Susceptibility of Singapore Chinese schoolgirls to anorexia nervosa-Part I (Psychological factors, СS Tian

Tags: Singapore, Singapore schoolgirls, eating disorders, bulimia nervosa, Psycho, study, anorexia nervosa, ineffectiveness, body dissatisfaction, thinness, Psychiatry, Sxmuckler O. Screening, Br J Psychiatry, Pauline Chan, Frances Lee, Dr J Psychiatry, weight problem, cultural differences, underweight, American subjects, Ministry of Health, Chinese girls, Chinese societies, Res, Nasser M. Odiase, Kent Ridge Road Singapore, non Western societies, fat, body weight, traditional Chinese, Gleneagles Medical Centre Singapore, PSYCHOLOGICAL FACTORS, Pala G. Mann A. Walkcling A. Abnormal, Eating Disorder, The Institute of Education, Eating Disorders Inventory, Mann AI I. Wakeling A. Wood K. Mooch E. Dobbs, Child Psychiatry
Content: SUSCEPTIBILITY OF SINGAPORE CHINESE SCHOOLGIRLS TO ANOREXIA NERVOSA - PART I (psychological factors) L P Kok, C S Tian
ABSTRACT
Of 656 GCE "O" level Chinese Singapore schoolgirls, it was found that 56% perceived themselves as being too fat, and
38% had been teased about being overweight. On the Eating Disorders Inventory (EDI), 15 (2%) had a score at the
anorectic range. Compared the drivefor thinness scores,
to a group of American undergraduates, Singaporean subjects had no significant but had significandy higher scores on bulimia, ineffectiveness, body dissatisfaction,
difference on interpersonal
distress and greater maturity fears.
In a population which appears to be susceptible to anorexia nervosa, possible reasons for the low incidence of this disorder is discussed.
Keywords: drive for thinness, bulimic, ineffectiveness, body satisfaction.
SINGAPORE MED J 1994; Vol 35: 481-485
INTRODUCTION Concern for weight has been described as a recent Western phenomenon, associated with a trend to link thinness with a number of desirable traits like self discipline, control over one's eating habits, elegance, attractiveness, sexual liberation, and a higher socio economic status° -t. The preoccupation with weight and dissatisfaction with body weight is especially high in adolescents and Young Adults(37) and even occur in childrentst. It has been postulated that eating disorders and a preoccupation with weight is a culture bound syndrome, not common in non Western societies. In the seventies virtually no cases of anorexia nervosa were found in non white countries, although since the eighties, as noted by BryantWaugh et alt9j, some cases have been reported among the blacks in t he US(10.1 ), Bri taint13t and Africa(" 15), in JapanesetnO, Singaporeanst"t, Malaysianstlst, Vietnamese refugeest"t, and Arab studentst2t. Among the Chinese, it was pointed out that the reason for this low incidence is because "the Chinese associated fatness with prosperity and longevity and their gods were always portrayed as fat"then. "This, while true for traditional Chinese in the older age groups regarding babies and young children (fat being associated with health and vigour), is certainly not so for adolescent girls and young adults. The classical concept of beauty in a Chinese girl is that of someone willowy and somewhat fragile, with an oval face, almond shaped eyes, and jet black hair, as exemplified by the heroine Lin-Daiyu in "Dream of the Red Chamber" t00н. The modern concept is Department of Psychological Medicine National University Hospital 5 Lower Kent Ridge Road Singapore 0511 LP Kok, MBBS, MD, DPM, FRCPsych, FRANZCP Associate Professor C S Tian, MBBS, M Med (Psychiatry) Registrar Correspondence to: Dr L P Kok 6 Napier Road #10-08 Gleneagles Medical Centre Singapore 1025
still that of a slim girl, with delicate features, as evident in film stars and singers0't. Thus slimness is a common factor in Chinese and Western concepts of beauty and ideal body shape. If so, would not the attitudes towards weight and dieting he similar in schoolgirls of Chinese ethnic origin and their Western counterparts? The aim of this study is to assess the susceptibility of a representative sample of Singapore schoolgirls to anorexia nervosa. Singapore is a rather Westernised society, where English and the Mother Tongue are taught in school. Because it is a multiracial society (comprising Chinese 75%, Malays 15%, Indians 8% and others 2%), English is used as the common language of the 3 main races. It is open to many Western influences and adolescents are conversant with the latest Western popular culture. METHODOLOGY All GCE `O' level year Singapore Chinese schoolgirls (mean age 16.4 years) from four girls' schools in the postal district where the hospital (that the authors were working in) was located, were chosen to participate in the survey. Rating scales were distributed to the principals and discussed with them. Subjects were given information about the study and asked to answer the questionnaires with the understanding that their replies were anonymous, to ensure more accurate response, as some questions pertaining to self and family might not be answered otherwise. The following questionnaires were used: I) A questionnaire including questions on height. weight. past history of being overweight, being teased for this. past treatment for weight problems. 