A virtual issue highlighting eating disorders in people of Black/African and Indigenous heritage

Abstract

While eating disorders affect people from all racial/ethnic backgrounds, research has traditionally focused on eating disorders in white populations. In this virtual issue, we present a collection of 14 articles previously published in the International Journal of Eating Disorders highlighting eating disorders in people of Black/African and Indigenous heritage. Featured articles examine the prevalence and presentation of disordered eating in Black and Indigenous populations; access to care and treatment experiences for Black and Indigenous people; and environmental stressors, such as acculturative stress and discrimination, that may contribute to disordered eating in these populations. Future directions for inclusive research with people of Black/African and Indigenous heritage are discussed, including reporting participant demographics, examining differences in risk factors and treatment outcomes across race/ethnicity, and partnering with Black and Indigenous communities to produce culturally sensitive research attuned to the needs and priorities of these populations.

This virtual issue was conceived amid the COVID-19 pandemic, which has starkly illustrated racial/ethnic health disparities in the United States (US). These disparities have contributed to greater infection rates and mortality for people of color (Adhikari et al., 2020), and specifically Black/African American (Kullar et al., 2020; Suleyman et al., 2020) and Native American/Indigenous (Kakol et al., in press) people. While lack of universal healthcare in the US may exacerbate racial inequities in healthcare access and outcomes (Chaudhary et al., 2018), similar racial/ethnic disparities in COVID-19 infection rates and mortality have been observed in other nations with different healthcare models (Townsend et al., 2020). It was striking to us that many of the factors contributing to more severe COVID-19 disease course and increased mortality for Black and Indigenous people are also highly relevant to the field of eating disorders. Particularly resonate are disparities in timely illness identification (Azar et al., 2020), insurance coverage and access to care (Hargraves & Hadley, 2003), and rates of pre-existing medical conditions arising in part from unequal exposure to socioeconomic disadvantage (LaVeist et al., 2009) and maladaptive food environments or food insecurity (Becker et al., 2017, 2019; Singleton et al., 2016).

The creation of this virtual issue was also informed by international calls for racial justice and the centering of experiences of Black, Indigenous, and other people of color (BIPOC) following the deaths of George Floyd, Breonna Taylor, and other Black Americans at the hands of police in the US. Despite growing recognition of the need to include people of racially and ethnically diverse backgrounds (Becker 2007; Franko 2007; Kazdin et al., 2017), BIPOC, and particularly Black and Indigenous people, remain underrepresented in eating disorder research, intervention, and prevention efforts. In this virtual issue of the International Journal of Eating Disorders (IJED), we focus on Black and Indigenous people to inform understanding of symptom presentation, treatment experiences, and risk/protective factors for disordered eating in these populations.

Articles in this virtual issue address three primary questions that provide a foundational understanding of eating disorders (EDs; i.e., anorexia nervosa [AN], bulimia nervosa [BN], binge-eating disorder [BED], and other specified feeding and eating disorders [OSFED]) in Black and Indigenous people relevant for both clinicians and researchers. First, what is the prevalence of disordered eating in Black and Indigenous populations, and are some symptom presentations (e.g., binge eating versus restrictive eating) more common than others? Second, how do Black and Indigenous people experience treatment, and what are the barriers to care for these populations? Third, how are environmental stressors that disproportionately affect Black and Indigenous people (e.g., discrimination, acculturative stress, and structural inequalities) associated with disordered eating? These questions addressing prevalence, treatment, and environmental stressors were particularly compelling for their potential to illuminate parallel racial/ethnic health disparities to those experienced during the COVID-19 pandemic.

