Abstract
Purpose
Black individuals are at risk for developing eating disorders (EDs), while also facing an increased mental health burden as a marginalized group. However, few studies have examined whether treatment-seeking Black individuals with EDs present with different symptom profiles than White individuals. This study sought to characterize baseline ED symptomatology in Black participants with bulimia nervosa spectrum or binge eating disorder spectrum pathology compared to White participants in a treatment-seeking sample.
Methods
The sample consisted of 33 Black participants and 126 White participants who participated in a clinical trial at a mid-Atlantic University from 2015 to 2020. Data was analyzed using chi-square and independent samples t-tests.
Results
Black participants were much less likely to engage in self-induced vomiting, despite being just as likely to meet criteria for a bulimia nervosa spectrum diagnosis and having similar rates of binge-eating and distress towards body image concerns. Black participants were more likely to experience obesity but maintained similar levels of body image concerns as White participants.
Conclusion
Given the evidence that Black participants often are under-diagnosed, particularly with bulimia nervosa spectrum disorders, these results could suggest that weight biases and/or expectations that patients with bulimia nervosa spectrum disorders will primarily present with self-induced vomiting could be contributing to these diagnostic errors.
Level of evidence
Level I, randomized controlled trials
Keywords: Binge eating, Racial and ethnic minority, Body image, Eating disorder symptomatology, Black, Bulimia
Introduction
Historically, eating disorder (ED) research has primarily focused on White individuals partially due to a widely held belief that minoritized racial/ethnic groups are less likely to experience EDs [1]. Due to this belief, clinicians have been less likely to screen for and detect an ED in minoritized racial/ethnic individuals compared to White individuals, regardless of ED symptom presentation [2, 3]. However, acculturation of the Western thin ideal by minoritized racial/ethnic groups over the years has shifted this perspective [4, 5]. This finding highlights a need to challenge what is commonly believed about eating disorders and the racial stereotypes associated with them.
An emerging literature base has begun to not only recognize that minoritized racial/ethnic groups are just as likely as White individuals to endorse distorted body image and eating pathology, but also that ED symptomatology might present differently in minoritized racial/ethnic groups. Specifically, previous research identified that Black individuals were more likely to use laxatives [4], have higher levels of body image flexibility and body esteem [6], had less concern with eating, weight and shape concerns [7], and among those with obesity, were more likely to experience binge-eating [8–10] compared to White individuals. Prior literature suggests these differences can be attributed to cultural norms, such as Black individuals being encouraged to eat larger portions [11], being more likely to use food to cope with negative emotions [11], being more likely to use other less conventional compensatory methods [4], and having a higher acceptance of a larger body ideal [12]. However, these few studies also suggest that it is critically important to understand how ED symptoms present in minoritized racial/ethnic groups to ensure that EDs are accurately diagnosed.
In particular, there is a dearth of literature exploring how Black individuals seeking treatment for an ED might differ from White individuals. Most studies focused only on Black individuals seeking treatment for binge-eating disorder (BED) or sub-clinical binge eating, and produced mixed results. For example, Franko et al. [8] aggregated data from eleven treatment trials indicated that Black individuals with binge-eating pathology reported lower weight concern and higher dietary restraint scores compared to White individuals, while Lydecker and Grilo [10] found that Black and White individuals had similar concerns regarding weight, shape, and eating. To our knowledge, only one study to date has included Black treatment-seeking individuals with bulimia nervosa (BN)-spectrum disorders (e.g. BN and Other specified feeding and eating disorder (OSFED)-BN) [13], despite evidence that BN is more common in Black individuals compared to White individuals in the United States [14]. This study found that Black individuals had less fear of weight gain and higher levels of body dissatisfaction compared to White individuals [13]. Given the limited research and mixed findings presented in the literature examining BN-spectrum disorders, there is a need for more research characterizing treatment-seeking Black individuals meeting these diagnoses.
