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Published in final edited form as: Eat Behav. 2020 Nov 24;40:101458. doi: 10.1016/j.eatbeh.2020.101458

Eating Disorder Symptoms in Asian American College Students

Rachel C Uri 1,2, Ya-Ke Wu 1,3, Jessica H Baker 1, Melissa A Munn-Chernoff 1
PMCID: PMC7906921  NIHMSID: NIHMS1649396  PMID: 33307468

Abstract

Inconsistent information on levels of eating pathology in Asian Americans exist. We investigated whether there were differences in mean scores for eating disorder (ED) symptoms among Whites, Asian Americans, and individuals identifying as another race (i.e., non-Asian people of color [NAPOC]). Participants included 716 college students (M age=19.23; SD=1.65) from a southeastern university. ED symptoms were assessed with the Eating Pathology Symptom Inventory (EPSI). Internalizing symptoms were evaluated via the Depression Anxiety and Stress Scale (DASS). One-way ANOVAs investigated mean differences in symptoms between racial groups, with and without adjusting for sex, BMI, and internalizing symptoms. Overall, 16% (n=114) of the sample identified as Asian American, 67% (n=477) as White, and 17% (n=125) as NAPOC. After correcting for multiple testing and adjusting for covariates, Asian Americans reported higher mean scores of purging, muscle building, and cognitive restraint (qs<.05) than Whites and NAPOC. Asian Americans also scored higher on restriction compared with Whites (qs<.05), as well as body dissatisfaction and negative attitudes towards obesity compared with NAPOC (qs<.05). These findings demonstrate the existence of racial differences amongst specific ED symptoms, highlighting the importance of considering these distinctions when diagnosing and treating EDs among diverse communities.

Keywords: eating disorders, disordered eating, Asian Americans, mental health, college student

1. Introduction

In the United States (U.S.), the prevalence of eating disorder (ED) diagnoses in Asian Americans is similar to other ethnic/racial groups (Marques et al., 2011; Cheng, et al., 2019). The lifetime prevalence for any ED diagnosis in adults is 2.31% for non-Latino Whites, 4.22% for Latinos, 2.84% for Asian Americans, and 2.94% for African Americans (Marques et al., 2011). However, less research has examined differences in the prevalence or mean scores of ED symptoms between racial groups, particularly Asian Americans, information which could identify facets of EDs that may be particularly prevalent in one population and ultimately inform prevention and treatment. Asian American adults endorse more binge eating (Lee-Winn et al., 2014), and female Asian American college students report more body dissatisfaction (Forbes & Frederick, 2008) and distress related to ED cognitions (Masuda et al., 2014) than their White peers. Additional research is needed to investigate differences in ED symptoms between Asian Americans and other racial groups because presentation specific to this population has not been critically evaluated.

ED symptoms emerge during major life events, including the transition to college (Eisenberg et al., 2011). Transitioning from high school to college requires adjustments to increased independence, stress, and academic pressure, making college a pernicious time for mental health problems. An elevated prevalence of ED diagnoses among U.S. college students versus the general population exists (Fitzsimmons-Craft et al., 2019). Further, Asian Americans may be particularly susceptible to developing ED symptoms during college. Asian American women have reported more frequent experiences of racial and foreigner discrimination in college, possibly contributing to heightened ED symptomatology and self-objectification versus other racial minority groups (Cheng et al., 2017; Yokoyama, 2007). Therefore, the increase in EDs and their symptoms throughout college provides an ideal period to examine racial differences in ED symptoms, particularly in Asian Americans.

We assessed whether mean scores across a range of ED symptoms differed among Asian Americans, Whites, and individuals identifying as another racial minority, and examined whether associations between ED symptoms and race were influenced by BMI, sex, and internalizing symptoms, which have been associated with ED pathology and race in college students (Chen et al., 2019; Eisenberg et al., 2011). We hypothesized that Asian Americans would report higher mean scores for binge eating and body dissatisfaction than participants of other racial backgrounds, after adjusting for factors suggested to influence the association. Results from this study could be informative to clinicians and college health administrations in recognizing and preventing ED pathology among Asian Americans.

2. Method and Materials

2.1. Participants and Procedure

Students (≥18 years old) attending a large southeastern university participated in the Carolina College Assessment of Research and Education in Science (Carolina C.A.R.E.S.) study. Students from an introductory psychology course (n=716) completed an online survey in Qualtrics from Fall 2016 to Fall 2017, receiving course credit for participation. All students consented to the study online before survey completion. The local Institutional Review Board approved the study.

