Tendency toward deliberate food restriction, fear of fatness and somatic attribution in cross-cultural samples

Eating Behaviors 8 (2007) 407 – 417

Tendency toward deliberate food restriction, fear of fatness and somatic attribution in cross-cultural samples Nonna Viernes a , Ziad A.J. Zaidan a , Atsu S.S. Dorvlo b , Mami Kayano c , Kazuhiro Yoishiuchi c , Hiroaki Kumano c , Tomifusa Kuboki c , Samir Al-Adawi a,⁎ a

b

Department of Behavioral Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, P.O. Box 35, Al-Khoudh 123, Muscat, Oman Department of Mathematics and Statistics, Sultan Qaboos University, P.O. Box 36, Al-Khoudh 123, Muscat, Oman c Department of Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113, Japan Received 6 May 2006; received in revised form 20 November 2006; accepted 21 December 2006

Abstract Objective: To compare Omani and western teenagers attending schools in Muscat, Sultanate of Oman and Filipino teenagers residing in Manila, Philippines on indices of deliberate food restriction and dieting behavior. Methods: The sample consisted of 444 students who were assessed using the cross-culturally valid measure, Eating Attitude Test26, a subscale of Eating Disorder Inventory to gauge the presence of the drive for thinness or ‘fat phobia’ and the Bradford Somatic Inventory to elicit the presence of somatization. Result: Significant differences in attitudes to eating, body image and somatization between the western and non-western teenagers were found. Conclusion: This paper suggests that trajectories of eating disorder, such as body image disturbances as expressed in fat phobia and somatization, tend to vary from culture to culture and underscore the view that some of the health related behavior among adolescents need to be examined within socio-cultural contexts. © 2007 Elsevier Ltd. All rights reserved. Keywords: Deliberate food restriction; Oman; Philippines; Euro-American; Fat phobia and somatization

1. Introduction Dysfunctional eating behaviors and unhealthy weight-loss practices leading to dieting and body image disorder are now being recognized as a ‘silent epidemic’ in many parts of the world (Hoek & van Hoeken, 2003; Kuboki, Nomura, Ide, Suematsu, & Araki, 1996; Tsai, 2000). Well-known ramifications of deliberate food restriction include pervasive and persistent conditions including anorexia nervosa, bulimia and their variants. Exposure to western culture's ideal of beauty, the phenomenon of ‘medicalization’ (Paquette & Raine, 2004) and the stigmatization of the overweight ⁎ Corresponding author. Tel.: +968 24141139; fax: +968 24545203. E-mail address: [email protected] (S. Al-Adawi). 1471-0153/$ - see front matter © 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.eatbeh.2006.12.003

