Culture and Weight Consciousness

Mervat Nasser

• Publisher: Routledge
• Year: 2003
• Print ISBN: 9780415161534
• eBook ISBN: 9781134719358
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Anorexia nervosa and bulimia are among the few psychiatric syndromes with a plausible socio-cultural model of causation. Issues of culture and slimness are usually considered in terms of the experience of the western world, but there is a growing body of research suggesting that concern with slimness is becoming more prevalent in non-western cultures.
In Culture and Weight Consciousness, Mervat Nasser brings together this research and looks at the recent emergence of eating disorders in cultures that were previously free of such problems. She relates the feminist theories that have been put forward to explain the phenomenon of eating disorders in the west to the condition of modern women in many non-western cultures and concludes that their position is not at all that different from that of their western counterparts. This leads her to address the current limitations of the concept of culture and draw out the implications for future research.

Chapter 1
The sociocultural model of eating pathology

WEIGHT CONSCIOUSNESS AND THE PURSUIT OF THINNESS

Weight phobia, fear of fatness and pursuit of thinness are modern terms that are now used interchangeably to refer to anorexia nervosa, a condition that was first reported in the latter part of the nineteenth century by William Gull in Britain and Charles Lasègue in France. Both described a distinct state of self starvation, peculiar to young women and likely to be caused by a host of emotional factors.

Implicit in their description is the presence of concern over weight and a desire to be thin. Lasègue was intrigued by the patient’s indifference to her thinness and her total acceptance of her weight loss.

What dominates the mental condition of the patient is above all a state of quietude, I might also say a condition of contentment purely pathological…. Not only does she not sigh for recovery but she is not ill pleased with her condition.

(Lasègue 1873)

It could not have been a simple coincidence that at the time of describing this syndrome, both London and Paris were witnessing their first feminist movement. Contemporary feminist writers viewed thinness as a way of resolving the modern woman’s inner conflict, torn between a desire to conform to old traditional stereo-types of womanhood and the new values related to what the modern woman ought to be. It has been argued that in our century the thinness ideal has evolved as the ultimate metaphor, representing a perfect synthesis of the old notions of attractiveness, frailty and fashionability that women are still expected to have and the new values of autonomy, achievement and self-control (Orbach 1986, Wolf 1990, Gordon 1990).

The debate about whether thinness has indeed provided women with an answer to their current predicament is an important aspect of this book and will be dealt with in more detail later on. However, the cult of thinness has historically evolved for a number of other reasons, some of which could perhaps be seen as being directly or indirectly connected with the position of women in our society today.

In the nineteenth century, for instance, thinness began to be positively perceived as representing a kind of spiritual beauty. This is clearly seen in the romanticization of the thin, tubercular look in literature and poetry. TB was believed to affect only sensitive people and enhance their creative power. Gautier, one of the leaders of the romantic movement, commented that he could not have accepted as a lyrical poet any one weighing more than 99 pounds! Shelley consoled Keats by saying that consumption was a disease fond of people who wrote good verses. Byron, too, starved himself to unnatural thinness and wished to die from consumption ‘because the ladies would say, look at the poet Byron, how interesting he looks in dying’ (cited in Sontag 1978). The fashion of looking consumptive and pale was taken up by some women, who used whitening powder to achieve it (Vincent 1979).

It is interesting that, at that time, physicians had to be aware of the distinction between this emerging new syndrome of anorexia nervosa and the more familiar condition of consumption. Interest in comparison of the two conditions has not disappeared; questions have recently been raised as to whether some of the past romantic literary figures had TB or anorexia nervosa (Dally 1989, Frank 1990).

Art provided another platform for the expression of society’s new aesthetic values, with notable departure from the fuller and sensuous figures of Rubens and Renoir to the dream-like women of the Pre-Raphaelites. The ultimate endorsement of thinness as the new form of beauty was through Picasso’s painting, the Girl in Chemise, where, according to Clark (1980), ‘A new beauty has emerged, withdrawn, melancholic, delicate and frail’. The fashion industry was ready to capitalize on this new look and promote the thinner image: ‘An abundance of fat’, said Helena Rubinstein, ‘is not in accord with the principles that rule our conception of the beautiful’ (Rubinstein 1930).

The change in aesthetic values, with more admiration given to the thinner female figure, was initially endorsed by the rich, who were able to purchase this fashionable look; this is epitomized in the often-quoted saying by the Duchess of Windsor, ‘One cannot be too rich…one cannot be too thin’.

