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The Cultural Implications of Eating Disorders: A Comparative Study Between Argentina and the United States

Megan Goldring, Steven Lopez, Ph.D.

Published on May 26, 2013

Abstract

As a culture consumed with body image and beauty, Argentina is a mecca for eating disorder patients. In fact, Argentina has a higher incidence of anorexia and bulimia than either the United States or Europe, with one in ten Argentines suffering from the illness. These statistics clash with common conceptions of eating disorders and body dismorphia, as many assume that eating disorders are unique to the United States and Europe. Many studies in recent years have addressed this issue and have investigated eating disorder prevalence in non-Western countries. However, little has been done to assess the direct pathways between culture and eating disorders, and how these pathways influence treatment. This study aims to elucidate the specific effect of culture on eating disorders in Argentina and the United States, and to address how these effects guide treatment. Based on 15 interviews, 12 weeks of observation in Argentina and the United States, and a comprehensive review of current literature, this study is an examination of pathology and treatment of eating disorders in these two countries. The study found that Argentina and the United States are more similar than they are different in regards to the pathway between culture, eating disorder development, and subsequent treatment.

Introduction

Eating disorders have historically been labeled as culture-bound syndromes resulting from the internalization of an unhealthily thin body-image ideal represented and idolized in western society [1, 2, 3]. According to Barlow and Durand, "eating disorders are unique among psychiatric disorders in the degree to which social and cultural factors influence their epidemiology" [4]. Proponents of this model cite the high levels of both anorexia and bulimia nervosa in western culture, as well as the high prevalence rates among gymnasts, models, and dancers [5]. This makes sense, as patients suffering from the disorders discuss dissatisfaction with weight, fears of becoming fat, and a perfectionistic propensity to be thin. At the same time, it is imperative to remember that eating disorders are multifaceted and are not the result of one variable, even culture. Individual environments and genetic factors may also play a role in their development [5, 6]. However, considering the degree of influence that culture has on eating disorders, we not only need to understand that culture plays a role in the development of anorexia and bulimia nervosa, but also how culture impacts them. Only when clinicians have a clear understanding of the specific pathology behind these disorders can they effectively move toward proper treatment and prevention. Some authors have proposed theoretical models that explain the direct ways in which culture influences eating disorders.

Charlotte M. Markey attempts to elucidate the pathways between culture and eating disorders in her Tripartite Model. She developed three routes from culture to eating disorders, including eating behaviors, body image ideals, and perceptions of health, as shown in Figure 1. Her model explains that culture affects eating behaviors by determining acceptable quantities of food intake, admissible foods to eat, and exposure to certain foods. In the second pathway, culture establishes the parameters of acceptable body types, reinforces 'attractive' images, and creates an environment in which peers pressure each other to have a certain weight. Finally, culture establishes perceptions of health and determine the diagnostic criteria for healthy weight, healthy psyche, and healthy dietary practices [7]. These three pathways were integral in generating specific questions used in this study that were then directed at practitioners in Argentina and the United States. Questions were based on Markey's Tripartite Model and attempted to unravel, more specifically in these two countries, the ways in which culture leads to the development of eating disorders. Once these pathways were broken down within each cultural context, we could then analyze the influence of culture on treatment techniques.

Figure 1: Charlotte M. Markey's Tripartite Model

Based on Markey's Tripartite Model and the theories of Melanie A. Katzman and Susan Haworth-Hoeppner [8-12], this study looks deeper into the pathways between culture and eating disorders. A revised model has thus been generated, which is more specific than the original Tripartite Model and is shown in Figure 2.

Figure 2: Revised Model Based on this Study

Materials and Methods

The results of this study are the result of intensive interviews conducted in treatment centers in the Los Angeles, California and Buenos Aires, Argentina. Ten interviews were conducted at the Monte Nido Treatment Center for Eating Disorders in Los Angeles, and seven interviews were completed at ALUBA (Asociacion de Lucha contra Bulimia y Anorexia) in Buenos Aires. The questions asked to practitioners in these interviews addressed the theoretical issues discussed above. First, familial issues were discussed and the following questions were asked:

1. What role does the family play in the development of anorexia and bulimia nervosa?

a. Can you give me specific examples of how the family plays this role in the patients you see?

b. In your clinical work, to what extent do you address family issues? How do you address them? Can you give me some specific examples of doing so?

