by Rebecca Gwira

Rebecca Gwira is a 2022 UNC CEED Summer Research Fellow and a graduate student in the Department of Counseling and Psychological Services at Georgia State University.

This June while training with CEED as a summer fellow, I was able to travel back to Ho and Accra, Ghana, where my family is from and currently lives. Between enjoying needed time with loved ones and steadily working on my dissertation and CEED projects, I was reminded of how little I know about eating disorders presenting in Ghana, let alone across other African countries. Upon reviewing the literature to learn more, I found that there have been relatively few works published on prevalence rates and risk factors of eating disorders across Africa, though there has been a notable increase in recent years. Dr. Daphne van Hoeken and colleagues wrote the first review of studies on the epidemiology, specifically prevalence and risk assessment, of eating disorders on the African continent. They found that four studies provided epidemiological data on anorexia nervosa (AN), bulimia nervosa (BN), and EDNOS, which included binge-eating disorder and “atypical” presentations of AN and BN in the DSM-IV. Specifically, they found full syndrome or partial BN in Egyptian girls, no cases of AN among Ghanaian college women despite morbidly low weight due to religious fasting, EDNOS among Tanzanian girls and women aged 13-30, and BN among Kenyan adults.¹ Furthermore, they found pica behaviors and bulimia reported in a case study of an Ethiopian 17-year-old girl, though her pica behaviors were culture-laden, thus not warranting a pica diagnosis. Read more about pica here.

Many studies in the review used screeners for eating attitudes and behaviors (e.g., BITE and EAT-26) to assess risk, and found that there is a risk for developing an eating disorder in African samples across countries, consistent with past research (e.g.,²). Van Hoeken and colleagues¹ found one in South Africa that assessed risk among a general population sample. This study reported that those with mixed ethnic ancestry had lower body esteem than their monoracial Black and White counterparts and monoracial Black girls reported an increase in weight loss practices. Nasser and colleagues³ note increases in eating disorder pathology among Black South African girls after the fall of the apartheid regime as “cultural marker[s] of distress, caused by transitional and conflicting cultural forces” which may contextualize that finding. 

The authors highlight the potential for misunderstandings of eating disorders in Africa in the studies they reviewed regarding the use of the DSM-IV diagnostic criteria and the unknown validity of the screening measures in these samples. Indeed, they note that given the removal of fear of fatness, desire to be thin, and amenorrhea as central diagnostic criteria for AN in the DSM-5, many of the college women assessed in the aforementioned Ghanaian study likely would have met criteria for AN today.¹ Regarding validity, LeGrange and colleagues⁴ underscore the importance of culturally informed research. For Black South African girls who scored high on a disordered eating screener, post-survey interviews revealed more culture-laden and economic nuance to their behaviors unrelated to weight/shape concerns typically associated with high scores in Western countries.^1,4

The Van Hoeken review was the first of its kind when it was published, and we have since seen more published on disordered eating in African countries. For example, one study reported that among 587 secondary school students in Nigeria, 8.7% reported eating disorder pathology across scores on abnormal eating attitudes measures and structured clinical interviews (i.e., the EAT-26 and MINI).⁵ Furthermore, Gyasi and colleagues⁶ found older Ghanaian adults who had moderate to severe food insecurity, measured by increased meal skipping and late first meal of the day, reported increased psychological distress. Continued efforts in this emerging area of eating disorder research are needed to expand what we know about prevalence, incidence rates, and global burden of disease throughout Africa. Additionally, research on eating disorders in Africa should continue validating screening tools and using follow-up interview data across various diverse countries, as well as continue exploring risk factors such as food insecurity/hunger, globalization, and acculturative stress.

References

1. van Hoeken, D., Burns, J. K., & Hoek, H. W. (2016). Epidemiology of eating disorders in Africa. Curr Opin Psychiatry, 29(6), 372-377.

2. Makino, M., Tsuboi, K., & Dennerstein, L. (2004). Prevalence of eating disorders: a comparison of Western and non-Western countries. Medscape Gen Med, 6(3).

3. Nasser, M. (2009). Eating disorders across cultures. Psychiatry, 8(9), 347-350.

4. Le Grange, D., Louw, J., Breen, A., & Katzman, M. A. (2004). The meaning of ‘self-starvation’ in impoverished Black adolescents in South Africa. Culture Med Psychiatry, 28, 439-461

5. Ehimigbai, M., Otakpor, A. N., & Uwadiae, E. (2017). Prevalence of eating disorders among school-attending adolescents in Benin city, Nigeria. Int J Innov Res Adv Stud, 4(3), 353-7.

6. Gyasi, R. M., Peprah, P., & Appiah, D. O. (2020). Association of food insecurity with psychological disorders: Results of a population-based study among older people in Ghana. J Affect Disord, 270, 75-82