2) Eating Disorders Inventoryf21t. 'the Eating Disorders Inventory is a 63 -item questionnaire on a 5-point scale which comprises subscales that measure the drive for thinness, bulimia scores, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust. interoceptive awareness and maturity fears. These are psychological and behavioural traits that have been found to be important in anorectic patients. 3) Family Adaptability and Cohesion Evaluation scale. This is an instrument developed by Olson et al (1982)1c2) used to measure family cohesion (or emotional bonding
481
of family members to one another) and family adaptability (the flexibility of a family system to change in response to stresses). 4) Parental Bonding Instrument (Parker et al 1979)m), The Parental Bonding Instrument was developed by Parker to measure the bond between child and parent, in particular the parental components of this bond, which were found to comprise: a) care, a bipolar factor along a dimension of care, involvement, emotional warmth and support, empathy, closeness versus indifference, rejection and neglect. h) overprotection: this included control, infantilisation and intrusion versus permitting and encouragement of autonomy and independence. Only data from the first 2 questionnaires will be presented in this paper. RESULTS There were 656 schoolgirls with a mean age of 16.5 years. After explanation by the teachers, none refused to participate in this study and the response rate was 100%, but the forms were incomplete in 2. Height and weight There was no significant difference between the mean height, weight and mean and median body mass index of the group and all Secondary 4 female students in Singapore. The mean height was 160.6 cm compared to a mean of 158 cm for all Secondary 4 female students in Singaporet2^) and the mean weight was 48.4 kg compared to a mean of 49.2 kg for all Singapore Secondary 4 schoolgirls. The mean and median body mass index (BMI) were 18.89 and 18.72 respectively for the subjects as compared to 19.58 and 19.4 for all Secondary 4 schoolgirls of Singapore. The mean ideal weight that subjects would prefer to have was 2.1 kg less than the mean weight. Perception of not being the right weight Three hundred and sixty-nine (56%) of the subjects felt they were too fat, 130 (20%) thought they were too thin and 157 (24%) perceived themselves as being of just the right weight. Compared to a celebrity figure like Princess Diana (who was known to all of them, and whose photographs all had seen), 48 (7%) preferred to be fatter, 432 (66%) would like to be similar to her in size while 174 (27%) wished to be thinner. Teasing about being ovenveight and action taken Two hundred and forty-nine (38%) had been teased about being overweight and of these, 115 (46%) had felt moderately to very embarrassed, while 80 (32%) were only slightly embarrassed, and 54 (22%) did not mind. Of those who had been teased, 77 (31%) had not resorted to any dieting, 110 (44%) had dieted slightly (cut down one fattening item that was usually eaten eg ice cream); 51 (20%) had dieted moderately (cut down two fattening items usually eaten or reduced food intake by less than half); and 11 (4%) had dieted strictly (cut down three or more fattening items
or reduced food intake by half or more).
Treatment for a weight problem Eighteen (2.7%) had been treated previously for a weight problem, 6 (0.9%) being obese, and 12 (1.8%) underweight. Of these 18 subjects, 2 (11%) had been hospitalised for being underweight, while 16 (89%) had been treated as outpatients. Only one said she had not recovered at the time of the survey.
Menstruation Forty-one (6.3%) were not having monthly periods and of these, 3 (7%) had previously been menstruating.
Wish to be a model/dancer/aerobics teacher Two hundred and sixty-four (40%) expressed a wish to be either a model, dancer or aerobics teacher.