2. How do daughters develop their eating habits?

a. If the family teaches these disordered eating behaviors, how do you propose to decrease the onset of anorexia and bulimia nervosa if the behaviors are learned habits?

Next, questions were asked pertaining to body image and gender roles:

1. What is the role of women in this culture?

a. How or why is gender important in eating disorders?

b. How much do thinness and fashion come into the discussion when talking to eating disordered patients? How much do the disorders relate to society's reinforcement of a thin body ideal?

2. Do many of your patients discuss fears of becoming overweight? Is fatness their main concern and reason for restricting food?

a. If not, what are some common reasons patients restrict their eating?

And finally, questions regarding treatment were asked:

1. In diagnosing someone with anorexia nervosa, what are the criteria you keep in mind? What are the symptoms they display?

a. What about for bulimia?

2. What are some of the most important treatment techniques that you use in this clinic?

a. Can you give me some examples of effective treatment?

Three therapists and two nurses in Los Angeles completed the interviews while two nutritionists, three therapists, and two clinical directors completed the interviews in Buenos Aires. In addition to these interviews, six weeks were spent (by first author, M.G.) volunteering at the Monte Nido Treatment Center for Eating Disorders and 5 weeks volunteering at ALUBA in order to observe important aspects of treatment that are discussed later in the paper.

Results and Discussion

The Role of the Family

First and foremost, it is important to note that Argentina is often called the "Paris of Latin America" and is culturally comparable to the United States. These cultural similarities can be seen in the role that the family plays in everyday life. Thus, the findings regarding the role of the family in regards to eating disorders resemble each other more than they diverge. When discussing the development of the disorders, both treatment teams discuss the role of the families in the establishment of food rules, rituals, and beliefs. Therapist Candelaria Escalante of Argentina said, "the family is the primary educator and all families have a culture that determines respective behaviors of eating disorders" and went on to say how some families worship the body. Similarly, some families use food in celebration, while others restrict and control food. This quote is almost identical to that of therapist Julia Szpakiewicz of the United States who said, "the family plays a primary role in things such as food rules, food rituals, and food habits." Both of these therapists cite the role of the family in the development of food relationships. Like Markey discussed in her Tripartite Model, the family teaches primary food behaviors.

The respective teams also discuss similar behaviors and attitudes exhibited by their clients. Many times, therapists work with clients who express "secondary gain" from their eating disorder. By this, they mean that clients gain more from their eating disorder than simple weight loss such as attention from the family, perceived control over family members, or the "identified patient" role within the family. On a superficial level, patients discuss fashion, models, and image, but both treatment teams stress the superficiality of this complaint and strive to find deeper issues that lead to the onset of eating disorders. Because of this, both treatment centers take on a holistic approach that encompasses familial issues, pressure from society, childhood problems, relationship malfunctions, emotional distress, and other feelings of anxiety or discomfort. Both treatments also discuss the multifaceted nature of eating disorders, and the belief that eating disorders have genetic causes as well as environmental and cultural origins.

Despite the striking similarities in the discussion of the family, the respective treatment teams also diverge in important ways. Perhaps most striking is the logistical and geographic factor that comes into play in each of these countries. Because most people in Argentina live in urban areas and the country has high population density, patients have easy access to treatment centers. Most patients already live in Buenos Aires and thus do not need to move far away to receive treatment from ALUBA. Moreover, the transition from residential care to day care generates only a slight change, as the client is able to reside in the same area they live, receive treatment, and transition to day treatment. Alternately, Monte Nido Treatment Center in the United States admits young female patients from all over the country. The treatment team needs to be aware of many treatment centers over a larger geographical area when they look into step-down treatment for a client. How does this affect families and treatment? In the United States, girls travel thousands of miles and therefore their families may not be able to visit them on a regular basis if at all. The family calls for phone sessions or perhaps attends family weekend once a month but are often physically unable to provide hands-on aid in recovery. Alternatively, ALUBA does not need to take geographical distance into account when creating their program. For this reason, ALUBA utilizes family members multiple times per week. They involve the family in the treatment process, and the team consistently encourages parents to visit because travel costs are cheap with public transportation and parents do not need to negotiate time-off from work. On the other hand, clients in the United States experience treatment that is often times geographically removed from their families.

