Correspondence

Lack of Relation between Culture and Anorexia Nervosa — Results of an Incidence Study on Curaçao

N Engl J Med 1998; 338:1231-1232April 23, 1998

Article

To the Editor:

Anorexia nervosa is considered to be a Western-culture–bound syndrome occurring mainly in young, white women. In Western culture, the preoccupation with thinness and sociocultural pressures to diet have been regarded as etiologic factors in the pathogenesis of anorexia nervosa.1 It is thought to be very rare outside the Western world and in black women in industrialized countries.2 Therefore, we hypothesized that we would find no or very few cases of anorexia nervosa in a population-based study on the Caribbean island of Curaçao, where overweight is socially acceptable.3 The mean body-mass index (the weight in kilograms divided by the square of the height in meters) for women in Curaçao is similar to that of black women and higher than that of white women in the United States (28.3, 28.2, and 26.0, respectively).3

We first reviewed the medical records of all inpatients of the Curaçao General Hospital for the period 1987 through 1989 for cases of an eating disorder as well as for diagnostic terms that might indicate missed cases (Table 1Table 1Incident Cases of Anorexia Nervosa among 44,192 People Admitted to Curaçao General Hospital from 1987 through 1989.). Second, we screened the Curaçao Psychiatric Case Register, which contains records of all patients treated in mental health care facilities from 1987 through 1989. To be considered a case, a patient's disorder had to fulfill the criteria for anorexia nervosa according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, 4 on the basis of information in the patient's medical record and an interview with the physician who had treated the patient. Reliable population data are available as a result of a census carried out in 1981 and 1992.

Six incident cases of anorexia nervosa were identified. One other patient who died of anorexia nervosa in the 1990s had received a diagnosis before 1987. All six were women, born and living on Curaçao (ages 13, 18, 19, 23, 24, and 41 years). Five were Creole (black or mixed) and the other was of Portuguese origin. All the patients had serious weight loss, with a mean body-mass index of 14.6 (range, 11.3 to 16.6), and all had amenorrhea. The yearly incidence of anorexia nervosa on Curaçao was 2.6 (95 percent confidence internal, 0.5 to 4.7) per 100,000 women. This rate is within the range of rates reported in Western countries.2,5

Our finding challenges the ideas that sociocultural pressure to diet is a crucial factor in the causation of anorexia nervosa and that it occurs only in Western societies.

Hans Wijbrand Hoek, M.D., Ph.D.
The Hague Psychiatric Institute, 2555 VZ The Hague, the Netherlands

Peter N. van Harten, M.D., Ph.D.
Dr. D.R. Capriles Hospital, Curaçao, Netherlands Antilles

Daphne van Hoeken, Ph.D.
The Hague Psychiatric Institute, 2555 VZ The Hague, the Netherlands

Ezra Susser, M.D., Dr.P.H.
Columbia University, New York, NY 10032

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Citing Articles (14)

Citing Articles

1. 1

   Beth Watkins. 2011. Eating Disorders: an Overview. , 19-55.
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2. 2

   Ingrid D. C. Balkom, Michaeline Bresnahan, Marrit F. Vogtländer, Daphne Hoeken, Ruud B. Minderaa, Ezra Susser, Hans W. Hoek. (2009) Prevalence of treated autism spectrum disorders in Aruba. Journal of Neurodevelopmental Disorders 1:3, 197-204
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3. 3

   Laila Qadan. (2009) Anorexia Nervosa: Beyond boundaries. International Journal of Eating Disorders 42:5, 479-481
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4. 4

   Katherine A. Halmi. (2009) Perplexities and provocations of eating disorders. Journal of Child Psychology and Psychiatry 50:1-2, 163-169
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5. 5

   Hans Wijbrand Hoek. (2006) Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Current Opinion in Psychiatry 19:4, 389-394
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6. 6

   Ellen M.C. Willemsen, Hans W. Hoek. (2006) Sociocultural factors in the development of anorexia nervosa in a black woman. International Journal of Eating Disorders 39:4, 353-355
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   Nerissa L. Soh, Stephen W. Touyz, Lois J. Surgenor. (2006) Eating and body image disturbances across cultures: a review. European Eating Disorders Review 14:1, 54-65
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8. 8

   Anne E. Becker. (2004) New Global Perspectives on Eating Disorders. Culture, Medicine and Psychiatry 28:4, 433-437
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   Richard A. Gordon. (2004) Commentary: Towards a Clinical Ethnography. Culture, Medicine and Psychiatry 28:4, 603-606
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10. 10

    Melanie A. Katzman, Karin M. E. Hermans, Daphne Van Hoeken, Hans W. Hoek. (2004) Not Your ?Typical Island Woman?: Anorexia Nervosa is Reported Only in Subcultures in Curaao. Culture, Medicine and Psychiatry 28:4, 463-492
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11. 11

    Daniel Le Grange, Johann Louw, Alison Breen, Melanie A Katzman. (2004) The Meaning of ?Self-Starvation? in Impoverished Black Adolescents in South Africa. Culture, Medicine and Psychiatry 28:4, 439-461
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12. 12

    Hans Wijbrand Hoek, Daphne van Hoeken. (2003) Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders 34:4, 383-396
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13. 13

    Elizabeth Rieger, Stephen W. Touyz, Tony Swain, Peter J.V. Beumont. (2001) Cross-cultural research on anorexia nervosa: Assumptions regarding the role of body weight. International Journal of Eating Disorders 29:2, 205-215
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14. 14

    Walter H Kaye, Lisa R Lilenfeld, Wade H Berrettini, Michael Strober, Bernie Devlin, Kelly L Klump, David Goldman, Cynthia M Bulik, Katherine A Halmi, Manfred M Fichter, Allan Kaplan, D.Blake Woodside, Janet Treasure, Katherine H Plotnicov, Christine Pollice, Radhika Rao, Claire W McConaha. (2000) A search for susceptibility loci for anorexia nervosa: methods and sample description. Biological Psychiatry 47:9, 794-803
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