We examined the title, abstract, and (if unclear) methods section of each article published in IJED between September 1981 and October 2020 to identify studies that investigated disordered eating in Black and Indigenous people. We included both articles with a primary focus on Black and Indigenous populations, and articles that analyzed how disordered eating might differ in Black and Indigenous people as compared to people of other races/ethnicities (e.g., by examining whether race moderated the association between a putative risk factor and symptoms). In total, we identified 100 articles published in IJED that examined disordered eating in Black and Indigenous people. While these articles form a substantial body of research, we note that they represent only about 2.5% of the studies published in IJED over this timeframe and often included small samples of Black/Indigenous individuals, underscoring the need for additional research on disordered eating in diverse populations. Though we were unable to include all relevant articles in this virtual issue, all identified citations are presented in Table S1 (grouped by primary article focus and listed in reverse chronological order). We encourage readers to access additional articles relevant to their research and clinical interests, including articles on the psychometric properties of common symptom measures across race/ethnicity, body image in Black and Indigenous people, and racial/ethnic and cultural differences in symptom presentation.

From the initial list of identified citations, we chose 14 articles for this virtual issue that address our primary questions regarding disordered eating in Black and Indigenous populations. We balanced several selection criteria for featured articles. When examining prevalence, we prioritized studies with large, population-based (rather than clinical or convenience) samples that captured individuals who might not be able or willing to seek treatment. For treatment-related studies, we prioritized research on access to and experiences of care, with a particular emphasis on studies with a qualitative component that incorporated the voices of Black and Indigenous people with EDs. When examining environmental correlates of disordered eating, we prioritized studies that focused on stressors that disproportionately affect BIPOC (e.g., discrimination), or used particularly innovative research designs. While most research to date has focused on African American and Native American people within the US, EDs are not confined to the US or other Western cultural contexts. We therefore also sought to incorporate geographic diversity in the selected studies, and included two recent articles conducted outside of the US (Gerbasi et al., 2014; Tuffa et al., 2020). A summary of the primary findings of each featured article is included in the text below and Table 1 (listed in reverse chronological order in Table 1, and grouped where possible by study population or thematic focus in the text). We strongly encourage reading these articles to gain an understanding of their results and implications for EDs in Black and Indigenous people.

Table 1.

