Assessment Of Disordered Eating By Israeli And American College Women
Generalizing from research showing that group norms influence disordered eating, college women from Israel. whose culture differs from America’s in important ways, were predicted to show lower levels of disordered eating than comparable Americans. We assessed disordered eating in typical Israeli and American college women, using two validated measures of disordered eating. Multivariate analysis of variance comparing scores from 113 Americans and 124 Israelis on the two measures indicated that Americans indeed scored significantly higher than Israelis (p [is less than] .0001). The greatest differences were in body dissatisfaction (p [is less than] .006) and introceptive awareness (p [is less than] .006). Internal consistency reliabilities and subscale intercorrelations were similar for the two samples, suggesting that factor-structure differences cannot account for the national effects.
The occurrence of disordered eating behavior among American college women and other women from Western cultures is widespread. For example, in one study. 64% of American college women sampled exhibited some degree of disordered eating behavior (Mintz & Betz, 1988), suggesting that disordered eating is the rule rather than the exception among these women. A recent study of American collegiate women indicated that 40% had intentionally vomited to control their weight (Tsai, Hoerr, & Song, 1998). Even among American college women who perceived themselves as of normal weight, 88% reported wanting to be thinner (Raudenbush & Zellner, 1997). These studies and others (e.g., Fairburn & Garner, 1986; Hawkins & Clement, 1980; Patton, 1988; Wardle, 1980) suggest a problem of major proportions in American society.
One explanation for the prevalence of disordered eating focuses on the role of sociocultural factors (e.g., Garner & Garfinkel, 1982; Swift & Stern, 1982). Because of the overrepresentation of disordered eating in the Western, adolescent female population, investigators have argued that the unrealistic standards of beauty in American and other Western cultures are a primary factor in the development and maintenance of disordered eating.
Crandall (1988) has tracked the influence of social norms on binge eating in two American collegiate social sororities. His results clearly indicate that sociocultural forces can facilitate disordered eating via the influence of social norms. This work revealed that such norms were significant predictors of the extent of student binge eating in American samples.
Within American culture, different subcultures also can differ in their disordered-eating rates. Black collegiate women suffer from disordered eating less than White collegiate women (Abood & Chandler, 1997; Powell & Kahn, 1995). Consistent with Crandall’s (1988) results, Powell and Kahn (1995) found that normative pressures to be thin were less intense for Black then for White American women. For example, Black American men had greater desire to date heavy women then did White American men, and the Black American men were less likely than the White men to believe they would be ridiculed for dating heavy women.
There is some controversy in this field regarding the relationship between anorexia and bulimia, on the one hand, and disordered eating that is not clinically diagnosable, on the other. This article is concerned with disordered eating, generally, including both clinically-diagnosable and other forms. Like other researchers (e.g., Mintz & Betz, 1988; Schwitzer, Bergholz, Dore, & Salimi, 1998; Vernado, Williamson, & Netemeyer, 1995), we view disordered eating along a continuum, with healthy eating at one end, subclinical disordered eating in the middle, and such disorders as anorexia and bulimia at the other end. Both formal eating disorders and subclinical forms of disordered eating constitute important problems in and impediments to the development of Western women.
Research on anorexia suggests that cultural pressures on women to be thin may have a causal role in the manifestation of anorexia (e.g., Garner & Garfinkel, 1980; Habermas, 1990). Most conceptualizations of anorexia are consistent with Garner and Garfinkle’s notion that cultural factors are important in the development or maintenance of anorexia (Swartz, 1985).
Culture and Disordered Eating
If sociocultural factors actually influence disordered eating, cultures without an emphasis on thinness should show less disordered eating. For example, disordered eating patterns should differ outside of Western nations because non-Western cultures often hold standards of beauty that do not emphasize thinness. In fact, plumpness is considered attractive in much of the non-Western world and obesity is sometimes considered a secondary sexual characteristic (Buhrich, 1981; Hamodi, 1960; Meyer & Tuchelt-Gallwitz, 1968; Orbach, 1978; Rudofsky, 1972).
