A Comparative Approach to Explanations of Anorexia and Bulimia Nervosa

2024 Spring/Summer Online Research Symposium Winner’s Paper – Sophia C

Each season, we select insightful, well-researched and original research projects completed as part of our Online Research Programme to present in our Symposium. Our Spring/Summer 2024 Symposium winner is Sophia C, who presented research on eating disorders.

Her paper can be read below. Access her presentation slides here.

Introduction to Eating Disorders 

A modern illness, eating disorders have been on the rise since the late 20th century. Sociocultural and environmental changes brought by rapid modernization and technology have ingrained the pursuit of beauty, defined by thinness, in society. However, while eating disorder symptoms, like dieting and the pursuit of thinness, are relatively common in society, the prevalence of pathological eating disorders is comparatively low to that of disordered eating habits, with only a select few who actually develop a disorder (Bushnell et al., 2009). 

According to the National Institute of Mental Health (NIH), eating disorders (ED) are mental illnesses in which the patient displays severe disturbances and peculiarities in their eating habits as well as distorted thoughts and emotions. While the disorder is presented with distorted eating habits, ED patients also fight the internal battle of an unhealthy preoccupation with food, body weight, and body image. There are multiple variants of EDs, but this paper will focus on anorexia nervosa (AN) and bulimia nervosa (BN). 

The NIH characterizes anorexia nervosa (AN) with extreme restrictive eating, akin to starvation. Primary symptoms of AN include extreme thinness, a distorted body image, and an intense fear of weight gain coupled with the relentless pursuit of thinness. Physical symptoms like osteoporosis, anemia, brittle hair and nails, constipation, low blood pressure, multiorgan damage or failure, and more manifest over time as a result of extreme and prolonged malnourishment. The mortality rate for AN is relatively high as these health concerns increase the risk of death by malnourishment or suicide. 

The other type of ED is bulimia nervosa (BN). As Mond (2013) explains, BN is characterized by recurrent episodes of binge eating and extreme weight-control behaviors, at least twice a week for three months according to the DSM-V. Bulimics experience the cyclic struggle of binge eating followed by compensatory behaviors. Binge eating refers to the consumption of objectively large amounts of food in a short period of time, while weight-control behaviors include self-induced vomiting, misuse of laxatives or diuretics, extreme dietary restriction, and excessive exercise. BN is also extremely harmful to one’s physical health; inflamed throat, damage to the stomach lining from stomach acid, and the erosion of tooth enamel are common physical signs of BN. Besides physical symptoms, bulimics are also plagued with concerns about weight and body shape, suffering from distorted body image similar to those with AN. However, BN is less identifiable from physical appearance than AN as bulimics tend to fluctuate in a normal weight range. 

Prevalence of Eating Disorders

Eating disorders affect. 3-10% of people worldwide, and patients mostly fit the demographic of young, adolescent to early-adulthood females, with 15 to 24 years old being the most vulnerable age group (Makino et al., 2004; Polivy and Herman, 2002). According to Miller and Pumariega (2005), eating disorders have been more prevalent in Western cultures and countries. However, illnesses are reportedly on the rise also among people of color as recently more studies have been conducted on minority populations as well. This indicates that the previous lack of research on EDs in minority groups may have contributed to statistical discrepancies and misunderstandings (Miller and Pumariega, 2005).

Comparing the prevalence of EDs between males and females, EDs significantly affect females more than males, with females outnumbering males 10 to 1 (Hsu, 1996). Furthermore, Hsu reports that the disorder is more prevalent in Western cultures in terms of pathology and diagnosis. 0.5% of women suffer from AN and 2% of women suffer from BN in Western cultures. Also, no evidence points to an epidemic of eating disorders, though global incidence rates have been on the rise. 

Specifically in AN, a meta-analysis on female AN incidence rates conducted by Martínez-González and colleagues (2020) reveals approximately 0.5 to 318.9 cases of AN per 100,000 women. The researchers further investigated that depending on ICD or DSM classifications and various versions, there is great variability in the incidence rates of AN (Martínez-González et al., 2020). These variations are most probably caused by differing criteria, like weight requirements; stricter criteria may exclude a relevant population of AN patients. 

