Update on the epidemiology and treatment of eating disorders among Hispanic/Latinx Americans in the United States

Abstract

Purpose of review

This review provides a 6-year update on the prevalence and treatment of eating disorders among Hispanic/Latinx Americans in the United States.

Recent findings

Prevalence of eating disorders tends to be lower in Hispanic/Latinx American adolescents and adults relative to non-Hispanic White peers. Numerous risk factors for disordered eating symptoms have been identified, including negative body image, depression, sexual assault and culturally specific risk factors, including ethnic discrimination and acculturative stress. Hispanic/Latinx individuals seek treatment less often with the most influential barriers being cost of treatment, eating disorder stigma, eating disorder shame and mental health shame in general. Limited research on the treatment for eating disorders continue to persist. Culturally adapted cognitive behavioural therapy yielded similar outcomes to traditional cognitive behaviour therapy and had better treatment adherence and retention rates.

Summary

The medical and sociopolitical climate of the United States has changed significantly since our previous review. The need for research on the effectiveness of eating disorder treatments for Hispanic/Latinx Americans remains important for one of the fastest growing populations in the U.S.

INTRODUCTION

There is significant variability in self-identification across individuals of Latin America, indigenous to what is now the United States, and Spanish descent. The 2020 United States (U.S.) national census defines individuals of Hispanic, Latino or Spanish origin as individuals who self-identify from Latin, South or Central America, Spain, Cuba, Puerto Rico and the Dominican Republic [1]. This can constitute individuals of any race who immigrated or whose family origins begin from these countries. As of 2020, there are 62.1 million adults and children that identify as Hispanic, Latino or Spanish origin, constituting some of the fastest growing populations in the U.S. [2].

Through medical and financial concerns caused by the coronavirus-19 pandemic, and sociopolitical stressors in the United States involving racial/ethnic discrimination, Hispanic/Latinx communities have experienced significant changes to their internal and external environments.

Through medical and financial concerns caused by the coronavirus-19 pandemic, and sociopolitical stressors in the United States involving racial/ethnic discrimination, Hispanic/Latinxⁱ communities have experienced significant changes to their internal and external environments. Consistent with our last review in 2016 [4], we conducted a literature search for published studies in PsycINFO, PubMed and Google Scholar using the terms Hispanic, Latina, Latinx, eating disorders, disordered eating, eating pathology, treatment, body image, acculturative stress, acculturation and discrimination. Since our last review [4], additional research has been published on prevalence of eating disorders, diagnoses and individual symptoms. The field has advanced risk factor research including within an intersectional framework (e.g. the study of multiple social identities related to systemic inequity) [5]. In addition, a few empirical studies on treatment have emerged. However, there are still significant gaps in understanding and knowledge on eating disorders within Hispanic/Latinx individuals and scholars have provided tangible recommendations for next step forward. This update aims to highlight recent descriptive studies examining prevalence of eating disorders, etiological studies exploring risk factors, treatment studies and calls to action for improving future research and treatment practices for this population.

INCIDENCE AND PREVALENCE OF EATING DISORDERS

Incidence and prevalence of eating disorders among Hispanic/Latinx populations vary across disorder, sex and age range. One study examined the 8-year incidence of psychiatric disorders from adolescence to early adulthood among Mexican adolescents [6]. One thousand and seventy-one young adults aged 19–26 years were re-interviewed in 2013, 8 years after they were originally interviewed as adolescents when they were between 12 and 17 years of age. The period of incidence thus covers the age span of 12–26, the age period with the highest risk for eating disorders. Incident cases of an eating disorder were defined as those that developed an eating disorder between waves I and II among those who never had an eating disorder at the first wave. During the adolescent years into emerging adulthood, a total number of 40 participants experienced the onset of a new eating disorder, resulting in a 3.7% 8-year incidence of eating disorders, which is equivalent to an incidence of 0.47% per year. The 8-year incidence for anorexia nervosa was 1.3%, for bulimia nervosa was 1.7% and for binge eating disorder was 1.3%. Of these, only bulimia nervosa had a significantly higher incidence rate in women than in men [6].