The class structure of society was changing significantly towards the end of the nineteenth century, with the rise of the middle class. Lasègue (1873) was clever enough to make the link between his new syndrome L’anorexie hystérique and the changes that were happening in middle-class families, with increased emphasis on eating and appearance. Eating emerged as a new style that set the members of the middle class apart from the working class, and meal times began to symbolize the spirit and values of these new middle-class families (Brumberg 1988, Selvini-Palazzoli 1985).

It is not surprising therefore that attention was given to the subject of class and weight; an inverse relationship between socio-economic class and prevalence of obesity has often been reported (Goldblatt et al. 1965, Sobal and Stunkard 1989). In keeping with the class symbolism of thinness, early literature on anorexia nervosa showed an over-representation of these disorders among patients from upper socio-economic classes (Crisp 1970, Bruch 1973, Morgan and Russell 1975).

The glamorization of thinness in fashion was to spread throughout society on account of the ready-to-wear industry’s investment in this smaller and thinner look through the introduction of standard sizing for all women (Walsh 1979, Shorter 1984). It was predicted that as fashion became increasingly more accessible to women from different class backgrounds, a rise in the proportion of patients with anorexia nervosa from lower socio-economic classes would be expected (Garfinkel et al. 1980).

The historical evolution of the thin look and the role played by the fashion industry and the media in propagating this idealized image have been the subject of a number of publications in recent years (Schwartz 1986, Brumberg 1988, Gordon 1990). Advertisements on slimness targeted towards women were shown to have grown dramatically more numerous in the past two decades (Garner and Garfinkel 1980, Schwarz et al. 1986, Anderson and Di Domenico 1992). Also the number of diet articles and diet books increased significantly. The most influential has been the Beverly Hills diet, which according to Wooley and Wooley (1982), represents the mass marketing of anorexia nervosa: ‘Anorexia nervosa has been marketed as a cure for obesity…the popularity of this diet can be seen as yet another symptom of a weight obsessed culture’.

As a result, more women than men began to show higher levels of body dissatisfaction. Women were consistently found to view themselves larger than their real shape and the shape they think men prefer. Interestingly too, men were also found to prefer women to be thinner than the women felt themselves to be, indicating that the preference for a thinner body shape for women is shared by both sexes (Fallon and Rozin 1985). This explains the results of the studies that looked at the prevalence of dieting behaviour, which showed more women than men to be commonly engaged in dieting. Dieting behaviour was found to be prevalent in 50–80 per cent of younger women, who repeatedly described themselves as being overweight and reported an exaggerated concern with their weight (Dwyer et al. 1969, Nylander 1971, Moses et al. 1989, Rand and Kuldau 1991).

One of the reasons for the high susceptibility of young people to dieting is the fact that they develop early in life a negative attitude towards obesity, concomitant with increased awareness of the stigma attached to it in society (Wooley et al. 1979). The negative attitude towards obesity partly stems from the recognition of the possible health risks associated with it. Obesity was linked to a wide variety of diseases, particularly hypertension and heart conditions; even early mortality was also attributed to it. The link between obesity and heart diseases still dominates medical thought and is regarded by the lay public as a health fact, despite some medical publications questioning this relationship and warning against interpreting correlation figures as indicative of definite causality (Mann 1975).

Coinciding with the trend in fashion towards a thinner body shape, the medical establishment started to pay a lot of attention to body weight, with the introduction of weight charts and standard body weights for heights. Weighing the patient became routine and standard procedure in all medical examinations (Brumberg 1988). This contributed to the growing obsession with fitness. Thinness and fitness are closely linked and exercising through such activities as jogging and aerobics have become common preoccupations. Overexercising was found to occur in 18 per cent of the American population, and 30 per cent of those aged 18 to 24 reported regular jogging. The level of jogging per week was found to be directly linked to involvement with dieting (Richert and Hummers 1986).

All of this meant more pressure being put on women to pursue thinness, as thinness not only offered beauty but also became increasingly synonymous with the healthy younger look that everyone desired.