From studying BN, Bushnell and colleagues (2009) report that the overall lifetime prevalence of BN is 1.0%. The overall lifetime prevalence rate for men is 0-2% and 1-9% for women. Reported to have the onset of 18-44 years old in women, most patients experience their first symptom between the ages of 14 and 25, in concurrence with the higher lifetime prevalence among younger women. Retrospective studies support this notion as most bulimic patients report their eating disorder beginning during adolescence. In a study done by Gross and Rosen (1988) between high school girls and boys in Northeast America, 9.6% of girls and 1.2% of boys had BN of both subtypes, purging and nonpurging. 

Comparing the prevalence rates of AN and BN, bulimic patients outnumber anorexic patients 2 to 1 (Polivy and Herman, 2002). BN patients, though harder to identify with physical appearance, are more likely to seek treatment whereas AN patients more often report indifference toward their disorder and mental state. 

Fairburn and colleague’s (1999) study reports 14.6 (±3.0 years) and 15.5 (±3.9 years) being the average ages of onset for AN and BN, respectively. As explained by Martínez-González and colleagues, adolescent and teenage girls, who in this stage of life are going through life-altering physical, hormonal, and emotional changes, are especially vulnerable to unrealistic and unachievable beauty standards normalized by the media. The researchers claim that the search for the “perfect body” and “perfect appearance” causes an imbalance and primes the pursuit of perfection, or thinness, leading to restrictive diets and disturbances in eating behaviors.

However, not everyone who exhibits disordered eating habits develops an eating disorder. Despite incidence rates that suggest the rarity of eating disorders in the general population, syndrome symptoms are comparatively high and more common. Among women ages 18 to 44, 22.5% report recurrent binge-eating episodes, and at least 5% of diet or use diuretics (Bushnell et al., 2009). Thus, it is clear that many are affected by the symptoms of AN and BN, though few go on to develop an eating disorder. The next question posed is what mediating factors that increase the vulnerability of eating disorder patients. 

Approaches

Social Explanation

When analyzing the explanations of EDs, it is important to consider the relationship between the social environment and EDs. The media, both its content and users, as well as the globalization of Western media, are important factors in ED discussion. 

Media   

Content 

The media capitalizes on the image of thinness. By emphasizing the desire for thinness, the media transmits thinness-oriented norms associated with self-control and success (Garfinkel and Garner, 1982). A study done by Tan (1997) reveals that television beauty advertisements cultivate greater estimates of the importance of sex appeal and beauty in adolescent girls than exposure to neutral ads. The author concluded that unrealistic representation of feminine beauty in mass media may push young adolescent girls and media consumers to pursue thinness to a disordered level. 

Harrison and Cantor (1997) conducted a study to investigate the relationship between mass media consumption and eating disorder symptomatology, specifically body dissatisfaction and drive for thinness. They found that reading fitness magazines and viewing TV shows that promote thinness positively both correlate with anorexic behavior. The researchers thus concluded that the content of media reinforces norms that support eating disorder behavior. Just as the consumption of thinness-depicting and thinness-promoting media can fuel disordered eating habits, individuals with EDs are also more likely to consume fitness and dieting media than individuals without EDs. 

Users 

Users of the media may also use their platform to promote eating disorder behavior. Csipke and Horne (2007) explain that pro-anorexia, or pro-ana, communities are found throughout different media platforms and websites to promote ED behavior. On these platforms, anorexia is viewed as a lifestyle choice, and those who embrace the disorder are praised for their determination, self-control, and self-discipline as a “successful” anorexic. The content of websites usually includes calorie charts, exercise advice, and BMI calculators. Advice is also given on how to hide EDs as well as tips on different ways to lose weight, restrict eating, and more. On some of the more extreme pro-ana websites, one can find doctrines referred to as “ana psalms” or “ana creeds” which outline the rules and guidelines to live an anorexic lifestyle. These doctrines include rules about eating as well as affirmations that beauty is judged by thinness. 