Key findings from featured articles

Article	Study Population	Key Findings
Prevalence and presentation of disordered eating in Black and Indigenous people
Tuffa, T. A., Gebreyesus, S. H., Endris, B. S., Getnet, Y., & Abebe, D. S. (2020). Unhealthy weight control behaviors among Ethiopian female adolescents. International Journal of Eating Disorders, 53(4), 525–532. doi:10.1002/eat.23227	High school girls in Addis Ababa, Ethiopia (N = 690).	Overall, 30.7% of girls reported practicing unhealthy weight control behaviors (e.g., skipping meals, fasting, vomiting). Participants were more likely to practice unhealthy weight control practices if they had a higher socioeconomic status, greater adiposity, or severe depressive symptoms. Appearance satisfaction was associated with unhealthy weight control behaviors at a bivariate level, but this association did not remain significant after adjusting for covariates.
Nagata, J. M., Murray, S. B., Bibbins-Domingo, K., Garber, A. K., Mitchison, D., & Griffiths, S. (2019). Predictors of muscularity-oriented disordered eating behaviors in US young adults: A prospective cohort study. International Journal of Eating Disorders, 52(12), 1380–1388. doi:10.1002/eat.23094	A nationally representative sample of girls (N = 7,873; 15.4% Black/African American, 0.5% Native American, 11.5% Latina, 3.1% Asian/Pacific Islander, 68.8% white, 0.6% other ethnicity) and boys (N = 7,018; 14.4% Black/African American, 0.6% Native American, 12.3% Latino, 3.7% Asian/Pacific Islander, 68.2% white, 0.9% other ethnicity) in the US.	Black girls and boys were more likely than their white counterparts to engage in attempts to gain weight or report muscularity-oriented eating behavior.
Striegel-Moore, R. H., Rosselli, F., Holtzman, N., Dierker, L., Becker, A. E., & Swaney, G. (2011). Behavioral symptoms of eating disorders in Native Americans: Results from the add health survey wave III. International Journal of Eating Disorders, 44(6), 561–566. doi:10.1002/eat.20894	Young adult women and men in a nationally representative sample in the US (N = 10,334; 4.7% Native American/Alaska Native, 95.3% white).	Among Native American/Alaska Native participants, women were more likely to report disordered eating than men. Native American/Alaska Native women were more likely than white women to experience binge eating; prevalence of other disordered eating symptoms was similar across ethnicity. Disordered eating symptoms were similar across ethnicity in men.
Marques, L., Alegria, M., Becker, A. E., Chen, C. N., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44(5), 412–420. doi:10.1002/eat.20787	Pooled data from nationally representative Black/African American, Latinx, Asian/Asian American, and white samples of adults in the US.	There were no significant racial/ethnic differences in lifetime rates of AN, BED, or BN in women. Lifetime prevalence of any binge eating was greater in Black/African American, Latinx, and Asian/Asian American participants relative to white participants. White participants with a lifetime eating disorder were more likely to have used mental health services than participants of color.
Taylor, J. Y., Caldwell, C. H., Baser, R. E., Faison, N., & Jackson, J. S. (2007). Prevalence of eating disorders among Blacks in the National Survey of American Life. International Journal of Eating Disorders, 40(S3), S10-S14. doi:10.1002/eat.20451	A nationally representative sample of African American and Caribbean Black adolescents (N = 1,170) and adults (N = 5,191) in the US.	Rates of lifetime eating disorders were 0.17% for AN, 1.49% for BN, and 5.08% for any binge eating in adults. Adult women reported greater lifetime prevalence of binge eating than adult men; however, there were no sex differences in rates of eating disorders among adolescents.
Access to treatment and treatment experiences of Black and Indigenous people
Goode, R. W., Cowell, M. M., Mazzeo, S. E., Cooper-Lewter, C., Forte, A., Olayia, O. I., & Bulik, C. M. (2020). Binge eating and binge-eating disorder in Black women: A systematic review. International Journal of Eating Disorders, 53(4), 491–507. doi:10.1002/eat.23217	A systematic review of research on binge eating and BED in Black women.	While the prevalence of binge eating and BED is similar (or higher) among Black women relative to white women, research suggests Black women are less likely to receive treatment for an eating disorder and more likely to drop out of treatment. Additional research is needed on best practices for treating binge eating in Black women.
Becker, A. E., Hadley Arrindell, A., Perloe, A., Fay, K., & Striegel-Moore, R. H. (2010). A qualitative study of perceived social barriers to care for eating disorders: Perspectives from ethnically diverse health care consumers. International Journal of Eating Disorders, 43(7), 633–647. doi:10.1002/eat.20755	Past and prospective clients in eating disorder treatment (N = 32; 12.5% Black/African American, 9.4% Latinx, 6.3% Asian/Asian American, 62.5% white, 9.4% multiethnic).	Participants of color reported embarrassment/shame, stigma, lack of recognition within their communities, and lack of recognition by health care providers as barriers to seeking care for an eating disorder.