Consistent with this notion that sociocultural factors influence disordered eating, research indicates that at least until recently anorexia has been rare or absent in non-Western cultures (German, 1972; Neki, 1973; Okasha, Kamel, Sadek, Lotaif, & Bishry, 1977). Taking a somewhat different perspective on the issue of the influence of Western culture, Goldblatt, Moore, and Stunkard’s (1965) Midtown Manhattan study found an inverse relationship between the length of exposure to the American society and obesity. Likewise, Furnham and Althai (1983) demonstrated that Kenyan women with Asian backgrounds rated larger human figures more favorably than Kenyan women with British backgrounds, suggesting that exposure to British culture may have led to a valuing of thinness. Similarly, Fichter, Weyerer, Sourdi, and Sourd (1983) identified a higher incidence of anorexia among Greek girls in Munich than among Greek girls in Greece. Nasser (1988) assessed two matched samples of Arab female students attending universities in London and Cairo. Six cases of bulimia were identified in the London sample and none in the Cairo sample. Cogan and her colleagues found that Ghanian collegians rated larger body sizes as ideal significantly more often than Americans did, and that Americans dieted more and more often viewed weight as a social impediment (Cogan, Bhala, Sefa-Dedeh, & Rothblum, 1996). These studies document that for citizens of countries experiencing recent social upheaval (China, the Czech Republic, and South Africa) greater Western influence has been accompanied by increases in disordered eating (Krch, 1995; Le Grange, Telch, & Tibbs, 1998; Lee, Leung, Lee, Yu, & Leung, 1996). Taken together, this group of findings lend support to the notion that Western culture may influence disordered eating.
One potential limitation in many of these studies is the failure to use validated measures of disordered eating, such as the Eating Attitudes Test (EAT; Garner & Garfinkel, 1979) or Eating Disorders Inventory (EDI; Garner, Olmsted, & Polivy, 1983a). This limitation will be addressed in the present study.
Although somewhat influenced by the West, Israel is not a Western society. Because of their nearly constant and often bloody struggles with their continental neighbors regarding the right of Israel to exist, as well as with Israeli occupation of Gaza and the West Bank, Israel has an intense national consciousness unparalleled in America. This struggle for national safety and survival involves all segments of the population, including men and women, young and old. Israel’s non-Western culture, coupled with the strong nationalism throughout Israeli society, is likely to have reduced Israeli adolescents’ self focus and their desire for thinness, compared with their American counterparts (see Shouval, Venaki, Bronfenbrenner, Devereux, & Kiely, 1984). Israeli college women make an ideal comparison to American college women because the quality of the college educations is comparable, yet the cultures differ clearly with respect to eating-relevant beliefs.
Based on research regarding the relationship between sociocultural influences and disordered eating, on the markedly different beauty standards in Eastern and Western cultures, and on the different levels of nationalism and self-focus in Israeli vs. American adolescents, we predict that Israeli college women will have significantly lower overall levels of disordered eating than American women, as indicated by scores on two validated measures of disordered eating.
Samples and Procedure
Samples of undergraduate female students from both a large major university in Israel and a large major university in America were recruited for this study. The samples contained only Israeli-born women attending the Israeli university (n = 124) and American-born women attending the American university (n = 113). The average age for both samples was 19.5. The Israeli students were recruited a few months after the American students and in both cases were recruited with the assistance of local professors. The students in Israel were approached by the third author for completion of the research questionnaires. The students in America completed materials in an undergraduate psychology of adjustment course representing a cross section of student majors. Participation in the study was voluntary, but students received extra credit in the course. All of the students were assured anonymity and given the option to withdraw participation at any time, though none exercised that option.
Eating Attitudes Test
The Eating Attitudes Test (EAT; Garner & Garfinkel, 1979) was developed as an objective, self-report measure of the symptoms of anorexia. The EAT has been validated with anorexic patients, but has also been useful in identifying eating disturbances in non-clinical samples (Garner & Garfinkel, 1980; Button & Whitehouse, 1981; Thompson & Schwartz, 1982). Although most individuals from these non-clinical groups who score highly on the EAT do not satisfy the criteria for anorexia, the majority have been identified, in personal interviews, as experiencing abnormal eating patterns that interfere with normal psychosocial functioning (Button & Whitehouse, 1981; Garner & Garfinkel, 1979; 1980).