Csipke and Horne found that many individuals go on these sites to sustain or incite disordered eating, as participants admitted to visiting these sites to maintain their disorder and to steer away from recovery. Moreover, a trend of worsening body image was found after individuals visited these sites. However, Csipke and Horne note that these websites may also provide emotional support for those struggling with an ED as some websites offer chatrooms for struggling patients to connect with one another. Still, the content presented on these websites is problematic in promoting EDs and glorifying the anorexic lifestyle. 

Culture 

Exposure to Western Media 

While the demographic of ED patients used to be mainly White adolescent girls, more and more people around the world are being diagnosed with an ED. A plausible explanation for this trend is the effect of Western media on different cultures. The definitions of beauty, health, and success are different under different cultural contexts. However, with the influence of Western media, these cultural definitions may be altered. 

In the 1990s, Becker and colleagues investigated the effects of the introduction of television in Fijian society, specifically the prevalence of EDs. Through the cross-sectional study, the researchers found strong, positive correlations between television exposure time and Eating-Attitudes-Test (EAT-26) scores and also with greater instances of self-induced vomiting to lose weight on the other side. Specifically, study results in 1995 revealed that 12.7% of the subjects had EAT-26 scores higher than 20, whereas the percentage rose to 29.2% in 1998. Within the 1998 sample, EAT-26 scores higher than 20 were significantly associated with dieting and self-induced vomiting, which both are symptoms of EDs. Upon exposure to Western media through television, participants also reported an increased appeal for dieting, weight loss, and Western aesthetic ideals (Becker et al., 2018). 

The significance of the Fiji study by Becker and colleagues is that Western ideals of beauty disparate from traditional Fijian beauty and cultural standards. Exposure to media, specifically Western media, reflects a disruption of the traditional preference for a robust and fuller body and the traditional disinterest in dieting and changing the body (Becker et al., 2018). Consequently, it may be interesting to further investigate the manifestation of ED symptoms under different cultural contexts, and how these cultural contexts may change because of modernization and westernization. 

Western Ideal of Thinness and Acculturation 

The Western ideal of thinness holds prominent influence over its people. Miller and Pumariega (2005) found that Western culture prioritizes thinness as White students hold less favorable attitudes about their own body image and have a stricter criteria for thinness compared to African American students. They also found that Euro-American males are more attracted to thinner silhouettes. Another finding is that Black female athletes reported less body dissatisfaction than White athletes. Overall, the trend infers greater body satisfaction in African cultures compared to White cultures. Relatably, in cultures where plumpness is considered attractive EDs are less commonly found, just as in cultures that overvalue thinness weight phobia is more prevalent. 

While clear cultural differences in the standard of beauty may explain why EDs are more prominent in Western cultures and affect the White demographic more, growing rates of EDs in minority populations hint at the effects of acculturation. Acculturation refers to the assimilation of a dominant culture, usually referring to the White, Western culture (Miller and Pumariega, 2005). As Western cultures become more intertwined with other cultures, the influence of Western ideals and standards may change how individuals in different cultures perceive themselves under their traditional context. 

The aforementioned assumption is illustrated by Abrams and colleagues (1993) as they found a significant negative correlation between the desire to be skinny and a strong Black identity. Furthermore, Miller and Pumariega (2005) found a positive correlation between acculturation and EAT-26 scores. With the acculturation of mainstream U.S. culture, traditional cultural beliefs and standards of beauty are eroded and replaced by Western culture, explaining why EDs are becoming more prevalent in other cultures. 

