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. Author manuscript; available in PMC: 2025 Oct 1.
Published in final edited form as: Int J Eat Disord. 2024 Apr 5;57(10):2074–2087. doi: 10.1002/eat.24200

A Cultural Models Approach to Understanding Body Fatness Perceptions and Disordered Eating in Young South Korean Men

Lawrence T Monocello 1, Jason M Lavender 2, Lauren A Fowler 3, Ellen E Fitzsimmons-Craft 4, Denise E Wilfley 5
PMCID: PMC11452565  NIHMSID: NIHMS1977484  PMID: 38578204

Abstract

Objective:

The eating disorders field has been limited by a predominant focus on white, Western women, and there is growing recognition of the need to understand cross-cultural variation in key constructs (i.e., ideal body-types). A transdisciplinary, cultural models approach systematizes the incorporation of an “emic” perspective (a culture’s own understandings of phenomena) into assessments of relationships between body shapes and eating disorders.

Method:

Eighty-one young South Korean men ages 19-34 living in Seoul participated in this research. A cultural model of body fatness was identified using cultural consensus analysis during 18 months of ethnographic, mixed-methods fieldwork. Participants also completed questionnaires assessing age, height, weight, sexual identity, university prestige, body dissatisfaction, eating disorder symptoms, and cultural consonance with the Korean cultural model of the ideal male body. Variation in these factors was analyzed using a series of chi-squares and ANOVAs with the culturally defined categories of body fatness as the independent variables.

Results:

Cultural consensus analysis found that young South Korean men are consistent in identifying categories of “too thin,” “balanced,” and “too fat.” The “balanced” category contained the lowest proportion of high-prestige university attendees and the highest average cultural consonance. The “too fat” category was characterized by the highest levels of body dissatisfaction and dieting, as well as proportion of probable eating disorders.

Discussion:

A cultural models approach identified culturally important factors and patterns in disordered eating among young South Korean men and may be effective for understanding eating disorders in other populations not typically studied.

Keywords: eating disorders, body ideals, ethnobiocentrism, cultural models, emic validity, South Korea, men, cultural consonance

Introduction

Men comprise over 30% of cases of eating disorders (EDs) globally (Streatfeild et al., 2021), and up to 50% in South Korea (S.-C. Hong et al., 2015), but remain underrepresented in the ED literature (Murray et al., 2017). Cultural associations of EDs with femininity and vanity, barriers to men self-identifying problematic symptoms and then seeking and effectively accessing care, and research and treatment protocols rooted in women’s experiences that may be inappropriate for, or even stigmatizing to, men are common explanations (Bunnell, 2021; Darcy & Lin, 2012; Räisänen & Hunt, 2014). While men can experience any ED symptoms, men’s body image concerns are often associated with muscularity (Pope et al., 2000), making them particularly vulnerable to muscularity-oriented disordered eating. Such dietary (e.g., high protein consumption) and compensatory (e.g., overexercise, fat-burning and/or muscle-building supplement use) behaviors are driven by the pursuit of lean muscularity, in contrast to the weight loss- and thinness-oriented behaviors (e.g., purging, overall caloric restriction) more traditionally associated with EDs among women. However, “the extent that core cultural values are represented in body shape ideals and dietary norms, rationale for food refusal, concern with body shape, and distress associated with overeating will be culturally particular” (Becker, 2007, p. S112). Associations of “proper” masculinity with muscularity are not universal; therefore, understanding cultural variation in meanings associated with body shapes is necessary to address disordered eating among males.

Although some theories related to body image and EDs in Western women center cultural factors (e.g., Objectification Theory, Feminist theories of EDs; Bordo, 1993/2003; Boskind-Lodahl, 1976; Fredrickson & Roberts, 1997; Rodin et al., 1985), broader theories of culture have been underdeveloped in cross-cultural ED research (and psychopathology research more broadly; Bredström, 2019). Barring some notable exceptions (e.g., Chua et al., 2021; K. M. Pike & Borovoy, 2004; Thomas et al., 2015), cross-cultural ED research typically approaches culture as a post hoc rationalization for deviations from ethnobiocentric expectations or via nominal variables which only describe—rather than explain—cross-cultural variation (Anderson-Fye, 2017; McClure, 2020).

Therefore, the current investigation uses a cultural models approach (Dressler, 2018) to examine relationships between culturally defined parameters of body fatness and ED risk among young Korean men. Understanding how a society perceives and defines fatness and thinness informs how disordered eating may manifest in individuals with different culturally defined body-types, how communities police bodies (e.g., fat stigma), and how local healthcare providers may address these issues. In focusing on Korean men specifically, we address the intersection of two underdeveloped axes of experience in ED research—cultural variation and male gender—and discuss limitations of norms developed primarily on white, Western samples.

Ethnobiocentrism

Normative assessments linking health, size, and morality are fairly particular to US culture, rooted in “healthism” (Crawford, 1980; Saguy, 2013), anti-Black racism (Strings, 2019), the War on Fat (Boero, 2007), and a human tendency toward “biological normalcy” (Wiley, 2021): conflating statistical norms and social normativity. “Ethnobiocentrism”—how cultural beliefs and practices underlie popular, clinical, and research-oriented assessments of (non)normal biology (Wiley, 2021)—emphasizes that diagnostic criteria and treatments rooted in experiences of “Western” populations may not be universal. While hegemonic Western knowledge structures and the US media scaffold the rapid global emergence of fat stigma, globalized messages of “fat = undesirable” and “thin/muscular = desirable” are filtered through existing local cultural models and framed by social-political-economic structures, shaping their internalization across societies (Monocello, 2023; SturtzSreetharan et al., 2021). For example, Anderson-Fye and colleagues (2017) found that urban Nepalese participants stigmatized weight in relation to taking up space on public transportation, but were confused by questions about body size and marriageability, as they were culturally unrelated. Culture shapes the risk factors for and lived experiences of disordered eating (Lee, 2004), often in ways unanticipated by Western-centric theories and methods (Becker, 2007). So, while men’s body ideals can comprise dimensions of both fatness and muscularity, neither can be taken for granted and require explication within their cultural settings. While we focus on fatness in this investigation, the muscularity concerns among Korean men have been addressed elsewhere (Monocello, 2023).