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(Friedman, 2004) have denigrated traditional features of body preference. Although generally benign and an integral part of adolescent behavior, empirical evidence suggests that a preoccupation with body image and weight-loss behavior increases the risk of clinical eating disorder (Keel et al., 2003). Deliberate food restriction coupled with the psychopathology of anorexia nervosa affects normal bodily function and may lead to other intransigent chronic conditions such as osteoporosis, anovulation or even death (Beumont & Touyz, 2003). With the increase of deliberate food restriction in different parts of the world, there is an urgent need to understand the socio-cultural factors underlying eating behavior in young people. With an increase in the number of young people in the population structure of many developing countries, the rate of abnormal attitude to food and weight is likely to increase. There is debate about whether the tendency for deliberate food restriction has similar manifestations in different cultures and whether such persuasion constitutes a culture-bound or culture-reactive phenomenon. Although there are suggestions that susceptibility to weight-loss behavior is linked to a traditional rather than a Westernized cultural orientation (Mumford & Whitehouse, 1994), studies have shown that adolescents exposed to westernization in developing countries are affected by deliberate food restriction, occurrence already evident in their counterparts in the industrialized world (Brewis & McGarvey, 2000; Gupta, Chaturvedi, Chandarana, & Johnson, 2001; Nasser, 1994; Yates, Edman, & Aruguete, 2004). Most of the studies available so far have compared western and non-western populations in different western countries or settings. There is a scarcity of studies that compare the tendency toward deliberate eating restriction in non-western cultures. One of the aims of this study is to address such a deficiency by studying divergent ethnic groups in developing countries. In the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (American Psychiatric Association, 1994), clinical manifestation of deliberate food restriction such as anorexia nervosa is characterized by significant weight loss, amenorrhea, distorted body image and a relentless pursuit of thinness. Emerging evidence from studies conducted in different ethnic groups suggests that a distressing preoccupation with ‘fat aversion’ is not consistently present in these groups (Ngai, Lee, & Lee, 2000). Although the orthogonal manifestation to ‘fat aversion’ in deliberate food restriction is characterized by the lack of exaggerated dread of fatness, it is still associated with a marked reduction in body mass index (Rieger, Touyz, Swain, & Beumont, 2001). In western populations, manifestations of fat phobia have been shown to vary among various ethnic groups (Altabe, 1998; Contento, Basch, & Zybert, 2003), with notably low incidence among African–Americans in some studies but not in others (Duncan & Robinson, 2004). In some of these studies the rate varies from 15% to 20% among some ethnic groups (Ramacciotti et al., 2002). Studies carried out among different Asian populations have revealed contradictory results. For example, a lack of fat phobia has been shown to characterize the majority of patients with dieting disorder among some Chinese populations; however, this has not been consistently confirmed in other populations (Ngai et al., 2000). Comparative studies are needed to examine whether the lesser drive for thinness, as one of the indices of non-fat phobia in eating disorder, is found in other non-western ethnic groups. In a previous study Al-Adawi et al. (2004) compared eating disorder among Indian, Omani and Euro-American children in Oman. Despite the fact that non-fat-phobics tended to have a more benign prognosis and less severe forms of dieting disorder (Strober, Freeman, & Morrell, 1999), non-fat phobics with deliberate food restriction have predominantly been characterized with somatic complaints. This is manifested as diminished appetite, hunger for food, or the inability to consume adequate amounts of food (Rieger et al., 2001). The preponderance of ‘somatic metaphors’ has sparked uncertainty as to whether the presentation of non-fat phobia reflects how different sociocultural groups use different ‘languages of distress’ in communicating their suffering (Helman, 1990). In various ethnic groups, numerous studies have suggested that sufferers tend to use “somatopsychic” idioms of distress rather than verbalize their distress in psychological concepts (Kleinman, 1987). However, even though somatic idioms of distress have been found to be integral parts of how distress is communicated in many ethnic groups, such issues have not been adequately dealt with in relation to deliberate food restriction. Instead, the lack of fat phobia has been depicted as a tendency of ‘concealment’ or ‘denial’ (Casper, 1998). It is worthwhile to note that the characteristics of somatopsychic culture appear to be related to those ethnic groups that have been suggested to have a lack of fat phobia. Although other forms of somatoform disorders have been explored in the context of anorexia nervosa (Waller et al., 2003), to our knowledge, studies using assessment measures that directly elicit a tendency to a somatopsychic idiom of distress are lacking. One aim of this paper, albeit indirectly, is to examine whether there are ethnic variations among age groups that are vulnerable to deliberate food restriction in endorsing attitude and behavior central to somatopsychic idiom of distress. This study aims to compare the performance of Omani and Filipino students on indices of (i) deliberate food restriction (ii) fat phobia and (iii) somatopsychic idiom of distress. A comparative group of European students living in Oman was also assessed with similar indices. A related aim of this study is to examine whether variation in deliberate food restriction is related to endorsing a tendency for fat phobia and somatization.

