Potential stressors contributing to eating disorder symptoms in African American women: implications for mental health counselors.

Eating disorders initially were considered to occur among young, White middle class women. However, during the last two decades, high rates of obesity-related symptoms (e.g., binge-eating) and obesity have been documented among African American women. Despite emerging findings about the presence of eating and health concerns among African American women, few counseling models of eating disorder symptomatology have included the socialization experiences of African American women. This paper examines, from a contextual perspective, the unique stressors that may contribute to eating disorder symptoms in African American women, implications for race and culture-specific counseling are discussed and recommendations for mental health counselors are presented.

INTRODUCTION

Eating disorders such as anorexia, bulimia, and binge eating disorder are considered major health concerns among women because they are associated with adverse mental and physical repercussions including depression, low self-esteem, suicide, obesity, infertility, and malnutrition (Polivy & Herman, 2002; Stice, 1999). It has been argued that more clinical and media attention has been given to the predominant eating disorders of anorexia and bulimia (Paul, 2003; Polivy & Herman, 2002). However, research findings suggest that African American women exhibit high rates of binge eating behaviors (Abrams, Allen & Gray, 1993; Gray, Ford, & Kelly, 1987; Smith, Marcus, Lewis, Fitzgibbon, & Schreiner, 1998; Striegel-Moore et al., 2003; Striegel-Moore, Wilfrey, Pike, Dohm, & Fairburn, 2000) and obesity (Davis, Clance, & Gailis, 1999; Foreyt & Poston, 1999; Smolak & Striegel-Moore, 2001). For instance, African American women in the United States have the highest prevalence of combined overweight and obesity (77.3%) (National Institute of Diabetes and Digestive and Kidney Diseases). Even so, traditional research and counseling approaches used to assess women's eating disorder symptoms do not necessarily incorporate the unique socialization experiences of African American women.

Several theorists have argued that African American women, as members of two low status groups (i.e., race and gender), may face additional stressors beyond the daily life stressors that all women face since they are being raised in a society where experiencing and internalizing racist, discriminatory, and prejudicial attitudes are potential realities (Clark, Anderson, Clark, & Williams, 1999; Constantine & Blackmon, 2002; Greene, 1994; Paul, 2003; Thomas, Witherspoon, & Speight, 2004). Furthermore, empirical evidence supports the notion that societal stressors such as racism are related to African American women's mental and physical health concerns (Clark et al., 1999; Paul, 2003; Thompson, 1997; Thompson & Neville, 1999; Wyatt, Williams, Calvin, Henderson, Walker, & Winters, 2003). Not surprisingly, African American women experience higher disease and illness rates and more chronic conditions (e.g., obesity, hypertension and diabetes) in comparison to their White counterparts (Davis et al., 1999; Leigh, 1995; Myers & Rodriguez, 2002; Smolak & Striegel-Moore, 2001).

According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994), anorexia is defined as an eating disorder characterized by a person's refusal to maintain her or his body weight through use of excessive dieting and inaccurate perceptions of her or his body image based on an obsessive fear of becoming fat. Bulimia is characterized by a person's excessive rapid binging followed by purging through use of self-induced vomiting, laxatives, diuretics, restrained eating or excessive exercise. Binge eating disorder, a conditional diagnosis undergoing further empirical study, is defined by recurrent episodes of binge-eating that occur in the absence of regular use of compensatory behaviors such as purging (Streigel-Moore, Fairburn, Wilfley, Pike, Dohm, & Kraemer, 2005). Obesity refers to having a body mass index (BMI) of 30 or greater and/or weighing more than 20% above the upper limit for height (Davis et al., 1999).

While research concerning eating disorders in African American women has increased, the literature remains plagued with conceptual and methodological challenges (Lynch, 2004; O'Neill, 2003; Smolak & Striegel Moore, 2001). Considering the presence of eating disorder symptoms and high prevalence rates of overweight and obesity in African American women, it is imperative that researchers include African American women in their studies of eating disorder etiology. Furthermore, it is critical that counselors working with African American women become aware of, acknowledge, and understand the cultural and sociopolitical histories that contribute to African American women's psychological well-being.