Emic Validity

Ethnobiocentrism in research can be challenged with emic validity. Emic validity refers to the extent to which a measure reflects and is interpreted through a given society’s meaning systems (Dressler & Oths, 2014). “Emic” refers to the “insider” perspective of the community in question; its opposite, “etic,” refers to approaches which take an “objective outsider” perspective and assume universality (Becker, 2007; K. Pike, 1954). Emic validity may be especially important in ED research, in which purportedly “etic” approaches—the perspective taken in most psychological research—are often just the unexamined, exported, and reinforced emic approaches of globally dominant (i.e., white, Western) populations.

A lack of emic validity can have significant consequences. Becker (2007) notes that phenotypic variation in the cross-cultural presentation of EDs can lead to true cases being counted as noncases and vice-versa. Lee and colleagues’ (1993) identification of non-fat-phobic anorexia nervosa in Hong Kong, that is, all of the symptoms of anorexia nervosa without body image disturbance, which would otherwise be missed in screening, exemplifies the former. The latter is exemplified in Le Grange et al.’s (2004) finding that a significant proportion of black South African girls scored above the standard clinical cutoff on a widely used ED screening questionnaire (the Eating Attitudes Test-26; EAT-26). However, follow-up interviews revealed that, rather than reflecting ED symptoms severity as expected, scores actually reflected behaviors related to poverty and food insecurity, such as Muslim girls eating pork and then purging before digestion to satiate hunger while avoiding taboos.

Culture

Ethnographic attention to local ethnobiocentric assumptions which frame a measure’s interpretation is fundamental to valid cross-cultural research (Snodgrass et al., 2023). However, ethnography does not easily fit into statistical models. A cultural models approach mobilizes intracultural variation (i.e., ethnography) as variables defined by community members to account for culture in statistical models of health outcomes (Monocello et al., 2024). A cultural models approach defines culture as shared knowledge that facilitates living appropriately in a given society (Goodenough, 1957/1964), and can advance the emic study of culture in ED research. Culture is understood as “consensus” (Romney et al., 1986), existing at the points of overlap in individuals’ understandings of how the world tends to be even if that sharing is imperfect and intraculturally variable (Henderson et al., 2022). Cognitive anthropological methods center varied local knowledge in co-constructing research instruments and evaluating their results (see Figure 1). Effectively, these methods provide scalar, emically valid measures of culture, as opposed to categorical descriptors. A detailed glossary of cognitive anthropological terms is collated in Table 1.

Figure 1.

Figure 1.

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General Process Model for Cultural Domain, Cultural Consensus, and Cultural Consonance Analyses.

Table 1.

Glossary of Cognitive Anthropological Terms.

