Disordered Eating in Asian Americans: Background and Clinical Implications

Eating disorders are diagnosable mental illnesses as outlined by the American Psychiatric Association’s (2022) Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR), which can originate from disordered eating (DE) behaviors (Neumark-Sztainer et al., 2006). In contrast to a diagnosable eating disorder, DE refers to problematic eating behaviors and attitudes that an individual may experience, such as skipping meals, binge eating, excessive use of diuretics, or even dieting practices (Pereira & Alvarenga, 2007). The critical feature to note is that while these non-normative eating behaviors range in severity and may not meet the strict criteria for a psychiatric disorder as outlined in the DSM-5 TR, they still lead to significant health impairments and distress for the individual (American Psychiatric Association, 2022). 

It is important to note that research on eating disorders (and, by extension, DE research) has traditionally focused on White, European American women (Sun et al., 2023; Wildes et al., 2001). As the population of ethnic minorities in the United States continues to increase, Asian Americans are the second fastest-growing group (U.S. Census Bureau, 2018). As such, it is more relevant than ever for psychological research, assessment, and treatment to incorporate inclusivity and diversity.

Disordered Eating Behaviors in Asian Americans

One population-based study found that the prevalence of unhealthy weight control behaviors among men was higher for Hispanic/Latino American (60.7–68.0%) and Asian American (41.9–56.7%) identifying men compared to Black/African American (24.6-36.9%) and White American men (25.7-34.9%; Simone et al., 2022). The literature also suggests that Asian American adults experience elevated mean scores for DE symptomatology when compared to their White counterparts (Bucchianeri et al., 2016; Rodgers et al., 2016; Uri et al., 2021; Yoon et al., 2023). Asian Americans reported higher mean restriction scores (defined as deliberately consuming less food) compared to White Americans, higher mean scores on body dissatisfaction than non-Asian people of color, and higher mean scores of purging (self-induced vomiting, and abuse of diuretics and laxatives) than any other ethnic group (Uri et al., 2021). 

Among college students identifying as either White Americans, Asian American, or non-Asian people of color (NAPOC), Asian Americans had higher mean scores of purging, muscle building, and cognitive restraint (effort to regulate food intake and its influence on body weight and shape) than White and NAPOC students (Uri et al., 2021). Additionally, Asian Americans scored higher on restriction (Uri et al., 2021) and endorsed more binge eating than White Americans (Lee-Winn et al., 2014).

Another recent study found that after adjusting for sociodemographic variables, DE behaviors were greater in all racial/ethnic minorities compared to non-Hispanic White Americans (Yoon et al., 2023). More specifically, associated symptoms of binge eating were more prevalent for Asian Americans than for non-Hispanic White Americans (Yoon et al., 2023). Associated symptoms of binge eating are defined as “eating much more rapidly than usual, eating until uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because embarrassed by how much you were eating, feeling disgusted with oneself, depressed, or feeling guilty after overeating” (Yoon et al., 2023, p. 6). 

Understanding Disordered Eating Behaviors in Asian Americans

Several concepts have been described in the literature to explain the increased prevalence of DE behaviors in Asian Americans. Using the ecological systems theory (Bronfenbrenner & Morris, 2006) in a sample of Asian and Asian American women, intergenerational family conflict and the value of honoring family through achievement was indirectly associated with restricted eating via thwarted psychological needs (Han, 2020). Here, restricted eating was measured using the 10-item Restrained Eating Subscale of the Dutch Eating Behavior Questionnaire (van Strien et al., 1986). Ecological systems theory is a theoretical framework that suggests that the macrosystem of culture impacts the individual through the impact of culture on the microsystem of family, peers, and school (Bronfenbrenner & Morris, 2006). Therefore, understanding the cultural context of the individual and the impact culture has on micro-level factors is an important consideration in disordered eating treatment and research (Han, 2020).

Asians’ rates of higher DE behaviors may also, in part, be contributed by the concept of acculturation and the related stressors individuals may experience (Aware, n.d.). Acculturation is defined as the process through which individuals from one culture are introduced to a new culture (Berry, 1997). This process is complicated by the choice of individuals to adopt the beliefs, attitudes, and behaviors of the majority culture or maintain their original cultural identity. It is also possible that the prevalence of DE behaviors among Asians in the literature is an underestimation due to the lower rates of mental health service utilization within this group (Chu & Sue, 2011; Gupta et al., 2011).

Clinical Considerations for Disorder Eating Behaviors in Asian Americans

It is important for clinicians to consider and be aware of the clinical presentation of various DE behaviors amongst Asian Americans, as assessment will be relevant to treatment. Asian Americans may endorse different forms of body dissatisfaction related to their height, facial features, or skin tone (Grabe & Hyde, 2006; Frederick et al., 2016). Additionally, it is theorized that Asian Americans may be less likely to report distress or DE symptoms due to cultural differences in the experience of these symptoms and the mental health stigma that surrounds them (Lee-Winn et al., 2014). These factors provide important considerations for the clinical interview portion of the assessment with this population.

Yu and colleagues (2019) provide an integrative framework for practice recommendations when working with the Asian American population. Highlights of these recommendations are presented below:

• Motivational Interviewing techniques can be utilized when encountering resistance to psychological services.
• When shame, guilt, or stigma are present, psychoeducation surrounding the complex nature of DE and eating disorders can be beneficial.
• When doubts surrounding the efficacy of psychotherapy are present, it may be helpful to sperate the individual from the illness and using action-oriented techniques rooted in solution-focused therapy.  
• Conceptualizing the intersectionality of DE behaviors and related factors, such as acculturative stress, can inform treatment.
• When possible, clinicians are encouraged to include family members in aspects of assessment and treatment to address familial and cultural factors contributing to DE.

Conceptualizing DE behaviors among the Asian American population through a lens of cultural competence is crucial to obtain the most appropriate assessment, accurate diagnosis, and effective treatment. This may be accomplished by utilizing the multicultural guidelines promoted by the American Psychological Association (2017), which include cultural humility, utilizing a strengths-based approach, and recognizing one’s biases and beliefs. Ultimately, applying evidence-based treatments through culturally-informed practice will be helpful in tailoring interventions for a population that has traditionally been under-represented in DE literature, therapeutic intervention strategies, and assessment development.