However, the acculturation of Western culture also poses major implications for the self-esteem of minorities. When minorities are exposed to standards and expectations that are different from themselves, consequences of low-esteem may follow. Williamson (1998) explains that modern-day media is comparison-driven. All users are vulnerable to being judged by their appearance, and all people are subjected to the unrealistic expectations outlined by social media, whether that be social, wealth, or beauty expectations. When one fails to meet the unrealistic expectations, they may feel discontent regarding their situation and as a result suffer from low self-esteem. This poses serious implications for minorities consuming Western media. As Williamson (1998) evaluates, with Western culture highlighting the ideal of thinness on models with Anglican features and a Caucasian appearance, women from other cultures, whose physical features contrast starkly with the ideal, suffer even greater blows in their self-image and acceptance of their appearance. While one may argue that protective cultural ideals shield minority women from the harsh, unrealistic Western standard of beauty, it would be foolish to believe that minority women are immune to Western standards of beauty (Williamson, 1998). Thus, it may be notable to further research how acculturation affects minorities’ self-image and how it correlates with EDs. 

Biological Explanation 

Hormonal Differences 

Females outnumber males 10:1 in ED diagnosis (Hsu, 1996). Thus, it is notable to investigate biological and hormonal differences between males and females to understand if there is a biological explanation for the high female prevalence rate for EDs. Culbert and colleagues (2021) published a narrative review studying the biological factors underlying gender-differentiated prevalence rates. They found that prenatal exposure to testosterone, which drives the development of male-typical physical and behavioral characteristics, also known as the masculinization of the brain, works as a protective factor against eating pathology. Prenatal exposure to testosterone contributes to fewer sugar-taste preferences, and lesser binge-eating tendencies and palatable food intakes in males versus females. 

Within-male comparisons reveal that lower levels of testosterone predict higher levels of dysregulated eating habits in boys; males with lower levels of testosterone exhibit higher incidences of binge eating, eating concerns, and feelings of loss of control over eating (Culbert et al., 2021). Moreover, in a rodent study, the removal of testosterone in adult male rodents resulted in increases in sucrose consumption (Zucker, 1969). Consequently, testosterone holds a prominent influence in the eating habits of males.  

However, within-female comparisons reveal that high levels of testosterone have opposite effects in women than in men. Instead of lower testosterone levels, women with higher testosterone levels experience elevated risks to eating pathology (Culbert et al., 2021). For instance, women with polycystic ovarian syndrome (PCOS), a condition associated with higher levels of testosterone, report increased incidences of BN and binge eating disorder (Thannickal et al., 2020). Similarly, when women with BN were given an antiandrogenic oral contraceptive, which reduces testosterone levels, the hormonal change was associated with decreases in appetite and binge-purge symptoms (Naessén et al., 2007). Therefore, these findings suggest that ED risks in women may be heightened due to high testosterone levels, especially in women with BN. 

Culbert and colleagues (2021) further investigated gender differences in neural activation to food-related stimuli. They found that women respond to palatable food stimuli, both visual and taste, with greater activation in brain regions related to executive functioning, inhibitory control, and reward, than men. Additionally, when exposed to food stimuli, men were more able to suppress their desire for food while women were less able to do so, revealing females’ amplified brain sensitivity and responsivity to palatable foods. As a result, women may have increased vulnerability to eating habits like overeating and binge eating, and overall increased predispositions to eating pathology. 

Altered Ghrelin and Leptin Levels

Ghrelin 

According to Fabbri and colleagues (2015), ghrelin is a significant hormone involved in regulating food intake. Called the “hunger hormone,” ghrelin’s main function is to signal hunger. Ghrelin levels are usually high before a meal and fall after food intake. In investigating the relationship between ghrelin levels and body mass index (BMI), Fabbri and researchers found a negative correlation between ghrelin levels and BMI; in other words, obese people have lower levels of ghrelin compared to normal-weight individuals. Another notable activity of ghrelin is that the decrease in ghrelin after a meal was lower in obese individuals compared to control groups, meaning that the feeling of hunger may be maintained in people with obesity even after eating, thereby reinforcing obesity eating habits. 

However, in studying ghrelin levels in individuals with AN, studies show that AN patients have higher levels of ghrelin compared to normal-weight individuals. This abnormality may be a result of prolonged starvation in AN, but not as a pre-existing condition. Moreover, these ghrelin levels were normalized after patients regained their normal weight, suggesting that ghrelin levels may be affected by weight and nutritional status. Higher observed levels of ghrelin are also present in BN patients, especially those who participate in fasting and purging (Fabbri et al., 2015). 