Overall, 46.9% of the sample were first-year students, 28.2% were sophomores, 17.7% were juniors, 7.0% were seniors, and 0.1% were graduate students (mean age±standard deviation [SD]=19.2±1.7 years). The sample was 61% female and 39% male, and the racial breakdown was 66.2% White, 15.9% Asian American, 9.2% African American, 0.1% Pacific Islander, 4.2% Multiracial, and 3.9% identifying as another race. The sex ratio and racial identification in this study closely matched that of the university at the time of study.

2.2. Measures

2.2.1. ED Symptoms

The Eating Pathology Symptom Inventory (EPSI; Forbush et al., 2013) assessed ED symptoms. It is a self-report questionnaire answered on a 5-point Likert scale (0=Never to 4=Very Often), with scores summed for eight subscales: restriction, body dissatisfaction, purging, binge eating, excessive exercise, muscle building, negative attitudes toward obesity, and cognitive restraint. The Cronbach’s alpha for this measure ranges from 0.67-0.91 and correlates highly with related constructs, evidencing convergent validity in college samples (Forbush et al., 2013). The Cronbach’s alphas for the subscales were 0.77-0.90 in this study.

2.2.2. BMI

Self-reported current height (in inches) and weight (in pounds) were collected. We converted height to meters and weight to kilograms to calculate BMI (kilograms/meters2). Three implausible current BMI values (i.e., <6) were recoded as missing.

2.2.3. Depression, Anxiety, and Stress

We evaluated internalizing symptoms using the Depression Anxiety and Stress Scale (DASS; Lovibond & Lovibond, 1995), a self-report measure assessing indicators of negative affect with three subscales—depression, anxiety, and stress. Past studies show Cronbach’s alphas for the DASS ranging from 0.78-0.87; it correlates with similar constructs, demonstrating convergent validity among college samples (Norton, 2007). In this study, the Cronbach’s alphas were 0.95 for depression, 0.89 for anxiety, and 0.92 for stress.

2.3. Statistical Analysis

We used SAS version 9.4 (SAS Institute, 2014) to perform analyses. We combined Asians and Pacific Islanders into an “Asian” group, and African Americans and individuals of multiracial and other racial backgrounds into a non-Asian people of color (NAPOC) group to evaluate ED symptoms in a non-White, non-Asian American comparison sample. Although the NAPOC group includes multiple racial identities (n African American=66; n Multiracial=30; n Another race=28), we created a single racial minority group given similar mean scores on the EPSI subscales across groups (Supplemental Table 1) and to increase statistical power. Overall, 14 individuals had missing data for BMI, whereas three people had missing data for age. Because less than 2% of data were missing, missing data were replaced using mean imputation with PROC STDIZE. Mean differences in symptoms were examined among White (n=476), Asian American (n=115), and NAPOC (n=124) individuals via analysis of variance using PROC GLM. We used the false discovery rate (FDR, represented by “q”; Benjamini & Hochberg, 1995) to correct for multiple testing (q<.05; n=96 tests for all models). Due to the different sample sizes across groups, Hedges' g effect sizes were provided to determine the magnitude of mean group differences (Cohen, 1988).

3. Results

Mean EPSI scores for this sample were consistent with normative data in college students (Forbush et al., 2013; K. T. Forbush, personal communication, June 16, 2020). Table 1 shows mean ED symptom and internalizing scores in the total sample and each racial group. Significant differences among racial groups in mean scores for many ED symptoms existed, after adjusting for sex, BMI, and internalizing symptoms (Table 2 and Supplemental Table 2). Asian Americans reported higher mean scores on purging (q<.009), muscle building (q<.013), and cognitive restraint (q<.001) than Whites or NAPOC. Asian Americans had higher scores on restriction compared with Whites (q<.004). Additionally, Asian American participants reported higher levels of body dissatisfaction (q<.011) and negative attitudes toward obesity (q<.004) than NAPOC. Finally, White participants scored higher on negative attitudes towards obesity (q<.001) compared with NAPOC.

Table 1.

Mean (standard deviation) scores for demographic characteristics, eating disorder symptoms, and internalizing symptoms across racial groups.