Grilo, C. M., Lozano, C., & Masheb, R. M. (2005). Ethnicity and sampling bias in binge eating disorder: Black women who seek treatment have different characteristics than those who do not. International Journal of Eating Disorders, 38(3), 257–262. doi:10.1002/eat.20183	Clinical (N = 337; 10.4% Black/African American, 89.6% white) and community (N = 150; 34.7% Black/African American, 65.3% white) samples of women with BED in the US.	Differences in eating pathology between clinical and community samples were larger for Black women than for white women. Within the clinical sample, Black and white women were similar on measures of eating pathology, but Black women had higher BMIs.
Becker, A. E., Franko, D. L., Speck, A., & Herzog, D. B. (2003). Ethnicity and differential access to care for eating disorder symptoms. International Journal of Eating Disorders, 33(2), 205–212. doi:10.1002/eat.10129	Women and men on college campuses involved in the 1996 National Eating Disorders Screening Program in the US (Study 1 N = 9,069; 6.6% Black/African American, 0.9% Native American/Alaska Native, 81.6% white, 3.4% Latinx, 3.0% Asian or Pacific Islander, 2.5% other ethnicity; Study 2 N = 289; 4.3% Black/African American, 1.8% Asian/Asian American, 1.1% Latinx, 92.1% white).	In study 1, after controlling for severity of eating disorder symptoms, Native American and Latinx participants were less likely to be referred for further evaluation for an eating disorder than white participants. In study 2, participants of color reported that doctors and (at a trend level) mental health professionals were less likely to ask about their eating behaviors. Participants of color who acknowledged concerns about their eating were less likely to receive a recommendation to see a health professional during the screening than white participants, despite having a similar level of eating pathology.
Cachelin, F. M., Rebeck, R., Veisel, C., & Striegel-Moore, R. H. (2001). Barriers to treatment for eating disorders among ethnically diverse women. International Journal of Eating Disorders, 30(3), 269–278. doi:10.1002/eat.1084	Women from the community in the US who fulfilled criteria for a DSM-IV eating disorder (N = 61; 20% Black/African American, 13% Asian/Asian American, 36% Latina, 31% white).	The majority of women (85.2%) reported wanting treatment for an eating problem, but only 57% sought treatment. Among women who sought treatment, only 14% had received treatment (8% of the total sample). There were no significant differences between treatment seekers and non-seekers on race/ethnicity. The most common reasons for not seeking treatment were financial difficulties, lack of insurance, a belief that others could not help, fear of being labeled, and not knowing about resources.
Discrimination, oppression, and other environmental stressors that are associated with disordered eating in Black and Indigenous people
Kelly, N. R., Smith, T. M., Hall, G. C., Guidinger, C., Williamson, G., Budd, E. L., & Giuliani, N. R. (2018). Perceptions of general and postpresidential election discrimination are associated with loss of control eating among racially/ethnically diverse young men. International Journal of Eating Disorders, 51(1), 28–38. doi:10.1002/eat.22803	Men ages 18–30 in the US (n = 789; 32.7% Black/African American, 33.3% Asian/Asian American, 34% Latino).	Perceived discrimination was associated with loss of control eating frequency among Black men and Latino men.
Munn-Chernoff, M. A., Grant, J. D., Agrawal, A., Koren, R., Glowinski, A. L., Bucholz, K. K.,…Duncan, A. E. (2015). Are there common familial influences for major depressive disorder and an overeating–binge eating dimension in both European American and African American Female twins? International Journal of Eating Disorders, 48(4), 375–382. doi:10.1002/eat.22280	Young adult female twins in the US (N = 3,776; 14.6% Black/African American, 85.4% white).	In the best fitting model, there were similar and significant genetic and non-shared environmental influences on binge eating and depression across Black and white women.
Gerbasi, M. E., Richards, L. K., Thomas, J. J., Agnew-Blais, J. C., Thompson-Brenner, H., Gilman, S. E., & Becker, A. E. (2014). Globalization and eating disorder risk: Peer influence, perceived social norms, and adolescent disordered eating in Fiji. International Journal of Eating Disorders, 47(7), 727–737. doi:10.1002/eat.22349	Ethnic Fijian girls and women ages 15–20 (N = 523).	Disordered eating symptoms were correlated with age, BMI, Western/global cultural orientation, perceived peer influences on eating behavior/concerns, and (inversely) ethnic Fijian cultural orientation.
Perez, M., Voelz, Z. R., Pettit, J. W., & Joiner Jr, T. E. (2002). The role of acculturative stress and body dissatisfaction in predicting bulimic symptomatology across ethnic groups. International Journal of Eating Disorders, 31(4), 442–454. doi:10.1002/eat.10006	Undergraduate women in the US (N = 118; 30% Black/African American, 19% Latina, 51% white).	For Black and Latina women, the association between body dissatisfaction and bulimic symptoms was stronger at higher levels of acculturative stress.

