ethnic-racial differences in feelings of embarrassment associated with binge eating and fear of...

Ethnic-Racial Differences in Feelings of EmbarrassmentAssociated with Binge Eating and Fear of Losing Control

Sarah Bennett, MPhil*Tonya Dodge, PhD

ABSTRACT

Objective: Limited research exists on

ethnic-racial differences in the objective

and subjective experiences of binge eat-

ing among women in the United States.

The present study examined binge eating

related psychopathology in a nationally

representative sample of White, Black,

Native American, Asian, and Hispanic

women.

Method: A subsample of 5,726 women

between the ages of 19 and 27 years

were selected from the National Longitu-

dinal Study of Adolescent Health.

Results: Ethnic-racial differences in

binge eating related psychopathology

were found. Asians and Native Americans

were more likely than Whites to report

they would feel embarrassment related

to binge eating. Hispanics were more

likely than Whites and Blacks to report

they would be afraid to start eating for

fear of losing control.

Conclusion: Findings suggest that the

affective dimensions associated with

binge eating are differentially repre-

sented among ethnic-racial groups.

Implications for treatment and preven-

tion programs are discussed. VVC 2007 by

Wiley Periodicals, Inc.

Keywords: binge eating; ethnic-racial

differences; embarrassment; fear of losing

control

(Int J Eat Disord 2007; 40:454–459)

Introduction

Anorexia nervosa (AN) and bulimia nervosa (BN)are the two major diagnosable eating disorders andboth have received a great deal of empirical atten-tion.1 Mounting evidence suggests the existence ofa third eating disorder, binge eating disorder (BED)that is marked by recurrent periods of binge eatingwithout compensatory behaviors. Binges are char-acterized by eating an amount of food larger thanwhat is considered normal and experiencing a lossof control over eating.2 Indicators of lack of controlinclude feelings of embarrassment, guilt, and self-disgust associated with the binge.2 Because theembarrassment is so great, binging regularly occursin private.2 Thus, BED is an eating disorder plaguedby repeated periods of uncontrolled eating andthese periods are generally associated with feelingsof embarrassment.

BED is not listed as an officially diagnosable disor-der in the Diagnostic Statistic Manual-Fourth Edition

Revised (DSM-IV-TR) but is listed in the Appendix asan area for further research. Because awareness ofBED is relatively new, national prevalence estimatesare difficult to estimate. Studies have suggested thatBED affects 1–5% of the general population in theUnited States3 and that females are about 1.5 timesmore likely than males to meet criteria for BED.4

BED adversely affects one’s psychological andphysical well-being. Feelings of shame, self-disgust,and guilt associated with the binge can lead todepression, anxiety, and suicidal thoughts.5 Individ-uals with BED are at increased risk for high bloodpressure, heart disease, high cholesterol, obesity,and diabetes mellitus.5 Overall, BED is associatedwith a lower quality of life and poor physical andmental health.5

Although research on BED is somewhat limitedit appears that the feelings of embarrassmentassociated with binge eating and fear of losingcontrol are important affective dimensions experi-enced by individuals with BED. The present studyattempts to better understand the feelings ofembarrassment and fear of losing control and theethnic-racial differences that exist with respect tosuch feelings.

Affective Dimensions of Binge Eating Disorder

Two affective dimensions associated with BEDinclude feelings of embarrassment and experien-

Accepted 3 January 2007

Department of Psychology, The George Washington University,

Washington, District of Columbia

*Correspondence to: Sarah Bennett, 2125 G. Street, NW, Washing-

ton, DC 20052. E-mail: [email protected]

Published online 15 February 2007 in Wiley InterScience

(www.interscience.wiley.com). DOI: 10.1002/eat.20374

VVC 2007 Wiley Periodicals, Inc.

454 International Journal of Eating Disorders 40:5 454–459 2007—DOI 10.1002/eat

REGULAR ARTICLE

cing a loss of control during a binge. Althoughresearch has focused on the feelings present duringa binge, it is likely that individuals with BED experi-ence these feelings in anticipation of eating.

It is important to examine how the feelings asso-ciated with BED are experienced during periodswhen a binge may not be occurring. How thesedimensions operate and their degree of associationis important to consider when treating individualswith BED. Are feelings of embarrassment and fearof losing control highly related, or do they operateindependently? Do individuals who would experi-ence embarrassment if others saw them eat a largeamount of food also report a fear of losing controlin anticipation of eating? It is likely that these affec-tive dimensions operate independently wherebyan individual may experience strong feelings ofembarrassment but experience little fear of losingcontrol prior to, or in between binges. If the dimen-sions are not highly associated with one anotherthen treatment approaches should be tailored toaddress the feelings that are experienced. To dateno studies have examined the degree of associationbetween the feelings of embarrassment associatedwith binge eating and fear of losing control. Oneobjective of the present study is to examine thisrelationship.