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2. Subjects The present study involved three groups — Omani, Euro-American and Filipino students. These students differed in terms of ethnicity and culture. In Oman, a sample of Omani students was recruited from three state schools in the Muscat metropolitan area, the nation capital. These schools were selected because they drew students from a cross section of Omani society. The second group consisted of teenagers from Europe or North America. These teenagers reside with their parents and attend English medium schools in the Sultanate of Oman. A third group consisted of Filipino adolescents residing and attending school in the Manila metropolitan area, the national capital of the Philippines. For all participants in either country, a brief explanation of the study was given and participants were assured that the data would be confidential, and then their oral consent was taken. The students were interviewed during class time, and instead of a lecture, they were asked to give their time towards this study. The homeroom teacher at the selected lecture helped supervise the dispensing of the assessment measures to the students. It was explicitly stated that their responses would have no influence on their academic performance. To steer clear of peer influence, the students were asked not to discuss the questionnaire among each other. 3. Assessment measures 3.1. Eating attitude and behaviour The Eating Attitude Test, EAT-26, is a 26 item self-report questionnaire that measures symptoms associated with deliberate food restriction and, at a pathological level, the symptom of anorexia nervosa (Garner & Garfinkel, 1979). Participants rated the frequency with which they experienced each statement on dieting, bulimic behaviors, and selfcontrol of eating behavior, using a six-point scale. Various authors have reported that EAT-26 is effective for assessing a wide range of attitudes and behavior characteristics of deliberate food restriction in both clinical and general populations (Nasser, 1994; Al-Subaie, Al Shammari et al., 1996). While high scores on the EAT-26 do not necessarily equate with clinical eating disorders, many of the characteristics represented constitute deliberate food restriction. The EAT-26 is considered to be an appropriate screening device for eating disorders and has been widely translated. In the majority of studies in the Arab part of the world and Philippine, its cross-cultural application has been found to be acceptable (Al-Subaie, Al Shammari et al., 1996; Lorenzo, Lavori, & Lock, 2002; Nasser, 1994). EAT-26 was scored using the Al-Subaie et al. (1996) system in which the three categories at the non-anorexic end of the six-point Likert scale scored zero; the other categories scored 1, 2 and 3 for each question. The scores on the individual questions were summed up to obtain a composite score. Subjects who scored 20 or greater on the composite score, as established elsewhere in many cross-cultural studies were considered to have a tendency towards disturbed weight and dieting behavior (Al-Subaie, Al Shammari et al., 1996; Nasser, 1994). 3.2. Presence of fat phobia: the drive for thinness A subscale derived from one of the most widely used assessment measures of eating disorder; the Eating Disorder Inventory (EDI) (Garner, Olmsted, & Polivy, 1983) was used to measure fat phobia or a ‘drive for thinness’. The EDI is a self-report measure, validated on both clinical and non-clinical populations (Garner et al., 1983). It has valid and reliable psychometric properties that were established in various ethnic groups including the Arab part of the world (AlSubaie, Bamgboye et al., 1996) and among Filipinos living overseas (Yates et al., 2004). The subscale utilized here contained seven items that elicit the drive for thinness. Higher scores indicate greater levels of fat phobia, with a score of 15 or more on the composite scale suggesting a preoccupation with weight and/or body shape, or demonstration of a morbid fear of weight gain, an excessive concern with dieting or a strong desire for thinness. 3.3. Somatization Bradford Somatic Inventory (BSI) (Mumford et al., 1991) is a 44-item inventory for psychosomatically expressed psychological distress. The BSI is an instrument that is reported to be relatively free of cultural bias. The BSI enquires