One possible reason for the mixed literature is the diverse range of assessment procedures across the studies. Most studies relied on self-report measures such as the Eating Disorder Examination–Questionnaire [15] and the Eating Disorder Questionnaire [16]. Self-report measures can lead to over and under endorsement of symptoms due to factors such as social desirability, shame and avoidance, difficulty disentangling disordered eating symptoms such as binge eating from more normative overeating, and difficulty recalling information [17, 18]. To better understand how ED symptoms may present in Black individuals with recurrent binge eating, it is critical that more accurate assessment procedures, such as semi-structured interviews like the Eating Disorder Examination (EDE) [19], be utilized.
Therefore, the current study aimed to characterize ED symptomatology in Black treatment-seeking participants with BN- and BED-spectrum disorders compared to White participants. We also examined differences in other demographic variables (e.g. age, sex) and body mass index (BMI). Taking into account prior findings on binge frequency, compensatory behaviors, body image constructs of Black individuals [7–10, 13], and existing literature on cultural norms on eating, shape, and ED behaviors, we hypothesized that compared to White participants, Black participants would have higher rates of binge-eating and higher BMI, but lower rates of all compensatory behaviors, except laxative misuse and body image related concerns. This study expands prior research on Black and White treatment-seeking adults with BN- and BED-spectrum disorders using interviewer-based assessment strategies.
Methods
Participants
Participants were obtained from a larger sample of individuals enrolled in four different clinical trials (N = 184) at a mid-Atlantic university from 2015 to 2020. These four clinical trials targeted participants who had clinically significant BN- or BED-spectrum disorders and met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [20] criteria for BN, BED, OSFED-BN and OSFED-BED. Participants were offered free treatment and were compensated for completing assessments.
Participants were categorized as Black if they self-identified as Black/African American and were categorized as White if they self-identified as non-Hispanic Caucasian/White. Table 1 shows a breakdown of the sample characteristics such as age, sex, and diagnoses. Of the entire sample, we included 33 Black participants and 126 White participants.
Table 1.
Summary characteristics of Black and White participants at baseline
| Variable | Black participants (n = 33) |
White participants (n = 126) |
X 2 | t | df | p | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| % | M | (SD) | % | M | (SD) | |||||
|
| ||||||||||
| Age | – | 44.94 | 13.60 | – | 41.77 | 15.10 | – | − 1.132 | 159 | 0.259 |
| Sex | – | – | – | – | – | – | – | 1 | 0.637 | |
| Female | 81.8 | – | – | 84.9 | – | – | 0.223 | – | – | – |
| Male | 18.2 | – | – | 15.1 | – | – | – | – | – | – |
| Diagnosis | ||||||||||
| BN spectrum | 45.5 | – | – | 57.9 | – | – | 2.107 | – | 1 | 0.147 |
| BED spectrum | 54.5 | – | – | 40.5 | – | – | – | – | – | – |
| Binge– eating episodes | ||||||||||
| OBEs | – | 13.85 | (10.77) | – | 15.30 | (17.02) | 0.046 | 0.466 | 157 | 0.520 |
| SBEs | – | 10.33 | (11.29) | – | 9.76 | (11.02) | 0.105 | − 0.304 | 157 | 0.949 |
| Engagement in compensatory behaviors | ||||||||||
| Self– induced vomiting | 3.0 | – | – | 29.4 | – | – | 9.972 | – | 1 | 0.002** |
| Laxative misuse | 12.1 | – | – | 11.2 | – | – | 0.022 | – | 1 | 0.882 |
| Diuretic misuse | 0.0 | – | – | 4.8 | – | – | 1.633 | – | 1 | 0.201 |
| Driven exercise | 24.2 | – | – | 30.3 | – | – | 0.467 | – | 1 | 0.494 |
| Other extreme weight–control behaviors | 6.1 | – | – | 8.0 | – | – | 0.140 | – | 1 | 0.708 |
| EDE subscales, EDE Global | ||||||||||
| EDE Eating Concern | – | 1.98 | (1.35) | – | 2.09 | (1.32) | – | 0.407 | 157 | 0.684 |
| EDE Restraint | – | 2.18 | (1.38) | – | 2.39 | (1.52) | – | 0.710 | 157 | 0.479 |
| EDE Shape Concern | – | 3.99 | (0.91) | – | 3.75 | (1.17) | – | − 1.115 | 157 | 0.267 |
