & Junquera, P. (2023). Understanding and Addressing Mental Health Stigma Across Cultures for Improving Psychiatric Care: A Narrative Review. Cureus, 15(5), e39549. https://doi.org/10.7759/cureus.39549 
5. Assari, S., & Moghani Lankarani, M. (2017). Discrimination and psychological distress: Gender differences among Arab Americans. Frontiers in Psychiatry, 8, 23. https://doi.org/10.3389/fpsyt.2017.00023 
6. Javier, S. J., & Belgrave, F. Z. (2019). "I'm not White, I have to be pretty and skinny": A qualitative exploration of body image and eating disorders among Asian American women. Asian American Journal of Psychology, 10(2), 141–153. https://doi.org/10.1037/aap0000133
7. Kalantzis, M. A., Braden, A. L., & Haidar, A. (2024). Disordered eating and emotional eating in Arab, middle eastern, and north African American women. Eating behaviors, 53, 101868. https://doi.org/10.1016/j.eatbeh.2024.101868 
8. Khatib, H. E., Alyafei, A., & Shaikh, M. (2023). Understanding experiences of mental health help-seeking in Arab populations around the world: a systematic review and narrative synthesis. BMC psychiatry, 23(1), 324. https://doi.org/10.1186/s12888-023-04827-4 
9. Melisse, B., de Beurs, E., & van Furth, E. F. (2020). Eating disorders in the Arab world: a literature review. Journal of Eating Disorders, 8(1), 59. https://doi.org/10.1186/s40337-020-00336-x 
10. Ricciardelli, L. A., McCabe, M. P., Williams, R. J., & Thompson, J. K. (2007). The role of ethnicity and culture in body image and disordered eating among males. Clinical Psychology Review, 27(5), 582–606. https://doi.org/10.1016/j.cpr.2007.01.016 
11. Semaan, K., & Tumin, D. (2024). Middle Eastern and North African: Recognizing the new US Census category in anesthesiology research and practice. Anesthesia & Analgesia, 139(6), e61-e62. https://doi.org/10.1213/ANE.0000000000007198