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about a wide range of somatic symptoms during the previous month, and whether or not the subject has experienced a particular symptom, on fewer or more than 15 days during the month (scoring 2 or 1 respectively). For the present purpose, 12 items derived from the BSI were employed (Table 4). These items covered the parts of the body that are likely to be affected by eating and body image due to preoccupation with food. The psychometric property of BSI has been established for Arabic speaking populations (Zahid, Motaal, & Razik, 2001) as well as other cross-cultural populations (Al-Adawi et al., 2002; Havenaar et al., 1996). The scoring was based on Zahid et al. (2001) where a higher score suggested somatoform disorder. All of the above-mentioned assessment measures were translated by experienced staff members into Arabic using a method of back-translation (Al-Adawi et al., 2002). Efforts were made to make certain that all items of these measures fulfilled conceptual, semantic and technical equivalence to the original versions. The translated measures were only given to the Omani subjects. The other participants, Euro-American and Filipino subjects, were given the original English version. Euro-American students were attending schools where the medium of instruction was English. For the students in the Philippines, a research assistant was present to assist in clarifying any items of the questionnaires. 3.4. Statistical analysis The statistical packages SPSS and StatXact were used for the analysis. Summary statistics, chi-square tests for independence, logistics regression, and both parametric and non-parametric analyses of variance were some of the procedures used. The study was approved by both the ‘Ethic Committee for Human and Clinical Research’ and the ‘Medical Research Committee’ (Project No. 96) of the College of Medicine, Sultan Qaboos University. 4. Result 4.1. Demographic and anthropomorphic variables The sample consisted of 444 students. One hundred and ninety-six (44%) of the sample were Filipino students, 135 (30%) were Omani and 113 (26%) were of Euro-American origin but resident in Oman. There were 200 (45%) males and 244 (55%) females in the sample. The students were aged between 13 to 18 years. The average age was 15.09 years with a standard deviation equal to 1.08 years. They weighed between 27 and 94 kg. The average weight was 54.58 ± 13.28 kg. The average height of all the students was 1.61 ± 0.10 m. The average BMI was 20.9 ± 4.4. The BMI ranged between 10.7 and 37.8. On average, this sample would be classified as normal on the BMI scale. Only 56 (13%) were classified as over-weight or obese while another 115 (27%) were classified as under-weight on the BMI scale. There was a simple linear relationship between the current weight of the students and the most they had weighed at the current height (r = 0.96). Table 1 summarizes the age, height, weight and BMI of the students by nationality. Both parametric and nonparametric tests show that the Filipino students (14.9 years) were the youngest group. Their age was significantly different from the Omani (15.4 years) and Euro-American students (15.1 years) (F = 7.67, p-value = 0.001). Also significant differences were observed between the height, weight and BMI of the three nationalities. However, only the Omani and Filipino students were significantly different in height. The Filipino students were almost 10 kg lighter than the Omani and Euro-American students. With regards BMI, the Filipino students scored significantly lower than both the Omani and Euro-American students. 4.2. Behaviour and attitudes towards deliberate food restriction The second aim of this study was to elucidate the hypothesis that deliberate food restriction differs between ethnic groups. The twenty-six questions correlated well with each other as measured by Cronbach's alpha of 0.9. The composite scores for the twenty-six items ranged from 0 to 73. It is noted that the maximum possible was 78. Five Filipino students scored greater than 60. The highest scores, 70, 72 and 73, were scored by Filipino students. Of the 17 highest scores only 2 were by Omani and the rest Filipino students. The average composite score for the entire sample was 11.23 ± 12.79. The average composite scores are low when compared with the threshold score, 20. However the average scores are significantly different (F = 22.1, p-value b 0.001) for the three nationalities. The Filipino students

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Table 1 Summary statistics of demographic and anthropomorphic variables

Age

Height (cm)

Weight (kg)

Most ever weighed (kg)

Body Mass Index (kg/m2)

Ethnicity

N

Mean ± SD

Minimum

Median

Maximum

Filipino Omani Euro-American Total Filipino Omani Euro-American Total Filipino Omani Euro-American Total Filipino Omani Euro-American Total Filipino Omani Euro-American Total

196 134 113 443 196 132 106 434 195 126 105 426 196 135 105 436 195 125 100 420

14.9 ± 1.33 15.37 ± 0.80 15.06 ± 0.77 15.09 ± 1.08 159.95 ± 9.21 163.17 ± 9.84 161.82 ± 9.68 161.39 ± 9.60 49.67 ± 12.46 59.08 ± 12.49 58.30 ± 12.66 54.58 ± 13.28 51.84 ± 14.07 62.17 ± 12.69 61.00 ± 14.73 57.25 ± 14.64 19.25 ± 3.70 22.38 ± 5.20 22.21 ± 3.65 20.89 ± 4.45

13 14 14 13 122 127 141 122 27 32 36 27 28 33 42 28 11.69 10.69 14.87 10.69

15 15 15 15 160 167 160 162 48 57 56 53 50 59 60 55 18.82 20.82 21.46 20.26

18 17 17 18 180 179 201 201 90 92 94 94 99 92 99 99 31.14 37.78 34.21 37.78

F( p-value) 7.67 (0.001)

4.65 (0.010)

27.79 (0.00)

27.43 (0.00)

27.91 (0.00)

had the highest average scores (15.5), followed by the Omani students (9.2). The group with the minimum average composite score was the Euro-American students (5.59). Bonferroni's multiple comparison test indicated that the Filipino students had significantly different averages from the Omani and Euro-American students. The male students had a larger average composite score than the female students but this was not significantly larger (F = 1.88, p-value = 0.171). Of the ten students with the highest composite scores six were males and four females. Over 81% and 85% of the students eat lunch and dinner respectively everyday. A significantly lower proportion of the students, 66%, eat breakfast everyday. A higher proportion of the Filipino students (71%) eat snacks between meals than Omani (39%) and Euro-American (43%) students. None of the Omani and Euro-American students enjoyed trying new rich foods while all except two Filipino students enjoyed trying new and rich foods. Among the Filipino students 23% gave a lot of time and thought to food. Most of the students (94% Omani, 100% Euro-American and 88% Filipino) did not feel guilty after eating. However, they, 92% Omani, 100% Euro-American and 82% Filipino did not go on