Scores on Eating Disorders Inventory Table I - Comparison on EDI scums between Singapore subjects and American female undergraduates
Singapore American
subjects undergraduatesm)
(n=656)
(n=64)
Mean SD Mean SD Signif.
Drive for thinness
3.6 4.5 3.82 5.4 NS
Bulimia
1.3 2.4 0.85 1.75
Body dissatisfaction 11.0 7.6 5.85 6.33
Ineffectiveness
3.8 4.0 1.02 2.14
Perfectionism
6.1 4.4 6.64 3.35
Interpersonal distrust 4.3 3.6 2.19 2.24
Interoceptive awareness 3.6 4.3 1.61 2.41
Maturity fears
7.4 4.5 1.39 1.66
* <.05 <.005
The subjects were compared with American undergraduatest2S) on the scores of the EDI. There was no significant difference between the Singapore and American subjects on the drive for thinness, but Singapore subjects had significantly higher scores on bulimia, were more ineffective, felt greater body dissatisfaction and interpersonal distress and had greater maturity fears. However they were less perfectionistic (Table I). The subjects were divided into 2 groups on the basis of the drive for thinness scores. Group 1 (641 subjects) comprised the low scoring group (less than 15) and Group 2 (15 subjects) comprised the high scoring group (15 and above). Garner et al (1983)12) found a cut-off point of 15 in anorexia nervosa subjects. The 2 groups were compared on the scores for the EDI. Group 2 had very significantly higher scores on the drive for thinness (p<.001), body dissatisfaction (p<.001), and significantly higher scores on perfectionism (p<.01) and bulimia (p<.05) (Table II).
482
Table II - Comparison of subjects with high and low drive for thinness on the Eating Disorders Inventory
n Mean SD T value Sigrid.
Drive for thinness
Gp 1 641 3.22 3.98 -30 Gp2 15 17.80 1.78
Bulimia
Gp 1 641 1.21 2.35 -2.08 0.05
Gp2
15 3.60 4.42
Body
Gp 1 641 10.82 7.46 -5.53 z**
dissatisfaction Gp 2 15 19.73 6.13
Ineffectiveness Gp 1 641 3.73 4.34 -L46 NS Gp2 15 5.46 3.84
Perfectionism Gp 1 641 6.07 4.34 -3.7 Gp2 15 9.80 3.84
Interpersonal Gp 1 641 4.34 3.64 0.49 NS
distrust
Gp 2 15 4.00 2.67
Interoceptive Gp 1 641 3.53 4.23 -1.6 NS
awareness
Gp 2
15 5.85 5.61
Maturity fears
Gp 1 641 7.37 4.52 -0.85 NS
Gp 2
15 8.60 5.52
Group 1 : Subjects below 15 on the Drive for Thinness Scale. Group 2 : Subjects above 15 on the Drive for Thinness Scale.
< .01 ** < .001
*** < .0001 NS: not significant
When the 2 groups were compared on the body mass index (BMI), significantly more of those in the high drive for thinness group had a higher BMI than those with a low drive for thinness (DT) (Table III). It can be seen that in the BMI range of 15 to 19.9, there were 58% of Group I subjects compared to 30% of Group 2 subjects ie the majority of the schoolgirls with low DT had a low BMI (below that of 19). The BMI of normal men and women should be in the range 19 to 27 kg/mt"'u> and a well trained marathon runner has a BMI of 2099. Table III - Body Mass Index (BMI) by drive for thinness scores
BM 15 -18.9 19 - 27.9 28 + Total p <.0001
Drive for
"Thinness
Low
372 (58.1%) 263 (40.9%) 6 (1.0%) 641
High 5 (33.0%) 10 (67.0%) 15
An additional comparison was made of the high DT group with an anorexia nervosa groupt't> (Table IV) and no significant differences were found in the drive for thinness, bulimia and perfectionism scores but the anorexia nervosa group had significantly lower body dissatisfaction, interpersonal distrust and interoceptive awareness scores while the Singapore group with high DT had significantly greater maturity fears.