Term Definition
Culture Whatever an individual needs to know in order to live in a society in a way acceptable to its members (Goodenough, 1957/1964).
Cultural Answer Key The cultural answer key is the best cultural estimate of how a reasonably culturally competent respondent would answer the questions in a cultural consensus interview or questionnaire, usually in the form of a rating, ranking, or true/false task. The items within the questionnaire/cultural answer key usually come from members of the community themselves, consisting of frequently-mentioned concepts elicited during free-listing or open-ended interviews during earlier phases of research. The values in the cultural answer key are calculated as the average response weighted by the cultural competence (see below) of the participant, such that the responses of those participants whose responses accord with those of every other participant more (i.e., cultural consensus) are weighted more heavily than those who disagree (Romney et al., 1986).
Cultural Consensus Cultural models are “cultural” because they are shared; cultural consensus analysis refers to this sharedness as “consensus” (Romney et al., 1986). Cultural consensus is measured by cultural consensus analysis and primarily used to test the “one culture” hypothesis (see below), in order to demonstrate that people tend to talk about the cultural domain in the same ways.
Cultural Consensus Analysis Data collected via rating, ranking, or true/false tasks are analyzed using cultural consensus analysis (Romney et al., 1987). Cultural consensus analysis uses factor analytic methods to determine the latent factor between people rather than items. This latent factor is “culture.” (Factor analytic methods happen to solve the set of equations required to estimate cultural competence, although it is not a factor analysis strictly speaking.) Importantly, cultural consensus analysis must be performed on cultural questions. For example, “Would a typical Korean person describe X as too thin?” is a cultural question which addresses an individual’s knowledge of their culture; “Do you think X is too thin?” is a question of individual belief or preference which, while culturally informed, is inappropriate for cultural consensus analysis and better fits into a cultural consonance analysis framework (see cultural consonance).
Cultural Competence Cultural competence coefficients represent the degree to which that individual agrees with every other individual; the product of any two individuals’ cultural competence coefficients is the correlation between their responses. Cultural competence coefficients are the factor loadings on the first extracted factor and range from 0 to 1 (negative numbers are possible but usually represent someone misunderstanding the direction of the scale; to get a negative coefficient, one must answer opposite the overall model). Higher cultural competence coefficients (those approaching 1) indicate greater agreement with every other person. In other words, higher cultural competence indicates greater knowledge of the phenomenon (Romney et al., 1986). In general, average cultural competence should be greater than 0.4 (Romney et al., 1986).
Cultural Consonance People do not just know things; they also do things with that knowledge. Cultural consonance refers to the extent to which individuals in their beliefs and behaviors can approximate the information encoded in the cultural model in their own life (Dressler, 2018). In short, it is a measure of an individual’s ability to act in accordance with cultural expectations, typically based on the cultural answer key derived from cultural consensus analysis. That is, cultural consonance is an emic measure of belief or behavior which can be used to connect individuals’ relationship with their culture to other outcomes. Cultural consonance measures in other domains, such as lifestyle, family life, social support, and religiosity, have been associated with blood pressure, c-reactive protein, HbA1C, T-cell count, depression, and anxiety across societies (Andrews, 2019; Copeland, 2018; Dengah, 2014; Dressler, 2018; Reyes-Garcia et al., 2010).
Cultural Domain Whatever a group of people talks about (Weller & Romney, 1988).
Cultural Domain Analysis A set of emic, systematic ethnographic methods used to understand, from the ground up rather than imposing outsiders’ perspectives, a society’s approach to phenomena (cultural domains). In the first step, freelisting, researchers elicit the words and phrases people use when talking about the cultural domain. In the second step, pilesorting, researchers examine how freelisted items are cognitively related to each other in participants’ minds. These are followed by rating, ranking, or true/false tasks and analyzed using cultural consensus analysis. See Monocello & Dressler (2020) for an extended example of the entire cultural domain analysis process.
Cultural Models Culture is encoded in cognitive schemas or models skeletal mental representations of phenomena. These models are “cultural” because they are shared (members of a society tend to understand a phenomenon in generally the same way; see cultural consensus) and distributed (individuals’ understandings of the model are not perfect facsimiles but instead vary based on the totality of their own experiences) (D’Andrade, 1995). Cultural models are individuals’ instantiations of a cultural domain.
Eigenvalue Ratio The ratio between the eigenvalues of the first and second factors calculated in the cultural consensus analysis. If the ratio of the first to the second eigenvalues is greater or equal to three, meaning that the first factor explains at least 3 times as much variation as the second factor, there is “one culture,” and therefore, cultural consensus in the sample. (Romney et al., 1986).
Emic Derived from “phonemic,” emic refers to the “insider” perspective, or paying specific attention to, using the terms and meaning systems of, and interpreting data from the perspective of the community in question (K. Pike, 1954).
Emic Validity The extent to which a measure and its interpretation aligns with the meaning systems of the community in question (Dressler & Oths, 2014). Emic validity requires ethnography, and cognitive anthropological methods are systematic methods used for developing emically valid measures.
Etic Derived from “phonetic,” etic refers to taking the “outsider” or “universalist” perspective, or using measures and interpretation frameworks from outside the community in question, usually with the assumption that they are true for everyone (K. Pike, 1954).
Freelisting* The first systematic method of cultural domain analysis. Once a cultural domain has been identified through ethnographic participant-observation, a sample of individuals from the community in question are asked to list all of the words and phrases people tend to associate with a given cultural domain (e.g., “What do people in South Korea say when talking about men’s bodies? What are features people tend to like? What are features people tend to dislike?”). See Borgatti (1999) for more detail on how to conduct freelists, and Monocello (2023) for an extended, relevant example.
The “One Culture” Hypothesis Traditionally, cultural consensus analysis is performed with the understanding that there is “one” culture—one set of cultural knowledge—that the community draws on (Romney et al., 1986). The “one culture” hypothesis is tested by determining whether the ratio of the first and second eigenvalues in cultural consensus analysis is greater than 3:1 and the average cultural competence is at least 0.4. In short, it means that individuals in the focal community tend to talk about the cultural domain in the same ways.
Pilesorting* Usually the second step of cultural domain analysis. Once the freelisting has been completed, terms mentioned by at least 10% of people are written onto individual notecards and given to participants. In unconstrained pilesorts (the most common), participants are then asked to sort cards however they see fit, making at least two piles. In constrained pilesorts, participants are asked to sort the cards into a predetermined number of piles (Borgatti, 1999). Online methods which replicate this are possible. Pilesorts can be analyzed using nonmetric multidimensional scaling (Kruskal & Wish, 1978) and hierarchical cluster analysis (Johnson, 1967). See Sturrock and Rocha (2000) for guidance on interpreting the stress variables in nonmetric multidimensional scaling.
Residual Agreement Residual agreement is calculated as the factor loadings on the second factor for each individual. Residual agreement coefficients represent the ways in which individuals diverge within the overall cultural model. When graphing residual agreement coefficients against cultural competence coefficients, these usually take one of four forms: monofocal (there is strong overall agreement and minimal intracultural variation; circular), multifocal (there is overall agreement with significant, continuous cultural variation at the poles; oblong), multicentric (there may or may not be overall agreement, with two non-continuous clusters, indicating two or more “cultures”), and noncoherent (there is no overall agreement, and variation is random and centered on the origin). For analysis, residual agreement is examined largely through the signs (positive or negative) of the coefficient. Residual agreement is often patterned by other demographic factors, such as gender, age, or politics (Henderson et al., 2022).
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*

Not performed in this paper, but usually a necessary step in the cultural domain analysis-cultural consensus analysis-cultural consonance analysis process.

Male Body Image in South Korea

Koreans have been found to have the highest levels of body dissatisfaction and drive-for-thinness in the world (Lim & Paek, 2016). In a large sample of 10-24-year-olds, 50% evidenced disturbed body image and 6.8% a probable ED on the EAT-26, with no difference between genders (S.-C. Hong et al., 2015). In a nationally representative survey of 12-18-year-olds, boys were half as likely as girls (3.1-vs-6.6%) to fast for 24 hours, purge, or use diet pills (Yu et al., 2018). However, disordered weight control behaviors common in boys were not assessed (e.g., shorter fasts, single-food diets, compensatory exercise).

Young men often compare themselves to K-Pop idols who embody kkonminam (beautiful flower boy) appearance ideals. The kkonminam has a thin, lean physique, pretty features, fashionability, and assiduously uses skincare and cosmetics. Bodies are valued for their ornamentality rather than instrumentality. Further, in contrast to the US, Korean male body ideals and masculinity norms actively devalue muscle mass (Monocello, 2023; Monocello & Dressler, 2020).

Supporting the utility of this approach, prior work demonstrated that young Korean men’s conformity to the kkonminam cultural model (see Cultural Consonance (Attractiveness), below) predicted disordered eating beyond body dissatisfaction and body mass index (BMI), and it interacted with measures of university prestige and sexual orientation to predict disordered eating in two patterns (Monocello & Dressler, 2022). These data evidenced multiple, intersectional pathways by which men’s bodies were made meaningful in Korea and demonstrate the utility of a cultural models approach to understanding ED risk.

Current Study

This investigation represents a novel effort to connect a non-white, non-Western society’s cultural model of male body fatness to ED symptoms, building on previous work (Monocello, 2020; Monocello & Dressler, 2022) by focusing on what constitutes fatness/thinness among South Korean men and then connecting their own positioning within that schema to disordered eating symptomatology. There were two primary hypotheses. First, it was expected that cultural consensus analysis of figure rating scale responses would indicate consistency in young Korean men’s characterizations of “too thin” or “too fat.” Second, it was expected that the proportion of men with clinically significant disordered eating symptoms would significantly differ across the culturally informed categories of body fatness. Exploratory analyses were also conducted to examine the relationships of culturally informed categories of body fatness to theoretically related demographic, cultural, and body image variables, providing further context.

