The Rise of Eating Disorders in Asia

Trends don't mimic the West but instead are unique to each geographic area.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP

Two Columbia University researchers report that the increasing incidence of eating disorders in Asian countries is not due solely to "Westernization" but more often is due to forces independent of Western influences.

Drs. Kathleen M. Pike and Patricia E. Dunne of New York State Psychiatric Institute have written a very thoughtful and thorough review of the rise of eating disorders in Asia, including Japan, China, Malaysia, and India. Their overall findings show that eating disorders are "not culture-based or culture-specific, but culture-reactive" (J Eat Disord. 2015; 3:33).

According to the authors, the rise in disordered eating throughout Asia is actually a result of unique cultural transformations in each country, including increased industrialization and urbanization, shifts in population, changes in the food supply, new gender roles, and alterations in traditional family structures. Eating disorders have spread in tandem with economic changes, led by Japan, then Hong Kong, Singapore, Taiwan, and South Korea, according to the authors. Here are a few of the trends.

Japan: a relatively stable increase in eating disorders

Proliferation of eating disorders in Japan coincides with industrialization and urbanization and changes in gender roles and in the traditional family. Most eating disorders are reported among teenage girls, and prevalence estimates range from 25.2 to 30.7 cases per 100,000 population. According to the authors, while conventional forms of anorexia nervosa (AN) have been the norm, unique differences among individuals have emerged. For example, in one study of patients with AN, three distinct groups emerged: 200 women had typical AN, 86 had non-fat-phobic AN, and 97 had AN related only to body shape and weight. The three groups had widely differing durations of illness, body mass index ranges, and EAT scores (Int J Eat Disord. 2011; 1:130).

Singapore: one well-meant program backfired

Starting in the 1990s, eating disorders became increasingly common in Singapore, according to Drs. Pike and Dunne. Body dissatisfaction has been particularly common among university students and Singaporean Chinese schoolgirls, even though rates are relatively lower than in the West. In one 8-year review of persons with AN seen at an eating disorders clinic, a large majority were female, but males accounted for 8.7% of patients seen during 1994 to 2002. Malays made up 4.8% of cases, compared to 84.1% who were Chinese and 7.9% who were Indian. 

In an attempt to address rising obesity rates among schoolchildren, the government in Singapore established a compulsory (and ultimately unsuccessful) school-based weight-loss program, "Trim and Fit." The social stigma and teasing from peers doomed the program and may even have contributed to an upsurge in eating disorders in vulnerable children. One outcome of the program was that 11% of the individual AN patients seen during 1994-2002 had participated in the program and reported social stigma as a result of it.

Hong Kong: a unique form of AN

In their research into eating disorders in Hong Kong, the authors found a variant of AN in which the usual fat phobia and distorted body image were absent, very unlike the pattern usually seen in western patients. In this form of AN, patients attributed their restriction of food intake solely to somatic complaints, such as bloating, abdominal/stomach pain, or to lack of hunger/appetite (Int J Eat Disord. 2003; 3:423). Also unlike the case of the typical AN patients in the West, these patients had fewer bulimic symptoms and tended to have lower pre-morbid BMIs. Over time, reports of this type of AN have decreased while bulimia nervosa and fat-phobic AN have steadily increased.

South Korea, China, and Thailand

In South Korea, increases in rates of eating disorders and associated risk factors occur in conjunction with dramatic and pervasive social changes from the early 1960s through the late 1990s, matching the country's rapidly accelerating economy. Although eating disorders reported in South Koreans have clinical profiles very similar to those of the West, body dissatisfaction and internalization of the thin ideal may be more widespread in Korea than in the West, according to the authors. Another interesting finding from a study of three generations of Korean women (including one group of Korean-Americans) suggested that native Korean values may inadvertently promote eating disorders, due to an "emphasis on appearance rather than ability or talent as the crucial factor to a woman's success in marriage and career" (Int J Eat Disord. 2006; 39:198).

Among women in mainland China, a significant but more recent increase in eating disorders has emerged. Drs. Pike and Dunne note that the first reports of eating disorders in mainland China appeared in the early 1990s, and the hallmark "fear of fat" was the underlying stimulus. Later, mass migration from rural areas to cities and the effects of sociocultural transformation, including economic stress and competition, resulted in many of the cases reported later. Other factors include concerns about body shape and size, preference for a thin body, a history of child abuse, elevated anxiety levels, and newly hostile relationships with parental figures. As more recent and larger-scale community-based studies have concluded, the incidence of eating disorders may be relatively low but subclinical and/or partial eating disorders and maladaptive eating behaviors are widespread. 

The results of a 1999 study gave a good illustration of the effects of industrialization upon eating disorders when it compared three groups: high school girls in urban Hong Kong, high school girls living in the largely rural Hunan province, and schoolgirls of the same age living in Shenzhen, a semi-urban and rapidly growing area. Girls in Hong Kong had the most marked eating disorders, followed by girls in Shenzhen, and last by girls in Hunan Province (Int J Eat Disord 1999; 1:505).

Fiji, Pakistan, and Taiwan: The effects of media

Traditionally, the Fijian ideal of beauty was a robust female body shape, and eating disorders were so rare that only a single case was reported prior to the mid-1990s. However, once Western media, especially television, became available in the 1990s, cases of disordered eating surged among ethnic Fijian women. The trend continues today, and the specific modeling of behavior upon western television characters may reflect a desire for women to position themselves competitively in their rapidly changing culture. Fijian men report increasing pressure to achieve a muscular body ideal. Studies by Becker and colleagues of eating disorder symptom prevalence before and after the arrival of Western television are often cited as evidence for the role of media in development of eating disorders (Cult Med Psychiatry. 2004; 28:533). Dr. Becker's work is very important because he studied eating disorders and body image in Fiji before television reached the island.

In Pakistan, a more conservative society traditionally closed and with less exposure to western media, fashion, and advertising, has been affected by increasing industrialization and modernization. Males as well as females may be facing growing risk of developing eating disorders. In one 2008 study that examined body dysmorphic disorder in a sample of 156 medical students (slightly more than half were females) revealed that 78.8% of students had some degree of dissatisfaction with their bodies. 'Being fat' was a concern for 40.4% of the women, while the males were more concerned with being too thin (BMC Psychiatry. 2008; 8:20).

In contrast to the evidence of increased risks of media exposure and rising eating disorders incidence, data from Taiwan suggest clinical eating disorders are less common than in Western countries. However, risk factors associated with development of eating disorders, such as body dissatisfaction and dieting, are increasing and may now be common among teens and young adults. Younger teens were more likely to watch television, to use the Internet, and also to snack while watching television-increasing media exposure and risk of exposure to the thin ideal.

The authors concluded that even as Asian countries become more urbanized and developed, we cannot assume each country will automatically will follow the path of Westernized countries to greater obesity and increased eating disorders.