Eating Disorders in the Asian American and Pacific Islander Community

• One study that looked at eating disorder prevalence across many ethnic groups, including Asian Americans, found that there were similar rates of anorexia nervosa and binge-eating disorder among all groups.⁷ Researchers estimated:⁸ 
  • 0.10% of all Asians experience anorexia nervosa during their lifetimes
  • 1.50% experience bulimia
  • 1.24% experience binge-eating disorder
  • 4.74% experience binge eating behaviors
• Hispanic and Asian girls reported significantly greater body dissatisfaction than white girls according to one study.⁹ 
  
• Another study found that Asian American college students reported higher rates of food restriction compared with their white peers and higher rates of “purging, muscle building and cognitive restraint” than white or non-Asian college students.¹⁰
• One study reviewing the literature on the prevalence of eating disorders among Pacific Islander populations found that data was extremely sparse (no data from Indonesia, Timor-Leste, East Timor, New Guinea, Micronesia, Tahiti, Samoa, Cook Islands, New Caledonia and Vanuatu):¹¹
  • Maori and Pacific peoples in New Zealand – 1.7% lifetime prevalence of any eating disorders across groups.
  • Fiji – 42% of adolescent girls reported purging behaviors and 4% adult women reported symptoms consistent with binge-eating disorders.
  • Guam – 10.9% of adolescent females and 5.1% adolescent males reported purging by vomiting or laxative use.

What are the Risk Factors Among AAPI Communities?

AAPI communities experience unique sociocultural and psychological pressures that contribute to body image, eating habits, as well as body and appearance dissatisfaction, including:

• Dual-cultural impact – AAPIs are impacted by both Western body and beauty ideals, as well as beauty standards from their own heritages and cultures:
  • Thinness is emphasized within Eastern beauty standards and started since the Han Dynasty (206 B.C.–220 A.D.). Historically, being thin has been associated with desirability and femininity, which promotes the likelihood to get married, move up the social ladder and gain more wealth and power.^12,13
  • Pacific Islanders have more appreciation of larger bodies traditionally but are now getting more confused messages regarding body ideals, which are influenced by Western body ideals through Western colonization and globalization, and obesity interventions.¹⁴  
    
• Sexual objectification and racial microaggressions – Experiences of sexual objectification and racial microaggressions increase appearance awareness and constant self-monitoring, which contributes to the development and maintenance of eating disorders.¹⁵
  
• Cultural representation and conception in the media – AAPI communities receive different representation or portrayals in the media which reinforces stereotypes on body and beauty ideals. For example, Asians are often represented and perceived as a feminine race, and therefore, Asian American men are even more underrepresented than Asian American women in the media. A common and stereotypical perception of Asian American men is that they are “weak” and not “sexually attractive.”¹⁶ Both Asian American women and men experience objectification as they adopt the mainstream American culture, and thus may develop body image issues and disordered eating.¹⁷  
  
• Collectivistic values and psychological self-censoring – Collectivistic values encourage adhering to group norms and parental expectations, including those related to appearance and believing that family recognition and honor came through achievement, including appearance:¹⁸
  • Mothers play a critical role in shaping body image through comments about weight and appearance, which sometimes can serve as a source of pressure and body dissatisfaction.
  • The belief that “emotional self-control” is important (distress cannot be overtly shown) significantly predicts disordered eating for some women, especially when it serves as a method to cope with emotional distress, meet family demands, and manage “face” in a socially acceptable way.
• Impact of social media – The rise of social media plays a role in amplifying cultural body and beauty ideals in AAPI individuals, introducing new risks especially among adolescents.¹⁹ Extensive use of social media, especially platforms promoting an ideal thin body image, has been linked to increased body dissatisfaction and eating disorders, in both Western and non-Western contexts:
  • Popular Chinese TikTok (Douyin) “body challenges” were shown to impact users’ body image, reflecting concerns similar to those posed by “thinspiration” content on Western social media. These challenges, encouraging users to showcase their thinness, could negatively affect viewers’ and participants’ body image.²⁰
  • In Malaysia, Singapore, Thailand, and Hong Kong, a significant number of adults reported disordered weight-control behaviors and undergoing cosmetic procedures, influenced by traditional or social media and sociocultural standards of appearance.²¹

What are the Barriers to Seeking Help?

• Clinicians are trained to recognize Eurocentric/white eating patterns but not those from other cultures – In one 2006 study, clinicians were less likely to recognize eating disorder symptoms and recommend professional help when the subject was not white.²² AAPI may not feel comfortable opening up to clinicians who are not culturally competent or share the same background.
  