It is ironic that this heightened weight consciousness and the rise in society’s expectation of thinness took place against an increase in population weight norms, particularly for women (Garner et al. 1980). Women are biologically more prone to weight gain than men; a woman has twice as much fat as the male and an increase in body fat is expected to take place around significant times in the female life cycle, i.e. puberty, pregnancy, and menopause. Women also have a lower metabolic rate than men which increases their difficulty in reducing their weight through dieting. Dieting in itself is known to lower the metabolic rate even further, thus initiating the familiar cycle of repeated frustration through unsuccessful dieting that a lot of women experience (Bray 1976, Bennett and Gurin 1982).

It has been argued, however, that the pursuit of thinness is not only about the cult of appearance; it is more indicative of the competitive spirit that pervades our time: ‘Of importance here is the pressure on women to be competitive and successful; these achievement pressures may force an adolescent girl into a position where weight control becomes equal to self control and success’ (Garner and Garfinkel 1979).

Slade (1982) proposed that the stress generated by insecurities about adult roles could drive the potential anorexic to seek thinness as a source of achievement and success. Women were found to be easily manipulated into thinking that their body image was a measure of their value and sense of achievement and control, with success and self-worth equating to a desirable body shape (Bruch 1978).

If dieting is successful, the woman’s behaviour is reinforced by the weight loss. The more competitive the environment, the stronger the environmental reinforcers (Garner et al. 1980). On the other hand, excessive dieting behaviour could also be successfully brought under control in the absence of these environmental reinforcers (Szmukler et al. 1985).

Thinness is not only seen as a measure of success, but also sometimes as a licence to succeed. Overweight individuals were more likely to be discriminated against in educational and vocational settings than thinner ones. The commonest form of prejudice was clearly found to be targeted towards women who are perceived as having typically feminine bodies as reflected in bust/waist ratios. These women are commonly seen as less academically inclined and possibly less competent professionally (Canning and Meyer 1966, Larkin and Pines 1979, Cash and Janda 1984).

In view of all this, some women had no choice but to identify with the thinness ideal which would not only render them more beautiful and attractive but could also provide them with an important credential for success and professional enhancement.

FROM DIETING TO EATING DISORDERS

The symptoms of eating disorders clearly revolve around fear of fatness and a strong desire to be thin. These symptoms can easily be seen as extensions of culturally acceptable behaviours and preoccupations. However, the boundary between formal eating pathology and the more prevalent dieting behaviour is far from clear and is the subject of continuing debate.

Russell (1979) considered the dread of fatness to be the essence of eating disorders, but Palmer (1993) argued against using weight concern as the defining issue in these disorders. In support of Russell’s argument, those engaged in obsessional dieting were found to have the potential risk of developing eating disorders at a later stage (King 1989). Within the course of one year, the dieters among adolescent schoolgirls were found to have an eight-fold increased risk of developing an eating disorder (Patton 1988). Body dissatisfaction was also shown to be a significant predictive factor for the later development of the full syndromes (Garfinkel et al. 1992).

The main source of support for the link between dieting and eating disorders did in fact emerge from community surveys that looked for the prevalence of these disorders among normal student populations. This age group was repeatedly found to be concerned with dieting and was subsequently considered most at risk of developing eating disorders. It was also thought that the spirit of achievement that pervades academic establishments could increase the risk in this group. The morbid concern with weight was measured by a positive response on the Eating Attitude Test questionnaire (EAT). The EAT is a self-report questionnaire that was devised to elicit abnormalities in eating attitudes and measure a broad range of symptoms characteristic of anorexia nervosa (Garner and Garfinkel 1979). The concern over these issues ranged in these student populations between 6.3 and 11 per cent. On clinical interviewing, 2–5 per cent of the students were found to have a partial syndrome of an eating disorder, manifesting with morbid concerns over food and body weight that were none-theless not severe enough to qualify for the diagnosis of the full syndrome (Button and Whitehouse 1981, Clarke and Palmer 1983, Szmukler 1983, Mann et al. 1983, Johnson-Sabine et al. 1988).

Subclinical forms of eating pathology were generally estimated to be five times more common than the full-blown syndromes (Dancyger and Garfinkel 1995). The actual presence of these sub-clinical forms and the frequency of their occurrence clearly suggest that eating pathology behaves on a continuum of severity, with dieting representing one end of the spectrum and the extreme forms of disordered eating representing the other.