Note: AN = anorexia nervosa; BN = bulimia nervosa; BED = binge-eating disorder; BMI = body mass index; US = United States. Studies are listed in reverse chronological order under each subject heading.

Question 1: What is the prevalence of disordered eating in Black and Indigenous populations, and are some symptom presentations more common than others?

Five articles discuss the prevalence and presentation of disordered eating in people of Black/African and Indigenous heritage (Marques et al., 2011; Nagata et al., 2019; Striegel-Moore et al., 2011; Taylor et al., 2007; Tuffa et al., 2020). These articles represent an important start to understanding how disordered eating might present in people with these identities, with the caveat that there are many unique subgroups and experiences within each of these broad racial/ethnic identity groups.

Striegel-Moore et al. (2011) represents one of the few prevalence studies examining EDs in a large, representative sample of Native American/Alaska Native women and men in the US. The authors found that Native American/Alaska Native women were more likely than white women to experience binge eating and fear losing control over their eating. Conversely, rates of binge eating in men and other disordered eating behaviors/indicators (e.g., skipping meals, unhealthy weight control behaviors, receiving an ED diagnosis) were similar across ethnicity. While disordered eating in Native American populations has received relatively little attention, results suggest that disordered eating may be equally or more prevalent among Native Americans than among white Americans. Recent studies of other Indigenous peoples outside of the US have generated similar findings. For example, Burt and colleagues (2020) found that 27% of Aboriginal and Torres Strait islander people in Australia had a DSM-5 ED, which was significantly greater than the proportion of Australians with other racial/ethnic identities affected by an ED. Additional research with large samples of Indigenous participants from different tribes and geographical contexts is urgently needed to more fully understand the nuances of disordered eating among diverse Indigenous populations.

Marques et al. (2011) and Taylor et al. (2007) addressed similar epidemiological questions regarding rates of disordered eating among African American and Caribbean Black people in the US. In a study using pooled data from large, nationally representative samples of adults in the US, Marques et al. (2011) found no racial/ethnic differences in rates of DSM-IV AN, BN, or BED. However, lifetime prevalence of binge eating was greater in Black/African American participants than white participants, and white participants with a lifetime ED were more likely to have received mental health services than participants of color. Similarly, Taylor et al. (2007) found that rates of BN and binge eating in a nationally representative sample of African American and Caribbean Black adults in the US were comparable to those found in white adults. While rates of AN were low in this sample, some Black/African American participants did meet criteria for DSM-IV AN. Interestingly, while EDs were more common among Black/African American adult women than Black/African American adult men in Taylor et al. (2007), Black/African American adolescents did not show sex differences in rates of EDs, contrary to the female predominance often found in research and clinical settings (e.g., Klump et al., 2017).

Together, Marques et al. (2011) and Taylor et al. (2007) suggest that differences in the prevalence of EDs between Black/African American people and white people in clinical samples within the US may reflect access to care more than differential rates of these disorders in the general population, particularly for BN and BED. Taylor et al. (2007) also suggests that sex differences in disordered eating may show a different developmental trajectory in Black/African American people than in white people. This is an intriguing finding that, if replicated, can inform clinical identification of EDs and research on etiology in diverse populations.

We chose to highlight Tuffa et al. (2020) as a recent example of research examining the prevalence of disordered eating among people living in an African nation. Tuffa and colleagues (2020) found that unhealthy weight control behaviors were relatively common among high school girls in Addis Ababa, Ethiopia, with 1.5% of participants reporting purging weight control behaviors (i.e., using laxatives, diuretics, or self-inducted vomiting) and 29.8% reporting non-purging weight control behaviors (i.e., excessive exercise, fasting, skipping meals, using slimming tea, and eating food substitutes) at least once per week in the past month. Findings suggest that disordered eating is a global phenomenon experienced by Black people in Africa as well as the African diaspora. Some correlates of disordered eating in the Tuffa et al. (2020) sample, such as greater adiposity and more severe depressive symptoms, mirrored associations in the US. However, unlike most studies examining girls in the US, appearance satisfaction was not independently associated with unhealthy weight control behaviors after adjusting for covariates, suggesting that there may be different correlates/predictors of disordered eating in culturally distinct contexts.