Table 2 Perception of fat phobia by nationality Omani

I think about dieting I am afraid of getting fat I care too much about my weight I think about getting thinner If I gain a pound, I worry that I will keep gaining I get upset when I eat sweets I feel sorry after eating too much food

Euro-American

Filipino

Never

At least once

Never

At least once

Never

At least once

113 83.7% 55 40.7% 114 84.4% 94 69.6% 59 43.7% 134 99.3% 134 99.3%

22 16.3% 80 59.3% 21 15.6% 41 30.4% 76 56.3% 1 0.7% 1 0.7%

22 19.5% 21 18.6% 45 39.8% 41 36.3% 22 19.5% 15 13.3% 0 0.0%

91 80.5% 92 81.4% 68 60.2% 72 63.7% 91 80.5% 98 86.7% 113 100.0%

187 95.4% 67 34.2% 168 85.7% 156 79.6% 94 48.0% 186 94.9% 165 84.2%

9 4.6% 129 65.8% 28 14.3% 40 20.4% 102 52.0% 10 5.1% 31 15.8%

Chi-square ( p-value) 219.6 (0.000) 14.5 (0.001) 89.4 (0.000) 61.0 (0.000) 25.9 (0.000) 317.2 (0.000) 320.0 (0.000)

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Table 3 Logistic regressions showing the effect of age and Body Mass Index (BMI) by nationality on drive for thinness 95% bounds on odd ratio

I think about dieting

I am afraid of getting fat

I care too much about my weight

I think about getting thinner

If I gain a pound, I worry that I will keep gaining

I get upset when I eat sweets

I feel sorry after eating too much food

Age BMI Omani Euro-American Age BMI Omani Euro-American Age BMI Omani Euro-American Age BMI Omani Euro-American Age BMI Omani Euro-American Age BMI Omani Euro-American Age BMI Omani Euro-American

Odd ratio

p-value

Lower bound

Upper bound

1.12 1.03 2.70 77.31 1.16 0.98 0.73 2.31 1.09 1.04 1.03 8.01 1.08 0.97 1.60 8.17 1.05 0.97 1.27 4.37 0.70 0.94 0.26 215.69 0.82 1.01 0.05 ⁎

0.52 0.47 0.03 0.00 0.14 0.51 0.22 0.01 0.50 0.17 0.93 0.00 0.51 0.31 0.09 0.00 0.64 0.19 0.34 0.00 0.12 0.27 0.22 0.00 0.21 0.86 0.00 1.00

0.79 0.95 1.11 33.10 0.95 0.94 0.45 1.26 0.85 0.98 0.54 4.47 0.87 0.92 0.92 4.63 0.87 0.92 0.78 2.41 0.44 0.83 0.03 71.35 0.59 0.91 0.01 0.00

1.58 1.10 6.54 180.57 1.41 1.03 1.20 4.21 1.38 1.10 1.97 14.37 1.34 1.03 2.79 14.41 1.26 1.02 2.05 7.91 1.10 1.05 2.23 652.03 1.12 1.12 0.36 ⁎

⁎Possibly quasi-complete separation. Model fit uncertain. NB: Filipino is the reference nationality in the equations.

eating binges where they were not able to stop. Very high proportions (the lowest for the groups is 82%) of the students did not engage in dieting behavior and therefore did not eat diet foods. The students didn't like their stomachs to be empty. The level of this attitude was however significantly different among the cultural groups. 4.3. Presence of fear of fat The three nationalities were different in their perceptions of fatness. The Euro-American students scored significantly higher than the other groups (F = 235.9, p-value b 0.001). The scores for the Euro-American students were more than three times the scores of the Omani and Filipino students. There was no difference in the perception of the Omani and Euro-American students. The female students scored significantly higher on the composite score of the fear of fatness (F = 16.2, p-value b 0.001). This perception is independent of height, weight and their composite, BMI. There is a significant but negative association between the composite EAT-26 scores and the composite fat phobia scores. The Kendall's tau was − 1.30, which was significant at the 0.01 level. However no association was observed between the composite scores for the individual nationalities taken separately. The thought of becoming fat terrified over 81% of the Euro-American students while that thought terrified 59% and 66% of the Omani and Filipino students respectively (Table 2). More Euro-American students (60%) cared about their weight. Only about 16% of the Omani and 14% of the Filipino students cared about their weight. About 64% of the Euro-American teenagers were preoccupied with the desire to be thin as opposed to 30% of Omani and 20% of Filipino teenagers.