This difference poses an important question: do girls recover better when their families are heavily involved, or do clients benefit from experiencing physical isolation from the family that possibly facilitated the development of their disorder? It is impossible to compare the recovery results from Monte Nido Treatment Center and ALUBA due to the vast differences in treatment that would present confounding variables. However, it is interesting to note this difference and realize that varying levels of family involvement in treatment might either help or harm the recovery process, which may be a possible matter for future studies to investigate.

In regards to treatment philosophy, the two countries' systems differ in one substantial way: the attitudes of parental involvement during the treatment process. In Argentina, fathers often times believe eating disorders "will pass" and are "concerns of teenagers and are a part of the teenage angst." Fathers sometimes hinder recover by denying that their daughters need treatment. Therefore, mothers typically present the primary source of familial support for their daughters in treatment. While the team encourages the fathers to aid in recovery, they are often reluctant. The therapists and doctors in the United States discussed no such problem. The other attitudinal difference is the relationship between mothers and daughters. Argentina specialists cite numerous examples of mothers competing with daughters. This is also a problem in the United States but is certainly not the largest factor that goes into the development of an eating disorder.

This reluctance and competition may also be due to the level of involvement that differs within the two countries. The simplest way to compare the difference of family involvement is to consider physical involvement vs. spiritual involvement. At ALUBA in Argentina, the families immerse themselves in the treatment of their daughters and visit the center on a regular basis. Part of this is due to the geographical aspect discussed above. While family members do not receive any actual therapy with their daughters, they are involved in meal plans and visit their daughters often. Regardless of age, Argentine treatment reflects the close-nit realities of family life and therefore bases treatment on heavy family involvement. The number of family volunteers reflects this entangled relationship between family and recovery. Mothers whose daughters have been out of treatment for years continue to visit the center to help the new patients and families. This happens partially because the center does not have enough funding to pay for abundant staff but also speaks to the physical involvement of the family in Argentina.

Alternately, the Monte Nido Treatment Center monitors interactions with clients and limits the control of the family in treatment. Parents receive direct therapy from the therapists and engage in group therapy sessions. They learn about the treatment plan and participate in phone sessions and family weekend, but they are not allowed at the center on a regular basis to monitor treatment. While the American model involves parents, provides information, and utilizes them in recovery, it does not mandate family inclusion. While this Maudsley method certainly utilizes family in a significant way, it still contrasts from the Argentina model in that Argentine doctors, therapists, and nutritionists work with clients as much as parents.

This important difference arose when clinicians were asked if an anorexic daughter could heal even if her anorexic mother did not. In Argentina, Dr. Bello said that a daughter could absolutely not recover without the recovery of her family and the support of her mother. In the United States, many therapists decided that it is possible for an anorexic daughter to recover without the help or recovery of her parents and family. Even though American therapists stress the importance of the relationship with the family and the internal feelings that the client expresses about familial issues, the family does not need to be physically present in order to heal the relationship with the family. Therapists educate about communication, utilize empty chair technique, and reveal the spiritual connection the daughter has with her mother. In Argentina, the treatment requires the physical presence of the family and on-cite interaction and healing. While the inner issues are also discussed, Argentine treatment also requires the physical presence of the family.

The Body Image Ideal

The aesthetic values represented, taught, and ingrained in Argentinian culture mirror the thin ideal of American culture. Walking down the streets of Buenos Aires, women see multiple ads displaying skinny models on billboards and advertisements urging them to lose weight and join gyms. A common social interaction between two women on the street involves comments such as "Que flaca!" or "Que linda," meaning "how skinny" or "how pretty" you are. Perhaps most startling is the percentage of women who undergo plastic surgery: Argentina is ranked 11th in the world on the International Society of Aesthetic Surgery scale [13]. This number does not surprise most locals, as the public health care plan includes plastic surgery. While the cultural climate of America comprises unrealistically thin models and objectified female actresses, 35.7% of Americans are obese [14]. Nutritionist Senanes from Argentina declared that Argentina does not have this problem, and in fact most women are either of normal weight or underweight. While this may seem ironic considering Argentina is known as the "land of beef," doctors explain that women simply do not eat instead of exhibiting orthorexia or limited food intake. Since supermarkets do not sell low carbohydrate or low calorie foods, women avoid certain foods altogether and orthorexia is more difficult to maintain.