Method

Participants

LTM speaks Korean and collected data during ethnographic fieldwork in Seoul, South Korea from August 2019 to January 2021. Inclusion criteria included identifying as male, Korean, and being between 19-35-years-old (per Korean age, in which, at the time of data collection, an individual was age 1 at birth). A total of 103 young Korean men (ages 20-34-years) participated. Due to social stigmas surrounding LGBTQIA+ identity, an informal respondent-driven, ethnographic sampling approach (Heckathorn, 1997; Werner & Bernard, 1994) was utilized by asking participants to provide LTM’s contact information to friends and acquaintances who might be interested in participating. The survey took around 20 minutes to complete, and participants received 5,000 Korean won as compensation for their involvement. Three did not complete the survey. Due to an error in Qualtrics, 19 participants were not shown the figure rating scales; 81 participants are thus included in this analysis. This project was approved by the Institutional Review Board of the University of Alabama.

Measures

Demographics

Participants self-reported their age, gender, height, weight, sexual orientation, and university. Height and weight were used to calculate BMI (kg/m2); Korean men 19-29-years-old tend to accurately report height (likely following measurement for mandatory military service at age 19) and negligibly underestimate weight (Ko et al., 2022). Continuous BMI values were categorized into “underweight,” “normal weight,” “overweight,” and “obesity” using global and East Asia standards (World Health Organization, 2000). Sexual identity was self-reported as “heterosexual (isŏngaeja), bisexual (yangsŏngaeja), homosexual (tongsŏngaeja), and other (kit’a) (please describe)” and recoded into “heterosexual” (0) and “gay/bisexual” (1) due to low numbers of bisexual participants. None identified as “other.” Self-reported university was transformed into a dichotomous variable reflecting level of prestige: “high-prestige university” (1) included Seoul National University, Korea University, Yonsei University, Sungkyunkwan University, and KAIST; “low-prestige university” (0) included all other universities. Definitions referenced published rankings (e.g., US News & World Report and Chosun Ilbo), the sociology of Korean education literature (e.g., Jung & Lee, 2016), and ethnographic interviews. At least 70% of Koreans in this age group pursue tertiary education (Ministry of Education, 2023), as did everyone included in the current analysis.

Cultural Consonance (Attractiveness)

A previous paper describes the development of a scale of cultural consonance in the ideal male body for young Korean men, here referred to as “cultural consonance (attractiveness),” and demonstrates its association with disordered eating (Monocello & Dressler, 2022). Participants indicated the extent to which 29 features of the Korean model of the ideal male body were represented in their own bodies from 0 (not at all represented) to 3 (completely represented). Items included being at least 180-cm tall, being neat (kkalgŭmhada), having an “8-head body” (p’aldŭngsin), “small muscle” (chan’gŭnyuk), and having a “V-line jaw.” These scores were summed, with higher scores representing greater culturally-defined attractiveness. Cronbach’s alpha was good (0.86) in the current sample.

Body Dissatisfaction

The Male Body Attitudes Scale (MBAS; Tylka et al., 2005) is a 24-item scale assessing body dissatisfaction and includes three subscales: body fat, muscularity, and height. Participants indicate how often each statement applies to them on a scale from 1 (never) to 6 (always). Responses are averaged and higher scores indicate greater body dissatisfaction. The measure was translated into Korean and back translated into English by two fluent speakers of Korean and English. In the current sample, Cronbach’s alphas were 0.88 for the total score, 0.83 for body-fat, and 0.79 for muscularity; the Pearson correlation of the two-item height subscale was 0.42.

Disordered Eating

The Eating Attitudes Test (EAT-26; Garner et al., 1982; validated Korean translation: Rhee et al., 1998) is a 26-item scale assessing ED symptoms that includes three subscales: dieting behaviors, bulimia nervosa and food preoccupation, and oral control. Participants indicate how often each statement applies to them on a 6-point scale, and items rated 1 (always), 2 (usually), and 3 (often) receive a score of 3, 2, and 1, respectively; items rated 4 (sometimes), 5 (rarely), and 6 (never) receive a score of 0. Responses are summed and higher scores indicate greater ED symptoms. Among Korean men, scores above 18 indicate a probable ED (Rhee et al., 1998). In the current sample, Cronbach’s alphas were 0.87 for the total score, 0.85 for dieting, 0.83 for bulimia and food preoccupation, and 0.66 for oral control (low, but a common finding; Gleaves et al., 2014).

Figure Rating Scale

Participants were shown a figure rating scale depicting masculine bodies with 9-increments of increasing adiposity (Ralph-Nearman & Filik, 2018), chosen, in part, because figures had black hair resembling the Korean population (see Becker, 1995). For each figure, participants indicated whether a typical Korean person would describe it as “too thin” (nŏmu marŭta) and then separately as “too fat” (nŏmu ttungttunghada). These were terms used by participants in ethnographic interviews and are employed here to examine how people talk about body fatness in relation to health outcomes (i.e., to combat weight/fat stigma, it is important to understand what a society deems “too fat”). Participants were further asked to indicate which figure best represented their current and ideal body shapes, and to describe why they chose their ideal shape.

Analyses

Analyses were performed in SPSS 28. Ratings of “too thin” and “too fat” were analyzed using “cultural consensus analysis” (Romney et al., 1986). This approach was used to (1) determine whether Korean men share a cultural model of male body size (i.e., the ratio of the first to second eigenvalues is greater than 3); (2) estimate each participant’s “cultural competence,” and “residual agreement”; and (3) calculate the “cultural answer key,” the proportion of participants who indicated that a given body shape was “too fat” or “too thin”, weighted by participants’ cultural competence (see Table 1 for more detailed definitions and Figure 2 for the process model for this analysis). Fisher’s Exact tests (FE) were used to compare body-fatness categories based on the cultural consensus analysis versus Western and East Asia BMI categories.

Figure 2.

Figure 2.

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Process for Assessing Cultural Parameters of Body Fatness and Their Relationship to Body Dissatisfaction and Disordered Eating.