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Most of the Omani and Filipino students never thought about dieting. In contrast the Euro-American students (80%) thought often about dieting. Significant proportions of the student groups ‘are afraid of getting fat’. Fifty-nine percent of Omanis, 81% Euro-Americans and 66% of Filipino were afraid of getting fat. However, high proportions of Omanis (84%) and Filipinos (86%) did not care about their weight. These groups did not think about getting thinner. In comparison the Euro-American students cared about their weight (60%) and therefore thought about getting thinner (64%). All the Euro-American students in the sample felt sorry after eating too much food. The logistic regression analysis did not show any age or BMI effect on any of the factor of fear of fat. The odd ratios for age, weight and height were in general around unity (Table 3). Significant differences were observed between the nationalities. 4.4. Somatization The twelve psychosomatic factors correlated well with each other. The Cronbach's alpha was 0.94. The response rate for the absence of these factors in the sample was 89%. The average composite scores were very low. The lowest scores were recorded for the Euro-American students (0.09 ± 0.51). On all the psychosomatic factors the EuroAmerican students recorded the highest absence rate (Table 4). Ninety-nine percent of the Euro-American students reported that they never had throat discomfort or burning sensation in the stomach that would render them unable to consume adequate amounts of food. Corresponding percentages for the Omani and Filipino students were 90% and 89%. All the Euro-American students also did not have a diminished hunger or appetite for food. Among the Filipino students 78% did not and 91% of the Omani students did not have a diminished hunger for food. The scores for males and females were low although not significantly different. The logistic regression analysis did not show any age, weight and height effect on any of the somatic factors. The odd ratios for age or BMI were in general around unity (Table 5). Significant differences were observed between the nationalities. However most of the differences occurred between the Filipino and Euro-American students. There is a strong positive association between EAT-26 scores and composite indices of somatization (Kendall's tau = 0.352, p-value b 0.001). Among the different nationalities there was no significant association between the scores

Table 4 Distribution of somatic attributes by nationality Omani Absent Throat discomfort unable to consume adequate amounts of food

122 90.4% A burning sensation in my stomach unable to consume adequate amounts 123 of food 91.1% I have been suffering ache or discomfort in the abdomen 126 93.3% I have fluttering or a feeling of something moving in your stomach? 122 90.4% I suffer from indigestion 123 91.1% I have diminished hunger for food renders me to unable to consume 123 adequate amounts of food 91.1% I feel my stomach is swollen or bloated 118 87.4% I feel sick in the stomach (nausea) 125 92.6% I am troubled by constipation 120 88.9% I have a bitter taste in my mouth 123 91.1% I have suffered from excessive wind (gas) or belching? 108 80.0% I have diminished appetite for food renders me unable to consume adequate 113 amounts of food 83.7%

Euro-American Present

Absent

13 112 9.6% 99.1% 12 112 8.9% 99.1% 9 110 6.6% 97.3% 13 112 9.6% 99.1% 12 113 8.9% 100.0 12 113 8.9% 100% 17 113 12.6% 100% 11 113 7.4% 100% 15 113 11.1% 100% 12 113 8.9% 100% 27 112 20% 99.1% 22 112 16.30% 99.1%

Filipino

Present Absent

Present

1 0.9% 1 0.9% 3 2.7% 1 0.9% 0 0 0 0% 0 0% 0 0% 0 0% 0 0% 1 0.9% 1 0.9%

13 6.6% 31 15.8% 32 16.3% 45 23% 36 18.4 41 21.9% 56 28.60% 39 19.9% 30 15.3% 24 12.2% 33 16.9% 41 20.9%

183 93.4% 165 84.2% 164 83.7% 151 77.0% 160 81.6 153 78.1% 140 71.4% 157 80.1% 166 84.7% 172 87.8% 163 83.2% 155 79.1%

Chi-square ( p-value) 10.6 (0.032) 20.3 (0.000) 20.1 (0.000) 38.0 (0.000) 26.8 (0.000) 34.1 (0.000) 57.1 (0.000) 31.8 (0.000) 27.6 (0.000) 16.9 (0.002) 23.0 (0.000) 29.7 (0.000)

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Table 5 Logistic regressions showing the effect of age and Body Mass Index (BMI) by nationality on somatic attributes 95% confidence Odd ratio Throat discomfort unable to consume adequate amounts of food

A burning sensation in my stomach: unable to consume adequate amounts of food

I have been suffering ache or discomfort in the abdomen

I have fluttering or a feeling of something moving in by stomach?