Table IV -Comparison of subjects with high drive for thinness scores and American anorexia nervosa girls
Drive for
Gp 1
thinness
Gp 2
Bulimia
Gp 1 Gp 2
Body
Gp 1
dissatisfaction Gp 2
Ineffectiveness Gp 1 Gp 2
Perfectionism Gp 1 Gp 2
Interpersonal Gp 1
distrust
Gp 2
Interoceptive awareness
Gp 1 Gp 2
Maturity
Gp 1
fears
Gp 2
n Mean SD T value Signif.
15 16.5 1.91 1.277 NS 129 15.2 5.3
15 3.25 4.06 1.309 NS
129 2.2
3.8
15 19.50 5.99 3.951 c.001 129 13.8 7.1
15 6.28 5.66 -4.781 <.001 129 13.9 8.0
15 9.60 4.21 -0.290 NS
129 9.9
5.1
15 4.21 3.03 -3.185 <.01 129 7.4 5.1
15 5.85 4.97 -4.624 <.001
129 12.3
7.0
15 8.07 4.88 1.959 <.05
129 5.9
5.4
Group 1 : Singapore subjects with high strive for thinness. Group 2: American anorexia nervosa subjects. (Garner et al, 1983) NS : not significant
DISCUSSION In this sample of Singapore schoolgirls, 56% felt they were overweight, about 38% were actually teased about their weight problems and 26% had dieted as a result of this. The preoccupation of being too fat is also common in Western adolescents where as many as 70%-80% have such a complaints"") and also in College Students, of whom 50% of the women undergraduates perceived themselves as being overweightt'e>. Dieting as a response to this is commorM39 and even in economically and racially diverse schoolchildren, 63% of the girls were on a weight reducing regimen with little difference between whites and hispanicst32>. Among preadolescent children, 37% had tried to lose weightts>. On the EDI scores, the drive for thinness subscale scores in the Singapore girls were not significantly different from a group of American college girls. High scores were found in Asian schoolgirls, University students94>, and Japanese female studentstss> on the Eating Attitude Test scale, a scale to measure eating attitudes developed earliers3n. However, King et al (1989)07> cautioned that findings of high scores could have been due to linguistic and cultural differences that had to be taken into consideration; but it was observed that even when such factors had been taken into account, the scores were still high94>. In the Singapore subjects, English was the first language studied, while the mother tongue was learned as a second language. Thus there was little possibility of linguistic pitfalls and the findings should be taken as reflecting the actual attitudes. About 2% of the Singapore schoolgirls were high scorers on the Drive for Thinness Scale (above 15 points). Whether they would later develop anorexia nervosa is left to be seen. It is likely that, as has been suggestedtrs>, there is a continuum of eating disorders, ranging from those with dieting behaviour, then a sub -clinical group and finally to those with true eating disorders. Certainly epidemiological studies have
483
found that sizeable proportions of young girls have been shown to have an anorectic type of attitude. In a study of London schoolgirlst5), about 8.2% scored above 20, using the Eating Attitudes 'rest, and in Mumford et al's study (1991)08) 12.3% of Asians and 8.7% of Caucasians did likewise. These proportions are higher than that of the Singapore schoolgirls. In addition, when compared to American undergraduates using the EDI, although the drive for thinness scores were not significantly different, other scores were, viz bulimia, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness and maturity fears. Thus, it would appear that several postulated factors important for the development of anorexia nervosa ie disturbance of body image and body concept, disturbance of the identification of stimuli in the body and sense of ineffectiveness, difficulties in interpersonal relationship and separation individuationt3940), fears of maturation and sexualitytAt) difficulty in identifying emotionst4), and perfectionistic tendenciest43"4) are present to a significant extent in Singapore schoolgirls. Therefore, if these factors, in addition to concern for weight and dieting behaviour are present among these Singapore schoolgirls, why then is there such a low incidence of anorexia nervosa in general, in adolescents of Chinese ethnic origin compared to Caucasians? In Hong Kong, Lee et alн45) found less than 10 cases over 5 years in a psychiatric unit serving 500,000 people. In addition they quoted an unpublished epidemiological