Beccia et al. [7] analysed data from 11,514 U.S. high school students identifying as Hispanic/Latino, Black/African American or White who participated in the 2013 National Youth Risk Behavior Surveillance System. They studied the prevalence of disordered eating (e.g. purging, fasting, diet pill use). Disordered eating was prevalent in 29.2% of the Hispanic/Latina girls compared with 20.4% in Black/African–American girls and 21.4% in White girls. For boys, the prevalence of disordered eating was 12.4% for Hispanic/Latino, 13.4% for Black/African–American and 8.1% for Whites; there was a positive interaction between sex and race/ethnicity heightening risk for Hispanic/Latina girls [7]. When comparing across racial/ethnic groups among adolescents 13–18 years of age, Hispanic/Latino adolescents endorse fewer weight concerns, less dieting and fewer exercise behaviours than their non-Hispanic/Latino peers [8]. Racial/ethnic minoritized adolescents have been found to display different binge eating symptoms than non-Hispanic White adolescents, as Hispanic adolescents specifically report more ‘fear of weight gain while binge eating’ than non-Hispanic Black adolescents [8]. Higher rates were observed in a study of younger adolescents who were 12–16 years old, with 34.7% of Hispanic boys and 44.8% of Hispanic girls reporting unhealthy weight control behaviours [9]. Furthermore, in a study of adolescents 10–13 years old, Latino boys and girls with overweight/obesity display an increased risk for disordered eating [10].

Moving to adulthood, it is estimated that 0.46% of Hispanic adults will at some point in adulthood meet criteria for anorexia nervosa, 0.24% for bulimia nervosa and 0.75% for binge eating disorder [11]. The U.S. Census data estimated 42.9 million Hispanic adults in 2020 [1,2], suggesting that 623,122 adults will meet criteria for an eating disorder. However, it is important to keep in mind that underreporting is routinely discussed in research due to secrecy related to eating disorder, stereotypes of eating disorder and screener items that may systematically exclude ethnic minorities [11,12]. Latinas have shown the highest rates of bulimia nervosa and binge eating disorder of all ethnic groups [12] and higher appearance compared with Black adult women [13]. In a study examining correlates of eating disorders with psychosocial and health factors, prevalence of eating disorders among Mexican Americans was associated with higher rates of major depressive disorder, self-rated poor physical health and BMI, while prevalence among other Hispanics was associated with higher rates of major depressive disorder, self-rated poor mental health and BMI [14]. Latinx adults tend to report higher weight and shape concerns than non-Latinx adults [15], with weight concerns (i.e. strong desire to lose weight and fear of weight gain) constituting a central symptom of eating disorder among ethnic minority women [16]. Rates of compensatory behaviours such as excessive exercising, self-induced vomiting and laxative misuse have been comparable among Hispanic and White women [17]. Purging behaviours have been found to be a central symptom in eating disorder across Hispanic women, suggesting a key symptom to target for treatment [16].

RISK FACTORS FOR EATING DISORDERS

Significant advances have been made, including examining the generalizability of risk factors found in the existing literature with Hispanic/Latinx individuals, cultural-specific risk factors and examination of risk factors from an intersectional framework. Common sociocultural risk factors have been found to generalize to Hispanic/Latinx individuals. For example, family weight-based teasing is associated with unhealthy weight control behaviours and body satisfaction among Latinx youth [18]. Among collegiate adult women, the tripartite model of body image and disordered eating was found to be invariant across ethnic/racial groups in the U.S.; specifically, peer, and media pressure to be thin was significantly associated with thin ideal internalization, which in turn, was associated with lower body satisfaction [19]. Body satisfaction was significantly associated with overvaluation of weight and shape, and dietary restraint [19]. Another study among Latino college students found that depression mediates the relationship between history of sexual assault and disordered eating consistent with the literature among non-Latino men [20]. Thus, similarities in risk factors across ethnic groups continue to emerge for both youth and adults.

In the previous review, acculturative stress and acculturation were culture-specific risk factors for disordered eating [4]. In the past 6 years, acculturative stress continues to be associated with disordered eating and emotional eating [21–23], adding to the existing literature the importance of this construct for Hispanic/Latinx individuals across psychiatric disorders including depression [24], anxiety [25] and substance use [26]. Further, ethnic discrimination is associated with disordered eating symptoms [27^■]. Interestingly, even when cultural protective factors such as familismo (e.g. perceived importance of being united as a family, sense of security from family) or ethnic identity are accounted for, ethnic discrimination continues to associate with disordered eating [27^■], highlighting the unique deleterious impact of discrimination on disordered eating above and beyond protective factors.