• Stigma around mental health within the AAPI communities – According to the Substance Abuse and Mental Health Services Administration, Asian adults had the lowest rate of mental health service use out of any ethnic background.²³ Of those who experienced eating disorders, Asian Americans typically had the lowest rate of seeking help than other groups, and this includes eating disorder treatments.  
• Cultural emphasis on thinness – Family criticism of weight and/or appearance, as well as comparison to others, tends to be the norm for East and South Asians.^18,24 
• Language barriers – Many AAPI do not speak English as their primary language. According to the National Alliance on Mental Health, 30.9% of AAPI do not consider themselves fluent in English.²⁵ Additionally, 60% of AAPI senior citizens (age 65 and above) have limited English proficiency. Language barriers coupled with limited availability of culturally competent mental health professionals may serve as an additional obstacle in AAPI receiving the care they need.
  
• Acculturation and cultural conflict with older generations and/or immigrant parents – Second-generation Asian American women reported significantly more disordered eating than their first- and third-generation peers, indicating another risk factor for eating disorders, due to bicultural stress and perceived pressure to achieve.¹⁷

What are the Barriers to Support and Treatment?

• Lack of awareness on signs, symptoms and severity of ED and co-occurring mental health conditions – As mentioned earlier, cultural stigma in seeking support on mental health-related issues apply to seeking care for eating disorder recovery. Denial of the need to seek help is common. Studies have shown that AAPI communities have tendencies to delay mental health treatment, so lack of awareness on the severity of eating disorders can be a contributing factor.^26,27
  
• Perfectionist tendencies particularly in East Asian and South Asian cultures – The pressure to excel translates to getting through eating disorder treatment and recovering “sooner.”²⁸
  
• Model minority myth – Model minority myth stereotypically assumes that all Asian Americans and Pacific Islanders are intelligent and hardworking, which make them socioeconomically more successful than other minorities. However, AAPI folks that are underrepresented, particularly Southeast Asians and Pacific Islanders, might not get the eating disorder support they need. This is because they are expected to conform to the “model minority myth” of AAPIs being “successful” and the assumption that cultural practices and body types are similar across all AAPI groups.²⁹
  
• Generational and intergenerational trauma – Unresolved trauma could continuously perpetuate in families, such as mistrust in any institutional systems, difficulty coping with emotional distress, low self-esteem and challenges in expressing one’s thoughts/emotions.³⁰ This makes eating disorder support less reachable and accessible.
• Lack of financial and culturally-competent resources – First, eating disorder treatments can be expensive and time-consuming.³¹ One study shows that youth of color with public insurance are less likely to receive recommended eating disorder treatment.³² Second, the language barrier is huge for seeking mental health treatment because they are not able to have a full understanding of the condition.26 Additionally, talk therapy might not be culturally-appropriate and perceived to be helpful.³³ Lastly, there is a lack of diverse and culturally-competent providers in various eating disorder settings, given most of the practitioners are Caucasian, heterosexual and female-identifying individuals.³⁴
  
• Food means more than just food – The implied meaning of food is tied to cultural identities, emotions and ancestral connections in AAPI communities. When relationships with food changes because of eating disorders, it can create a lot of confusion for AAPI individuals on how to express themselves and navigate this during treatment.^35,36

Considerations for Providers

• Cultural competence – When working with AAPI individuals and families, providers should consider the cultural context of family dynamics, developmental processes and intergenerational conflicts:
  • Therapists in one study viewed a connection between Asian American clients’ eating disorders and culturally appropriate coping strategies to disconnect emotionally and to express distress. It’s suggested therapists use safety-focused care that takes into consideration different factors that may impact the client, to help them regulate emotions, challenge rigid perceptions and experiment with new behaviors.³⁷
  • Another study encourages the use of motivational interviewing to enhance response to eating disorder treatment for AAPIs.³⁸ Additionally, they pointed out that therapeutic approaches that promote Western values – such as being assertive, developing a unique identity, setting boundaries and confrontation – may disrupt familial harmony and can be counterproductive during eating disorder treatments. 
    
• Trauma-informed care – Many individuals with eating disorders or disordered eating have experienced different forms and types of trauma, which makes it important for providers to incorporate trauma-informed care.^39,40 For AAPI communities, trauma could come from generational trauma, intergenerational trauma and other traumas related to body and beauty ideals.^30,41 Trauma-informed care promotes a sense of safety, empowerment, transparency and collaboration when working with people with eating disorders to help ease emotional distress.
  
• Expand network of referrals and seek supervision – Individuals with eating disorders may prefer working with providers who share similar cultural backgrounds, values, practices and/or lived experiences. Connect with AAPI eating disorder providers in your area, and consider referring to someone who may be a better fit (if necessary). If referring out is not feasible, seek supervision from AAPI eating disorder providers and mentors.

Ending Note

AAPI communities are uniquely affected by many intersecting sociocultural and psychological factors that increase body dissatisfaction and risk for eating disorders. Efforts to address these issues must focus on raising awareness and developing targeted interventions to effectively support AAPI individuals.

Resources

• Directory of Asian American & Pacific Islander (AAPI) eating disorder providers.
• Black, Indigenous & People of Color (BIPOC) eating disorder providers.
• Eating disorder support groups and harm reduction circles:
  • Yellow Chair Collective  
  • Project HEAL 
  • Nalgona Positivity Pride