| EDE Weight Concern | – | 3.47 | (0.99) | – | 3.41 | (1.13) | – | − 0.269 | 157 | 0.788 |
| EDE Global | – | 2.91 | (0.88) | – | 2.91 | (1.02) | – | 0.012 | 157 | 0.990 |
| BMI | – | 37.25 | 6.78 | – | 30.34 | 6.98 | – | − 5.040 | 158 | 0.000*** |
| BMI categories | – | – | – | – | – | – | 9.907 | – | 2 | 0.007** |
| Normal | 3.1 | 24.60 | (0.00) | 23.8 | 18.05 | (0.21) | ||||
| Overweight | 12.5 | 27.73 | (1.49) | 20.6 | 27.13 | (1.34) | ||||
| Obese | 84.4 | 39.13 | (5.55) | 55.6 | 35.60 | (4.33) | ||||
M mean, SD standard deviation
p< 0.05
p< 0.01
p< 0.001
Participants responded to advertisements for ED treatment studies for binge-eating spectrum disorders. They were included if they were between 18 and 75 years old and met DSM-5 criteria for BN, BED, OSFED-BN, and OSFED-BED. Participants were excluded if they were receiving ED treatment, had a BMI below 18.5, had a mental handicap or severe mental illness that could interfere with clinical assessment (e.g. psychosis), or were pregnant.
This was a retrospective study of previously collected data. The IRB approved each individual clinical trial, and consent was obtained at the baseline assessment for each clinical trial.
Measures
Trained assessors administered the Eating Disorder Examination (EDE) [19] at baseline to assess for BN- or BED-spectrum diagnoses and to characterize ED psychopathology. Assessors measured participants’ height and weight and calculated BMI (in kg/m2). Assessors had at least a bachelor's degree and attended 40 h of training, which included 6 h of EDE didactics (e.g. interview skills, diagnostic criteria), 10 h of role-playing and observing interviews, and 24 h of supervised administration of EDEs.
Eating disorder examination
The EDE is a semi-structured investigator-based interview and was used to assess for BN- or BED-spectrum features. Two types of binge eating episodes are assessed during the previous 28 days: objective binge episodes (OBEs; eating unusually large amounts of food with the presence of loss of control) and subjective binge eating episodes (SBEs; eating a normative amount of food with the presence of loss of control). The EDE has four subscales (Restraint, Eating Concern, Shape Concern, and Weight Concern) as well as a Global score. Cronbach’s alphas in this study were: Restraint (0.89), Eating Concern (0.86), Shape Concern (0.83), Weight Concern (0.83), and Global (0.78). The EDE is a well-established interview with good interrater and test–retest reliability for ED symptomatology and in racial/ethnic groups [21, 22].
BMI
Per CDC guidelines, BMI was considered to be in the underweight range if it fell below 18.5. BMI was in the normal weight range if it fell between 18.5 and 25, the overweight range if it fell between 25 and 30, and the obese range if it was greater than 30 [23].
Statistical analysis
To characterize racial/ethnic group differences at baseline between Black and White participants, we used chi-square tests (categorical variables) and independent samples t-tests (continuous variables) on a merged dataset consisting of data from four RCTs. Levene’s test for equality of variances was used to correct for the homogeneity of variances in our analyses. Data were analyzed using the Statistical Package for the Social Sciences (SPSS, Chicago, IL), version 26. To control for multiple comparisons and Type I error, alpha levels of less than 0.01 were considered statistically significant.
Results
Binge eating frequency and compensatory behaviors
No significant differences were found for the rate of OBEs and SBEs between Black and White in the last 28 days. As shown in Table 1, White participants were significantly more likely to engage in self-induced vomiting (29.4% of the sample) compared to Black participants (3.0% of the sample). There were no significant differences between Black and White individuals in rates of engagement in laxative misuse, diuretic misuse, driven exercise and other-extreme weight control behaviors. Black and White individuals were diagnosed with BN- and BED-spectrum disorders at similar rates.