From an intersectional framework, research has found that perceived stress mediates the relationship between food insecurity and emotional eating among Latinx adults [28]. Having multiple minoritized labels such as Latinx and food insecurity can increase the frequency and amount of perceived stress, and potentially disordered eating. Another intersectional study found that Hispanic women who report weight stigma are more likely to cope using disordered eating relative to White women [29]. When examining adults who identify as gay, lesbian or bisexual, and across race/ethnicity, Hispanic sexual minorities reported significantly higher rates of eating disorder symptoms, probable eating disorder diagnosis, body dysmorphic disorder and appearance and performance enhancement drug misuse than other sexual minoritized adults of other racial/ethnic groups [30]. Collectively, the emerging research on intersectional identities seems to suggest that having a Hispanic/Latinx identity combined with another minoritized identity such as sexual minority, food insecurity or experiencing weight stigma increases the rates of eating disorder symptoms and risk of diagnosis.

TREATMENT OF EATING DISORDERS

Hispanic adults seek treatment less often than their non-Hispanic White counterparts across all eating disorder diagnoses, with about 14.6% of Hispanic adults who meet the criteria for anorexia nervosa, about 44.4% of those who meet the criteria of bulimia nervosa and 25.9% of those who meet the criteria for binge eating disorder seeking treatment [31]. Among a sample of Latinas with binge eating disorder or bulimia nervosa, 65% had sought treatment for their eating disorder [32]. The most influential barriers to accessing care reported was cost of treatment, eating disorder stigma, eating disorder shame and mental health shame [32]. Interestingly, Latina’s report of treatment helpfulness was associated with their level of acculturation, such that those who were more immersed in White majority culture found treatment more helpful [32]. However, there remains a lack of research examining predictors of treatment seeking behaviours and utilization among Hispanic/Latinx populations. One study using data from the National Survey on Drug Use and Health (2004–2018) reported a general increase in seeking mental healthcare through internet support groups among U.S. adults, except for Hispanic adults [33]. Another study among Mexican adolescents showed that being female, greater parental education and all lifetime disorders except eating disorders predicted incident service use [6], demonstrating unique barriers to service use among patients with an eating disorder.

A few studies on treatment have been published solely focused on Hispanic/Latinx Americans. For example, one case study utilizing culturally adapted brief family therapy for a Mexican American adolescent with bulimia nervosa was shown to be effective [34]. Cultural adaptations included delivering bilingual treatment in the client’s preferred language, considerations of therapeutic relationship dynamics (e.g. power, privilege, marginalization, discrimination), using culturally appropriate metaphors, integrating family’s values (familismo, respeto, personalismo) by codeveloping intervention with all members of the family, reframing problems located in the family as ‘cultural conflicts’ due to acculturative stress and integrating ancestral consejos (mantras) into treatment [34]. This case study also illustrates the importance of integrating positive family experiences (e.g. family meals) and engagement in community events consistent with the family’s values into eating disorder treatment among this population. Similarly, a qualitative analysis outlined topics families wanted to discuss during a six-session family component added on to an outpatient cognitive behavioural treatment for adult Latinas [35]. Topics included involvement of extended family and friends, economic stress, language barriers, acculturative and immigration stress, partner emotional struggles and marital issues [35]. All patients noted the utility of involving their families in treatment for addressing stigma and shame, increasing familial support and understanding, and increasing treatment retention[35].In a pilot randomized clinical trial comparing culturally adapted cognitive behavioural therapy with culturally adapted cognitive behavioural therapy with the six-family therapy sessions, both treatments were equally successful in reducing bingeing and purging with large effect sizes, and general eating disorder symptoms with small effect sizes; however, treatment with family sessions yielded more treatment retention and adherence with an 83% treatment completion rate [36]. Another study conducted a randomized controlled trial for culturally adapted cognitive–behavioural therapy-based guided self-help for binge eating in a sample of overweight or obese Latinas with binge eating disorder [37]. Relative to the waitinglist control group, the intervention group demonstrated significant reductions in frequency of binge eating, depression and psychological distress with 47.6% of the intervention group maintaining abstinence from binge eating at 3-month follow-up. Collectively, the existing treatment studies suggest that culturally adapted cognitive behaviour therapy may be a preferred and effective treatment for bulimia nervosa and binge eating disorder among Hispanic/Latinx women.