Garner and Garfinkle (1979) reported that the EAT demonstrated high internal consistency reliability: for a sample of anorexic participants KR-20 was 0.79 and for a sample of anorexic and normal participants, KR-20 was 0.94. A 23-item prototype of the EAT was tested for known groups validity. Scores for a sample of anorexics was significantly higher than for a sample of non-anorexics, a finding replicated with a separate sample. The EAT was shown to be independent of weight fluctuations, extroversion, and neuroticism. Post hoc analysis of a group of recovered anorexics indicated that scores were in the normal range, suggesting the scale is sensitive to change (Garner, Olmsted, Bohr, & Garfinkel, 1982).
In this study, the questionnaire was translated into Hebrew by an Israeli-born Hebrew language teacher, and the Hebrew translation was then retranslated into English by an independent translator. The retranslated version was found to match the original closely. This procedure of backtranslation has been recommended to increase the validity of the test when given in another language (Brislen, Lonner, & Thorndike, 1973). In this study, the EAT was administered and participants were instructed to answer the items on a scale ranging from 1 to 6, with 1 being “always,” and 6 being “never.” Scores were reversed where appropriate. The EAT has not been validated for any non-Western population, but the limited number of participants in this study rendered confirmatory factor analysis inappropriate.
Eating Disorder Inventory
The Eating Disorder Inventory (EDI: Garner, Olmsted, & Polivy, 1983a) is a measure designed to assess the degree to which the respondents possess behaviors and attitudinal characteristics associated with anorexia and bulimia. The measure is a 64-item self report questionnaire consisting of 8 subscales: Drive for Thinness (e.g., “I am terrified of gaining weight”), Bulimia (e.g., “I have gone on binges where I felt that I could not stop”), Body Dissatisfaction (e.g., “l think that my thighs are too large”), Ineffectiveness (e.g., “I have a low opinion of myself”), Perfectionism (e.g., “I have extremely high goals”), Interpersonal Distrust (e.g., I am open about my feelings”), Introceptive Awareness (e.g., “I get confused about what emotion I am feeling”), and Maturity Fears (e.g., “I wish that I could return to the security of childhood”). After reverse scoring on selected items, higher ratings reflect more ineffective attitudes and behaviors. Garner, Olmsted, and Polivy (1983b) have provided clear evidence of reliability and validity for the scale and its subscales. In addition, Welch, Hall, and Norring’s (1990) factor analytic study of the EDI on patients validated the original factor structure and provided an independent demonstration of the reliability of the EDI subscales. Eisele, Hertsgaard, and Light (1986) provided evidence supporting the validity of the EDI with adolescent women who responded to 5 of the subscales. This questionnaire was also translated to Hebrew and retranslated to English, with a close match.
To test the hypothesized relationship between disordered eating and nationality, a multivariate analysis of variance (MANOVA) was performed. Nationality served as the independent variable. The EAT and the EDI scores from the American sample reflected significantly more disordered eating than scores from their Israeli counterparts, F(9, 244) = 4.55, p [is less than] .0001.
In order to determine the more specific sources of these nationality differences, individual one-tailed, Bonferroni-corrected t tests were performed on the EAT and on each of the EDI subscales. These analyses reveal that American women showed significantly more disordered eating than Israeli women on the Introceptive Awareness (IA) scale, suggesting that the Americans were less attuned to their inner thoughts and feelings than their Israeli counterparts. Likewise, American women showed significantly more disordered eating than the Israelis on the Body Dissatisfaction (BD) scale, indicating that American respondents were more dissatisfied with their bodies than their Israeli counterparts. Though the means were in the predicted direction, scores on the Perfectionism (P) scale fell just short of achieving statistical significance, with the Bonferroni correction. The remaining scales failed to reach statistically significant differences, suggesting that they were less important sources of differences between the American and Israeli college women (see Table 1).
