Multiple suggestions for improving
diagnosis among blacks.
Reprinted from Eating Disorders Review
March/April Volume 24, Number 2
©2013 Gürze Books
To more accurately classify eating disorders in certain ethnic groups, future versions of the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM) should incorporate more culturally sensitive criteria, according to findings from the National Survey of American Life. This study surveyed cultural differences among several groups of blacks (J Health Care Poor Underserved. 2013; 24:289) Drs. Jacquelyn Taylor, associate professor at Yale University School of Nursing, and colleagues from the University of Michigan and from the Program for Research on Black Americans (PRBA), evaluated data from the National Survey of American Life, from 2001-2009.
Blacks consistently have lower rates of anorexia nervosa (AN) and bulimia nervosa (BN) and equal or higher rates of binge-eating disorder (BED) as whites (Am J Psychiatry 2003; 36:1326; Int J Eat Disord. 2007; 40:481). Studies examining risk factors for eating disorders among blacks have relied on small, regional samples of subjects, with little variation in correlates, according to Dr. Taylor. The authors feel that reporting the prevalence of eating disorders for ethnically diverse blacks in a national sample, using DSM IV-TR criteria, would be a step in the right direction. However, gaps remain in knowledge about correlates of eating disorders among ethnically diverse black populations. The authors also stressed that criteria used in the diagnosis of eating disorders may not be as useful for identifying individuals who do not meet these criteria, due to cultural differences.
Prevalence and sociodemographic factors
Dr. Taylor and colleagues sought to answer three main questions. First, how will the prevalence rate of eating disorders compare between standard DSM-IV-TR criteria and culturally altered criteria based upon the previous literature among African-American and Caribbean blacks? Second, are the sociodemographic correlates among African-American and Caribbean blacks the same? The final question was what are the sociodemographic correlates of obesity, comorbidities, and other risk factors that could be associated with development of an eating disorder among blacks?
The authors studied 3,570 adult African-Americans and 1,621 Caribbean blacks and 1,170 adolescents (810 African-Americans and 360 Caribbean blacks). Between February 2001 and March 2003, data were collected from face-to-face interviews in the participants’ homes; the response rate was 73% among adults and 81% among adolescents. The researchers’ goal was to interview as many original youth selected for the study as possible. Therefore 18% of the interviews were partially or completely conducted by telephone in addition to the face-to-face interviews.
Dr. Taylor and her colleagues found that BED was the most prevalent eating disorder identified among both adult African-American and Caribbean blacks. BN was the second-most-prevalent eating disorder, followed by AN. Among adolescents, BED was the most prevalent eating disorder for African-American and Caribbean blacks, followed by BN and AN, respectively.
African-American adults who were unemployed were 2.91 times more likely than an employed blacks to have a lifetime history of an eating disorder. Those with low or high average incomes were approximately half as likely as those living in poverty to have a lifetime history of an eating disorder. Among Caribbean blacks, none of the sociodemographic factors were significantly associated with lifetime history of an eating disorder. Never-married African-Americans had significantly greater odds of being classified with an eating disorder in comparison to those who were married or had a partner. Never-married African-Americans also had greater odds of being classified with an eating disorder if they were unemployed. Among Caribbean blacks, age and gender affected the risk of an eating disorder: women were more likely than men to have an eating disorder and men and women 45 years of age or older were much less likely than those 18 to 24 years of age to have an eating disorder during the 12 months preceding the study.
Establishing the true incidence of BN and BED
The incidence of BN was more common than AN; when some DSM-IV-TR criteria were eliminated, the number of people who would be classified as having BN increased. The authors note that African-Americans have less body image dissatisfaction and desire to be thin than do whites, as has been shown in earlier studies. Also, risk factors for eating disorders among white women were not predictive of disordered eating in African American women. Thus, the usual requirements for a diagnosis of AN, including body image dissatisfaction (an intense desire to be thin), and compensatory behaviors may not apply to blacks.
Changing the ethnic criteria also increased the number of subjects classified with BED. The authors note that current classifications for BED are inadequate to assess and identify African-Americans and Caribbean blacks. Obesity, which can be related to binge-eating, is not classified in the DSM-IV-TR as an independent eating disorder. Considering that the obesity rate among blacks is high, the authors suggest that a better approach to diagnosis and treatment for blacks with BED would be to link the criteria to weight levels reflecting obesity as a symptom. The authors hastened to add that they were not trying to classify obesity as an eating disorder but as a symptom of BED.
Those at greatest risk for developing an eating disorder
The authors identified numerous characteristics of black African-Americans and Caribbean blacks who were at greater than normal risk of developing an eating disorder. Those at greatest risk included: younger blacks, those with at least 12 years of education, those who were U.S. natives living in the Midwest, or western regions of the country, and those who had a prior history of anxiety, or mood or substance disorders. They also identified some cultural differences between U.S. natives and immigrants. For example, the possibility that eating disorders may be increasing in blacks in the Caribbean should be addressed but as a result of assimilation and differences in cultural norms. Caribbean blacks may be more resistant to eating disorders, binge-eating, and obesity until they move to the U.S.