A review by Acle et al. [38^■] sought to reveal the cultural considerations key to improving eating disorder treatment among racial/ethnic minority groups. Participants of Hispanic/Latino ancestry were the most represented racial/ethnic group in the review (about 30% of all articles). Authors determined the 11 core themes, namely use culturally sensitive interventions; address barriers to treatment; understand patients within their cultural context; explore the impact of culturally contextual factors; assume a collaborative, curious therapeutic stance; understand nuances that impact clinical presentations; explore family/social supports; provide education/ psychoeducation; explore ethnic identity, acculturation and acculturative stress; become educated about working with ethnic and racial minorities; and use a culturally flexible diagnostic model [38^■]. One recent case study demonstrated the necessity of evaluating the cultural context during assessment of eating disorders highlighting how cultural context can impact the development of eating disorder symptoms [39]. For example, a typical presentation is for dieting and restricting of food to lead to binge eating; however, among Hispanic/Latinx Americans, overeating and binge eating can lead to dieting behaviour, which can impact treatment target goals.

DISCUSSION AND CONCLUSION

In the wake of political unrest in the United States and a global pandemic, various calls to increase accountability to participants and facilitators of eating disorder research have been made [40] to ensure that these historical events act as catalysts for growth within our field. Burke et al. [41] provide specific recommendations for quantitative and qualitative improvements to current eating disorder research. Quantitative suggestions include using large national datasets with sufficient sample diversity (e.g. Youth Behavior Risk Survey) to address difficulties in accessing minority populations, using additive (rather than multiplicative) interaction terms when examining risk of intersectional identities (see [42] for more information), and increasing multisite collaboration to create diverse datasets. Additional quantitative methods that may improve future eating disorder research include intensive longitudinal data collection methods (e.g. ecological momentary assessment or experience sampling) [43] that create large diverse data sets without requiring as many participants (e.g. 100 Hispanic/Latinx participants providing data three times a day for 2 weeks results in 4200 data points) and network modelling that identifies the most influential symptoms maintaining eating disorders[16] and dysfunctional mechanisms that maintain comorbidity (e.g. connections between eating disorders and social anxiety) [44]. Qualitative improvements include increasing research using samples with lived experiences and challenging our own biases when developing qualitative studies through increased community partnerships [41].

Relative to our previous review [4], there has been a growth in research on risk factors for eating disorders among Hispanic/Latinx populations, and a steady rate of research on prevalence, and treatment utilization. Most notably, the eating disorder research field has begun to conduct randomized controlled trials examining the effectiveness of culturally adapted cognitive behavioural therapy, but continued effectiveness research is needed to expand to dialectical behaviour therapy, and interpersonal psychotherapy. Further, adjunctive treatment components, such as the added family sessions to individual-based cognitive behaviour therapy [36], need to be further explored such as the utility of mindfulness, acceptance and commitment therapy, and motivational interviewing. In the last review, we noted a lack of research on restrictive eating disorders (which includes anorexia nervosa, atypical anorexia nervosa and avoidant/restrictive food intake disorder) [4], and this continues to apply today. Overall, the past 6 years have yielded important advancements in the understanding and treatment of eating disorders for Hispanic/Latinx Americans.

KEY POINTS.

• There is a 0.47% incidence of eating disorders per year from adolescence to early adulthood among Mexican-American youth.

• Among Hispanic/Latinx American adults, lifetime prevalence for eating disorders is 1.45%.

• Ethnic or racially based discrimination predicts eating disorders symptoms even in the context of protective factors such as familismo and positive ethnic identification.

• Hispanic/Latinx Americans seek treatment less than non-Hispanic Whites with numerous individual and systemic barriers identified.

• Culturally adapted cognitive behavioural therapy with adjunctive family sessions yielded similar outcomes to culturally adapted cognitive behavioural therapy with no family sessions in reducing eating disorder symptoms with added advantages in promoting treatment retention and adherence.