Both treatment teams use the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV for diagnostic criteria [15]. We were specifically interested in the fat phobic criterion considering the findings of Dr. Sing Lee in Hong Kong. The specialists in Argentina affirmed that fat phobia is a large factor to both anorexia and bulimia nervosa and is thus an acceptable measure of diagnosis. Monte Nido Treatment Center in the United States similarly reports fat phobia as a common concern among clients. Patients in both countries exhibit body distortion and an extreme desire for thinness. Thus, the body image ideal is a significant and important diagnostic criterion in both countries.

Despite its prevalence, both teams also emphasized the superficiality and danger of assuming that fat phobia contributes unilaterally to eating disorders. The media and models cannot be blamed as the sole contributing factor to eating disorder development. After all, almost every woman in both of these cultures is exposed to idealization of thin body images, but not all develop eating disorders. Both treatment teams stress the "loaded gun" theory. According to the loaded gun theory as described by Carolyn Costin, the Executive Director of the Monte Nido Treatment Center for Eating Disorders, a young woman who has all of the genetic predispositions to developing an eating disorder (such as perfectionism, controlling personality, or goal oriented) is the loaded gun whose trigger is pulled when living in certain environments. Although they do not use the same verbiage, the specialists in Argentina similarly cited family problems, peer pressure, and a traumatic event in life as the factors that push a girl with certain genetic predispositions into an eating disorder.

However, when discussing the gendered problem of anorexia and bulimia, both teams blamed the media and culture. When asked why women are afflicted more than men, nutritionist and professor Carina Ringel of Argentina stated that women receive pressure from society to be thin. Girls look to pop culture to find role models and find that they must use extreme measures to achieve the same aesthetic appearance. Similarly, Keesha Broome of the United States said that women as a whole are under more pressure to be thin, beautiful, and successful; women's success is often times based on their beauty. The body becomes a focal point of identity for women in both cultures, and they thus try to manipulate their bodies in order to achieve perceived perfection and happiness. While the internalization of the thin body ideal is not the sole contributing factor to the development of eating disorders, it might explain the disproportionate number of women who develop the disorder.

Melanie A. Katzman proposed that the role of women in culture contributes to the development of eating disorders. Importantly, the role of women in Argentina parallels that of the American woman. Women work, cook, bear children, and expect equal rights to men. Perhaps the reason these women develop eating disorders is to cope with the demands of such a multi-faceted lifestyle. Women are expected to maintain an unrealistic appearance, thrive in their careers, and also bear children. With so many competing pressures, women manipulate food as a coping mechanism. This may be a gross generalization of the many factors that go into the development of eating disorders, but experts in both countries cited women's role in society as being an important topic of discussion at their treatment centers.

One aspect of the development of eating disorders that was stressed in Argentina, but not in the United States, is the reluctance to mature. All of the nutritionists, therapists, and doctors in Argentina discussed adolescents' fears of maturity and responsibility. Calendaria Escandelaria of Argentina said, "A person stops eating because they have a lot of fears of food. In reality, these patients have a fear of getting older, confronting their lives, responsibility, and failing." The other specialists cited a similar problem. While this aspect of eating disorders is certainly accounted for in American treatment, it is not the most significant factor discussed by therapists. Instead, many talked about control issues, lack of communication, and trauma. Note that these conclusions are summarized and do not encompass the multi-factorial nature of eating disorders. However, it is significant to take note of the overall influences that contribute to the disorders—with Argentine specialists citing a fear of maturity and American specialists citing control issues. Because of these differences in cultural factors, the two treatment teams address different issues in therapy.

Treatment

Some authors pose concerns about using westernized treatment approaches in non-western countries [12]. This is legitimate for studies in Hong Kong and Singapore, where certain diagnostic criteria are not met in patients abroad. [11]. In a country where fat phobia presents no major concern, the DSM IV diagnostic criteria of fat phobia would prevent many women suffering from anorexia and bulimia nervosa from receiving proper treatment in these countries. However, because the cultural climate of Argentina resembles western culture so closely, this concern does not seem to raise major complications. When nutritionists, therapists, and doctors discuss the development of eating disorders in relation to culture, they speak about a culture comparable to westernized society. Fashion, media, television, advertisements, and aesthetic values are similar—albeit not identical—to the overall culture of western society. In regards to treatment techniques, Argentina utilized a westernized model since most philosophies regarding eating disorders were created within the western world and thus encompass the western societal context [16]. Despite the legitimate concerns that this question raises in non-western societies, Argentina does not seem to be afflicted.

