The prevalence of eating disorders, such as anorexia nervosa or bulimia nervosa, differs between white individuals and people of colour (Marques et al., 2011; Solmi et al., 2016). Presentations and symptoms of eating disorders are observed to be heterogeneous among racial and ethnic groups (Thomas et al., 2015), whilst the rates of treatment-seeking and receiving treatment are also lower in ethnic minorities (Sinha & Warfa, 2013). Possible explanations for these disparities are the cultural factors defining ethnic and minority groups, such as customs or family structure, as well as the discrimination people may experience when trying to access and use services.
Considering the differing barriers affecting treatment-seeking and eating disorders’ presentation among ethnic groups, recent studies highlight the importance of accounting for culture in treatment and guide potential practice adaptations. This systematic review by Acle and colleagues (2021) aimed to identify relevant literature on cultural factors impacting the treatment of eating disorders in order to develop a complete record of culturally-adapted treatment approaches.
The search involved using the following databases: PubMed, Cochrane Library, JSTOR, Google Scholar, PsycINFO, Web of Science, and ERIC.
Inclusion criteria for studies were as follows: (i) written in English, (ii) included adult populations of ethnic/racial minorities, (iii) participants experiencing a wide range of eating disorder variants, from body dissatisfaction to severe pathology resulting in hospitalisation and (iv) included cultural considerations or protocols on how to address culture in eating disorder treatment. However, studies that included adolescent or mixed adult and adolescent samples were excluded.
Data on the country, participants’ ethnicity/race, diagnosis, diagnostic criteria, study design, treatment approach, culture-specific treatment recommendations and outcome measure(s) were extracted. All articles were summarised using a thematic analysis approach.
A total of 31 articles were eligible for the systematic review. Most studies were conducted in the United States (81%), with a small number also included from the United Kingdom and China (6%). Regarding the race/ethnicity of the samples, 30% were Hispanic/Latino, and 23% were African American or Asian. The most used eating disorder treatment was Cognitive Behavioural Therapy (45%).
The researchers recognised 11 core themes of how to be culturally sensitive throughout eating disorder treatment. It’s important to stress that this review did not measure the effectiveness of these approaches, or the quality of the research included:
- Using culturally sensitive interventions, such as coordination with alternative medicine of community leaders
- Addressing potential barriers to accessing treatment such as stigma and healthcare disparities
- Communicating with the clients about their cultural context to better understand cultural norms and behaviours
- Conducting a comprehensive assessment of how their culture may impact their eating disorder, for example, gender and ableism
- Adopting a strong therapeutic alliance, for instance, being collaborative and non-judgemental
- Recognising nuances that may impact clinical presentations such as eating disorder onset
- Explore the individual’s social circumstances, such as family support
- Providing psychoeducation about eating disorders
- Exploring how ethnic identity, acculturation and acculturative stress may contribute as risk or protective factors
- Becoming competent at working with racial/ethnic minorities, such as not perpetuating stereotypes
- Using a culturally flexible diagnostic model that recognises how culture may influence the manifestation of symptoms, for example, complaints of abdominal bloating.
Overall, this review suggests various ways in which eating disorder treatments can be culturally sensitive to ethnic/racial minorities. For instance, conducting a thorough assessment of how culture may impact symptom manifestation and developing a strong therapeutic alliance. While we are unsure of the effectiveness of each of these strategies, this provides a first step to considering the needs of ethnic/racial minorities with eating disorders, which are often ignored.
Strengths and limitations
This was the first review that put together extensive literature on cultural dimensions influencing treatments of eating disorders and provided a list of treatment recommendations focusing on cultural adaptation. It has underscored the usefulness of using lenses that account for factors, such as customs, family structure, or beliefs specific to a person’s cultural identity when treating eating disorders among different ethnic and racial groups.
However, there are some downfalls to the systematic review. Throughout the article, there was no mention of whether the researchers examined the quality of the studies included in the review. Without a clear assessment of the studies quality, it is challenging to balance the recommendations made against the methodological quality. Also, there are concerns about the generalisability of the systematic review – all the individuals’ studies were either conducted in the United States, United Kingdom or China. This likely indicates the lack of research in other countries investigating this topic; nevertheless, we cannot be sure whether these findings apply to ethnic/racial minorities living in other countries. Furthermore, although this review provides recommendations that will be helpful to practitioners treating ethnic/racial minorities with eating disorders, the studies included did not evaluate the effectiveness of each strategy. It is therefore hard to know whether these strategies will benefit ethnic/racial minorities. Future research utilising a randomised controlled trial design, as well as more qualitative studies, could be useful to further our understanding of this topic.
Implications for practice
This review highlights the importance of cultural competence in treating eating disorders. Mental health professionals should aim to:
- increase their understanding and knowledge of cultural differences,
- acknowledge their own cultural biases and assumptions, and
- be keen to make changes in their thoughts, attitudes, and behaviours to target any pre-existing biases and stereotypes.
To facilitate expanding cultural knowledge, clinicians should consult minority ethnicities and provide constant self-assessment. Moreover, clinicians should identify resources relevant to the racial identities of their clients. The inclusion of mental health professionals from diverse backgrounds is also important as they can be more sensitive to the specific therapeutic needs of cultural minority groups.
Recognising how culture may influence the presentation of symptoms and accounting for these cultural factors in treatment will result in more person-centred support. Treatments can be culturally adapted in the areas of language, persons involved, metaphors, content, concepts, methods, and goals. For instance, clinicians can incorporate peer and family support to a greater degree when treating Mexican American women (Shea et al., 2012). In this manner, people from ethnic and racial minorities will feel listened to and more understood which can consequently increase treatment adherence, lead to stronger therapeutic relationships, and better treatment outcomes.
Statement of interests
Acle, A., Cook, B. J., Siegfried, N., & Beasley, T. (2021). Cultural Considerations in the Treatment of Eating Disorders among Racial/Ethnic Minorities: A Systematic Review. Journal of Cross-Cultural Psychology, 00220221211017664.
Solmi, F., Hotopf, M., Hatch, S. L., Treasure, J., & Micali, N. (2016). Eating disorders in a multi-ethnic inner-city UK sample: prevalence, comorbidity and service use. Social Psychiatry and Psychiatric Epidemiology, 51(3), 369-381.
Marques, L., Alegria, M., Becker, A. E., Chen, C. N., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44(5), 412-420.
Thomas, J. J., Eddy, K. T., Ruscio, J., Ng, K. L., Casale, K. E., Becker, A. E., & Lee, S. (2015). Do recognizable lifetime eating disorder phenotypes naturally occur in a culturally Asian population? A combined latent profile and taxometric approach. European Eating Disorders Review, 23(3), 199-209.
Sinha, S., & Warfa, N. (2013). Treatment of eating disorders among ethnic minorities in western settings: A systematic review. Psychiatria Danubina, 25(2), 295-299.
Shea, M., Cachelin, F., Uribe, L., Striegel, R. H., Thompson, D., & Wilson, G. T. (2012). Cultural adaptation of a cognitive behavior therapy guided self-help program for Mexican American women with binge eating disorders. Journal of Counseling & Development, 90(3), 308-318.