Total
(n=716)		 White
(n=477)		 Asian
(n=115)		 NAPOC
(n=124)
Age (years) 19.23 (1.64) 19.30 (1.81) 19.13 (1.17) 19.06 (1.32)
range: 18-35 range: 18-23 range: 18-27
BMI (kg/m2) 23.18 (3.71) 23.05 (3.65) 22.18 (3.33) 24.58 (3.91)
Eating Disorder Symptoms
Restriction 4.05 (4.68) 3.66 (4.35) 5.47 (5.77) 4.22 (4.55)
Body Dissatisfaction 8.80 (7.08) 8.56 (7.12) 9.95 (6.78) 8.64 (7.14)
Purging 0.75 (2.22) 0.63 (1.95) 1.36 (3.40) 0.65 (1.65)
Binge Eating 6.72 (5.89) 6.43 (5.58) 7.89 (6.89) 6.77 (5.97)
Excessive Exercise 5.87 (5.42) 6.09 (5.49) 5.84 (5.41) 5.06 (5.13)
Muscle Building 2.86 (3.64) 2.68 (3.34) 3.77 (4.62) 2.69 (3.64)
Negative Attitudes Toward Obesity 4.96 (4.78) 5.18 (4.99) 5.36 (4.44) 3.74 (4.01)
Cognitive Restraint 4.57 (3.14) 4.61 (3.09) 5.37 (3.29) 3.69 (2.98)
Internalizing Symptoms
Depression 4.88 (6.93) 4.74 (7.02) 6.09 (7.60) 4.31 (5.76)
Anxiety 4.66 (5.69) 4.54 (5.75) 6.12 (6.43) 3.76 (4.43)
Stress 7.50 (6.97) 7.32 (6.84) 9.00 (7.66) 6.77 (6.62)
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Note: NAPOC=Non-Asian People of Color; BMI=Body Mass Index.

Table 2.

Analysis of variance results comparing eating disorder symptom mean scores between groups.

Unadjusted Models Adjusted Models
Comparisons F p Comparisons F p Hedges' g
Restriction
(range: 0-24)		 W < A 14.12 0.0002** W < A 7.06 0.0081* 0.39
W < A+N 10.38 0.0013* W < A+N 9.55 0.0021* 0.25
W+N < A 9.70 0.0019* - - - - - -
Body Dissatisfaction
(range: 0-28)		 - - - - - A > N 6.06 0.0141* 0.19
Purging
(range: 0-24)		 W < A 10.12 0.0015* W < A 7.55 0.0061* 0.32
A < N 6.08 0.0139* W+N < A 6.83 0.0091* 0.33
W+N < A 9.39 0.0023* - - - - - -
Binge Eating
(range: 0-32)		 - - - - - - - - - - -
Excessive Exercise
(range: 0-20)		 - - - - - - - - - - -
Muscle Building
(range: 0-20)		 W < A 8.27 0.0041* W < A 10.52 0.0012* 0.30
W+N < A 7.92 0.0050* W < A+N 7.72 0.0056* 0.15
- - - - - W+N < A 7.14 0.0077* 0.30
Negative Attitudes Toward Obesity
(range: 0-20)		 W > N 9.08 0.0027* W > N 10.25 0.0014* 0.30
A > N 6.89 0.0088* A > N 7.86 0.0052* 0.38
W+A > N 9.62 0.0020* W+A > N 10.83 0.0011* 0.31
Cognitive Restraint
(range: 0-12)		 W > N 8.74 0.0032* W > N 15.46 <.0001** 0.30
A > N 17.62 <.0001** A > N 22.39 <.0001** 0.53
W+A > N 16.44 <.0001** W+A > N 23.48 <.0001** 0.34
W+N < A 13.85 0.0002** W+N < A 15.62 <.0001** 0.30
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Note: W=White; A=Asian; N=Non-Asian People of Color. Adjusted models were adjusted for sex, current body mass index, depression, anxiety, and stress. The p-values shown in the table are raw values.

*

Significant p-values that survive false discovery rate correction (q<.05)

**

Significant p-values that survive false discovery rate correction (q<.01). When we compared the mean symptoms between one group versus the other two groups, we combined means and standard deviations of the other two groups into one group before calculating the Hedges' g.

4. Discussion

We evaluated differences in mean scores across multiple ED symptoms in a racially diverse sample of college students. Asian American students reported higher mean scores of purging, muscle building, and cognitive restraint than any other racial group, even when controlling for relevant covariates. Additionally, Asian Americans had elevated mean scores of restriction than Whites, and higher mean scores of body dissatisfaction and negative attitudes toward obesity than NAPOC. Thus, specific ED symptoms may be particularly relevant in Asian Americans versus other racial groups.

These results corroborate previous reports of increased compensatory behaviors in Asian college women (Bruening & Perez, 2019) and heighted drive for muscularity in Asian college men (Kelly et al., 2015) than other racial groups, as well as increased body dissatisfaction in Asian Americans compared with NAPOC (Forbes & Frederick, 2008). No studies have evaluated differences in cognitive restraint and negative attitudes toward obesity between racial groups; thus, our findings in Asian Americans are novel. One possible explanation for our results is that higher levels of body dissatisfaction and negative attitudes toward obesity in Asian Americans may represent greater internalization of Western body ideals (Akoury et al., 2019), whereas increased cognitive restraint, purging, and muscle building may reflect culturally specific mechanisms by which Asian Americans attempt to attain these ideals (Bruening & Perez, 2019; Kwan et al., 2018).