Nagata et al. (2019) expands on how disordered eating and body dissatisfaction may manifest differently for people who identify as Black/African American within the US. While some (but not all; see Caldwell et al., 1997) studies have found that Black/African American people in the US have larger body image ideals and less internalization of the thin ideal (Miller et al., 2000; Rand & Kuldau, 1990; Thompson et al., 1997), little research has focused on other kinds of body image concerns that may be more common among people of African heritage. In a nationally representative sample of adolescents in the US, Nagata et al. (2019) found that Black girls and boys were more likely than their white counterparts to engage in attempts to gain weight or report muscularity-oriented eating behavior (e.g., eating more or taking supplements to gain weight or build muscle). Body satisfaction measures that only focus on desire for thinness may therefore omit body image concerns relevant to people of Black/African heritage and other people of color, such as desire for muscularity. Additional research on body image ideals and concerns of Black, Indigenous, and other people of color is needed.

Question 2: How do Black and Indigenous people experience treatment, and what are the barriers to care for these populations?

In this section of the virtual issue, we highlight articles examining treatment experiences and barriers to care for Black and Indigenous people (Becker et al., 2003, 2010; Cachelin et al., 2001; Goode et al., 2020), as well as the implications of these barriers for the representativeness of research samples (Grilo et al., 2005). Unfortunately, few articles have examined access to care and treatment experiences of Black and Indigenous people outside of the US. While the articles included in this virtual issue represent an important start to understanding treatment experiences of Black and Indigenous people, additional research in other countries with different healthcare systems and sociocultural contexts is needed.

We begin this section with a systematic review of binge eating and BED in Black women by Goode et al. (2020) that includes research on intervention efficacy and access to care. The authors highlight research showing that Black women are significantly less likely than white women to seek care for BED or receive treatment for an ED, and significantly more likely to drop out of clinical trials. Results suggest that additional work is needed to increase access to care and tailor treatment for Black people with binge eating-related disorders. Additionally, Goode and colleagues emphasize the need for treatment outcome measures that have been validated in Black women, and intentional investigation of outcomes for Black people to ensure that treatments are equally beneficial for people with different racial/ethnic identities.

Cachelin et al. (2001) and Becker et al. (2003) discuss potential barriers to identification and access to care for Black and Indigenous people with EDs. Cachelin et al. (2001) examined barriers to treatment for a diverse, community-based sample of women with DSM-IV EDs in the US. While most women reported wanting treatment (85.2%), only a small percentage were able to receive care (8%). Among those who did not seek treatment, the most common barriers were financial difficulties, lack of insurance, a belief that others could not help, fear of being labeled, and not knowing about resources. The insights from this article suggest that increasing insurance coverage and low-cost options for ED treatment, fighting stigma, and publicizing resources in communities of color may help combat inequities in access to care.

Becker et al. (2003) examined potential clinician biases that could contribute to decreased access to care for BIPOC by evaluating recommendations for ED treatment in women and men on college campuses involved in the 1996 National Eating Disorders Screening Program in the US. After controlling for severity of ED symptoms, Native American participants were less likely to be referred for further evaluation than white participants, and participants of color who reported concern about their eating were less likely to receive a recommendation to see a health professional during the screening than white participants. Participants of color also reported that medical professionals were less likely to ask about their eating behavior. These findings suggest that clinicians must be intentional about asking people of color about disordered eating symptoms, and be aware of potential unconscious biases when evaluating disordered eating in people of color and deciding whether a referral is needed.