Thus, it is clear that altered levels of ghrelin in AN and BN patients are a result of endocrine system failure due to starvation, malnutrition, and unhealthy eating habits. However, how ghrelin interacts with the psychological impulses for starvation, binge-eating, and purging remains unknown. If ghrelin levels are high in AN and BN patients, then other factors must explain patients’ control to withstand these signals of hunger and reinforce their disordered eating behaviors. 

Leptin 

Leptin, on the other hand, is a satiety hormone that acts as a hunger suppressant signal to the brain. Leptin communicates to our brains that we are full and that we don’t need any more food. Unsurprisingly, ED patients have abnormal leptin levels (Monteleone et al., 2000). 

As Montelelone and colleagues (2000) explain, leptin levels are severely low in anorexic patients, and these levels positively correlate with BMI and body fat content. Leptin levels are affected by a multitude of factors, including body fat, body weight, and eating patterns. Research shows that restrictive food intake and reduced daily caloric intake lead to decreased leptin levels in AN patients, and conversely, leptin levels return to normalcy during AN recovery. Reduced levels of leptin in AN patients explain the increased hunger sensation in anorexics, but it does not explain how anorexics continue their restrictive eating habits despite their lack of homeostasis and hunger satiety. 

Similarly, leptin levels are also significantly decreased in BN patients. Despite bulimics’ large caloric ingestion during binges, purging or the use of laxatives compensate for the overeating and ultimately result in a reduced caloric intake for bulimics. Similar to AN patients, BN patients report diminished satiety responses, explained by their reduced leptin levels. Moreover, their impulse for binge-eating can also be explained by their constant feeling of hunger and insatiety due to low levels of leptin (Monteleone et al., 2000). 

Consequently, in both AN, and BN, patients experience reduced levels of leptin as a result of caloric deficits, low body weight, and eating habits such as starvation and binging-purging. Leptin levels return to normalcy after patients receive treatment and depart from a state of starvation, suggesting that abnormal leptin levels are an effect of EDs rather than a pre-existing cause. 

Personality Explanation

When discussing the genetics of AN or BN, no direct relationships between specific genes and the onset of development of EDs have been found (Shih and Woodside, 2016). However, personality traits and temperament provide evidence for the possible heritability of EDs. Personality traits are 40-50% heritable (Culbert et al., 2015). A study by Fassino and colleagues (2002) reported a positive correlation between the temperament and character of AN patients and their mothers’. Thus, it is significant to investigate personality traits that may be risk or predictive factors of AN and BN. 

Perfectionism  

Perfectionism increases one’s susceptibility to developing AN and relates to a higher duration of the disorder and higher relapse rates (Jacobs et al., 2008). According to Jacobs and researchers, mothers of anorexics have more evident perfectionistic tendencies and an increased drive for thinness compared to normal controls. 

According to Wonderlich and colleagues (2004), perfectionism, obsessiveness, and affective disturbance are also features of bulimic patients. In fact, patients displaying high perfectionistic tendencies reported the highest levels of ED psychopathology. However, perfectionism is noted to increase BN symptoms only in patients with low self-esteem and who are overly critical of their bodies and physical appearance (Culbert et al., 2015). 

The perfectionist tendencies of BN patients resemble that of AN patients. Thus, more research should be done to further investigate other personality differences between anorexics and bulimics to find the differentiating factor between the two disorders. 

Neuroticism and Impulsivity 

In 2015, Culbert and colleagues investigated the individual relationships between neuroticism and impulsivity with AN and BN. Neuroticism is the tendency to experience unpleasant emotions such as anxiety and anger. Culbert and colleagues found that negative emotionality and neuroticism predict ED symptoms like drive for thinness and ED diagnoses. Impulsivity, on the other hand, seems to affect BN patients more than AN as impulsivity relates more to binge eating and purging. Cross-sectional research presents greater levels of impulsivity in BN patients compared to AN patients. 

