Introduction

Eating concerns are recognized as affecting all racial and ethnic groups [1, 2]. Furthering our understanding of ethnic diversity as it relates to eating disorders continues to be an area of critical importance. Specific aims should include improving identification, risk models and prevention efforts, and access to and tailoring of treatment for ethnically diverse individuals [3,4,5]. The present review aims to provide an up-to-date review of literature published from 2015 to 2018 related to these issues, as well as to identify needed areas of further research. Specifically, this review considers recent advances pertaining to the identification and assessment, prevalence rates, risk factors, and treatment and intervention for eating disorders among racial and ethnic minorities. Finally, important recent advances as well as directions for future research are highlighted.

Identifying and Diagnosing Eating Disorders

Historically, the majority of eating disorder assessment, screening, and diagnostic tools were developed among White female groups, leading to a call for more culturally sensitive diagnostic criteria and assessment instruments to reflect the specificities of presentations of eating disorders among ethnic minority populations [4, 6•]. The need to elucidate more useful diagnostic criteria and develop tools that are culturally sensitive has been highlighted as a critical area for research, with cascading implications for identification and detection, treatment access and utilization, and culturally tailored interventions [4].

Recent advances in the development of culturally sensitive and valid measurement tools may help to bridge some of these gaps [6•, 7, 8]. Overall, this emerging body of research suggests that existing tools may be appropriate for use across ethnic groups. However, further work should focus on moving beyond the use of tools originally developed among White populations. Consistent with this, it has been noted that some of these measures, while presenting invariance in terms of structure, appear less sensitive when used among ethnic minority populations [7, 9], which may limit their use as screening and diagnostic tools.

Prevalence Rates

Despite the potential limitations to our capacity to accurately determine rates of eating disorders and eating disorder symptoms described above, several studies have examined the prevalence rates of eating disorders and unhealthy eating and weight control behaviors in individuals from racial/ethnic minority backgrounds. In general, research suggests that high rates of disordered eating exist among racial/ethnic minority adolescents [10••, 11]. However, differences are found when examining specific types of eating disorders and disordered eating behaviors among different racial/ethnic groups. Recent findings on the prevalence of disordered eating concerns within racial/ethnic groups are summarized in Table 1.

Table 1 Prevalence rates for disordered eating by race/ethnicity in selected articles published 2015–2018
Full size table

Asian and Asian American

Several recent studies suggest people of Asian backgrounds may have an increased likelihood of engaging in disordered eating and unhealthy weight control behaviors when compared to people of other racial/ethnic groups, including White [10••, 30]. In a population-based study of 2793 adolescents, girls of Asian background reported the highest rates of disordered eating across all disordered eating behaviors when compared to their Black, Hispanic, and White counterparts [10••]. Interestingly, the relative risk of dieting was lowest for Asian girls with overweight when compared to their White, Hispanic, and Black peers with overweight. In the same study, Asian boys endorsed the highest rates of dieting, unhealthy weight control behaviors, and overeating when compared to their peers of other racial/ethnic groups. However, these results may not be representative of a broad range of Asian American identities, as 82% of the Asian participants were Hmong. However, Kelly and colleagues [31••] also found that Asian American college-aged men endorsed higher body image concerns, drive for muscularity, and internalization of the ideal male body when compared to White and Black peers, when controlling for BMI. Asian men in the study who reported binge eating also endorsed higher rates of compulsive exercise compared to Black men who binge eat. Thus, based on the literature, Asian males appear to be at significant risk for eating disorder symptoms and disordered eating behaviors.

Hispanic/Latino

Among Hispanic or Latino individuals living in the USA, lifetime prevalence rates appear lower for anorexia nervosa and comparable for bulimia nervosa and binge eating disorder (BED) when compared to non-Hispanic Whites [21••]. Previous research identified Latinos as showing higher prevalence rates of lifetime BED than other racial/ethnic groups, with BED being the most common eating disorder among Latinos [21••, 46, 47]. Lee-Winn and Reinblatt [19] found higher prevalence of lifetime recurrent overeating in Latinos than Whites, with Latinos reporting being more upset and more afraid of weight gain due to binge eating.