Becker et al. (2010) is unique in centering the voices of women of color with EDs in the US through a qualitative research design. Women of color in this study reported embarrassment/shame, stigma, lack of recognition within their communities, and lack of recognition by health care providers as barriers to seeking care for an ED. Participants discussed how stereotypes could increase shame and pose a barrier to care, with one African American woman poignantly stating, “not only is your health compromised, but your identity is compromised, too” (Becker et al., 2010). These findings highlight the importance of culturally responsive care for EDs and the harmful impact of stereotypic or stigmatizing statements on people of color. They also serve as a call for professionals to partner with communities of color to increase awareness of EDs and combat stigma, including the stereotype that EDs predominantly affect white individuals. Further research is needed to describe barriers to treatment experienced by boys and men of color.

In the final article in this section, Grilo et al. (2005) examined differences in eating pathology between women with BED in the community versus those who sought clinical care, and whether these differences were greater for Black women than for white women. Grilo and colleagues (2005) found that while Black and white women were similar on measures of eating pathology within the clinical sample, differences in eating pathology between clinical and community samples were larger for Black women than for white women. These findings align with the research discussed above in suggesting that Black women may wait longer or need to experience particularly severe disordered eating to seek treatment due to stigma or lack of recognition of their ED. Findings also suggest that research on treatment-seeking Black women with BED may not necessarily generalize to Black women with BED in the community, emphasizing the importance of community-based research that includes people of Black/African heritage.

Question 3: How are environmental stressors that disproportionately affect Black and Indigenous people associated with disordered eating?

The final section includes four articles examining how environmental stressors, including discrimination and acculturative stress, are associated with disordered eating in Black and Indigenous people (Gerbasi et al., 2014; Munn-Chernoff et al., 2015; Perez et al., 2002; Kelly et al., 2018). We note that relatively few articles on the potential association between discrimination and disordered eating have been published, and urge additional research on the impact of discrimination on disordered eating for people of color (particularly those with multiple marginalized identities, such as Black and Indigenous women and gender diverse individuals).

Gerbasi et al. (2014) and Perez et al. (2002) examined associations between acculturative stress (defined as stress associated with adjusting to an unfamiliar cultural context and cultural norms, often while simultaneously experiencing disconnection from one’s native culture; Berry et al., 1987) and disordered eating. In a large sample of ethnic Fijian adolescent girls, Gerbasi et al. (2014) found that girls were at greatest risk for disordered eating when they had a strong Western/global cultural orientation and a weak ethnic Fijian traditional cultural orientation. A positive connection to one’s cultural heritage may therefore buffer against disordered eating, even in the presence of competing cultural norms. Findings by Perez et al. (2002) suggest that acculturative stress may have a particularly strong influence on disordered eating in the presence of other risk factors. Specifically, among an ethnically diverse sample of undergraduate women in the US, Perez et al. (2002) found that body dissatisfaction was only associated with disordered eating symptoms among Black and Latina women with high levels of acculturative stress. These results underscore the importance of considering the broader social context and attendant stressors when examining body dissatisfaction in people of color.

Kelly et al. (2018) is one of few studies to directly investigate the association between discrimination and disordered eating. Kelly and colleagues (2018) found that perceived discrimination following the 2016 election in the US was associated with greater loss of control eating frequency among African American and Latino men. We encourage researchers to continue to examine how experiences of discrimination and oppression may increase risk for disordered eating in Black, Indigenous, and other people of color. Clinicians should also be aware that discrimination may exacerbate disordered eating.

In the final article in this section, Munn-Chernoff et al. (2015) used a twin design to examine whether genetic and environmental influences on disordered eating differ in Black and white women in the US. Results showed similar overall genetic and environmental influences on disordered eating across race (with the caveat that the specific environmental factors that are most influential may still differ across race). While behavior genetics studies have been used by some in the past to promote harmful and scientifically unfounded ideas about white superiority, we highlight this study as an example of how twin designs can be used to examine influences on disordered eating across ethnic and cultural groups in a respectful (and important) manner. While Munn-Chernoff and colleagues (2015) did not find large overall differences in genetic/environmental influences on disordered eating across race in women, research on other health phenotypes suggests that discrimination may amplify genetic risk through gene X environment interactions (e.g., Taylor et al., 2017). Investigation of such gene X discrimination interactions with respect to EDs could help us better understand how genetic and environmental risk may come together to give rise to disordered eating for Black individuals and other people of color.