Interaction of Biological and Social 

According to Jacobs and colleagues (2013), some individuals may have genetic predispositions for impulsive or perfectionistic tendencies that make them more vulnerable to developing an ED. However, personality traits, temperaments, and individual characteristics are not rigid; traits may change with time. As a result, environmental influences, like family dynamics, peer relationships, and more, may influence one’s personality development. Some environments, like ones that promote comparison or competition, may foster personality traits of perfectionism and neuroticism, which then increase one’s susceptibility to developing an ED. Consequently, the interplay between the biological and environmental when discussing the influence of personality traits on ED development is deserving of future research. 

Cognitive Explanation 

Cognitive Deficits

As explained by Lena and colleagues (2004), cognitive deficits may pre-exist in individuals, leading to the development of EDs. The researchers propose that neuropsychological cognitive deficits underlie ED development, causing overt symptoms of disordered eating behavior. In AN, patients present problems with attentional, memory, and visuospatial abilities whereas in BN, patients present deficiencies in problem-solving and visuospatial processing and an impulsive cognitive style. These cognitive deficits are postulated to exist to a degree of severity that ultimately interferes with one’s self-esteem, acceptance of changes in body image during puberty, identity formation, relationships, and personal autonomy. Improper development in these psychosocial areas then prepares a pathway that increases the risk for EDs. 

Research does show brain abnormalities in ED patients that may explain these deficits. Though it is not clear whether or not these brain abnormalities existed before the disorder or are an effect of malnutrition, research shows that few of these abnormalities return to normalcy after refeeding, indicating that maybe some brain abnormalities pre-exist to EDs (Lena et al., 2004). However, further research is needed to better understand this relationship. 

In short, cognitive deficits are a risk factor for ED development as these deficits may cause abnormal developments in psychosocial and developmental processes, especially during the vulnerable stage of adolescence. 

Discussion and Conclusion 

In understanding the complexity behind EDs, it is clear that many perspectives must contribute to the discussion of the development and causes of EDs. This paper covered a few of the many reasons, including some aspects of the social, biological, trait, and cognitive explanations, to contribute to the discussion of ED, specifically AN and BN, development. 

Social 

The social explanation was mainly focused on the influences of media and Western culture on the development of EDs, especially in adolescent girls and minority populations. Studies showed that the media, including television, magazines, and websites, have the potential to invoke EDs as well as encourage disordered eating behavior. Exposure to said content and unachievable beauty aesthetics and standards, coupled with genetic predispositions or vulnerabilities, threaten individuals’ development of EDs. 

Examining the relationship between media and its communication of Western ideals, the Fiji study is an excellent example of how both the media (television) and its content highlighting Western culture and ideals influence the development of EDs (Becker et al., 2018). The study successfully highlights the interplay between media, beauty standards, cultural assimilation, and the development of EDs and disordered eating habits. 

The social perspective, particularly the influence of media and Western culture, provides valuable insight into how modernization and globalization have contributed to the increased prevalence of EDs in other cultures, and it forces psychologists to reexamine the definition of EDs as a “Western disorder” in the age of modernization. 

Biological 

In the biological explanation, I primarily researched hormonal differences between males and females as well as the role of hunger hormones in ED symptomatology as there is insufficient understanding of the genetics behind EDs. Hormonal differences between males and females reveal the different effects of testosterone in males and females; while testosterone has protective abilities against dysregulated eating habits in males, high testosterone levels in females actually induce binge-eating and purging habits. These hormonal differences may explain why EDs disproportionately affect females more than males. 

Furthermore, hunger hormones in ED symptomatology provide valuable insight as to how EDs affect the physical human body but also how EDs are a psychological disorder influenced by distorted psychological and cognitive behavior. Unsurprisingly, ghrelin and leptin levels in AN and BN patients are abnormally high and low, respectively, due to ED patients’ abnormal eating habits. However, high ghrelin levels, which indicate a lack of fullness, and low leptin levels, which indicate hunger, do not explain why ED patients continue to participate in starvation and binge-purging habits. Thus, further research must be conducted to understand the psychology and decision-making process behind disordered eating behaviors, which are clearly not encouraged by physical feelings of fullness and satiety. 