However, observations of heightened restriction among Asian Americans versus Whites diverge from prior research suggesting that restriction is similar between these groups (Cheng et al., 2019). Indeed, our findings may differ because we included both sexes in our sample, whereas the previous study only included women. Still, increased restriction in Asian Americans may also reflect an emphasis on perfectionism in Asian culture, which has been associated with restrained eating (Lee & Lock, 2007). Finally, contrary to our hypothesis, mean scores on binge eating were similar across racial groups. Though this contradicts prior findings of cross-racial epidemiological research (Marques et al., 2011), our college sample may have experienced higher levels of binge eating regardless of race (Lipson & Sonneville, 2017).

Although this study precludes drawing conclusions regarding the influence of acculturative processes on ED symptoms, considering how distinct cultural experiences of Asian Americans contribute to our observations may offer insight into this pattern of findings. Asian Americans may experience a combination of racial discrimination, foreigner racism, and racial teasing within settings of higher education (Alvarez et al., 2006). Though other marginalized racial groups may encounter similar situations, theories of objectification, collectivistic culture, and U.S. beauty idealization have proposed that Asian Americans in particular regard appearance as a critical aspect of social approval and may be susceptible to self-objectification (Frederick et al., 2007; Hall, 1995; Masuda et al., 2014; Yokoyama, 2007). Additionally, sociocultural models incorporating thin-ideal internalization and pressures for thinness pertain to Asian American women who endorse a heightened value of the thin ideal (Akoury et al., 2019; Nouri et al., 2011). Consequently, the degree to which Asian Americans acculturate and assimilate to Western beauty standards may indirectly influence ED symptoms (Cheng et al., 2017). Acculturative stress predicts disordered eating in Asian American women (Akoury et al., 2019), suggesting a need for a greater examination of culture- and race-specific factors in developing ED symptoms in this group. Thus, discriminatory experiences and acculturative processes may play critical roles in understanding ED symptom development, prevalence, and presentation among Asian Americans.

A key strength of our study is that it assesses differences in multiple ED symptoms among Asian Americans and additional racial groups, rather than comparing findings to Whites only. Nevertheless, our study had limitations. First, we had a relatively small sample size for some group demographics. Second, though Whites were well-represented within this sample, small sample sizes in African Americans and individuals identifying as Multiracial or another race required merging these groups into one category. Lack of male representation in the Asian and NAPOC groups prevented examination of sex-based differences among groups. Third, information on ED diagnoses was not available, precluding estimating diagnostic prevalence. Fourth, although the term “Asian American” encompasses individuals from a broad range of countries, cultures, and identities, data on ethnic representation of the current sample was not collected; thus, generalizing results to Asian American communities with different cultural/ethnic representation may be limited. Fifth, specific demographic information regarding the backgrounds of multiracial participants was not collected. Therefore, multiracial participants of Asian descent were not included in the Asian American group. Sixth, the NAPOC group consisted of a racially heterogenous group of individuals. Finally, we could not specify the potential impact of generational status, immigration status, and degree of acculturation on ED symptoms.

5. Conclusions

In summary, our findings suggest that Asian Americans may report higher levels of certain ED symptoms than their White and NAPOC peers. These results may help clinicians detect and identify ED pathology among Asian Americans, especially in college. Future investigations of ED symptoms in U.S. Asian populations should assess acculturation, immigration/generational status, and ethnic and national identity. Moreover, differentiation between Asian ethnic subgroups, and between Asian immigrants and American-born Asians, will be critical to assess within-group cultural differences. Including sex and other demographic characteristics within longitudinal study designs will yield important information about additional specific group differences and how findings may change throughout college. Nevertheless, our results indicate that differences in levels of ED symptoms across racial groups exist, underscoring the importance of considering these differences in detecting, diagnosing, and treating EDs in diverse populations.

Supplementary Material

1

Highlights.

  • Few studies have examined eating disorder pathology in Asian Americans.

  • Eating disorder pathology is particularly prevalent among college students.

  • We examined eating pathology in Asian Americans and Non-Asian groups.

  • Asian Americans reported higher mean scores of some symptoms than the other groups.

  • Other differences in mean symptom scores existed between groups.

Acknowledgments

Role of funding sources

This work is supported by grants from the National Institute of Nursing Research (T32 NR007091 to Dr. Ya-Ke Wu), the National Institute of Mental Health (K01 MH106675 to Dr. Baker), and the National Institute on Alcohol Abuse and Alcoholism (K01 AA025113 to Dr. Munn-Chernoff). The funding sources were not involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

Footnotes

Conflict of interest

The authors declare that they have no conflicts of interest.

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