Table 1 T-Test results Comparing Scores of Israelis and Americans on the EAT and EDI Subscales
X SD X SD t p
EAT 17.04 8.95 19.50 11.36 -1.84 0.07
BD 9.62 8.24 12.58 8.03 -2.78 0.01
IA 1.94 3.06 3.22 3.96 -2.77 0.01
P 5.21 4.20 6.32 4.65 -1.90 0.06
MF 2.73 2.78 2.11 2.51 1.70 0.08
BUL 1.99 3.17 1.82 2.88 0.43 0.67
DT 5.79 6.22 6.10 6.12 -0.39 0.70
ID 2.64 3.05 2.40 3.20 0.60 0.55
I 1.95 3.21 2.60 4.04 -1.37 0.17
Note: EAT=Eating Attitudes Test, BD=Body Dissatisfaction, IA=Introceptive Awareness, P=Perfectionism, MF=Maturity Fears, BUL=Bulimia, DT-Drive for Thinness; ID=Interpersonal Distrust, I=Ineffectiveness.
One potential explanation for these differences between American and Israeli women involves the possibility that the factor structure of the EAT and the EDI differed for the two groups. The two measures were developed on American samples using English then used on an Israeli sample and translated into Hebrew. This fact, coupled with the finding that the American sample showed significantly more disordered eating than the Israeli sample, raises the possibility that higher scores for the Americans were simply an artifact of the measures failing to maintain their original factor structure with the Israeli sample. Confirmatory factor analyses (CFAs) would be an outstanding analytic choice to test this possibility. Unfortunately, the minimum sample size requirements and maximum variable requirements for CFAs (see Hatcher, 1994, p. 260 for details) both fail to be met for these samples, thus precluding the use of CFA. Nonetheless, inspection of the internal consistency reliabilities of the EAT and of the EDI subscales, along with inspection of the intercorrelations among EDI subscales, can provide useful insights regarding whether the factor structures differed for the American and Israeli samples (see Tables 2 and 3).
Table 2 Comparing Coefficient Alpha Internal Consistency Scores of Israelis and Americans on the EAT and EDI Subscales
EAT .81 .85
BD .92 .90
IA .73 .79
P .79 .82
MF .68 .71
BUL .79 .80
DT .90 .90
ID .78 .80
I .83 .87
Note: EAT=Eating Attitudes Test, BD=Body Dissatisfaction, IA=Introceptive Awareness, P=Perfectionism, MF=Maturity Fears, BUL=Bulimia, DT=Drive for Thinness; ID=Interpersonal Distrust, I=Ineffectiveness.
Table 3 Comparing Eating Disorder Inventory Subscale Intercorrelations of Israelis and Americans
IA P MF BUL DT
BD 43/32 17/12 17/13 52/31 69/64
IA 23/20 37/35 61/55 39/54
p 38/01(**) 11/00 24/27
MF 18/34 18/23
BD 21/19 36/34
IA 31/43 49/70(*)
p 09/33 00/-01
MF 22/39 19/40
BUL 26/39 54/49
DT 18/45(*) 37/39
Note: Correlation decimal points have been removed. Pearson rs for the Israelis are on the left side of the slash, those for Americans are on the right (Israeli/American). EAT=Eating Attitudes Test, BD=Body Dissatisfaction, IA=Introceptive Awareness, P=Perfectionism, MF=Maturity Fears, BUL=Bulimia, DT=Drive for Thinness; ID=Interpersonal Distrust, I=Ineffectiveness.
(*) p < .05, (**) p < .01
Inspection of these data reveal a very clear picture: there are only slight differences between the scale reliabilities and subscale intercorrelations for the two samples. Of equal importance, all but one of these reliabilities exceeded the .7 threshold for acceptable internal consistency reliability, using Cronbach’s alpha. The one reliability coefficient that was below threshold just failed to reach it (Israeli sample, EDI Maturity Fears subscale alpha = .68). It is also important to note that on the same subscale the American sample’s reliability was just above the .70 threshold (alpha = .71) and that the MF was not one of the EDI subscales for which univariate analyses revealed a significant difference between the two samples. So the EDI-MF subscale’s unreliability cannot account for any of the statistically significant findings.