Culture and Binge Eating Disorder

One’s ethnicity defines what behavior is appro-priate within a given culture. Culture can have asignificant impact on determining an individual’sfeeling of shame, guilt, loss of control, and dis-tress.6 As such, the emotions associated with bingeeating may be experienced differently by individu-als from specific ethnic-racial groups within theUnited States. Some studies have examined the rolethat ethnicity plays in the onset of BED7–10 butnone have examined whether there are ethnic-racial group differences in the feelings of embar-rassment and fear of losing control associated withbinge eating. Perhaps the most salient facet indetermining cultural values is the impact of collec-tivism or individualism on an individual’s world-view.

In collectivistic cultures, where family or com-munity is valued over autonomy, a wrongful behav-ior is viewed as a reflection of the group or familymembership rather than simply a reflection of theindividual.11 As a result, individuals from collectiv-istic cultures may be more likely to experienceembarrassment following a wrongful behavior thanindividuals from individualistic cultures whereautonomy is highly valued.11 This suggests that

individuals from collectivistic cultures may experi-ence greater embarrassment when engaging inabnormal behaviors such as overeating, than thosefrom individualistic cultures. We predict that AsianAmericans, Hispanic Americans, Black Americans,and Native Americans will endorse greater feelingsof embarrassment associated with binge eatingthan White Americans.

As with embarrassment, a fear of losing self con-trol may be more distressing for those from collec-tivistic cultures than for those from individualisticcultures, since the individual is burdened by know-ing that his or her loss of control reflects negativelyon the family and greater community. Thus, greaterfear of losing control may be expected among His-panic Americans, Asian Americans, Native Ameri-cans, and Black Americans than among WhiteAmericans.

To date there is limited research that examinesethnic-racial differences in the feelings associatedwith binge eating. The present study addressesthese shortcomings using a nationally representa-tive sample of females. The purpose of this study is3-fold: (1) to examine the degree of associationbetween feelings of embarrassment associated withbinge eating and fear of losing control, (2) to iden-tify ethnic-racial differences in feelings of embar-rassment associated with BED criteria, and (3) toidentify ethnic-racial differences in fear of losingcontrol. There are two specific hypotheses:

Hypothesis 1: Asian, Native American, Black, andHispanic women will be more likely to experiencefeelings of embarrassment associated with bingeeating than will White women.

Hypothesis 2: Asian, Native American, Black, andHispanic women will be more likely to experiencefear of losing control than will White women.

Method

Sample and Procedure

The present study is based on a subsample of the

National Longitudinal Study of Adolescent Health (Add

Health) database.12,13 Add Health is a school-based, lon-

gitudinal study of adolescent health-related behaviors. A

sample of 20,745 nationally representative adolescents

was selected from a random sample of 80 high schools

and associated feeder schools across the United States.

Initial interviews were conducted during September

1994–April 1995 with *20,745 adolescents in grades 7

through 12. Follow-up interviews were conducted one

year later (wave II) and again six years later during July

BINGE EATING AND FEAR OF LOSING CONTROL

International Journal of Eating Disorders 40:5 454–459 2007—DOI 10.1002/eat 455

2001–April 2002 (wave III). The present study uses the

wave III data that includes 15,197 participants, between

the ages of 18 and 27 years, from the original sample. Of

the 15,197 adolescents reinterviewed at the third wave of

data, 8,030 were female. When sampling weights were

applied the subsample was reduced to 7,036. Parent

income and maternal education from wave I data were

used to control for socioeconomic background. This in-

formation was available for 5,726 females. Thus, final

analysis for this study involved a subsample of 5,726

females.

Interviews were conducted in the participants’ homes

and all responses were recorded on laptop computers.

The interviews included a diverse set of topics including

health and diet, physical activity, substance use, family

relationships, friendships, and daily activities. Questions

pertaining to more sensitive topics were administered via

headphones and the respondents typed in their own

responses. For less sensitive subject matter, the inter-

viewer read the questions and recorded the respondents’

answers.

Measures

Embarrassment. The following item was used as a mea-

sure of embarrassment associated with a binge: \In the

past seven days, have you eaten so much in a short period

that you would have been embarrassed if others had seen

you do it?" Responses were coded 0¼ no and 1¼ yes.

Fear of Losing Control. The following item was used to

measure fear of losing control: \In the past seven days,

have you been afraid to start eating because you thought

you wouldn’t be able to stop or control your eating?"