I suffer from indigestion

I have diminished hunger for food: renders me unable to consume adequate amounts of food

I feel my stomach is swollen or bloated

I feel sick in the stomach (nausea)

I am troubled by constipation

I have a bitter taste in my mouth

I have suffered from excessive wind (gas) or belching?

Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican Age BMI Omani EuroAmerican

Pvalue

Lower bound

Upper bound

1.10 1.20 0.35 3.91

0.63 0.00 0.02 0.20

0.74 1.06 0.14 0.48

1.64 1.36 0.87 31.66

0.79 1.07 1.75 15.38

0.10 0.17 0.15 0.01

0.59 0.97 0.82 2.04

1.05 1.17 3.75 116.13

0.79 1.10 2.14 4.83

0.10 0.05 0.06 0.01

0.59 1.00 0.96 1.40

1.05 1.21 4.80 16.64

0.75 1.02 2.64 27.70

0.03 0.59 0.01 0.00

0.59 0.95 1.32 3.72

0.97 1.10 5.29 206.48

0.94 1.07 1.77 ⁎

0.63 0.14 0.13 1.00

0.71 0.98 0.85 0.00

1.23 1.16 3.68

0.81 1.08 2.59 ⁎

0.10 0.09 0.01 1.00

0.62 0.99 1.24 0.00

0.55 1.10 2.55 ⁎

0.00 0.02 0.00 1.00

0.43 1.02 1.36 0.00

0.70 1.10 2.56 ⁎

0.01 0.04 0.02 1.00

0.53 1.00 1.19 0.00

0.75 1.06 1.28 ⁎

0.04 0.20 0.48 1.00

0.56 0.97 0.64 0.00

0.86 1.06 1.13 ⁎

0.33 0.20 0.75 1.00

0.63 0.97 0.52 0.00

⁎

0.81 1.06 0.66 16.95

0.11 0.13 0.18 0.01

0.62 0.98 0.36 2.26

1.05 1.14 1.21 127.17

⁎

⁎

⁎

⁎

⁎

1.04 1.17 5.38

0.72 1.19 4.80

0.92 1.21 5.49

0.99 1.15 2.57

1.17 1.17 2.46

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Table 5 (continued ) 95% confidence Odd ratio I have diminished appetite for food: renders me unable to consume adequate amounts of food Age 0.90 BMI 1.04 Omani 1.25 Euro22.92 American

Pvalue

Lower bound

Upper bound

0.40 0.25 0.48 0.00

0.70 0.97 0.67 3.07

1.15 1.12 2.33 170.94

⁎Possibly quasi-complete separation. Model fit uncertain. Filipino is the reference nationality in the equations.