The difference between ideal and current body fatness was used as a discrepancy score reflecting degree of body dissatisfaction. Participants’ reasoning for choosing their ideal body fatness was analyzed using a thematic analytic approach (Bernard et al., 2017).

As a form of cultural consonance analysis, participants were assigned to body-fatness categories defined by the cultural answer key based on their self-reported current shape. Bivariate analyses of variance (ANOVAs) were conducted to compare body-fatness categories on age, ideal fatness, height, weight, BMI, cultural competence, residual agreement, cultural consonance (attractiveness), body dissatisfaction (i.e., MBAS and current-ideal discrepancy scores), and disordered eating (EAT-26). Chi-square tests were conducted to compare the body-fatness categories on binary outcomes of university prestige, sexual orientation, and EAT-26 cutoff. When overall models were significant, pairwise differences were analyzed by Bonferroni post-hocs in ANOVAs and FE in chi-squares (Shan & Gerstenberger, 2017). Effect sizes are reported as η2 for ANOVAs (0.01, 0.06, and 0.14 reflecting small, medium, and large effects), Cramer’s V for overall cross-tabulations (0.07, 0.21, and 0.35 reflecting small, medium, and large effects) (Cohen, 1988), and Number-needed-to-treat (NNT) for pairwise comparisons (NNT<10 is meaningful; Citrome, 2011). Analyses were repeated using FE on the Western and East Asia BMI parameters for comparison to the cultural answer key.

Results

Descriptive Statistics

Descriptives are reported in Table 2. The average age of participants was 26.27±3.23 years, height was 175.8±5.11 cm, weight was 72.99±9.61 kg, and BMI was 23.56±2.51 kg/m2. Average cultural consonance (attractiveness) was 35.26±12.40, perceived-ideal discrepancy was 0.26±1.56, MBAS total was 3.55±0.78, and EAT-26 total was 11.21±9.64. Thirty-five percent of the sample attended a high-prestige university, 22% identified as gay or bisexual, and 23% evidenced a probable ED (EAT-26 score>18). All included variables evidenced acceptable skewness and kurtosis except for the EAT-26 total and subscale scores (skewness: 1.02-1.76 kurtosis: 0.19-3.84), which is common in non-clinical samples (i.e., most score at the lower end).

Table 2.

Demographic Characteristics

Variable Mean (SD) Range
Korean Age (years) 26.72(3.23) 20 to 34
Perceived Fatness 4.73(1.50) 1 to 8
Ideal Fatness 4.47(0.76) 3 to 6
Perceived - Ideal Discrepancy 0.26(1.56) −4 to 4
Height (cm) 175.8(5.11) 164 to 187
Weight (kg) 72.99(9.61) 51 to 100
BMI (kg/m^2) 23.56(2.51) 18.17 to 29.54
% Attending a High-Prestige University 35% --
% Gay/Bisexual 22% --
Cultural Competence (Figure Rating Scale) 0.86(0.10) 0.44 to 0.96
Residual Agreement (Figure Rating Scale) 0.01(0.23) −0.41 to 0.57
Cultural Consonance (Attractiveness) 35.26(12.40) 9 to 65
MBAS Total Score 3.55(0.78) 2.13 to 5.21
  MBAS: Low Body Fat Subscale 3.07(1.10) 1.13 to 5.38
  MBAS: Muscularity Subscale 3.76(0.89) 1.6 to 5.7
  MBAS: Height Subscale 3.94(1.31) 1 to 6
EAT-26 Total Score 11.21(9.64) 0 to 36
  EAT-26 Korean Cutoff (>18) 23% --
  EAT-26 Diet Subscale 6.42(6.12) 0 to 23
  EAT-26 Bulimia and Food Preoccupation Subscale 2.22(3.17) 0 to 13
  EAT-26 Oral Control Subscale 2.43(3.01) 0 to 15
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Cultural Consensus Analysis

Cultural consensus analysis of the “Too Fat” and “Too Thin” ratings resulted in an eigenvalue ratio of 13.74:1, accounting for 89% of the variance. Average cultural competence was 0.86±0.10, indicating that young Korean men strongly share the same standards of thinness and fatness. With an established cutoff of 20% indicating cultural salience (Weller et al., 2018), the cultural answer key (Table 3) identified figures 1-3 as “too thin”, 4-5 as “balanced,” and 6-9 as “too fat” (34% and 21% of participants selected 3 and 6 as “too thin” and “too fat,” respectively).

Table 3.

Cultural answer key and within-groups means for cultural body fatness categories.

Cultural Answer Key "Too Thin"
(n=18)		 "Balanced"
(n-34)		 "Too Fat"
(n=29)
Distribution of Responses 1 2 3 4 5 6 7 8 9
Perceived Fatness 1.2% 3.7% 17.3% 25.9% 16.0% 24.7% 8.6% 2.5% 0.0%
Ideal Fatness 0.0% 0.0% 12.3% 32.1% 51.9% 3.7% 0.0% 0.0% 0.0%
Is Figure X Too Thin? (% Yes) 93.5% 88.3% 34.5% 11.2% 4,7% 1.8% 0.0% 0.0% 0.0%
Is Figure X Too Fat? (% Yes) 0.0% 0.0% 0.0% 0.0% 2.4% 20.6% 62.5% 93.7% 97.4%
Within-Groups Means ± Standard Deviation
Korean Age (years) 26.72 ± 3.54 26.00 ± 3.04 26.31 ± 3.33
Ideal Fatness 4.44 ± 0.92 4.29 ± 0.71 4.69 ± 0.66
Perceived - Ideal Discrepancy −1.72 ± 1.02 0.09 ± 0.83 1.69 ± 0.89
Height (cm) 173.36 ± 5.59 177.21 ± 5.52 175.67 ± 4.26
Weight (kg) 63.39 ± 7.20 73.29 ± 7.77 78.59 ± 8.33
BMI (kg/m2) 21.08 ± 2.04 23.30 ± 1.84 25.41 ± 1.98
% High Prestige University 44% 18% 48%
% Gay/Bisexual 33% 21% 17%
Cultural Competence (Figure Rating Scale) 0.89 ± 0.07 0.85 ± 0.12 0.86 ± 0.10
Residual Agreement (Figure Rating Scale) 0.03 ± 0.24 0.03 ± 0.26 −0.04 ± 0.21
Cultural Consonance (Attractiveness) 35.67 ± 13.32 40.05 ± 12.17 29.38 ± 9.62
MBAS 3.14 ± 0.77 3.27 ± 0.74 3.96 ± 0.69
 MBAS Low Body Fat Subscale 2.37 ± 0.85 2.77 ± 1.07 3.87 ± 0.77
 MBAS Muscularity Subscale 4.10 ± 1.10 3.63 ± 0.79 3.69 ± 0.82
 MBAS Height Subscale 4.02 ± 1.45 3.62 ± 1.29 4.26 ± 1.21
EAT-26 8.33 ± 7.65 10.68 ± 10.26 13.62 ± 9.71
 EAT-26 Korean Cutoff (>18) 11% 15% 41%
 EAT-26 Dieting Subscale 3.39 ± 4.58 6.32 ± 6.02 8.41 ± 6.44
 EAT-26 Bulimia and Food Preoccupation Subscale 1.28 ± 2.65 2.03 ± 3.00 3.03 ± 3.55
 EAT-26 Oral Control Subscale 3.67 ± 3.25 2.24 ± 3.34 1.90 ± 2.23
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Thematic Analysis