Personality  

The personality explanation acts as an interplay between biological and social perspectives. Studies show that multiple personality traits are present in ED patients and may act as potential “risk factors” for EDs. Traits such as perfectionism and neuroticism predict both AN and BN, but impulsivity is more prevalent in BN patients. The current understanding behind personality now is that some parts of personality and temperament may be genetically predisposed; however, the development of personalities and their fluidity infer environmental influences on traits. Thus, the interplay between genetics and the environment in personality, and whether or not these traits predict ED diagnoses, deserves further research and development. 

Cognitive 

While symptoms of EDs are manifested physically, the behaviors have psychological and cognitive underpinnings. Research finds that pre-existing cognitive deficits, like attentional, memory, visuospatial, and deficiencies in problem-solving, are present in AN and BN patients. Consequently, these cognitive deficits are potential risk factors and predictive factors for the development of EDs. A plausible explanation is that these cognitive deficits increase one’s risk of developing low self-esteem, which in turn increases one’s vulnerability to developing an ED. It is unclear if these cognitive deficits directly contribute to the symptoms and behaviors of EDs. However, the evidence that they pre-exist in ED patients makes it valuable as it may lead to potential prevention measures for EDs.

Future Directions for Research 

A possible direction for future research relates to Miller and Pumariega’s study in 2005 on body dissatisfaction in White and Black Americans. Miller and Pumariega’s overall consensus is that body dissatisfaction was higher amongst White Americans but is rising in minority populations due to acculturation. I hypothesize that there is a positive correlation between the level of cultural assimilation into American society and body dissatisfaction in Black Americans. 

To conduct this research, I would measure the two variables of acculturation and body image. Acculturation will be measured through an identification with the host culture (1 being not at all to 5 being completely) versus identification with native culture (1 being not at all to 5 being completely) (Angelini et al., 2015). Intermarriage with White families would be another distinguishing factor between acculturated and non-acculturated African Americans (Waters and Jiménez, 2005). Body image will be measured with the Body Dissatisfaction Scale (Mutale et al., 2016). The population would target female Black Americans from adolescence to adulthood, from cities all around the United States. 

These characteristics are based on previous research to achieve comparative results. I would gather the sample of participants through volunteer sampling as technology and the media’s algorithm allows us to target specific populations and backgrounds, creating a more representative sample. Then, I would analyze the data to see if body dissatisfaction correlates with a weaker cultural identity. If the results of the study align with my hypothesis, then it can be concluded that the influence of Western ideals and lifestyles on African American culture relate to higher body dissatisfaction and prevalence of EDs, highlighting the potential negative influence of Western media on minority beauty standards. 

Another direction for future research is to examine how EDs are presented under different cultural contexts. Since EDs have long been known to be a Western disorder, I wonder if the prevalence rates in Western nations and low prevalence rates in Asia are due to a misunderstanding of EDs under Eastern or Asian cultural contexts. The target population of this study will be adolescent and young adult women with ED habits, which will be measured with the EAT-26. Distinct cultures will be separated on the basis of different geographical locations; for instance, comparing South Korean women living in South Korea to Americans living in the United States. Next, I will examine the cultural context using the element of way of eating- does the culture emphasize communal eating or do people eat alone more often? Then, I will judge the manifestation of EDs using one ED symptom, that being induced vomiting. I want to examine whether cultural differences lead to different presentations of EDs, even though all participants struggle with a diagnosed ED. If the results show that ED symptoms are manifested differently under different cultural contexts, then it can be inferred that the criteria for ED diagnoses should be re-examined and reevaluated. 

Other directions of future research encompass the following goals: to better understand genetic predispositions for the development of EDs and to identify mediating factors or risk factors that make certain individuals more vulnerable to developing EDs. Answering these questions will advance our understanding of how different explanations interact to explain the development and cause of EDs, specifically AN and BN. 

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