for the Euro-American students. Even as there was significant association between the scores for the Omani (Kendall's tau = 0.185, p-value b 0.05) and the Filipino (Kendall's tau = 0.406, p-value b 0.001) students. 5. Discussion The first aim of this exploratory study is to examine if there exist any difference in the tendency toward deliberate food restriction and dieting behavior among teenagers from three different ethnic groups. This was operationalized to be elicited by using the widely used assessment measure, EAT-26. The comparison of Filipino, Omani and EuroAmerican children suggested the three ethnic groups appeared to have differences in their scores on deliberate food restriction and dieting behavior. On the whole, the present data suggest that non-western children had more tendencies for deliberate food restriction and dieting behavior than their Euro-American counterparts. The present finding further provides empirical support to the earlier observation that in non-western societies preoccupation with food restriction and dieting behavior appears to be as common as those reported in western industrialized countries (Hoek & van Hoeken, 2003; Tsai, 2000). The importance of fat phobia diagnostically has been eroded with studies suggesting conflicting results (Al-Adawi et al., 2002; Ngai et al., 2000). In western populations, manifestation of fat phobia has been shown to fluctuate differently among various ethnic groups (Johnson et al., 2004; Williamson, 1998). Similar variations were also observed in studies from some Asian countries (Ngai et al., 2000). To our knowledge, this potentially important aspect of eating disorders has not been looked at among Omani and Filipino populations. With exceptions, many studies examining eating disorder from developing countries have focused solely on whether eating disorder is pathoplastic to westernization (Al-Subaie, Bamgboye et al., 1996; Nasser, 1994). The present study used a subscale from the Eating Disorder Inventory (Garner et al., 1983) the ‘drive for thinness’ index to measure the presence or absence of fat phobia. Our data suggest that perception of body image in the teenagers from these three ethnic groups is generally different. The majority of Euro-American teenagers had strong desires or preoccupations with weight and body shape suggesting morbid fear of weight gain, an excessive concern with dieting or a strong desire for thinness, mindsets that were significantly different for teenagers from Oman and the Philippines. The present data with other findings from elsewhere underscore the view that constructs of fat phobia may not be a preoccupation in some cross-cultural populations (Gupta et al., 2001). This potentially important issue should be further empirically examined. As it was noted that subjects who did not endorse items of fear of fatness were likely to complain of somatic distress, the question arises whether the lack of fat phobia may be related to how certain populations around the world tend to verbalize their distress as noted by, for example, Kleinman (1987). In the present context, are Filipino and Omani styles of expressing distress contributing to the lack of fat phobia and therefore is somatization in these ethnic groups one of the idioms through which distress is communicated? Despite the potential importance of this issue, no previous study, to our knowledge, has examined the presence of somatization in an age group that is also vulnerable to eating disorder. Such a study is likely to shed light on whether ‘concealment’, ‘denial’ or ‘atypical’ manifestations equated with lack of fat phobia may be instead due to a different way of communicating distress. Using a modified Bradford Somatic Inventory (Mumford et al., 1991), this study suggests the presence of somatopsychic expression in Filipino and Omani students. The Filipino and Omani teenagers were more likely than their Euro-American counterparts to endorse the items linked to somatization. The frequent association of somatization and ethnicity and other morbidities suggested

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that somatization would be a predisposing factor as well as idiom of distress and not simply a reaction to disability (Katon et al., 1984). The fact that somatic metaphor is part of how certain cultural groups communicate their distress gives rise to new ideas in the ongoing debate regarding core features of eating disorders. More studies are needed to explore how explanatory constructs involving somatopsychic idioms are related to the lack of fat phobia in other crosscultural populations. Some limitations of this study should be highlighted. Firstly, carrying out protracted clinical interviews would have been logistically impossible in the circumstances of the present study noting that data collection with self-report questionnaires is likely to be inferior to a qualitative interview (Dunn, Pickles, Tansella, & Vazquez-Barquero, 1999). This suggests that the present result should be viewed with caution. Some writers have suggested that as slimness is often considered to be a mass obsession, against the background of personal distress and lack of empowerment, there is the tendency for questionnaires to elicit over identification of individuals with deliberate food restriction and dieting behavior (Al-Adawi et al., 2002). Notwithstanding such a view, the cases identified as severe cases of deliberate food restriction, suggesting the presence of caseness, were relatively small. Nonetheless, in order to circumvent such constrains on cross-cultural samples, qualitative interviews are likely to be more fruitful. As EAT-26 has been shown to give spurious results in non clinical populations (Wildes, Emery, & Simons, 2001), in future studies conventional clinical interviews would be essential to collaborate the present finding as well as explore further socio-cultural correlates of eating disorder in non-western cultures using culturally sensitive assessment measures. Secondly, although all the items of the screening instrument were carefully translated into Omani Arabic, their usefulness could still be obfuscated by certain subtle linguistic and conceptual misunderstandings that might not have been apparent during translation and piloting as causal attributions tend to differ from culture to culture. Similarly, although the Filipino group studied in English medium schools, their native language is not English. Within the confines of the present study, it would be impractical to translate the assessment into various languages for what are apparently diverse groups of Euro-American and Filipino students. This study hinges on the assumption of ethnic homogeneity in terms of identity and functioning. However, the concept of ethnicity could be eroded with globalization and acculturation and therefore, ethnic groups that have been lumped in the present study should be viewed with caution. 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