The aim of this paper is to provide a contextual framework which examines the potential stressors contributing to eating disorder symptoms in African American women living in the United States. Next, theoretical and empirical support for these factors are discussed. Finally, recommendations for culturally competent counseling are provided. Although this paper focuses on the experiences of African American women, the counseling strategies discussed can be applied to other women belonging to oppressed demographic-identity groups.

POTENTIAL STRESSORS FOR AFRICAN AMERICAN WOMEN

In general, physical appearance such as body shape has been identified as a primary motivation for the development of eating disorders in White women (Smolak & Striegel-Moore, 2001). In fact, researchers have argued that the dominant White American cultural ideals and obsession with thinness have been the leading cause of the development of eating disorders in women (Brownell, 1991: Lynch. 2004, Polivy & Herman, 2002). For example, women who exhibit anorexia-type eating disturbances are habitually concerned with their weight and body image and engage in restrictive behaviors (e.g., severe dieting for weight loss) to control them (Herman & Polivy, 1980: Smolak & Striegel-Moore, 2001). However, African American women's standards of beauty may be based on a different set of body image criteria (Abrams et al., 1993; Akan & Grilo, 1995; Lynch, 2004; O'Neill, 2003; Polivy & Herman, 2002; Rucker & Cash, 1992; Smolak & Striegel-Moore, 2001). Therefore, the emphasis on body image in a majority of the studies of eating disorders may present a distorted view regarding the extent of disordered eating among African American women.

Efforts to respond to the psychological realities of racism, sexism, classism, and acculturation are considered to provide the motivation for the development and maintenance of eating disorder symptomatology in African American women (Harris & Kuba, 1997; Lynch, 2004; Mastria, 2002; Root, 1990; Smolak & Striegel-Moore, 2001;Thompson, 1994, 1997). Moreover, binge eating behaviors (e.g., excessive overeating) are assumed to characterize some African American women's responses to contextual stressors. Indeed, empirical evidence suggests that African American women generally engage in equal or greater rates of binge-eating behaviors than their White counterparts (Abrams et al., 1993; Gray et al., 1987; Harris, 1995; Rucker & Cash, 1992; Striegel-Moore et al., 2000, 2003). Therefore, engaging in binge eating to alleviate societal stressors (e.g., racial or gender stressors) may be considered a risky health behavior since it may contribute to obesity and related negative health outcomes in African American women.

Race and Gender as Stressors

Despite societal efforts to provide equal opportunity to Black men and women (e.g., affirmative action practices), African Americans continue to experience individual and institutional racism in various forms ranging from direct violence (e.g., beatings) to more subtle forms (e.g., racial profiling) (Landrine & Klonoff, 1996; Paul, 2003; Thomas et al., 2004; Thompson & Neville, 1999; Utsey & Ponterotto, 1996). In fact, race was the basis of enslavement and continues to underlie social disadvantages such as residential segregation, educational, employment, and income disparities (Myers, 1998; Paul, 2003). Differences in gender privilege and racial socialization in the United States can cause the effects of racism to be different for African American women than for African American men since African American men benefit from male privilege, whereas African American women do not benefit from either (Greene, 1994; Myers, 1998, Thomas et al., 2004).

Several theorists have argued that their simultaneous membership in two oppressed demographic-identity groups (i.e., gender and race) subjects African American women to unique challenges of racism and sexism (Greene, 1994: Myers, 1998; Thomas et al., 2004). For example, from an historical standpoint, African American women have been exempt from traditional gender roles and have become self-reliant, taking on multiple roles within their families (e.g., economic provider, head of household). This was due to the absence of their husbands or the father of their children during the eras of slavery and post-reconstruction (Malson, Mudimbe-Boyi, O'Barr, & Wyer, 1990). Consequently, African American women have been socialized to take care of others before taking care of themselves (Greene, 1994; Thomas et al., 2004: Villarosa, 1994). Furthermore, they have been socialized to appear strong, resilient and self-sufficient despite the stressors they may be experiencing (Greene, 1994; Thomas et al., 2004). Overall, their need to portray an image of survival and strength combined with facing the possibility of being victimized by acts of racism may negatively affect African American women's physical, mental, and spiritual well-being (Greene, 1994; Myers, 1998; Thomas et al., 2004).