Responses were coded 0 ¼ no and 1 ¼ yes.

Ethnicity. Five ethnic-racial groups were created based

on the self-reported data: Hispanic, non-Hispanic White,

non-Hispanic Black, non-Hispanic Asian, and non-His-

panic Native American.

Body Mass Index. Self-reported height and weight were

used to calculate BMI for participants.

Socioeconomic Status. Because participants were en-

tering young adulthood their own income may not be a

valid indicator of the environment in which they were

raised. Parental self-reported total household income

and highest level of education from wave I were used as

indicators of SES. Respondents were asked to indicate

the highest level of education they achieved. In almost all

cases the respondents were mothers, so parental educa-

tion refers to mothers’ highest level of education. Both

maternal education and family income are believed to be

a good indicator of SES for young adults.14 Maternal edu-

cation was classified into seven categories: 0 ¼ never

attended school, 1 ¼ less than 8th grade, 2 ¼ did not

graduate from high school, 3 ¼ high school graduate, 4 ¼trade school, 5 ¼ some college but did not graduate, 6 ¼college degree, and 7 ¼ professional training beyond col-

lege. Family income was reported by rounding to the

nearest thousand.

Data Analysis

To control for design effects all analyses except Pear-

son correlation coefficients were conducted using

SUDAAN 9.12 Logistic regression analysis was used to test

for statistically significant differences among ethnic-

racial groups on the fear of losing control and embarrass-

ment dimensions of BED while controlling for SES. Given

that differences in SES exist among ethnic groups all

analyses controlled for SES using maternal education

and family income.

Given that limited research exists on BED, we tested

for differences between all ethnic-racial groups on feel-

ings of embarrassment and fear of losing control in addi-

tion to specific statistical tests of the hypotheses. To

obtain all possible comparisons, dummy variables repre-

senting each of the ethnic groups were created and anal-

yses were conducted with four of the five ethnic groups

serving as a reference. For example, a logistic regression

was run with Blacks as the reference group to isolate

comparisons between Blacks and Whites, Blacks and

Native Americans, Blacks and Asians, and Blacks and

Hispanics. To control for experiment-wise error rates, a

modified Bonferroni adjusted p-value, as suggested by

Jaccard15 was used to correct all significant findings. The

modified Bonferroni procedure controls for multiple

comparisons and is determined by dividing the � level

(.05) by the number of comparisons remaining. In this

case p-values were ordered from smallest to largest and

were compared sequentially against the adjusted p-val-

ues of .010, .0125, .0167, and .025.

Results

Descriptive Statistics

The median age for the sample was 22 years. Theethnic distribution of the sample was 69.1% White(N ¼ 3,956), 15.3% Black (N ¼ 877), 0.6% NativeAmerican (N ¼ 34), 3.3% Asian (N ¼ 189), and11.7% Hispanic (N ¼ 670). The mean BMI for thesample was 25.49, which is in the overweightrange.16 The modal level of maternal education forAsians was a college degree. For Whites, Blacks,Native Americans, and Hispanics modal maternaleducation was a high school degree. The median

BENNETT AND DODGE


household income ¼ $40,000 for Whites andAsians, $30,000 for Hispanics and Blacks, and$24,000 for Native Americans.

Relationship Between Embarrassment and Fear of LosingControl. To examine the degree of associationbetween embarrassment and fear of losing controla bivariate correlation was run. Results of the anal-ysis showed that the two dimensions were posi-tively correlated, (r ¼ .26, p < .01) but the correla-tion is low in magnitude suggesting there is consid-erable independence between feelings ofembarrassment and fear of losing control. This isfurther confirmed by inspection of a cross tabsanalysis. Of those young women who reported theywould have experienced embarrassment onlyabout 18.7% (Standard Error ¼ 2.79) also reportedbeing afraid to start eating because they thoughtthey would not be able to control their eating. Ofthose who reported being afraid to start eatingbecause they would not be able to control their eat-ing, only about 45% (Standard Error ¼ 5.04)reported feelings of embarrassment.

Embarrassment. Table 1 shows the percentage offemales who reported having eaten so much in thepast seven days that they would have experiencedembarrassment if others had seen them. Feelingsof embarrassment appear to be most commonamong Native Americans as 13.5% reported suchfeelings, followed by Asians (11.3%), Hispanics(7.0%), Whites (7.1%), and Blacks (6.8%).