EDE subscales and EDE global score
There were no significant differences between Black and White participants in all the EDE subscales and the EDE global score.
BMI
Black participants had significantly higher BMI compared to White individuals. There was a significant difference in the BMI categories Black and White participants fell under. Of 32 Black participants, 1 (3.1%) fell under the normal BMI category, 4 (12.5%) had overweight, and 27 (84.4%) had obesity. Of 126 White participants, 30 (23.8%) fell under a normal BMI category, 26 (20.6%) had overweight, and 70 (55.6%) had obesity. 3 (1.9%) cases in total were missing BMI data.
Other demographics
The sample age range was 18–71. There were no significant differences in age and sex between Black and White participants.
Discussion
Prior studies utilizing clinical samples have focused on the presence of binge-eating or BED in Black individuals rather than looking at symptom differences in a transdiagnostic binge-eating sample [7–10, 13]. This study is one of the first to characterize ED symptom presentations in treatment-seeking Black individuals with BN- or BED-spectrum disorders. The results of the present analyses show that Black participants were much less likely to engage in self-induced vomiting, despite being just as likely to meet criteria for a BN-spectrum diagnosis and having similar rates of binge-eating and distress towards body image concerns compared to White participants. These findings suggest it may be more common for Black individuals to present to treatment with non-vomiting compensatory behaviors and are just as likely to present with a BN-spectrum disorder compared to White individuals. It appears Black individuals with BN-spectrum disorders may be more likely to engage in laxative misuse. Consistent with Cachelin et al.’s findings [4], laxative misuse was the only compensatory behavior we found where a slightly higher percentage of Black participants endorsed engaging in compared to White participants. One study offers the explanation that Black individuals are at higher risk for constipation and colon cancer than White individuals, which might attribute to the greater use of laxatives as a compensatory method [24]. Health professionals working with Black populations need to be more mindful of screening for possible laxative misuse and presence of a BN-spectrum disorder as much as they would with a White population. In addition, clinician bias may contribute to poor detection of BN-spectrum disorders in Black individuals, considering the disproportionate number of White individuals presenting to treatment [7] and the belief that Black individuals are less likely to have an eating disorder [25]. Evidence suggests implicit biases in healthcare professionals significantly influence their diagnoses [26]. Given the under-diagnosis of Black participants, particularly with BN-spectrum disorders [2, 3], these results suggest that implicit biases about weight and/or expectations that patients with BN-spectrum disorders primarily present with self-induced vomiting could be contributing to inaccurate diagnoses in the Black population more broadly.
We also found that across the BN- and BED-spectrum disorders, Black individuals had a significantly higher BMI and a larger proportion of the sample with obesity (84.4%) compared to White individuals (55.6%), which is consistent with the literature. Despite the higher BMI, which is known to be correlated with higher body dissatisfaction [27, 28], Black individuals exhibited similar levels of body image concerns as White individuals. One potential explanation is that cultural contextual factors unique to Black individuals, such as less social pressure to be thin, more positive body image, and greater acceptance of larger portion sizes in Black communities, may protect against higher levels of body dissatisfaction. This is seen in previous literature where Black individuals with lower levels of acculturation to the Western thin ideal are more protected against the development of EDs [29].
The current sample of Black individuals presented similarly to White individuals in terms of diagnoses received, binge frequency, use of compensatory behaviors with the exception of self-induced vomiting, eating, restraint, weight, and shape concerns, and eating pathology, which is consistent with some studies [10, 30] while remaining inconsistent with others [7, 8, 13]. Taken together, these findings indicate that Black individuals may present to treatment at a higher weight than White individuals, have lower levels of body image concerns compared to White individuals presenting with a similar BMI, and are just as likely to have an eating disorder as White individuals.