A number of authors have suggested that racial stressors (e.g., acts of racism) may contribute to various forms of mental (e.g., depression) and physical (e.g., hypertension) illnesses in African American women (Krieger & Sydney, 1996; Landrine & Klonoff, 1996; Lynch, 2004; Thomas et al., 2004; Thompson & Neville, 1999; Thompson, 1994). Concerning African American women and eating disorders, theorists maintain that compulsive (or binge) eating behaviors may be typical of African American women who internalize racial oppression or reject White cultural standards of beauty (Harris & Kuba, 1997, Lynch, 2004; Mastria, 2002; Thompson, 1994). Consequently, African American women's eating and health concerns may be related to the double jeopardy of being Black and female. Given the fact that African American women experience high rates of disease and chronic health conditions, it is imperative that mental health counselors understand how the interaction of racism and sexism may contribute to eating disorder symptoms in African American women.

Classism

African American women in the United States experience classism (e.g., disparate effects of social policy on low status groups) since they have less access to positions of power and authority than White men and women, as well as their African American male counterparts (Greene, 1994). Not surprisingly, "Black female householders (without a spouse present) make up 39.3% of those living below poverty line" (Paul, 2003, p. 17). Since there are a disproportionate number of African American women who identify as low income, African American women are at risk for experiencing health concerns because they lack access to economic resources (Dounchis, Hayden, & Wilfrey, 2001; Downing, 2004; Greene, 1994; Paul, 2003).

Results from research examining race, socioeconomic status (SES) and disordered eating behaviors have been contradictory (O'Neill, 2003). Some findings have suggested that the risk of developing eating disorders such as anorexia nervosa and bulimia are higher among middle class African American women who adopt White middle-class values (Polivy & Herman, 2002; Pumariega, Gustavson, Gustavson, Motes, & Ayers, 1994; Rucker and Cash, 1992, Smolak & Striegel-Moore, 2001). Yet, other researchers have found the link between SES and eating disorder symptoms to be non-significant (Besselieu, 1997; Harris, 1994; Reel, 2000).

With regard to poverty and obesity, there has been some agreement based on research that lower SES African American women seem to be at higher risk for becoming obese than higher SES women (O'Neill, 2003). For example, Thompson (1994) interviewed several women of color who struggled with eating problems and found that they used emotional overeating behaviors to cope with their experiences with poverty-related stress. In addition, other researchers have argued that women who struggle with poverty may suffer from malnutrition or from food diets high in fats and sugars (Dounchis et al., 2001; Paul, 2003). Therefore, it appears that working or lower class African American women may be at risk for engaging in binge eating behaviors and/or becoming overweight or obese. Because of the inconsistencies in the research findings in this area, it continues to be important to study and understand how poverty-related stress relates to eating behaviors and obesity in African American women.

Acculturation

Acculturation refers to the process of adopting the cultural norms of the majority culture including adjusting to a new language, social interactions, and lifestyle changes (Kim & Abreu, 2001; Organista, Organista, & Kurasaki, 2002). The acculturation literature suggests that the process of acculturation (i.e., adoption of new values) may have psychological and physical ramifications such as anxiety, discomfort, and weight gain/loss (Anderson, 1991; Myers & Rodriguez, 2002; Organista, Organista, & Kurasaki, 2002). While acculturation has been researched mainly in Asian American and Latin American populations given the immigrant status of many of its members, the concept can also apply to African Americans because they also engage in the process of adapting to the dominant cultural norms (Anderson, 1991; Helms & Cook, 1999).

