Improving Diagnosis of Eating Disorders among Blacks

A suggestion that some current DSM criteria do not apply.

Historically, eating disorders have been viewed as diseases of young white women from upper socioeconomic classes. However, according to researchers at Yale University, New Haven, CT, a truer picture of the prevalence of eating disorders among blacks would emerge if culturally sensitive criteria could be added to future versions of the Diagnostic and Statistical Manual classifications for eating disorders. For example, specific risk factors such as body image dissatisfaction, desire to be thin, and use of compensatory behaviors used to predict eating disorders among whites may not be applicable to African-American or Caribbean blacks.

Dr. Jacquelyn Y. Taylor and her group examined how the prevalence rates of several eating disorders compare between DSM-IV-TR criteria and criteria altered in culturally sensitive ways. They also attempted to better define the demographic correlates of eating disorders among African-American and Caribbean blacks, and to evaluate sociodemographic correlates of obesity, comorbidities, and other risk factors that could be linked to development of eating disorders (J Health Care Poor Underserved 2013; 24:289). Their study included 5,191 adults (3,570 African-Americans and 1,621 Caribbean blacks) and 1,170 adolescents (810 African-Americans and 360 Caribbean blacks). The original database was derived from the National Survey of American Life, conducted in the 48 contiguous US states from 2001 to 2003, which evaluated psychiatric disorders, stressors, risk factors, and resilience factors among African-American and Caribbean blacks. The Yale researchers used the World Mental Health Composite International Diagnostic Interview and the DSM-IV-TR (2000) eating disorders criteria for their study. To account for cultural differences, three standard criteria in the DSM-IV-TR (body image disturbance, minimum weight requirements for diagnosis, and compensatory behaviors) were eliminated. Since one of the study goals was to complete an interview with as many of the original youths selected for the study as possible, 18% of the interviews were partially or completely conducted by telephone in addition to the face-to-face household interviews.

Overweight, obesity, and binge eating disorder

More than half of the survey participants were overweight or obese: 66% of adult African-Americans and 59% of Caribbean blacks in the study were classified as overweight or obese. This trend was also apparent among the teens: 30% of African-American and 29% of Caribbean black teens were overweight or obese. Just as in other studies, African-American women had the highest rates of overweight and obesity.

Binge eating disorder (BED) was the most prevalent eating disorder among both African-American and Caribbean black adults, occurring in around 5% for both groups. Bulimia nervosa (BN) was the second most prevalent eating disorder, with a prevalence rate of 1.44% for African-Americans and 1.98% for Caribbean blacks. For adolescents, the prevalence rate of BN was 0.52% for African-Americans and 0.71% for Caribbean blacks. BN was more prevalent than AN and when DSM criteria were eliminated, the number of persons who would be classified as bulimic increased. The lifetime prevalence of anorexia nervosa (AN), using DSM-IV-TR criteria, was 0.15% for African-Americans and 0% for Caribbean blacks. Lifetime prevalence of AN among African-American teens was 0.21% and 0% for Caribbean blacks.

Dr. Taylor and colleagues noted that the high rate of BED among Caribbean blacks (5.78%) might be explained by the abundance and availability of foods in the US, compared to the relative scarcity of fast food in the Caribbean islands. She also noted that current classifications for BED are inadequate to assess and identify African-American and Caribbean blacks. For example, obesity, which can be related to binge-eating, is not classified in the DSM-IV-TR as an independent eating disorder. She and her colleagues suggest that given the high obesity rate among blacks, a better way to diagnose and treat BED would be to link the criteria for weight levels as a symptom of BED. This would not reclassify obesity as an eating disorder, but as a symptom of BED

Who was at most risk for developing an eating disorder?

According to the authors, eating disorders are considered as uncommon among African-Americans and Caribbean blacks because they are often under-reported, untreated, or associated with other comorbid conditions, including anxiety, mood and substance disorders. The risk factors most linked to developing an eating disorder included: being a younger female, having 12 years of education, being a US native, living in the Midwest or western regions of the US, having a prior episode of anxiety, or a mood disorder, or substance abuse. The authors note that prior work has shown that black teens and women tend to be heavier than their white counterparts, they are less dissatisfied with their weight, tend to diet and exercise less to reduce weight, and see themselves as thinner than they are (Psychology of Women Quarterly 2000; 24:244).