Some research suggests Hispanics/Latinos endorse fewer weight concerns, less dieting, and fewer exercise behaviors than non-Hispanics [20••]. This may vary based on weight status, with other studies suggesting overweight Hispanics/Latinos are at a high risk for dieting [10••]. The relative risk for dieting may be highest for overweight Latino girls when compared to their Black and Asian peers, with similar rates among Latinos and Whites [10••]. In one study, Black, Hispanic/Latino, and White participants self-reported age of onset of disordered eating behaviors. For Hispanics/Latinos, the authors note that the typical sequence of disordered eating behaviors is binge eating, followed later by dieting. This contrasts with White and Black individuals, who use dieting behaviors first and later engage in binge eating [20••, 32]. This suggests that the course of disordered eating may differ for Hispanics/Latinos when compared to White and Black individuals. Thus, increasing evidence suggests that, among Latinos, eating disorders symptoms may be a particular concern among those of higher weight.

Black/African American

Findings on the prevalence of disordered eating among Blacks/African Americans relative to other racial/ethnic groups are mixed. Some research suggests that despite higher average BMI than White or Asian American men, Black men report higher body satisfaction, lower prevalence of negative feelings about binge eating, and lower prevalence of being afraid of weight gain due to binge eating [31••]. However, in another study, Black boys reported the second highest prevalence rates of unhealthy weight control behaviors (UWCB) and overeating, with 38.5% of Black boys endorsing UWCB and 10.1% reporting dieting [10••]. Yet another study found that the association between body dissatisfaction and UWCB is weaker for Black boys than their peers of other ethnic/racial groups, as Black boys endorsed similar rates of UWCB regardless of high or low body dissatisfaction [12].

Regarding girls, Rodgers and colleagues [10••] found that the prevalence of dieting behaviors was lowest among Black girls compared to their Asian, White, and Latino peers. Black girls endorsed the lowest prevalence of UWCB among the racial/ethnic groups studied, though the prevalence of UWCB among Black girls was still considerable at 43.1%. When weight status was considered, the relative risk of using UWCB was highest for overweight Black girls compared to their counterparts of other racial/ethnic identities. A study of college-aged women found that Black women endorsed significantly lower levels of eating disorder pathology as assessed by EDE-Q scores [26]. Taken together, these findings suggest that Black girls at lower weights may present lower levels of the behaviors typically assessed in the context of eating disorders, although this may not be true for higher weight girls.

Other Racial/Ethnic Minorities

Missing from recent research on eating disorders are prevalence rates among other racial/ethnic minorities including Native Americans and individuals of two or more racial/ethnic identities. In addition, some of the extant research may group participants together under a common racial/ethnic identity label, ignoring differences within groups. For example, people who identify as Asian American may further identify as Indian American or Korean American. Further research would help to elucidate similarities and differences in prevalence rates, presentation, and course of disordered eating among a wider range of racial/ethnic groups.

Risk Factors

Acculturative Factors and Ethnic Identity

Recent research has included an increasing focus on the identification of risk factors for eating disorders among specific groups. One of the conceptual frameworks that has been used to guide this work is grounded in the consideration of the role of ethnic identity, particularly identifying with a minority ethnic group, and the internal awareness and experience of minority status, as well as the interactions with members of the majority group. The stress associated with these experiences, termed minority stress, may be related to eating disorders [25]. Relatedly, authors have considered the role of acculturative stress in the development of eating disorders, defined as the stress incurred during the process of adapting to a new culture that is different from one’s culture of origin [30]. From this perspective, disordered eating behaviors may be thought of as the result of attempts to cope with the stress associated with the experience of visible minority status and the acculturative process [14]. In contrast, ethnic identity has been described as a protective factor for eating disorders, both due to its provision of social support and capacity to buffer from acculturative stress, and its capacity to decrease the personal relevance of thin-ideal pressures typically associated with White appearance ideals [20, 18].