African American Culture and Eating Disorders. In the eating disorders literature, acculturation has been suggested to play a role in the development of eating disorders among women of color (Lynch, 2004; Mastria, 2002; Root, 1990; Smolak & Striegel-Moore, 2001). Several researchers have argued that African American cultural factors may serve as protective barriers to the development of eating disorders in African American women since social pressures surrounding thinness may not exist (Abrams et al., 1993; Gray et al., 1987; Lynch, 2004; Rucker & Cash, 1992; Smolak & Striegel-Moore, 2001; Streigel-Moore et al., 2005; Thompson, 1994; Villarosa, 1994; Wilfrey et al., 1996; Wilson, Sargent, & Dias, 1994). For instance, since many women in African American culture have been socialized around food, Villarosa (1994) argued that it has become tolerable in African American culture to use food as a socially acceptable addiction to mask psychological distresses. Furthermore, obesity may not be stigmatized in African American culture as it is in the dominant White American culture (Davis, Clance & Gailis, 1999; Kumanyika, Wilson, Guilford-Davenport, 1993; Smolak & Striegel-Moore, 2001).

African American cultural factors may protect African American women from developing disordered eating attitudes such as a drive for thinness or body dissatisfaction (Abrams et al., 1993; Lynch, 2004; Smolak & Striegel-Moore, 2001). However, being acculturated to African American culture may be related to higher levels of binge eating behavior because this mode of coping with emotions is acceptable within the African American community and does not necessarily violate cultural standards of beauty. Alternatively, African American women who value White American cultural norms of thinness may exhibit greater restrictive behaviors (e.g., severe dieting behaviors) than African American women whose cultural standards of beauty are based on a different set of body image criteria and influences (Abrams et al., 1993; Akan & Grilo, 1995; Lynch, 2004; Rucker & Cash, 1992; Smolak & Striegel-Moore, 2001).

Only one study to date has examined the relationship between acculturation and disordered eating attitudes and behaviors in African American women. Pumariega et al. (1994) surveyed the Essence magazine Black female readership regarding their disordered eating attitudes and behaviors and their Black cultural identity. Results from their study suggested that the risk for developing eating disorders for African-American women were the same as for their White counterparts. Furthermore, they concluded that strong cultural identity protected African American women against some anorexia and bulimia-related risk factors. Although acculturation was measured in a fairly simplistic manner in this study, Pumariega et al.'s results provide a compelling argument for the need to examine disordered eating behaviors and attitudes in Black women. Needless to say, using theories of acculturation to understand the different levels of within group adaptation among African American women appear to be a critical factor in determining how eating disorder symptoms may be manifested in African American women.

Racial Identity and Eating Disorders. Racial identity differs from acculturation in that it refers to the manner in which a person internalizes racial oppression. This includes the extent to which the person identifies with the racial group to which he or she supposedly belongs with the belief that commitment to one's racial group is necessary for healthy psychological functioning (Helms & Cook, 1999). Helms' (1995) model of Black racial identity development consists of four race-related information processing schemas: (a) Preencounter, perceiving Whites and White culture as superior; (b) Encounter, confusion about how to respond to racial cues; (c) Immersion/emersion, idealizing Blackness and denigrating Whiteness; and (d) Internalization, treating Blacks as one's primary, but not exclusive, reference group. These racial identity schemas are fluid processes in that individuals may move back and forth from less sophisticated to more sophisticated forms of racial identity development, depending on the racial events to which they are exposed. According to Helms' (1995), the ultimate goal of these developmental processes is to abandon internalized racism and achieve a positive and healthy collective group identity.

Only a few studies to date have specifically investigated associations between racial identity and eating disorder attitudes and behaviors in African American women (Abrams et al., 1993; Akan & Grilo, 1995; Bessellieu, 1997; Dinsmore & Mallinckrodt, 1996; Harris, 1994; Talleyrand, 1998). A common finding has been that African American women who idealize Whiteness or use White-identified schemas (e.g., Preencounter) tend to engage in restrictive forms of disordered eating attitudes and behaviors (e.g., dietary restraint, body dissatisfaction) (Abrams et al., 1993; Bessellieu, 1997; Harris, 1994;Talleyrand, 1998). That is, African American women's use of the least sophisticated racial identity schema appears to be linked to anorexia or bulimia-type symptoms. Therefore, assessing which racial identity schemas African American women use when exposed to racial stimuli may provide valuable information regarding the manners in which they may manifest eating disorder symptoms.