The term “Balanced” was selected because 46% of participants justified their selection by calling it “moderate” (chŏng’gyŏkhada), “not excessive” (kwahaji anda), or “balanced” (paellonsŭ-ga itta, kyunhyŏngchaphida). An additional 10% referred to wide shoulders (okkaega nolta) or the overall frame (tŏngch’i) in reference to having ideal, inverted-triangle torso proportions. Six percent described these bodies as “sturdy” (t’ŭnt’ŭnhada, kŏnjanghada), contrasted with timidity in thinness. “Healthy” (kŏn’kanghada), “normal” (in English or pot’ong ch’ehyŏng), “average” (p’yŏng’gyun) and “standard” (English) were used by only 2.4% of participants each.

Body-Fatness Group Comparisons

Participants were categorized as “Too Thin” (n=18), “Balanced” (n=34), and “Too Fat” (n=29) based on their current body fatness as self-rated on the figure rating scale. ANOVAs (see Tables 3 and 4) revealed that all three of the cultural answer key categories significantly differed in perceived-ideal body fatness discrepancy (F[2,78]=81.68, p<0.001), weight (F[2,78]=21.03, p<0.001), and BMI (F[2,78]=28.77, p<0.001), with large effect sizes. Height also significantly differed (F[2,78]=3.556, p=0.033; medium effect size), with the “balanced” group taller than the “too thin” group. Significant differences with large effect sizes also were found for MBAS total (F[2,78]=7.05, p=0.002) and Low Body Fat (F[2,78]=17.14, p<0.001), with the “too fat” group higher than the “too thin” and “balanced” groups, as well as for cultural consonance (F[2,78]=5.178, p=0.008), for which the “too fat” group was lower than the “balanced” group. In terms of disordered eating, there were significant differences in EAT-26 dieting scores (F[2,78]=4.086, p=0.020; medium effect size), which were significantly higher in the “too fat” group than the “too thin” group. χ2-tests revealed that percentage of participants with EAT-26 total scores >18 significantly differed (χ2(2)=8.166, p=0.017, medium effect size), with percentages higher in the “too fat” group than the “too thin” (p=0.023, NNT=4) and “balanced” (p=0.047, NNT=4) groups, as well as significant differences in percentage of high-prestige university attendees (χ2(2)=7.489, p=0.024, medium effect size), with a smaller percentage in the “balanced” versus the “too thin” group (p=0.014, NNT=4) . No significant between-group differences were found for age, ideal body size, highest “too thin” rating, lowest “too fat” rating, percent “gay/bisexual,” cultural competence, residual agreement, MBAS muscularity, MBAS height, EAT-26 total, EAT-26 bulimia and food preoccupation, and EAT-26 oral control (ps>0.05).

Table 4.

ANOVAs, Chi-Square, and Fisher’s Exact Tests comparing the Cultural Answer Key and BMI Categorization Parameters

Cultural Answer Key Western BMI Categories East Asia & Pacific BMI Categories
Analysis of Variance F(2,78) p η2 F(2,78) p η2 F(3,77) p η2
Korean Age (years) 0.292    0.747 0.007 3.480    0.036 d,e 0.082 2.324    0.081 0.083
Perceived Fatness 247.943 < 0.001 a,b,c 0.864 13.491 < 0.001 e,g 0.257 17.964 < 0.001 f,g,h 0.412
Ideal Fatness 2.197    0.118 0.053 0.846    0.433 0.021 0.755    0.523 0.029
Perceived - Ideal Discrepancy 81.676 < 0.001 a,b,c 0.677 8.708 < 0.001 g 0.183 10.814 < 0.001 g,h 0.296
Height (cm) 3.556    0.033 a 0.084 1.456    0.239 0.036 3.572    0.018 g 0.122
Weight (kg) 20.824 < 0.001 a,b,c 0.348 42.700 < 0.001 d,e,g 0.523 69.418 < 0.001 d,e,f,g,h,i 0.730
BMI (kg/m^2) 28.404 < 0.001 a,b,c 0.421 79.082 < 0.001 d,e,g 0.670 131.911 < 0.001 d,e,f,g,h,i 0.837
Cultural Competence (Figure Rating Scale) 1.217    0.302 0.030 0.201    0.818 0.005 3.072    0.033 g 0.107
Residual Agreement (Figure Rating Scale) 0.680    0.510 0.017 0.457    0.635 0.012 0.414    0.743 0.016
Cultural Consonance (Attractiveness) 6.643    0.002 c 0.146 0.667    0.516 0.017 0.792    0.502 0.030
MBAS Score 7.407    0.001 b,c 0.160 5.080    0.008 g 0.115 3.838    0.013 i 0.130
  MBAS Low Body Fat Subscale 17.739 < 0.001 b,c 0.313 10.218 < 0.001 g 0.208 6.834 < 0.001 h,i 0.210
  MBAS Muscularity Subscale 1.796    0.173 0.044 0.283    0.754 0.007 0.928    0.431 0.035
  MBAS Height Subscale 1.968    0.147 0.048 1.743    0.182 0.043 1.602    0.196 0.059
EAT-26 Score 1.795    0.173 0.044 3.669    0.030 * 0.086 3.031    0.034 i 0.106
  EAT-26 Diet Subscale Score 4.033    0.022 b 0.094 5.517    0.006 g 0.124 3.655    0.016 * 0.125
  EAT-26 Bulimia and Food Preoccupation Subscale 1.847    0.164 0.045 1.969    0.147 0.048 1.645    0.186 0.060
  EAT-26 Oral Control Subscale 2.105    0.129 0.051 0.012    0.988 0.000 2.541    0.062 0.090
χ2 and Fisher's Exact Test χ2(2) p Cramer's V Fisher's exact p Cramer's V Fisher's exact p Cramer's V
% Gay/Bisexual 1.754    0.416 0.147    0.323 0.171 < 0.001 g,h 0.479
% Attending High-Prestige University 7.489    0.024 c 0.304    0.337 0.170    0.057 0.307
EAT-26 Korean Cutoff (>18) 8.166    0.017 b,c 0.318    0.023 g 0.303    0.042 i 0.326
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a:

Significant difference between "Too Thin" and "Balanced" groups,

b:

Significant dfference between "Too Thin" and "Too Fat" groups,

c:

Significant difference between "Balanced" and "Too Fat" groups,

d:

Significant difference between "Underweight" and "Normal Weight" groups,

e:

Significant difference between "Underweight" and "Overweight" groups,

f:

Significant difference between "Underweight" and "Obesity"groups,

g:

Significant difference between "Normal Weight" and "Overweight" groups,

h:

Significant difference between "Normal Weight" and "Obesity" groups,

i:

Significant difference between "Overweight" and "Obesity" groups,

*:

No significant between-group differences identified in post-hoc tests, Fisher's Exact test is used due to multiple cells with counts <5 in BMI-based analyses

The cultural model categorized participants differently than Western and East Asia BMI categories (ps<0.001), with large effect sizes. Only 2 participants were categorized as “underweight.” East Asia parameters categorized 23 participants under obesity; none had obesity based on Western categories (Table 5). ANOVAs, chi-squares, and FEs comparing the Western categories and East Asia BMI categories evidenced mostly similar patterns (Table 4). However, significant differences in cultural consonance and percentage of high-prestige university attendees were only found in the tests comparing categories from the cultural answer key, significant differences in cultural competence (medium effect size) and sexual identity (large effect size) were only found with the East Asia BMI categories, and significant differences on continuous EAT-26 total scores (medium effect sizes) were only found with Western and East Asia BMI categories.

Table 5.

Comparisons of the Cultural Answer Key to BMI Categories

Cultural Answer Key East Asia Body Mass Index Categories
Underweight Normal Weight Overweight Obesity Total
N % N % N % N % N %
Too Skinny 1 50.00% 16 48.50% 0 0.00% 1 4.30% 18 22.20%
Balanced 1 50.00% 13 39.40% 15 65.20% 5 21.70% 34 42.00%
Too Fat 0 0.00% 4 12.10% 8 34.80% 17 73.90% 29 35.80%
Total 2 100.00% 33 100.00% 23 100.00% 23 100.00% 81 100.00%
Cultural Answer Key Western/Global Body Mass Index Categories
Underweight Normal Weight Overweight Obesity Total
N % N % N % N % N %
Too Skinny 1 50.00% 16 28.60% 1 4.30% 0 0.00% 18 22.20%
Balanced 1 50.00% 28 50.00% 5 21.70% 0 0.00% 34 42.00%
Too Fat 0 0.00% 12 21.40% 17 73.90% 0 0.00% 29 35.80%
Total 2 100.00% 56 100.00% 23 100.00% 0 0.00% 81 100.00%
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p< 0.001, Cramer’s V = 0.496

p<0.001, Cramer’s V = 0.364

Discussion

This research employed cognitive anthropological theory and methods to explore how a systematic approach to culture challenges ethnobiocentrism in measures and elucidates local understandings of body fatness and their associations with disordered eating. Both primary hypotheses were supported in this study of young Korean men. First, there was cultural consensus in how men characterize “too thin” and “too fat” bodies, and second, the proportion of men with a probable ED varied significantly across emic body-fatness parameters. In exploratory analyses, emic body-fatness parameters were associated with other important cultural variables—university prestige and cultural consonance with the Korean cultural model of the ideal male body—while etic BMI categories were not, bolstering confidence in the emic validity of the cultural answer key (Snodgrass et al., 2023).

The high eigenvalue ratio and high average cultural competence indicated a single cultural model of male body fatness with strong intracultural agreement about what “too thin” and “too fat” shapes look like. These parameters were narrower than the parameters described by Cullin’s (2021) sample of adolescents from the midwestern US, indicating cross-cultural variation in body norms.

Whereas US ethnobiocentrism often collapses conceptions of “normal,” “healthy,” and “ideal” bodies (Cullin, 2021), Korean men instead condensed ideals with balance, moderation, or non-excess, consistent with broader cultural valuation of social/physical harmony and “not standing out.” Previous work indicated that “too thin” bodies were viewed as timid and easy to overpower, while “too fat” bodies were viewed as unattractive and lazy. Assessments were based on “lookism” rather than “healthism”: fat was not “bad” or “dangerous” due to health implications, but hindered appropriate self-presentation (e.g., dressing fashionably) in public and reflected disregard of chagi kwalli (“self-maintenance”), with related professional, romantic, and interpersonal implications (Elfving-Hwang, 2021; Monocello, 2020). A balanced body indicates vitality, self-assuredness, and engagement in appropriate self-maintenance practices. This instills: potential employers’ confidence in men’s professional contributions and ability to represent their company; potential romantic partners’ attraction and confidence in their earning potential; and friends’ desire to have connections (chŏng) with them (An, 2019; K.-H. Hong, 2007).

Although continuous EAT-26 total scores did not differ across the cultural answer key, men with scores above the clinical cutoff were most highly represented in the “too fat” category. These men also exhibited the highest scores on dieting and dissatisfaction with body fat, consistent with recent research showing high incidence of disordered eating among young men with higher body weights (Nagata et al., 2018).