Evidence supporting the association between acculturative stress and eating disorder symptoms in ethnic minority women had already emerged [31••]; however, recently, research grounded in this perspective has shed additional light on these processes. Thus, the cross-sectional association between acculturative stress and eating disorder-related outcomes was further supported among Asian American and Latina women [14, 32]. Similarly, other authors described second generation Asian Americans as displaying the highest rates of eating disorder symptoms, as compared to first generation or third and higher, suggesting that the stress of the acculturative process may play an important role [17]. Furthermore, recent work has contributed to clarifying the mechanisms through which acculturative stress might exert its influence on eating disorder outcomes. Thus, among Latinas, a mediated pathway through self-esteem has been described [14], as well as one through negative affect [32]. Importantly, it has also been found that acculturation itself was not significantly associated with eating disorder symptoms, thus highlighting that it is the stress resulting from this experience that is related to eating disorder pathology [22]. This work has also been extended to examining the role of race-related discrimination in eating disorder symptoms, with findings suggesting that among Asian American men in particular, racial discrimination may be associated with loss of control eating [16•].

Regarding ethnic identity, recent findings have again supported a cross-sectional positive association between stronger ethnic identity and lower level of eating disorder pathology [18], as well as higher levels of body appreciation [25]. Among Hispanic men, stronger ethnic identity was inversely associated with loss of control eating [16•]. In contrast, however, interestingly, in one study, certain culturally specific beliefs, such as the need for emotional self-control that can be found among Asian American women, were be associated with higher levels of eating disorder symptomatology [17]. In this way, related to ethnic identify also, increasing attention has been paid to clarifying the mechanisms underpinning the relationship between ethnic identity and eating disorder symptoms, with converging findings suggesting that internalization of social appearance ideals may mediate the relationship [25, 18]. Thus, consistent with theory, stronger ethnic identity among ethnic minorities might buffer against the internalization of the thin-ideal.

Sociocultural Factors

Sociocultural theory posits that the pressure to conform to unrealistic and extremely thin and muscular appearance ideals, largely exerted by the media but also by peers and family members, contributes to the development of body dissatisfaction which in turn may lead to disordered eating behaviors [33]. The usefulness of sociocultural models for investigating body image and eating concerns among ethnic minority groups has already been established [34]; however, recent research has sought to better characterize the associations between sociocultural influence and body dissatisfaction, and the relationship between body image and disordered eating behaviors among ethnic minority groups. In this way, recent work has suggested that peer influences are more strongly associated with poor body image among African American women as compared to White women [26]. In addition, among adolescents, the relationship between body dissatisfaction and disordered eating behaviors has been found to vary across ethnic groups, with the weakest relationship found among African American adolescent boys [12]. Finally, within adults identifying as Black, the relationship between body dissatisfaction and binge eating outcomes was found to be stronger among Caribbean Blacks as compared to African American individuals [35•].

In addition to the internalization of social ideals mentioned above, a second mechanism, appearance comparison, is thought to account for the impact of unattainable appearance ideals on eating disorder symptomatology [36]. Regarding appearance comparison, Black women have been described as reporting fewer appearance comparisons compared to White and Hispanic women and displaying weaker associations between appearance comparisons and eating disorder outcomes [23]. More specifically, when considering upward appearance comparisons (to individuals perceived as more attractive) and downward comparisons (to individuals perceived as less attractive), it has been suggested that while upward comparisons are associated with higher levels of eating disorder symptoms across ethnic groups, downward comparisons are associated with poorer outcomes among Latina women, but with lower levels of pathology among Asian and White women [36]. Thus, while overall contributing to eating disorder pathology, appearance comparison appears to function differently across ethnic groups.

Another theoretical framework that has lately been increasingly integrated into the sociocultural perspective is that of objectification theory [37]. Objectification theory holds that the tendency to view bodies, especially women’s bodies, as objects in Western society is internalized by women, leading to self-surveillance and body shame, and resultant eating disorder pathology [37].

Extensions of objectification theory to ethnic minority groups have started to emerge. A recent study exploring racism as a socialization experience, and in particular experiences of teasing related to racial/ethnic-related physical features, revealed that these experiences were related to increased self-surveillance and body shame, as well as eating disorder symptoms among Asian American college women [13•]. The model developed in this study also included the internalization of Western media appearance ideals as a mediator, highlighting how the endorsement of appearance ideals that are unattainable in terms of weight and shape, but also predominantly emphasize light skin and typically Caucasian facial features and body shapes, may increase eating disorder risk.