Both ALUBA and the Monte Nido Treatment Center utilize the DSM-IV for diagnosis. The Argentinian center also uses CIE 10 (International Classification of Illness), which has comparable diagnostic criterion. Even though both treatment teams utilize these standards of diagnosis, the Argentine team strictly follows the manuals. ALUBA only admits girls who fall under the diagnostic criteria for anorexia and bulimia nervosa. Monte Nido Treatment Center, on the other hand, admits girls based on their behaviors and psychological condition. This difference may be due to methods of payment. Since ALUBA is a public treatment center, the state wants to make sure patients fall under criteria before they dole out money to clients. In America, treatment is private and generally paid for by private insurance companies. These insurance companies are only willing to pay for girls who fall under criteria, but treatment centers would admit a cash-pay client with an Eating Disorder Not Otherwise Specified (EDNOS) diagnosis. Whatever the reason for this difference, the American treatment center focuses more on eating disordered behavior and thoughts rather than simply Body Mass Index (BMI) or Eating Attitudes Test (EAT) scores. Both centers emphasize the severity of EDNOS and the dangers of eating disorder behaviors, even when girls do not fall under diagnostic criteria. But the public Argentine center, unfortunately, does not have the flexibility to admit such girls. Despite American treatment centers' ability to accept cash pay and therefore help clients without criteria, treatment is too expensive for most women to afford. In other words, the only women able to stay in treatment once they do not fall under criteria (i.e. return to menses) are of the upper class.

This logistical difference comes into play with treatment philosophy as well. Since Argentina operates under public health care, treatment centers base their recovery programs on extended periods of residential stay. Dr. Bello of ALUBA stated that girls will even stay in residential treatment for four years if needed. Whether through private insurance, public insurance, or donations from the center, clients receive the resources they need until fully recovered. Contrastingly, treatment centers such as Monte Nido in the United States express concern about the length of time that clients stay in treatment. Many health care specialists discuss insurance care companies' reluctance to cover anorexia or bulimia nervosa for extended periods of time. Most of this comes into play when clients return to menses, reach a body fat percentage over 85% of normal, or abstain from binging and purging behaviors. Because of this, coverage only lasts a few months (length of time varies from client to client). For this reason, American treatment centers focus on giving clients the tools they need to recover outside of treatment and healing patients as much as possible within a short time period. On the other hand, Argentinian treatment keeps the patients in care until they are fully recovered.

The similarities in overall treatment techniques are astounding. Both teams emphasize the importance of a well-rounded and fully educated staff. As Lyn Goldring of the United States says, "it takes a village of people to heal one person with an eating disorder." According to treatment philosophy in both countries, treatment should include specialists in psychiatry, therapy, and nutrition, as well as any other doctors needed for gynecology, dentistry, or addiction. This philosophy of treatment speaks to the multi-causal nature of eating disorders. The treatment team must be specialized and interdisciplinary for proper recovery to occur.

They also both discuss the slow nature of recovery and weight gain. Weight gain must occur over a substantial period of time so that the client's body can adjust to the weight. Slow weight gain is also important for the client's psyche, as she must adapt to her new body and not be overwhelmed by rapid weight gain. Despite the slow rate of weight gain (about 2-3 pounds per week—a healthy amount), it is important to recognize that weight gain must occur on a regimented schedule. Clients are not allowed to skip meals and must participate in eating activities. Staff undergoes constant struggles with clients about the food they must eat and the menus they must follow. This may seem obvious, but both countries' treatment centers discussed the importance of staying on a strict meal plan that leads to weight gain and eventually weight maintenance once the patient has reached a healthy BMI.

Other similarities are the level of recreation and activity that are included in treatment. Every doctor, nutritionist, therapist, or psychologist in both countries stress overall health rather than simply weight gain. At the Monte Nido Treatment Center, clients take yoga classes, go on walks, and do circuit training even though many clients usually take such activities to an extreme. The overall goal is to be active, healthy, and balanced between food intake and exercise. Similarly, ALUBA holds yoga classes and recreational activities. Both teams stress that the clients must heal their relationship with food in order to recover. Neither center informs the clients of their weight nor focuses on strict caloric intake. Staff concern is to heal the whole person and not simply the body.