Men in the “balanced” category exhibited the highest cultural consonance with the Korean cultural model of the ideal male body (as expected) and the lowest proportion of high-prestige university attendees. In Korea, wealthy families are disproportionately represented in top universities (Byon, 2014), which confer social and cultural capital, resulting in advantages in the hypercompetitive job market. The job market also considers physical appearance in employment decisions, so men without high-prestige educations may feel more pressure to engage in (deleterious) appearance-maintenance/enhancement strategies than men with high-prestige educations to gain employment (Brewis, 2017; Monocello & Dressler, 2022)

Results also indicated that “etic” global and East Asia BMI categories sorted men differently than the cultural model: many men in the culturally-ideal “balanced” category were classified as overweight (BMI = 23.30±1.84), and therefore “unhealthy,” by biomedical standards. Despite this, only two participants described their ideal shape as “healthy.” Because BMI categories are based on health data with analytical decisions ethnobiocentrically framed by “Western” values, their interpretation may change in communities where “health” is less immediately intertwined with the morality of bodies.

Although cultural competence varied among men categorized as “normal” and “overweight” by East Asia BMI categories (not the cultural model categories), the effect size was modest. BMI cannot distinguish adiposity from muscularity, a weakness of BMI in male body image/ED research more broadly, so trends toward muscularity-appreciation, countering predominant “kkonminam” ideals, may lead to a “broadened” cultural model with lower cultural competence scores in this domain among emergent muscularity-oriented young men (Monocello, 2023).

While BMI was directly associated with disordered eating and body dissatisfaction, neither the Western nor East Asia BMI categories varied significantly in terms of university prestige or cultural consonance, which are cultural factors associated with disordered eating in Korean men (Monocello & Dressler, 2022). Therefore, findings support the notion that BMI alone lacks emic validity, and a cultural models approach to body fatness may help better understand relationships between body fatness and ED risk in non-Western societies.

Strengths and Limitations

Strengths of this study include its sample of men; a non-white, non-Western context; and the employment of cognitive anthropological mixed-methods based in ethnography. This study provides a unique a framework for studying these issues in ways that do not assume the universality of white, Western perspectives. It also provides a locally defined but replicable alternative to biomedical BMI categories—poor proxies of “health” and adiposity and cross-culturally questionable proxies for vulnerability to fat stigma—for understanding interactions between body shapes, social structures, and health outcomes.

Limitations include the cross-sectional design and ethnographic sampling techniques, necessitating replication with a random-sample design to more broadly characterize disordered eating in this population. Specifically, respondent-driven sampling approaches may reach like-minded people, potentially reducing variability of experiences. Moreover, all participants were college-educated, limiting generalizability for Korean men who do not pursue tertiary education. Sample size might have limited power to detect differences, and the number of models may have increased risk for type-I errors in this largely exploratory investigation. Additionally, muscularity and other potential confounders were not included in analyses. While the EAT-26 and MBAS were used based on face validity and previous use in South Korea, their emic validity requires further study. Replication with a locally validated ED diagnostic measure is suggested. Finally, while Korean colleagues facilitated the first author’s local academic affiliation, they were not involved in the implementation of this project or preparation of this manuscript.

Conclusions

This investigation employed a cultural models approach in examining young Korean men’s perceptions of body thinness and fatness, integrating local meaning systems into analyses and providing more culturally salient understandings of local risks for disordered eating. A single cultural model of body fatness was found with emically valid parameters of “too thin,” “balanced,” and “too fat” that were related to body dissatisfaction and disordered eating. Findings highlight the importance of attending to emic validity in research on EDs across societies. Adding to Bunnell’s (2021) calls for greater attention to men’s meaning systems in treatment settings (e.g., measures, information delivery), clinicians should also attend to patients’ culturally-informed reasonings for pursuing particular body shapes and perceived consequences for failure. Because healthcare providers, as well as those experiencing and fighting against weight/fat stigma, are also cultural beings, emic understandings of a society’s definition of “normal” and “fat” bodies are necessary for accurate analysis and advocacy, as these are the frameworks through which discourses regarding fatness emerge.

Public Significance Statement:

This study applies a systematic, “emic” perspective to young South Korean men’s body ideals. Young Korean men share a cultural model of body fatness, and this model frames how they experience risk for eating disorders. This study demonstrates a method for incorporating culture into research on eating disorder risk.

Acknowledgements:

We would like to recognize Professor Hyeon Jung Lee from the Seoul National University Department of Anthropology, who facilitated Lawrence Monocello’s affiliation as Visiting Researcher with the Seoul National University Institute of Cross-Cultural Research; officials from The Republic of Korea Ministry of Foreign Affairs and Fulbright Korea who partnered to connect fellows with scholars, politicians, and members of the K-Pop industry who, while not directly referenced in this article, contributed to the ethnographic panorama within which these data are interpreted; and the generous Korean participants who were promised anonymity but made this research possible. A previous version of this was presented as a virtual poster at ObesityWeek in 2022. William Dressler, Nicole Henderson, François Dengah provided comments on the manuscript. Research is supported by grants BCS #1918227 from the National Science Foundation and a Fulbright US Student Award (South Korea). Lawrence Monocello’s time is supported by T32HL130357 (PI: Denise Wilfley) from the National Heart, Lung and Blood Institute, and was supported during the 2021-2022 academic year by the Korea Foundation (during which some of the ethnographic analysis was conducted). Ellen Fitzsimmons-Craft’s time is supported by K08MH120341 from the National Institute of Mental Health. Lauren Fowler is supported by the National Institute On Minority Health And Health Disparities of the National Institutes of Health under Award Number K01MD017630. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Science Foundation, or Fulbright; the opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense.

Footnotes

Conflict of Interest:

Ellen Fitzsimmons-Craft receives royalties from UpToDate.

Contributor Information

Lawrence T. Monocello, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO

Jason M. Lavender, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Military Cardiovascular Outcomes Research (MiCOR) Program, Bethesda, MD; The Metis Foundation, San Antonio, TX

Lauren A. Fowler, Brown School of Social Work, Washington University in St. Louis, St. Louis, MO

Ellen E. Fitzsimmons-Craft, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO

Denise E. Wilfley, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO

Data Availability Statement:

De-identified quantitative data can be made available upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

De-identified quantitative data can be made available upon reasonable request.

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