Other Risk Factor Models

The previous sections above explore risk factor models that account for aspects of the experience, and particularly embodied experience, of identifying as an ethnic minority. However, other risk factors for eating disorders have also been shown to be informative, and recent work has aimed to examine the extent to which these can be extended to ethnic minorities. One such risk factor includes hereditary risk factors for eating disorders, which twin-studies have been shown to be similar for binge eating in European American and African American females [28]. Additionally, psychological aspects such as cognitive styles increase risk. For example, while rumination was found to be associated with higher rates of binge eating among both Caucasian and African American women, among the latter group optimism was found to be associated with lower levels of binge eating [27]. Another psychological risk factor that has been explored is food cravings that are known to be associated with higher levels of eating disorder pathology. However, in a mixed sample of adults in terms of race, ethnicity, and gender, no differences in the magnitude of the relationship between food craving and binge eating behaviors emerged [24].

A number of interpersonal factors have also been considered. In the same study, among Caucasian women, social support from peers was found to be associated with less binge eating while interestingly, social support from family was found to be associated with less binge eating among African American women but higher rates among their Caucasian counterparts [27]. Among high school students, youth experiencing dating violence were more likely to report disordered eating behaviors [19]. Among males, this relationship was significant for those identifying as Hispanic and White, and among females for all groups except for those identifying as non-Hispanic Black [19]. Thus, the findings from this direction of research so far reveal both broad similarities in the way that some individual-level risk factors are associated with eating disorder behaviors and risk, as well as similarities and differences in more interpersonal-level risk factors.

Treatment and Intervention

While literature documenting the existence of significant rates of eating disorders among diverse ethnic groups is starting to emerge, the understanding of culturally specific clinical presentations, barriers and facilitators to treatment seeking, and effective interventions for diverse groups are still areas that are only beginning to receive research attention [5, 38].

Relevant to the identification of factors that might affect treatment seeking, recent research has investigated the factors associated with correct self-identification of an eating disorder history among Latina women [48]. Findings revealed that Latinas who reported meeting or having met criteria for anorexia nervosa and bulimia nervosa, relative to other forms of eating disorders, were the most likely to correctly self-identify an eating disorder history. In addition, those who were less fearful of the stigma associated with seeking mental health treatment were also more likely to endorse an eating disorder history, suggesting that cultural attitudes toward treatment seeking may play an important role. These findings point to the importance of psychoeducation to facilitate treatment seeking.

Recent work has aimed to describe differences in the clinical presentations of binge eating disorder (BED), with findings suggesting that differences may exist in terms of behaviors and psychological functioning [39••]. In a large sample of 775 treatment-seeking Black, Hispanic, and White adults, higher body mass index and more frequent binge-eating episodes were found for Black individuals compared to White [39••]. In addition, however, Black individuals overall reported lower levels of depressive symptomatology compared to White and Hispanic individuals. In contrast, White individuals reported younger age of onset of dieting, binge eating behaviors, and obesity, but not BED, compared to Black and Hispanic participants [39••]. A very similar pattern emerged among a smaller sample of Caucasian and African American women seeking treatment for BED in primary care settings, with Caucasian women revealing earlier onset of binge eating, dieting, and overweight, and more frequent dieting as compared to the African American women [40]. However, in this sample, no differences in depression emerged. Together, these findings suggest that the developmental pathways of eating disorders may differ across ethnic and racial groups. In addition, the differences in terms of age of onset are important to consider with a view toward tailoring prevention efforts.