survey in Hong Kong where one possible case existed in a community of 7,229 subjects. In Singapore, 7 Singapore Chinese girls were treated in the medical wards for anorexia nervosa who had features similar in terms of clinical presentation, class, family factors, to those described in the Caucasian populationt17). Kok and Tiant"e) found 12 hospitalised cases of anorexia nervosa in a psychiatric unit of a general hospital serving a population of 250,000 over 4 years. It is difficult to single out a single factor as causing anorexia nervosa['). A stress diathesis model of multiple aetiological factors has been suggested, and Garner and Garfinkel (1980)(47) proposed that individual predisposing factors including individual, familial and socio cultural ones could lead to abnormal eating patterns when set off by precipitating factors. Piazza et al (1980)[18) stressed faulty ego development with defects in body awareness and ego boundaries. The exposure to Western lifestyle, leading to `slimness consciousness' and `performance expectations' of women to achieve and succeed materiallyo5) are present in Singapore. (Female graduates from institutions of higher learning increased from 1,733 in 1978 to 5,260 in 1988)tA9). In addition are maturity fears which have been postulatedt7-A0) to be one of the factors significant for the development of anorexia nervosa. However balanced against them are protective factors present in Chinese societies like the later onset of puberty, the relatively smaller changes in breast and body size at pubert(A5) and the small physique of Chinese girls (Table Ill shows that about 58% of the schoolgirls in this study with a low drive for thinness had a BMI of less than 19; compared to this, American datat50) show that in white and black American females aged 16 years, the following BMI were found: 15th percentile - 17.59 (whites); 17.48 (blacks) 50th percentile 20.11 (whites); 20.11 (blacks) - 95th percentile 28.95 (whites); 32.51 (blacks)
In addition there is the fairly common occurrence in Chinese societies of interdependent enmeshed families which would make such families more a norm than an exception[A5). In Singapore 17% of a group of schoolgirls had enmeshed families and the majority perceived their families as being rigidly cohesivet50. Although plumpness is not a desirable state in Singapore girls, perhaps a further possible explanation for the relatively few cases of clinical anorexia nervosa could be that in a population where the majority arc thin and obesity is relatively uncommon, any slight departure from the usual thin norm (ie being plump) would be easily obvious. The findings of this study showed that 38% of the girls said they had been teased about being plump and of these, 70% had taken action to reduce their weight. If dieting should start then it would not be difficult to attain the previous weight - Chinese home cooked food emphasises non fattening items like vegetables, seafood and white meat; steaming is a popular method of cooking and desserts are rarely eaten. Therefore if weight loss is not difficult to achieve, and if there are seldom any examples of gross obesity, the extreme fear of loss of control (that could result in great distortion of body weight) may not be present. Failure to seek medical treatment is unlikely to be the reason for the small number of clinical cases of anorexia nervosa as school children are screened regularly by the School health services (the number of medical checkups of female students increased from 113,900 in 1978 to 296,500 in 19Я809) and the current small size of Singapore families (the net reproduction rate in 1987 was 769 per thousand female population)t49) makes parents pay attention to the well being of their children. Also there is no lack of medical care in Singapore - in 1988 there was one doctor per 837 persons and one hospital bed per 270 personst49). Therefore it could be said that in a society where obesity is not a major issue, where extreme samples of obesity are rare, and control of weight is helped by the non fattening type of home -cooked food commonly eaten, the intense fear of being fat would be absent; thus instead of being driven into the overdieting behaviour of anorectics, the dieting would be mild, and would aim at a desired weight which would