Logistic regression analyses were run to test forethnic-racial differences in feelings of embarrass-ment where feelings of embarrassment wereregressed onto ethnicity, family income, and mater-nal education. The analyses showed that Asiansand Native Americans were more likely than Whitesto report feelings of embarrassment controlling forSES. Asians were over one and a half times morelikely than Whites (Exp b ¼ 1.87, 95% CI ¼ 1.25–2.80) to report having eaten so much they wouldhave felt embarrassed and Native Americans wereabout two and a half times more likely than Whites(Exp b ¼ 2.60, 95% CI ¼ 1.3–5.3) to report havingeaten so much they would have felt embarrassed.The statistically significant differences from thelogistic regression analysis are shown in Table 1with superscripts.

Fear of Losing Control. Table 1 shows the percentageof females who reported being afraid to start eatingbecause they thought they would not be able tocontrol their eating. A greater percentage of His-panics (5.6%) reported being afraid to start eatingfollowed by Asians (3.6%), Native Americans(3.0%), Blacks (2.7%), and Whites (2.6%). Logistic

regression analyses were run regressing beingafraid to start eating onto ethnicity and the covari-ates. Results showed statistically significant differ-ences between Hispanics and Whites, and His-panics and Blacks, such that Hispanics were abouttwice as likely as Whites (Exp b ¼ 2.06, 95% CI ¼1.20–3.54) and were about two and one-third timesmore likely (Exp b ¼ 2.37, 95% CI ¼ 1.04–5.37) thanBlacks to report being afraid to start eating becausethey thought they would not be able to controltheir eating. These statistically significant differen-ces from the logistic regression analysis are shownin Table 1 with superscripts.

Conclusion

Using a nationally representative sample offemales, the present study examined two character-istics of BED that seem to be critical to its treat-ment: feelings of embarrassment and fear of losingcontrol. Results of this study show that feelings ofembarrassment associated with binge eating andfear of losing control are relatively independentsuggesting that individuals who experience feelingsof embarrassment will not necessarily experience afear of losing control. This independence is furthersupported by the finding that ethnic-racial groupsdifferentially endorse a fear of losing control andfeelings of embarrassment related to binge eating.

Results of the study documented ethnic-racialdifferences in feelings of embarrassment and fearof losing control. As predicted, Asian and NativeAmerican women were more likely than Whitewomen to report having eaten so much in a shortperiod of time that they would have felt embarrass-ment. Results of the study also showed that His-panics were more likely to report a fear of losingcontrol compared to Whites and Blacks. Theseresults provide direction for future research. Thepresent data suggest that ethnic-racial differencesexist in the feelings that are associated with thetreatment of BED. Future research studies should

TABLE 1. Percentage of females from each ethnic-racialgroup to endorse embarrassment and a fear oflosing control

Embarrassed Fear of Losing Control

White 7.1a 2.6a

Black 6.8a,b 2.7a

Native American 13.5b 3.0a,b

Hispanic 7.0a,b 5.6b

Asian 11.3b 3.6a,b

Notes: Percentages with different superscripts indicate statistically sig-nificant differences from the logistic regression analyses.



attempt to identify the psychological mechanismsresponsible for these observed differences. The dif-ference between Hispanics and Blacks was unex-pected and future studies might explore why thesedifferences exist.

The present study provides direction for futureresearch on culture and BED. We suggested thatone’s worldview may be responsible for ethnic-racial differences in feelings of embarrassment andfear of losing control. Specifically, we believed thatthe feeling of one’s abnormal behavior (i.e., bingeeating) being reflective of the family would increasefeelings of embarrassment and fear of losing con-trol. The data were partially consistent with a cul-tural worldview explanation although several of theethnic-racial groups that we suspected subscribedto a collectivistic worldview were not more likely toexperience feelings of embarrassment or fear oflosing control. There are several possibilities withrespect to these findings. One possibility is thatthese ethnic-racial groups did not hold a collectiv-istic worldview as we believed or that the individu-als within these ethnic-racial groups experiencedhigh levels of acculturation. Another possibility isthat there are cultural factors responsible for eth-nic-racial differences other than one’s worldview.Such factors might include attitudes towards foodor differences in accepted portion sizes. It is possi-ble that Whites, Blacks, and Hispanics view largerfood portions as more acceptable than Asian orNative American women. Thus, women fromWhite, Black, and Hispanic ethnic-racial groupswould not be as likely to report embarrassmentwhen eating a significant amount of food. Futureresearch should test these possibilities and shouldinclude objective measures of the amount of foodthat would warrant embarrassment in differentcultures.