SUMMARY

In sum, although African American women in the United States have high prevalence rates of binge-eating behaviors, overweight and obesity, traditional research and counseling approaches used to assess women's eating disorder symptoms do not necessarily incorporate risk factors that are characteristic of African American women. Several theorists have maintained that extrapersonal (e.g., racism, acculturation) rather than intrapersonal factors (e.g., body dissatisfaction) are the primary motivating factors for African American women who develop eating disorder symptoms (Harris & Kuba, 1997; Lynch, 2004; Mastria, 2002; Root, 1990; Smolak & Striegel-Moore, 2001; Thompson, 1994, 1997). Therefore, the assessment of racial, cultural, gender and socio-economic variables in eating disorders research and practice appears to be a critical factor in determining why and how African American women may manifest eating disorder symptoms.

IMPLICATIONS FOR COUNSELING

As previously noted, multiple stressors such as racism, sexism, classism, and acculturation are potential realities in the lives of many African American women. Yet, African American women are either seen as women or people of color in the mental health field, failing to recognize their multiple identity statuses (Comas Diaz & Greene, 1994; Constantine, 2002; Thomas et al., 2004). Thus, mental health counselors who are working with African American women should be conscious of the fact that traditional models of eating disorder symptomatology may not incorporate the unique experiences of African American women. Accordingly, familiarity with the socialization experiences of various racial and ethnic groups is, indeed, a necessity for counselors working with diverse populations of women presenting with eating concerns (Lynch, 2004; Mastria, 2002; Root, 1990). The following are specific recommendations for providing culturally sensitive counseling when working with female clients of color.

First, understanding how a client's level of acculturation to her indigenous culture or the dominant culture influences her beliefs regarding food and physical appearance is critical. For example, an African American woman who internalizes the body image norms of the dominant culture may exhibit attitudes and behaviors that are consistent with a pursuit for thinness and body dissatisfaction (Abrams et al., 1993; Akan & Grilo, 1995; Lynch, 2004; Rucker & Cash, 1992; Smolak & Striegel-Moore, 2001). Consequently, she may be more at risk for exhibiting eating disorder symptoms that are consistent with anorexia or bulimia. Conversely, an African American woman who has been socialized to adopt the cultural norms of the African American culture may be less tempted to engage in severe dieting behaviors or experience body dissatisfaction (Abrams et al., 1993; Gray et al., 1987; Pumariega et al., 1994; Rucker & Cash, 1992; Smolak & Striegel-Moore, 2001; Streigel-Moore et al., 2005; Thompson, 1994; Villarosa, 1994; Wilfrey et al., 1996). However, she may use overeating as a coping strategy since this is a socially acceptable behavior in African American culture (Villarosa, 1994). A formal assessment [e.g., use of Landrine & Klonoff's (1996) African American Acculturation Scale] of a client's level of acculturation can provide useful information (e.g., cultural values, beliefs, traditions) regarding the socialization experiences of African American women.

Furthermore, it is imperative for mental health counselors to understand culture-specific themes in the lives of African American women (i.e., African American women's multiple roles as caregivers, providers, and survivors). This information may help mental health counselors understand why some African American women resist seeking help for their eating problems. Likewise, understanding the importance of an extended family network and spirituality in African American culture can have unique implications for eating disorder prevention and treatment (Davis et al., 1999; Greene, 1994; Lynch, 2004; Thomas et al., 2004). For example, a counselor working with an African American female who strongly identifies with African American culture and struggles with eating concerns may consider incorporating her family members in the counseling sessions, incorporating spirituality into the treatment process, and focusing on a holistic approach to health rather than on body image.

Second, in addition to assessing levels of acculturation, counselors should assess the degree to which African American female clients internalize racial oppression. More specifically, helping clients identify the conscious and unconscious methods they use to respond to racism and sexism could provide valuable information concerning their presenting eating concerns (Harris & Kuba, 1997; Lynch, 2004; Mastria, 2002; Thompson, 1994, 1997). One possible formal assessment tool in this regard may be the use of the Black Racial Identity Attitudes Scale (BRIAS-R; Helms, 1995). Helms' (1995) racial identity model can provide information related to how African American women identify with their socially ascribed racial group. Subsequently, this information can help identify the type of eating disorder symptoms they may manifest. That is, finding out which racial identity schema an African American woman uses when confronted with race-related information may help explain why she may be manifesting a particular eating behavior or attitude.

