Eating Attitudes and Behaviors in 1,435 South African Caucasian and Non-Caucasian College Students

The study was conducted over a 2-year period (July 1992–1994) during which a survey was administered to South African college students. Students at six tertiary institutions from two cities in South Africa (Cape Town and Durban) participated in the study. Although Caucasians are a minority in these communities, they are disproportionately represented in at least four of the six universities surveyed. Nevertheless, these geographical regions provide a representative study group of the ethnic diversity in South Africa. After consent was obtained, undergraduate social science students were invited to volunteer for an anonymous survey of eating attitudes and behaviors. (With South Africa's affirmative admission policy, “typical” undergraduate students from previously non-Caucasian schools tend to be older than those in the United States. Female students are overrepresented in the social sciences.) This invitation was extended during class time, and, instead of a lecture, students were asked to give their time toward this study. A small number of students (approximately 10%) declined to complete the questionnaires that were administered in English.

Subjects completed a demographic questionnaire that was compiled for this study and included items about weight, height, and eating history. The respondents' self-report of their present weight and height was used to calculate body mass index. Subjects also completed the Eating Attitudes Test (24) and the Bulimic Investigatory Test, Edinburgh (25). The Eating Attitude Test is a 40-item self-report scale measuring symptoms associated with anorexia nervosa. A score of 30 or higher suggests a possible eating disorder. The Bulimic Investigatory Test, Edinburgh, is a 33-item self-report measure of both the symptoms and severity of bulimia nervosa. A score of 25 or higher suggests a bulimic disorder.

The volunteers included 1,435 social science students 17–25 years years old (mean age=20.0, SD=1.8). We excluded 87 subjects older than 25 years (26–47 years) in order to confirm a study group representative of typical college students. The ethnic breakdown was 739 Caucasian subjects (51%) and 696 non-Caucasian subjects (49%). The mean ages were 20.0 years (SD=1.9) for males and 19.5 years (SD=1.6) for females. Black subjects were heavier (mean body mass index=22.9, SD=4.9) on average than Caucasian (mean=21.2, SD=2.6), mixed race (mean=21.5, SD=3.0), and Asian (mean=20.8, SD=3.7) subjects (F=22.92, df=3,1431, p<0.0001). Therefore, all analyses were conducted with weight as a covariate. The ethnic and gender composition of the study group is reported in table 1.

Our findings unexpectedly revealed that black subjects demonstrated significantly greater eating disorder psychopathology as measured by the Eating Attitude Test and Bulimic Investigatory Test, Edinburgh, than Caucasian, mixed race, and Asian subjects. An equal percentage of black and white subjects scored above the cutoff on these measures. In addition, the percentage of female subjects who reported irregular menses and who were underweight was meaningful in all racial groups. Taken together, our findings suggest that significant eating disorder pathology may be prevalent in developing non-Caucasian societies.

In terms of severity of eating pathology, the majority of high scorers on the Eating Attitude Test and Bulimic Investigatory Test, Edinburgh, were black and Caucasian females and were heavier than the rest of the study group. Hence, potential cases of eating disorder were as likely among black as among Caucasian subjects. Nine percent of subjects had Eating Attitude Test scores above the cutoff point, indicating anorexic-like behaviors. Previous investigations using the Eating Attitude Test vary in terms of scores within the clinical range. In Western Caucasian samples, scores ranged from 7% to 12% (26, 27), while 20% of Hispanic females in Texas scored within the clinical range (28). Mean Eating Attitude Test scores from previous studies vary from 11 to 19 (4, 26–30), similar to findings from our study. What needs to be noted from our results is the ethnic diversity of these high scorers.

Five percent of subjects reported Bulimic Investigatory Test, Edinburgh, scores above the cutoff point, indicating possible bulimic pathology. Compared to the Eating Attitude Test, it was surprising to find relatively few high scorers on the Bulimic Investigatory Test, Edinburgh. However, North American studies have found that between 4% (31) and 13% (2) of students experience symptoms of bulimia. In terms of subclinical bulimia nervosa, a recent study in Eastern Europe (32) found the rate to be between 2% and 4%. This rate is similar to that found in the present study, which may underline earlier claims (29) that North American findings are not necessarily transferable to other populations. Another study (27) underscores this point, stating that bulimia nervosa is rarely diagnosed in Poland. Moreover, there are indications that previous estimates of bulimic behaviors in Western samples may be inflated (33). However, these studies did not use the Bulimic Investigatory Test, Edinburgh, and all subjects were Caucasian, leaving our findings open for interpretation.

Subjects' weight may influence scores on the Eating Attitude Test and Bulimic Investigatory Test, Edinburgh. In our study, black subjects scored highest on these indices and also had the highest body mass indexes (weight was controlled for by means of covariate analyses). One hypothesis, supported by previous studies (21, 34), is that heavier subjects are more likely to have weight concerns. This point is emphasized by the fact that subjects with body mass indexes below 20 failed to reach the clinical range for either the Eating Attitude Test or Bulimic Investigatory Test, Edinburgh, regardless of ethnicity. In contrast to an earlier proposal that eating disorders are rare in non-Western societies in which plumpness is not stigmatized (35), our data support the contention made by a recent study (15) that black and white women experience similar weight concerns.

Our findings with regard to gender were as predicted; females scored higher than males on the eating disorder indices, and almost all cases of possible subclinical eating disorder involved female subjects. One unexpected finding, though, was that black males scored much higher on the Eating Attitude Test and Bulimic Investigatory Test, Edinburgh, than the other three male groups; and their scores were almost as high as those of the female groups. This is difficult to explain, and to our knowledge only one other study has reported similar findings (9). It is worth noting that 77% of the 26 males in our study who reported serious eating difficulties in the past were black, signaling that eating difficulties may not be that rare among this group. One hypothesis is that black subjects in general and males in particular face new social pressures and expectations by way of “Western syntonic” activities amidst a rapidly changing South Africa.

Some methodological issues concerning our study need to be considered. First, although the study group was representative in terms of ethnicity, most subjects were female university social science students. Our findings could therefore not be extended beyond this population. Second, the Eating Attitude Test and Bulimic Investigatory Test, Edinburgh, were conducted in English, which was not the first language for a large minority of our study group and could be a confounding factor. However, subjects studied English for several years in high school and passed English proficiency requirements for university admission, and instruction and testing at the universities were in English. Therefore, we believe the differences recorded between the ethnic groups may reflect genuine eating pathology as opposed to language difficulties. An alternative hypothesis is that blacks scored higher because of cultural differences. This question should be addressed in future research in which subjects receive the same questionnaires, one in English and a translated version in their first language.

Finally, this study is unique insofar as it is the first to examine eating disorder psychopathology in a large and ethnically diverse South African study group; and it provides much needed insight into the prevalence of unhealthful eating behaviors in this population. Future studies would do well to investigate the nature and course of the full spectrum of eating disorders (33) across a broader age, race, socioeconomic, and societal range than previously studied.

Received July 16, 1996; revisions received Feb. 14 and June 4, 1997; accepted July 10, 1997. From the Department of Psychology, University of Cape Town, Cape Town, South Africa. Address reprint requests to Dr. le Grange, Department of Psychiatry and Behavioral Sciences, School of Medicine, State University of New York, Putnam Hall, Stony Brook, NY 11794-8790. Supported in part by Eli Lilly South Africa (Ltd). The authors thank Joseph E. Schwartz, Ph.D., for statistical advice.