Perhaps the most striking similarity between the two treatment teams is their philosophy about recovery. Carolyn Costin and the Monte Nido Treatment Center were made famous by the philosophy that full recovery from eating disorders is attainable. The center hires recovered women and stresses the fact that women can live a full, healthy, and normal life after an eating disorder. Although this philosophy is not used everywhere in the United States, it is an important aspect of treatment at Monte Nido. ALUBA, and specialists in other Argentine treatment centers, similarly believe that full recovery is possible. In fact, Dr. Bello of ALUBA said that the clinic would help a woman until she is fully recovered. She even claimed that the center has never had a relapse as girls will stay in treatment for up to four years until they have improved their behaviors. While this statistic might be an exaggeration, it reflects the philosophy that recovery is possible.

Based on the idea that women can and do recover from eating disorders, both treatment centers utilize recovered patients to help current clients. However, the ways in which they use these recovered women is different. The climate of the Monte Nido Treatment Center is characterized by staff leading by example and understanding client's core issues. Staff also form healthy relationships with clients, who can then translate these relationships into "the real world." Despite the warm relationship that staff fosters with clients, there is still a clear distinction between staff and client. The relationship remains professional, as therapists do not provide private contact information during a woman's stay at the center. ALUBA in Argentina uses the same philosophy about recovered women's ability to sympathize, but they move it beyond the professional relationship and into the personal realm. In Argentina, recovered patients often work on a volunteer basis at the treatment centers. Former patients of ALUBA return on a regular basis to talk with current patients. Mothers with recovered daughters help mothers whose daughters are still suffering. None of these women are necessarily trained in therapy or treatment, but they approach patients with sympathy and personal experience. While the approach in Argentina is much less professional—ALUBA does not specifically employ recovered staff trained in psychology—the philosophy equates to that of the Monte Nido Treatment Center. Recovered women form empathetic relationships with struggling clients that help patients heal from their eating disorder behaviors.

Conclusion

After comparing and contrasting the development and treatment of anorexia and bulimia nervosa in Argentina and the United States, it is clear that the countries are more similar than they are different in regards to the three dimensions discussed above. The family acts as a mediator of determining eating behaviors, standard body sizes, and perception of health in both countries. In terms of treatment, the family is also heavily involved in the recovery process in both countries. In regards to the body image concern, both treatment philosophies looked "beyond the body image," as Katzman would say, and emphasized deeper psychological issues during treatment. Finally, effective treatment spans the geographical difference of these countries, as both utilize similar techniques when treating eating disorders. More research needs to be done to determine why and how these treatment techniques are effective, as these answers could inform clinicians which methods work better.

References

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14. Ogden, Cynthia L., Ph.D, Margarot D. Carroll, M.S.P.H, Brian K. Kit, M.D., and Katherine M. Flagel, Ph.D. "Prevalence of Obesity in the United States: 2009-2010." US Department of Health and Human Services (2010): n. pag. Print.

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16. Gordon, Richard A. Eating disorders. Anatomy of a social epidemic (2nd ed.), Blackwell Publishers, 2000.

Non-Cited References

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Birch, Leann L., and Jeniffer O. Fisher. "Development of Eating Behaviors Among Children and Adolescents." Pediatrics: Official Journal of the American Academy of Pediatrics (1998): 539-49. Print.

"Body Shape and Eating Disorders in a Sample of Students in the Basque Country: A Pilot Study." Colegio Oficial De Psicologos (n.d.): n. pag. Print.

Favaro, Angela, Lorenza Caregaro, Elena Tenconi, Romina Bosello, and Paolo Santonastaso. "Time Trends in Age at Onset of Anorexia Nervosa and Bulimia Nervosa." The Journal of Clinical Psychiatry 70.12 (2009): 1715-721. Print.

Meehan, Oscar L., and Jorge Insua. "Psychiatric Training in Argentina's Two Major Cities." The Psychiatrist (n.d.): n. pag. Print.

Wildes, Jeniffer E., Robert E. Emery, and Anne E. Simons. "The Roles of Ethnicity and Culture in the Development of Eating Disturbance and Body Dissatisfaction: A Meta-Analytic Review." Clinical Psychology Review (1998): n. pag. Print

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