not be exaggerated or abnormal. I-Iowever it has to he borne in mind that Westernisation is associated with higher rates of anorexia nervosat0). Mumford et a1н381 in their study of 559 girls found anorexia nervosa to be not uncommon among Asian schoolgirls in the United Kingdom, and suggested that Asian girls were probably adopting Western reactions to stress and conflicts. This Westernisation process is also happening in Singapore. A comparison of a group of Singapore Chinese university students and their mothers, showed that students' scores on a Chinese Culture Scale (a measure of Chinese beliefs and practices) were significantly lower than their mothers(5). Thus as Singapore becomes more Westernised and as the young consume more high fat, low fibre Western fast food, eating disorders are likely to become more prevalent. As this study has shown attitudes to weight are not dissimilar to those found in Western studies and obesity is becoming more common - in 1980, 556 per 10,000 female Secondary 4 schoolgirls were obese compared to 1,158 per 10,000 Secondary 4 schoolgirls in 1988(49). Thus, in future, the rates of anorexia nervosa may increase. ACKNOWLEDGEMENT We would like to thank the School Health Services of the
484
Ministry of Health for providing height/weight dala on Secondary 4 schoolgirls and Dr Frances Lee and Dr Pauline Chan, formerly of The INSTITUTE OF EDUCATION, for their advice. REFERENCES I. Dally 111.Gonn'x P. Anorexia nervosa. London: William I Icineman. 1979. 2. Nasser M. Odiase and weighs consciousness. l Psychaan Res 1988:33573.7. 3. Mann AI I. Wakeling A. Wood K. Mooch E. Dobbs RA. Sxmuckler O. Screening for abnormal caring altitudes and psychiaukmorbidily lean unseketedpopulalkn M IS.vear.old Rluolgirla Psycho, Med 1983:13:573.88 a. Selma DE. Seunkard Al. Bulimia vs bulimic behaviours on a college ampus. JAMA 1987:251:1213.1 Johnson.Sabine E. Wood K, Pala G. Mann A. Walkcling A. Abnormal caring altitudes In London schoolgirls - a prospective epidemiological study: factors associated wih Wmomal response onseecmng questionnaires. I4ychol Med 1988: 1861522. 6. Moore DC Body Image and eating behaviour in adololesceni girls. Am 1 Dis Child 1988: 14211144. 7. PalionGCTMapeesrum ofeatiugdisorder in adolescence.) Pashvavm Res 198$ 37:579.84. R Moloney JM, McGuire 1. Daniels SR. Soaker II. Dkling behaviour and caring naiades in ehBden. Paediatrics 1989:84:482.9. 9. Ilryani. Waugh R.1ask N. Anorexia nervosa in a group of Asian children living in Breain. lb 1 Psychiatry 1991:138329.33 10. Pesmariega Al. Edwards P. Mitchell CB. Anorexia nervosa in black adokrmaa. J t Am Acme Child Psychiatry 1984; 23:111. 11. Selbes Anorexia nervosa In black adokxcnrs. i Nail Med Assoc 1981:7619.32 12. I Isu 13(0. The aetiology of anorexia nervosa. Psycho) Med 1983:1323.8. 13. llohkrr N. Robinson B Anorexia nenvaa and bulimia nervosa in British blacks Dr J Psychiatry 198$132:544.9. 14. Nwaelua A. Anorexia nervosa in a developing country. Br 1 Psychiatry 19151: 1382701. IS. Duchan T. Gregory I_ Anorexia nervosa in a black Zinbabwcan Br 1 Psychiatry 1984:145:376.30. 16. Samara I1. ed. The ancep. and definition of anorexia nervosa. In: Anorexia neooa.'lbkyo: Igakoshoin. 19852.11. Ong Yl.: rsei W ECheah 1S. A clinical and psychosonal Rudy of7 eawo(anorexia nervosa is Singapore. Singapore Mcd 1 1982: 23:255.61. 18. Bnhrreh N. Fieguency of Neumarion of anorexia nervosa in Malaysia. Aun N Z.1 Psychiatry 1981;15:1535. 19. KopeT.Sack W. Arnacsa nervosa in Southeast Asian abets. a man Mecases. 1 Am Ac-ad Child Atlas Psychiatry 1978:76795.7. 20. Cao KC_ Dream of the Red Chamber (bated on 1792 anion). Taman: hag Men Wen Wu Publishing Co. 1986. la 21. Gainers 11M.(/lmsual MP. Polivy 1. Eating Disorder Insensory. A measure of cognnnc behavioural s0mensann of anorexia nervosa and bulimia. In: Darby PL. Garfinkel Pli.Garner l)M.Coana DV. e s Anorexia Nerrma. ream dew:lemmas ut Research. New Yea: Alan It Lin 1983:173.84. 22. Olsen 1511. McCubbin Ill. lama 111. lawn AS. Mama Mi. Wilmn MA. Families: What makes them work. Beverly Dins. USA Sage Publinlien 1983. 73. Parkes(;. Tuplingll. mown Ili. A partial bondingfarmmenl. Br J Mcd Psycho! 1979:52:140. 24 Ministry M Ileallh. School Doalsh Services 1990. (Dala piovrdal).
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