Results of the present study have several impor-tant implications for clinicians regarding the diag-nosis and treatment of BED. The feelings of embar-rassment experienced by Asian and Native Ameri-can women may prevent them from seeking help.As a result Asian and Native American women maybe under-diagnosed for BED. Clinicians should beaware that the emotional aspect of BED may serveas a barrier to treatment for these women.

Documenting differences among ethnic-racialgroups on the endorsement of the affective dimen-sions of BED is beneficial for the development andimplementation of treatment programs targetingthe specific needs of each population. Treatmentmodels that address the embarrassment associatedwith binge eating may be a priority in treatingAsian and Native American women, whereas

greater attention may be given to targeting the fearof losing control experienced by Hispanic women.

Although this study provides important informa-tion about the affective dimensions of BED thereare a number of limitations that deserve mention-ing. The study relied on self-report measures,which are subject to bias in that participants mayhave under-reported or over-reported their feelingsassociated with binge eating. The research reliedon a nonclinical sample and the outcome measuresdid not assess actual experience of embarrassmentand loss of control during a binge making it diffi-cult to generalize the results to clinical populations.The present study was correlational in nature socausality cannot be inferred. Future researchshould address these limitations so that greaterunderstanding of ethnic-racial differences in theaffective dimensions associated with BED can begained.

References

1. Wilfley D, Schwartz MB. Using the eating disorders examination

to identify the specific psychopathology of binge eating disor-

der. Int J Eat Disord 2000;27:259–269.

2. American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders, 4th ed. Washington, DC: American

Psychiatric Association, 2000.

3. Smith DE, Marcus MD, Lewis CE, Fitzgibbon M, Schreiner P.

Prevalence of binge eating disorder, obesity, and depression in

a biracial cohort of young adults. Ann Behav Med 1998;20:

227–232.

4. Wilson GT, Becker CB, Heffernan K. Eating disorders. In: Mash

EJ, Barkley RA, editors. Child Psychopathology, 2nd ed. New

York: The Guilford Press, 2003, pp. 687–715.

5. Johnson JG, Spitzer RL, Williams JB. Health Problems, impair-

ment, and illnesses associated with bulimia nervosa and binge

eating disorder among primary care and obstetric gynecology

patients. Psychol Med 2001;31:1455–1466.

6. Oltjenbruns KA. Ethnicity and the grief response: Mexican

American versus Anglo American college students. Death Stud

1998;22:141–155.

7. Cachelin FM, Veisel C, Striegel-Moore RH, Barzegarnazari E,

Striegel-Moore RH. Disordered eating, acculturation, and treat-

ment-seeking in a community sample of Hispanic, Asian, Black,

and White women. Psychol Women Q 2000;24:244–233.

8. Crago M, Shisslak CM. Ethnic differences in dieting, binge eat-

ing, and purging behaviors among American females: A review.

Eat Disord 2003;11:289–304.

9. Pike KM, Dohm F, Striegel-Moore R, Wilfley DE, Fairburn CG. A

comparison of black and white women with binge eating disor-

der. Am J Psychiatry 2001;158:1455–1460.

10. Croll JK, Neumark-Sztainer D, Story M, Ireland M. Prevalence

and risk protective factors related to disordered eating behav-

iors among adolescents: Relationship to gender and ethnicity.

J Adolesc Health 2002;31:166–175.

11. Sue DW, Sue D. Counseling the Culturally Diverse: Theory and

Practice, 4th ed. New York: Wiley, 2003.

12. Harris KM, Florey F, Tabor J, Bearman PS, Jones J, Udry JR. The

national longitudinal study of adolescent health: Research

BENNETT AND DODGE


design. Chapel Hill, NC: Carolina Population Center, University

of North Carolina at Chapel Hill, 2003. Available at http://

www.cpc.unc.edu/projects/addhealth/design [Contexts link].

13. Udry JR. The national longitudinal study of adolescent health

(add health), waves I & II, 1994–1996; wave III, 2001–2002

[machine-readable data file and documentation]. Chapel Hill,

NC: Carolina Population Center, University of North Carolina at

Chapel Hill, 2003.

14. Halpern CT, Udry JR, Campbell B, Suchindran C. Effects of body

fat on weight concerns, dating, and sexual activity: A longitudi-

nal analysis of Black and White adolescent girls. Dev Psychol

1999;35:721–736.

15. Jaccard J. Interaction Effects in Factorial Analysis of Variance.

Thousand Oaks, CA: Sage, 1998.

16. Department of Health and Human Services Centers for Disease

Control and Prevention. Body mass index: About BMI for

adults. Washington, DC: Department of Health and Human

Services Centers for Disease Control and Prevention. 2005.

Available at: http://www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/

about_ adult_BMI.htm.



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