Regarding the tailoring of interventions, increased efforts have been made to develop treatment approaches that are culturally sensitive and incorporate important aspects of treatment preferences and address barriers. In this way, the recent literature has been augmented by both rich case studies as well as data from randomized clinical trials. Binkley and colleagues [41] reported on a brief family therapy developed as a treatment modality for a Mexican American adolescent with comorbid depressive disorder and binge purge behaviors. The successful treatment approach followed a number of cultural adaptations including in the area of language, persons, metaphors, content, concepts, goals, methods, and context [41]. Another case report in which culturally adapted cognitive behavioral therapy for bulimia nervosa was used in the treatment of a Latina woman highlighted how adapting both the context and the format of treatment, for example to include other important family members, was helpful [42]. The detailed reporting of such cases of cultural adaptations of empirically based treatments represents a valuable contribution to the literature in that it provides a framework for further cultural adaptations as well as providing initial indicators of their usefulness. Similarly, findings from recent randomized controlled trials of culturally tailored treatments have shown promise in the context of binge eating, as well as provided further information regarding their feasibility and acceptability. Thus, a culturally adapted CBT guided self-help delivered to Mexican American women was found to be feasible among women with bulimia nervosa or BED [43]. Furthermore, participants provided useful feedback regarding the benefits of further incorporating peer and family support. In addition, a lifestyle intervention was found to be effective in reducing BED symptoms among African American and Hispanic women [44]. Thus, increasing efforts to develop culturally adapted interventions and to evaluate their usefulness, particularly among African American and Hispanic women, have been an important contribution of the recent literature.

Strengths of the Recent Research and Future Directions

In very recent years, the number of studies focusing on eating disorders among ethnic minorities has increased, highlighting a need for greater understanding of these concerns among minority groups and making a number of important contributions. Taken together, the findings provide further evidence of the high rates of eating disorder behaviors across ethnic groups, and of the intersection with weight status. In addition, they highlight the usefulness of using lenses that account for sociocultural location, identity, and lived experience in relation to other social groups and appearance standards such as the minority stress model and sociocultural theory when investigating risk factors for eating disorders among ethnic minority groups. Dimensions associated with the experience of ethnic minority identity when embedded in the larger mainstream US culture have emerged as relevant and important to consider although patterns may vary across groups. Finally, recent work focusing on the cultural adaptation of treatments, informed by ethnic minority clients’ experiences, has emerged as a promising and worthwhile endeavor.

This emerging body of literature boasts a number of strengths but also limitations. A first broad area of contribution is the increased recognition of the complexity of the issues embedded in research focusing on eating disorders among ethnic minorities. These complexities result from the evolving classification and definition of eating disorders, intra-ethnic group heterogeneity, and the intersection of ethnic minority status with other factors that are recognized risk factors for eating disorders, including socioeconomic status and attitudes related to weight and food [9, 35•]. As a result, recent literature is increasingly grounded in multifactorial ecological models of eating disorders and identity that better represent complex social realities. A second important area of contribution of the recent literature is the expanding of research to include previously neglected groups such as men [14, 16•], and Asian Americans [14, 22]. Three, the burgeoning literature on risk models that include experiences of being of visible ethnic minority status within a sociocultural context that overwhelmingly values White bodies [e.g., 25, 18, 23] represents an important advancement. Four, the increased focus on protective factors, as opposed to risk factors, is a critical contribution with a view to developing models that are increasingly strengths-based. In this way, the recent literature has examined ethnic identity and body appreciation, for example [25]. Finally, detailed and rich accounts are given of culturally tailored intervention approaches, particularly among Latina populations [41, 45].

While the above represent important areas of progress, a number of areas still require further investigation. In terms of measurement and assessment, authors have identified a need to strengthen efforts to represent the heterogeneity of typically described ethnic/racial groups and consider how presentation and risk might vary within these groups [49••]. In addition, although elements of such a program of research are emerging, more work grounded in strengths models that focus on protective factors would be important, particularly research that examines aspects of the experience of being from an ethnic minority group. Thus, additional research related to the impact of ethnic identity, or dimensions of multiculturalism would be important to conduct. While advances are clear, researchers have called for more research on the optimization of cultural adaptations of empirically supported and based treatments, and more systematic cataloging of these adaptations [21]. In addition, more work that can successfully identify and decrease barriers to treatment seeking and access to care among ethnic and racial minority groups is needed.

Conclusions

In sum, recent research has to some extent accelerated our capacity to identify, characterize, and treat eating disorders among ethnic minority groups. This work has aimed to better represent the heterogeneity of these groups, as well as develop models that account for the subjective minority and or immigrant experience, as well as the existence of predominantly White appearance ideals. Finally, culturally informed adaptations of empirically supported treatments have been increasingly developed. These advances illustrate a greater recognition of the importance of extending our work to be more inclusive of ethnic and racial minorities. Additional efforts in these directions continue to be warranted to decrease disparities in help-seeking and access to care.