Limitations
While these findings provide a novel contribution to the literature, they should be taken with the context of their limitations. Our sample was not a straightforward treatment seeking sample in that participants were offered access to free treatment and were not specifically assessed for their ability to pay for treatment. It is likely that our sample may be different in certain ways from a more traditional outpatient fee for service sample. Considering the limited number of Black treatment-seekers in the current study, replication of these findings is needed. Risk for Type II error is acknowledged due to being underpowered from the size of the sample of Black participants. Given the wide age range of the sample, these findings cannot confidently represent any particular age group or cohort. Further research will need to look into separating these effects. Despite assessors being highly trained, it is also important to consider the interviewer bias when administering interviewer-based measurement tools considering there is known clinician bias in underdiagnosing Black populations. For example, implicit biases in interviewers might influence severity ratings, therefore gathering less accurate information on ED symptomatology. This study is also composed of treatment-seekers at one facility, making the results difficult to generalize to other areas of the United States and outside of the United States. While the percent of Black individuals in our trials is close to the percentage of Black individuals in our metropolitan area (e.g. 17% in our clinical trials vs. 20% in the broader metropolitan area) [31] the overall numbers are small and suggest a need for more targeted recruitment procedures that might oversample minoritized racial/ethnic individuals in predominantly White areas in future studies.
Future directions and clinical implications
In order to more appropriately assess and diagnose Black individuals with EDs, future research should examine how EDs can be better captured by screening tools used with Black individuals and how to minimize assessor/clinician biases in diagnosing Black individuals with EDs. Considering that the vast majority of our current assessment tools were developed and validated in White middle to upper class women, and no studies to date have looked into EDE norms for adult Black and White populations, it is important to evaluate whether these tools sufficiently capture how Black individuals experience ED symptomatology. Additional studies assessing for EDE norms in Black treatment seeking populations are needed. Other variables, such as socioeconomic status, illness duration, prior treatment history, or food access/insecurity, should be considered for future research on marginalized individuals and their experience with EDs. Future research should also evaluate risk factors specific to Black individuals that are associated with the development of EDs so that preventative interventions can be adopted and disseminated into the community. Since there is increased mental health burden experienced by marginalized populations, it is important to consider the impact of race-specific factors (i.e. systemic racism) and whether factors of this kind may contribute to Black individuals’ experience with EDs. Lastly, considering the similar rates of EDs experienced by Black individuals, it is important to implement novel and innovative outreach programs in these communities to raise awareness about EDs, increase treatment-seeking behaviors and clinician screening efforts.
What is already known on this subject?
We know only a handful of studies have focused on Black treatment-seeking individuals with EDs, especially with BN-spectrum disorders. Among these studies, there has been an inconsistent use of methods, which has made it difficult to reach a consensus on ED symptomatology in Black treatment seeking individuals with EDs. This study was one of the first to characterize ED symptomatology in Black treatment seeking individuals with a wide array of transdiagnostic binge-eating pathology.
What this study adds?
We now know that Black treatment-seeking individuals are just as likely as White individuals to have a BN-spectrum disorder but are much less likely to engage in self-induced vomiting as a compensatory behavior. We also know that Black treatment-seeking individuals have significantly higher BMI but experience similar amounts of distress within body image constructs as White individuals. These findings suggest more attention needs to be given to Black individuals with BN-spectrum disorders, whether it be in screening, assessing, or diagnosing, especially since the majority of the literature we explored focused on binge-eating disorder in Black individuals.
Funding
The current study was funded by grants from the National Institute of Health to Dr. Juarascio (R34MH116021, R01DK117072, K23MH105680).
Footnotes
Declarations
Conflict of interest All authors declare that they have no conflicts of interest.
Ethics approval This was a retrospective study of already collected data and was conducted after the completion of the clinical trials. The IRB approved each individual clinical trial and consent was obtained at the baseline assessment for each clinical trial.
Informed concent The IRB approved each individual clinical trial and informed consent was obtained at the baseline assessment for each clinical trial.
Publisher's Disclaimer: Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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