Dieting was therefore considered to be a necessary if not sufficient factor for the development of the full syndrome. The question that remains largely unresolved is what determines the progression of a partial syndrome into a definite clinical case. Doubts were raised as to the degree of similarity in the psychological profile between those with partial syndrome and those with a definite eating disorder (Bunnell et al. 1990). Other studies showed them to be comparable in the level of their psychological disturbance with particular reference to the presence of anxiety and depression (Garfinkel et al. 1995).

In view of these reservations it was important still not to put all the emphasis on the dieting behaviour alone but to take also into account the individual’s other vulnerabilities, particularly psychosocial functioning, as the nature of the eating disorder lies more in the entanglement of the dietary restraint and its consequences with a variety of wider personal issues (Palmer 1993, Dancyger and Garfinkel 1995).

The discovery of subclinical cases in student populations encouraged interest in studying other populations that are not necessarily designated as being at risk of developing eating disorders. Studies conducted on general practice population showed similar levels of concern, and the significant finding was once again the presence of a higher number of those with partial syndromes as opposed to those with full eating disorders syndrome with a tendency to develop bulimia nervosa (Meadows et al. 1986, King 1986).

A close relationship was in fact found between dieting behaviour and bulimic symptoms, which tend to develop within a year from the onset of dieting, particularly in women who have poor impulse control. Purging was also found to be more prevalent among adolescents than originally thought, and it was suggested that it should be considered an early stage in the development of the full bulimic syndrome (Polivy et al. 1994, Killen et al. 1985).

The finding of greater prevalence of bulimia than anorexia nervosa in community studies contradicted the original assumptions held about the nature of the bulimic syndrome. The term bulimia was introduced by Russell to refer to a variant of anorexia nervosa that is possibly more sinister and could have poorer outcome. Russell’s description was based on the observation that nearly half of his anorexic population exhibited symptoms of binge eating following periods of self-starvation (Russell 1979).

Binge eating was initially considered to be synonymous with bulimia. Binge eating was found to be a fairly common behaviour which was not necessarily interpreted as evidence of pathology (Palmer 1983). The focus on binge eating created discrepancies in research findings, particularly between US and UK studies, where the reported prevalence of bulimia in the community ranged between 1 and 19 per cent (Halmi et al. 1981, Cooper and Fairburn 1983, Pyle et al. 1983, Katzman et al. 1984, Healy et al. 1985, Herzog et al. 1986, Howat and Saxton 1988, King 1989).

Notwithstanding variations in diagnostic practices, and indeed any possible underlying cultural differences, between British and US societies, these relatively high rates of bulimia in normal population studies clearly suggested that bulimia and not anorexia nervosa is the commonest form of eating disorder.

One explanation for the spread of bulimia is that purging and vomiting are seen as perhaps more successful means of controlling weight than is dieting. The individual can engage in normal if not excessive eating and still keep weight within desired limits. Those who have bulimia are often not thin enough to attract attention, and amenorrhoea, a diagnostic feature in anorexia nervosa, is also unusual. These are the features that make the bulimic disorder harder to identify.

Bulimia was also found to be easily mimicked to the extent that it can be considered a socially contagious behaviour. Women’s magazines and the media have been claimed to be responsible for increasing awareness of the existence of bulimic behaviours, which may have helped to spread them. When an advertisement was placed in Cosmopolitan magazine requesting people who use self-induced vomiting as a method of controlling their weight to come forward, 83 per cent of the respondents were considered to have met the criteria for bulimia nervosa. When similar work was done again, using on this occasion a television program, 63 per cent were regarded as having bulimia nervosa. These high rates raised the suspicion that the publicity surrounding these behaviours could be a factor in popularizing them (Cooper and Fair-burn 1982, 1984, Chiodo and Latimer 1983, Lawrence 1984).

Both anorexia and bulimia nervosa were subsumed under ‘eating disorders’—a term that was introduced to acknowledge the full spectrum of eating pathology. This concept has been incorporated in both the American Diagnostic Manual (DSM1V) and the International Classification of Mental and Behavioural Disorders (ICD10). Russell (1985) maintained that the concept of eating disorders implied an interrelated set of disorders with several underlyin...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Tables
• Preface
• Abbreviations
• Chapter 1 The sociocultural model of eating pathology
• Chapter 2 The concept of culture boundedness and eating disorders
• Chapter 3 The emergence of eating disorders in other cultures/societies
• Chapter 4 The other women—immune or vulnerable?
• Chapter 5 Culture: between differences and commonalities
• Bibliography