EDI subscale intercorrelations ranged in magnitude from -.01 to .69. We transformed all the correlations to z scores to compute the average subscale intercorrelations for Israeli and American samples and to test whether the magnitude of the resulting 28 intercorrelations differed significantly as a function of participant nationality.
Results from three sets of analyses suggest that there were only chance differences as a function of nationality on the magnitude of intercorrelations. First, the average EDI subscale intercorrelation for the Israeli sample was .33 and for the American sample was .35. These correlations were not statistically different from each other (z = .02, p [is greater than] .05)
Second, with an alpha level of p [is less than] .05, one could expect two statistically-significant differences to occur by chance alone, among the 28 pairs of EDI subscale intercorrelations for Israeli and American samples. We found three. Americans and Israelis differed significantly in the magnitude of association between subscales P and MF, ID and DT, and between I and IA. The Israelis had the larger intercorrelations between P and MF, whereas the Americans had the larger intercorrelations between the other two pairs. The magnitude of no other EDI subscale intercorrelations differed as a function of nationality. Third, the Bonferroni-corrected alpha was p [is less than] .0018 (.05/28). None of the 28 probabilities reached or approached this probability level, suggesting, again, that differences in the magnitude of the intercorrelations for Israelis and Americans are likely due to chance. Taken together, the reliability and subscale intercorrelation data suggest that the measures had similar factor structure for the Israeli and American samples. So, differences in the factor structure of the scales appears to be an implausible alternative explanation for the differences between the Israelis and the Americans.
We performed additional analyses, comparing our results to those from another data set, to address whether differences in how we recruited the American and Israeli samples could plausibly account for their differences. It could be argued that because we recruited our American sample from a psychology of adjustment class, but our Israeli sample from the undergraduate student body more broadly, that the psychology of adjustment class might have attracted more eating disordered students than other classes would.
To assess this concern, we identified a dissertation study conducted at the same university in which we collected our American data (Swinford-Diaz, 1991). The dissertation’s author collected EAT data on an all-female, undergraduate sample, as we did. Swinford-Diaz (1991) also collected data from students enrolled in the same psychology of adjustment class as we did, though in a different year. In addition, she collected data from two other classes, an abnormal psychology class and an introductory sociology class. So, the dissertation data set provides an opportunity to assess whether the psychology of adjustment students from that university differed in the level of their disordered eating from students taking other classes at the same university.
Swinford-Diaz (1991) conducted a statistical analysis regarding whether the three classes differed on the EAT and on five other measures, all having to do with object relations. These other measures tapped affiliation, egocentricity, alienation, social incompetence, and insecure attachment. Results of these analyses suggest that scores on the EAT and the other five measures did not differ as a function of class membership. There were no statistically significant differences among the three classes on any of the 6 measures (all F ratios were less than 1.0). These data suggest that the concern that those who took the course in psychological adjustment may be more eating disordered to begin with is not supported by the data. This finding is consistent with the fact that the psychology of adjustment course enrolls a broad cross section of university students.
One additional issue remains. There is a several-year time gap between the collection of Swinford-Diaz’s data and ours. Perhaps the kind of students who took the psychology of adjustment class changed over that time interval. To evaluate the plausibility of that concern, we compared the means and standard deviations of her data and ours on the EAT. Swinford-Diaz’s psychology of adjustment sample had a mean EAT score of 19.8 (SD = 10.3), compared with our sample, who had a nearly identical mean of 19.5 (SD = 11.4). These means are not significantly different, suggesting that time had negligible impact on the kinds of students taking the class.
The results of this study clearly support the hypothesis that on validated measures American college women would show significantly higher levels of disordered eating than Israeli college women. These findings are consistent with the notion that sociocultural factors may indeed cause disordered eating and begin to shed light on what some of those factors might be.
The difference between American and Israeli collegians was most clearly reflected in two subscales of the EDI, Introceptive Awareness and Body Dissatisfaction. Consistent with differences between American and Israeli cultures, American women were less self-aware and more unhappy with their bodies than their Israeli counterparts.