Other informal racial identity assessments may include inquiring about a client's racial socialization processes. For example, what racial socialization agents (e.g., parents, peers, religion) were present in her life? What messages did she receive about being African American? Did she live in a predominantly White neighborhood or attend predominantly White schools? These questions may enable a counselor to find out how a client has internalized racial oppression and also how she copes with anxiety or negative affect associated with race-related events.

Third, counselors should consider referring to stress and coping models that address issues pertaining to African American women to assist them in working with their clients. There is limited extant research on the types of coping strategies that individuals use to respond to racism. Some theorists suggest that the use of unhealthy coping strategies (e.g., avoidance, denial) to respond to racism may result in negative physical and mental health outcomes such as low self-esteem, hypertension, obesity, and suicide (e.g., Anderson, 1991; Clark et al., 1999; Landrine & Klonoff, 1996; Paul, 2003; Thompson, 1997; Thompson & Neville, 1999; Wyatt et al., 2003). Clark et al. (1999) have developed a conceptual model that evaluates both the mental and physical health consequences of perceiving racism as a stressor in the lives of African Americans. Specifically, their model proposes that when African Americans perceive environmental stimuli as racist, the type of coping mechanisms they use may trigger physiological and psychological stress responses that contribute to negative health outcomes.

For mental health counselors, assessing the relationship between African American women's appraisal of racial stressors and the enactment of subsequent coping strategies, particularly overeating, may be useful in evaluating how they manage their racial stress and in evaluating whether negative physical health outcomes (e.g., obesity) are related to the use of particular coping strategies. Use of formal measures such as the Schedule of Racist Events (SRE; Landrine & Klonoff, 1996) or the Index of Race Related Stress (IRRS; Utsey & Ponterotto, 1996) may help counselors assess the types and frequency of race-related stress experienced by African Americans. Informally, a counselor can ask clients to list the most salient stressors in their lives and then have them describe the types of coping mechanisms (e.g., active or passive) they use when they encounter these stressors.

Finally, African American women may be less likely to seek access to mental and physical health services because of their sociopolitical histories and cultural beliefs (Greene, 1994; Paul, 2003, Thomas et al., 2004). Consequently, developing health promoting workshops that incorporate culturally relevant activities may be a proactive and effective way of preventing a rise in the number of health issues that African American women face (Davis et al., 1999; Story et al., 2003). Considering that Black females aged 5 to 17 are also at risk for being overweight or obese (Dounchis et al., 2001), targeting Black female adolescents with eating disorder prevention programs that include culturally-relevant activities (e.g., dancing, family and community involvement, spirituality, psycho-educational programs emphasizing a holistic approach to health) may contribute to treating the widespread problem of obesity among African American women (Davis et al., 1999; Story et al., 2003).

CONCLUSION

Despite the assertion that African American women experience multiple sources of oppression, very few counseling interventions have focused on the effects of contextual stressors on the mental and physical well being of African American women. Furthermore, the use of food or overeating as a coping mechanism for racially-laden stressors is an area that has been understudied in African American female research.

Given the increasing numbers of African American women experiencing disordered eating symptoms and high prevalence rates of overweight and obesity in African American women, it is imperative that counselors acknowledge their multiple identities (e.g., race, ethnicity, gender and social class) and how those may contribute to psychological well-being. It is also pertinent for researchers to include African American women in their studies of eating disorder etiology. Furthermore, researchers should develop and use eating disorder measures that include risk factors and symptoms of eating disorders that may be characteristic of African American women. In sum, assessing African American women's racial and cultural socialization processes may be beneficial in determining what types of coping behaviors they use when responding to the multiple stressors they experience. Likewise, providing culturally competent counseling may increase utilization of mental health services for African American women, as well as prevent an increase in mental and physical illnesses in this population.

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Correspondence can be addressed to: Regine M. Talleyrand, George Mason University, 4400 University Drive, MSN4B3, Fairfax, Virginia 22030, 703-993-4419. Fax: [phone]. E-mail: [e-mail].