How to complete a culturally sensitive feeding and eating disorder assessment

By Deborah R. Glasofer, PhD and Evelyn Attia, MD, USA

Eating disorders have long been recognized as ‘culture-bound’ to Western traditions, and thus increasingly well identified and classified in North America, Europe, Australia, and New Zealand. However, the 21st century has brought with it the understanding that these devastating illnesses are, unfortunately, an equal opportunity problem. The designation of a World Eating Disorders Day is an important acknowledgment of this, and a good moment for us to reflect on what do and don’t know about how feeding and eating disorders are impacting people in all corners of the globe.

Here is some of what we know: Though the prevalence of eating disorders do not appear to be increasing in Europe or the US, a Global Burden of Disease Study indicates that the health burdens associated with eating disorders have substantially increased in the last twenty years. This suggests that these illnesses may be impacting individuals in low- and middle-income countries. Within the US, feeding and eating disorders are broadly distributed across socio-demographic categories. Simply put, there is no ‘typical’ individual (ethnically, racially, or socioeconomically) who gets an eating disorder.

The proliferation of feeding and eating problems worldwide may be attributed to improved identification of cases, an increasingly dynamic global economy that allows for the widespread exposure to products originating in the West, and/or emerging communications platforms through which ideas, messages and images that, for some people, compound the risk of developing of an eating disorder can rapidly spread.

We also know that culture can sometimes influence the type and presentation of disordered symptoms. For adolescent girls in Fiji, for example, the use of traditional herbs for the express purpose of weight management may signal eating-disordered psychological distress including concern with eating, body shape, weight, and dietary restraint. A ‘non fat-phobic’ variant of anorexia nervosa has been well documented in China, Japan, Singapore, India, and Asian communities within the US. This clinical presentation is distinguished by the absence of fear of fatness, and the presence of a different, culturally relevant, rationale for restrictive eating and failure to maintain normal weight [For an example of this depiction of symptoms, watch this related video (#5, Cultural Considerations).]. While there remain some differences among ethnic groups regarding pursuit of thinness and body satisfaction, there is growing evidence of eating disorders among black and Latino populations. It is also evident that boys and men (not just girls and women) are suffering from feeding and eating disorders, and that there are some differences but also many similarities in clinical presentation between groups.

‘All shapes, colours and sizes’

Since it is now clear that these disorders can come in ‘all shapes, colors and sizes,’ we clinicians must dedicate ourselves to eliminating bias and breaking down barriers that preclude people from getting the care that they need. In the US, nearly half of individuals with an eating disorder do not receive specialty treatment for the problem. Ethnic disparities abound, with problems evident on both the clinician and patient sides of the treatment-seeking equation. For example, clinicians may be less likely to refer non-white individuals for treatment, and services are utilized less frequently across African-Americans, Latinos, and Asian Americans than among white, non-Hispanic populations in the US. Global, ongoing outreach and education efforts on the community, state/province, and national level will be required to improve use of treatment resources, and these initiatives are likely to look different to suit the needs of different cultures.
Clinicians in all communities can begin to do our part by adapting our standard evaluations of feeding and eating disorder symptoms to provide a culturally sensitive assessment. This includes:
Using self-report eating disorder assessments that are available in several languages and have been used in a variety of study populations to augment an evaluation, or help start a conversation about specific symptoms
Asking questions about nutritional deficits due to lack of food resources, or fluctuations in eating behavior secondary to fluctuations in the availability of particular foods
Making inquiries into the use of indigenous or culturally traditional supplements that might impact appetite, weight, or digestion
Gathering knowledge about local social norms regarding eating behavior, body image ideals, etc., and using historical information from the patient’s family, when possible and appropriate
Remaining aware of barriers that may impede access to treatment, such as lack of fluency in English or poverty

To learn more about how to conduct a culturally sensitive feeding and eating disorder assessment, including use of the DSM-5’s Cultural Formulation Interview to elicit meaningful clinical information, please see Chapter 7, Eating Problems in Special Populations – Cultural Considerations, by Anne E. Becker, MD, in the Handbook of Assessment and Treatment of Eating Disorders.

It may well be that the only valid assumption relating to feeding and eating disorders and culture is that any person who needs to eat – any one of us all – could be at risk. Certainly, it will take the effort of our global village to more adequately address the problem.

For more information on the assessment of feeding and eating disorders, please see our book. If you suffer from an eating disorder and would like to join us in learning more about these conditions and their treatment, contact the Center for Eating Disorders at 646-774-8066 (New York State Psychiatric Institute/Columbia University Medical Center) or 888-694-5700 (New York-Presbyterian Hospital/ Westchester Division) to determine if you might be eligible for current studies.

About Deborah and Evelyn
Deborah R. Glasofer, PhD, is an Assistant Professor of Clinical Psychology (in psychiatry) at the Columbia University College of Physicians and Surgeons, and clinical psychologist at the Columbia Center for Eating Disorders at the New York State Psychiatric Institute.

Evelyn Attia, MD, is Director of the Center for Eating Disorders at New York-Presbyterian Hospital and New York State Psychiatric Institute. Dr. Attia is a Professor of Psychiatry at Columbia University Medical Center and Weill Cornell Medical College.

Join Deborah and Evelyn in supporting World Eating Disorders Action Day. Be sure to follow along on Twitter @WorldEDDay and hashtag #WeDoAct, #WorldEDActionDay, @WorldEatingDisordersAction on Instagram and World Eating Disorders Action Day on Facebook.