Conclusion

Contrary to stereotypes, research included in this virtual issue suggests that EDs and disordered eating behaviors are prevalent among Black and Indigenous people. Within the US, Black and Indigenous people may be at particularly elevated risk for binge eating and related disorders (Goode et al., 2020; Marques et al., 2011; Striegel-Moore et al., 2011), though additional research on diverse Indigenous populations both within and outside of the US is needed. Experiences of discrimination and acculturative stress are associated with greater ED symptoms for people of Black/African and Indigenous heritage, highlighting these as important variables to include in future research and clinical case conceptualizations when working with these populations. Research conducted in the US indicates African American and Native American people face many barriers to receiving care for EDs, including limited availability of care, limited financial resources, stigma within their communities, and (concerningly) stigma and stereotyping from clinicians. Reducing these barriers and increasing research on treatment retention and outcomes among Black and Indigenous populations are important priorities for the ED field.

In considering directions for future research, we wish to emphasize a spectrum of ways in which study designs can be inclusive of Black and Indigenous people. One best practice is to report the racial/ethnic makeup of a study sample to inform the generalizability of the findings to racially and ethnically diverse populations. A second approach is to examine whether associations between putative risk factors and disordered eating, or treatment outcomes/retention, differ across race/ethnicity. Excellent examples of this moderation approach can be found in Hermes & Keel (2007), Striegel-Moore et al. (2001), and French et al. (1997). Even when sample sizes may be too small to detect significant differences across race/ethnicity in a particular study, effect sizes can nevertheless be informative, and results can later be combined in meta-analyses.

While the above represent meaningful ways to contribute to our understanding of disordered eating in Black and Indigenous populations, as a field we must also strive to increase representation of Black and Indigenous experiences in research. Mixed methods research designs that incorporate quantitative and qualitative analyses are one important tool for amplifying the voices and lived experiences of Black and Indigenous people with EDs. Outreach and partnership with Black and Indigenous communities and community organizations may help researchers recruit more diverse study participants while helping to provide education and combat stigma in these communities. This may take the form of a formal community-academic partnership (Drahota et al., 2016) to collaboratively incorporate the perspectives and priorities of Black and Indigenous people in ED research design and execution. It is also vital to increase representation of BIPOC researchers in the ED field through recruitment and mentorship of students of color and early career faculty (Jennings Mathis et al., 2020).

Finally, research is beginning to make clear that disadvantage (Becker et al., 2017, 2019; Coffino et al., 2020; Lydecker et al., 2018) and discrimination (Kelly et al., 2018, 2020; Mason et al., 2017) are significant contributors to disordered eating. Inclusion of these social determinants of health in research, case conceptualization, and treatment is vital to understanding and affirming the experiences of Black and Indigenous people with EDs. For example, a clinician may wish to discuss with a client how experiences of prejudice, discrimination, and systemic racism influence their mood and eating behavior. Clinicians can also work with clients to develop a positive racial/ethnic identity and skills for coping with racism (Querimit & Conner, 2003), as well as tools for engaging in broader social justice and advocacy work (French et al., 2020). Relatedly, recent multicultural guidelines for psychologists (Clauss-Ehlers et al., 2019), social workers (NASW, 2015), and other healthcare professionals (AAMFT, 2015) encourage participation in advocacy and systemic interventions that may address the environmental roots of psychological distress. We encourage the ED field to consider how intervention on systemic levels (e.g., advocacy to combat racial discrimination and disenfranchisement) may advance the goal of reducing disordered eating in diverse populations.