These data are consistent with research by Johnson and Conners (1987), which shows that attaining thinness has increasingly become a very highly valued achievement that secures envy and respect among women in American culture. In addition, they are consistent with findings by Crandall (1988) who demonstrated that within American samples disordered eating was influenced by the norms of one’s social group and one’s degree of identification with that group. These data are also consistent with studies cited earlier showing less disordered eating for non-Western and less-Westernized samples than for western and Westernized sample. What this study adds to the literature is a finding based exclusively on collegiate women, using two validated measures of disordered eating, based on comparisons involving American and Israeli participants.
It is important to note that the Israeli and American samples were selected to be comparable. Both groups were comprised of women in the age range of 18-21 who were academically motivated and pursuing higher education within a large university setting. Moreover the similarity in affluence of Israeli and American collegians lessens the chance that concerns about hunger or poverty might account for the differing levels of disordered eating. Ancillary analyses that compared the American sample with other American samples provided evidence that the American sample indeed reflected a broad, cross section of female students on campus.
There is still the possibility, however, that sample differences may not reflect population differences. These results are potentially limited in several other ways, as well. First, self-report inventories rely on the sometimes dubious assumption that participants will accurately describe their symptoms. This may be of particular concern for anorexic participants because they often display significant denial regarding their disorder (Slade & Russell, 1973; Kalucy, Crisp, & Harding, 1977; Goldenberg, Halmi, Casper, Eckert, & Davis, 1977). It is difficult to gauge the biasing effects of denial on questionnaire responses. In addition, cross-cultural differences such as cultural variations in the readiness to share personal information related to eating, and the relative lack of experience Israeli women may have with inquiries into their experience may all serve to limit these results. On the other hand, our data suggest that the Israelis and Americans perceived the scales similarly, because the internal consistency reliabilities and intercorrelations differed only trivially between the two samples.
Future cross-cultural disordered eating research should take into account plausible rival hypotheses for these culture-related effects. Campbell (1969) has provided a starting point for such a list of rival hypotheses when he cautioned researchers to consider such questions as these: (1)How accustomed are the participants to taking paper and pencil tests?; (2) How accustomed are they to responding to lengthy questions?, (3) How representative are the participants?; (4) Do the questions have the same meanings for participants in different cultures?; and (5) Do participants’ culture influence their test or interview behavior?
These findings have several practical implications. First, these and related data call into question the accuracy of conceptualizing disordered eating as reflecting individual psychopathology. Second, the sociocultural explanation calls into question the appropriateness of offering individual psychological treatment to members of cultures or subcultures whose cultural norms support disordered eating. It is common for models, dancers, and jockeys, for example, to display disordered eating. As an alternative to traditional psychotherapy for members of such groups, focused, symptom-directed therapy designed to call into question group and cultural norms supporting disordered eating may be most appropriate.
Medical theories of health and disease, which form the basis of psychiatric and psychological classification, such as the classification of eating disorders, are culturally bound. What may be needed is a classification system that integrates psychology, psychiatry, anthropology, sociology, and neurobiology. Such a system should be based on a holistic view of both wellness and illness, one that takes into account the sociocultural, psychological, and physical factors involved in psychopathology. Indeed, theories of disease from nonWestern cultures that take a holistic view may serve as better models for the cross-cultural difference in disordered eating than the present American medical model (Fabrega & Manning, 1973). These data support the implementation of nonpathologizing prevention and education programs that identify the cultural pressures associated with disordered eating and focus on cognitive skills that ca be employed to reduce the influence of dysfunctional cultural norms on individuals.
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This article is based on a Masters thesis by the third author that was supervised by the first author. We would like to thank thesis committee co-chair Harry Grater and member Warren Bagard, as well as Tom Britt, Tracy Carroll, and Roberta Seidman for their helpful comments. Address correspondence to’ Martin Heesacker, Department of Psychology, University of Florida, Gainesville, FL 32611-2250; Email: email@example.com.
Department of Psychology
University of Florida
AMANDA W. SAMSON
School of Education
University of Denver
JODI L. SHIR
Department of Psychology University of Florida
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