In societies that champion health and well-being, what drives so many young lives towards a relentless pursuit of thinness, even to the brink of death? Anorexia nervosa (AN) is a severe psychiatric disorder associated with “aberrant patterns of feeding behavior and weight regulation, and deviant attitudes and perceptions toward body weight and shape”.1 In industrialized countries, eating disorders are the third most common chronic disease in female adolescents. In Western countries, the rate of AN is 0.3%.2 AN sees a high prevalence among adolescent females, yet it is multifaceted in its causation, with complex intersections of biology, psychology, and socio-cultural dynamics. Notably, this disorder has the highest mortality rate of any psychiatric condition: approximately 5% of individuals diagnosed with anorexia die within the first four years of diagnosis. Morever, AN is associated with various causes of death: suicide, pulmonary disease, diabetes, liver and other digestive disease, to shock and organ failure.3 While studies indicate that genetic factors account for approximately 40-50% of the risk for developing AN, social components still play a key role by exposing individuals to distinct environments that can lead them to developing this devastating eating disorder.4
Although twin studies show that genetics contribute by establishing personal traits that may increase vulnerability to AN, the primary factor remains the social environment individuals are immersed in. Historically, socio-cultural factors—especially those tied to body image and ideals of thinness—have strongly influenced the development and persistence of anorexia nervosa, forming a complex situation that demands more than clinical treatment alone. Discussions on the socio-cultural origins of AN date back to 19785, but in the 50 years since few actionable solutions have been implemented to curb its prevalence. A cultural shift in societal standards of beauty and success is vital to disrupt the cycle that continues to trap at-risk individuals.
The societal conditioning towards thinness is alarmingly powerful. Although there is a "window of opportunity" for successful treatment during the first few years of the disorder, most young people seek help well after the eating disorder has taken root for early intervention to be effective, in part due to socio-cultural forces..6 The Tripartite Model of body dissatisfaction indicates that the sociocultural emphasis on thinness is reinforced by media, parents, and peers.4 Mass media campaigns propagate an “ideal of beauty” that endorses thinness for women, equating slenderness with success and appeal and influencing individuals, often beginning at a young age, to internalize these ideals. As Uchôa et al. reveal, a significant 45.3% of adolescents report being moderately influenced by the media. Unsurprisingly, girls are more affected, with 25.7% experiencing pronounced media influence compared to 19.6% of boys.2 These media-driven ideals exacerbate body dissatisfaction and pose an increased risk for eating disorders during a vulnerable developmental period.
The cultural contagion of disordered eating behaviors is also seen through peer dynamics. During adolescence, female friendship circles can cultivate an unhealthy focus on dieting and weight loss. Peer discussion and the ensuing social validation for losing weight often leads to a group-sanctioned pursuit of thinness, which solidifies the unhealthy idea that thinness equals beauty, within individuals. In such environments, anorexia nervosa can soon develop as adolescents strive to belong or stand out within these social hierarchies. The disorder, for some, can even become a source of identity, offering a sense of distinction and accomplishment where many peers might falter in their dieting efforts. By succeeding where others fail (at dieting, self-discipline and thinness), “the progression towards an eating disorder offers the appeal of a new adolescent identity and social distinction in the group”.6 The sense of success is further strengthened if one has genetic predisposition of having the following traits: perfectionism, the desire to correspond to a certain ideal image of oneself, instability of Ego, unstable identity violations, and reduced ability to form a picture of the future and themselves in the future.7 Personal vulnerabilities, amplified by genetic predispositions, can heighten susceptibility to the environmental triggers discissed.4
Further, these environmental triggers of anorexia nervosa are not confined to Western societies or Caucasian populations. In fact, binge eating and purging behavior are reported among Black women at least as frequently as among White women, yet AN is rarely found among Black women.8 However, differences in the prevalence or rates of occurrence of eating disorders among individuals or social groups do not mean that they are not at risk.9 Willemsen and Hoek present a case of a Black woman from Curaçao who developed AN after moving to the Netherlands. Initially, she conformed to Caribbean ideals that celebrated fuller figures, but upon exposure to Western beauty norms that idolize thinness, she changed her perception of self-worth. Mainly through television, she noticed that in the Netherlands being thin is considered attractive and that many Dutch women diet. As a result, she decided to pursue dieting and later was admitted with the AN diagnosis. This case illustrates that the patient’s ethnic background did not protect her from developing AN. It highlights the contribution of sociocultural influences, in the form of local norms regarding body size and shape, towards the development of AN. There is danger in taking too seriously the idea that some groups, particularly African-American women, are “protected” from eating problems. Assigning “immunity” to a specific group could result in the misdiagnosis and under-representation among people of different gender, racial, ethnic, sexuality and class backgrounds with eating disorders.9
Although some individuals with anorexia find a sense of community within their disorder, the stigma and isolation surrounding anorexia present substantial barriers to recovery.6 The friendships that persist at earlier stages of the disorder are frequently lost rapidly as the condition progresses, leaving the person socially isolated. Once anorexia becomes entrenched, patients often find themselves alienated from peers and friends. “Unlike other illness categories, anorexia nervosa was transformed from a clinical entity into a friend: it became Ana, a comforter – especially during the early ‘honeymoon phase’ of the disorder,” Allison et. al say. For some, anorexia nervosa forms a sense of distorted community, where “shared experiences in inpatient or day patient settings create a 'team activity' atmosphere with its covert rules”.6 The false of community that AN patients might find themselves engulfed in, delays seeking treatment or even makes treatment impossible, as the condition often becomes self-reinforcing, embedded within a sense of belonging and understanding that the disorder falsely provides.
In addition to media and peer influences, economic and political factors are also associated with control over women's bodies. The perpetuation of the thin ideal is as much an economic construct as a cultural one, perpetuated by industries that profit from women's insecurities about their bodies. These industries promise empowerment through self-improvement and control over one’s eating habits and weight — ideals that resonate with but limit women's autonomy by keeping them focused on unattainable body standards, diverting time, money, and energy away from pursuits that could foster true empowerment. This self-imposed societal pressure creates a cycle of control that aligns with patriarchal capitalism, leaving few avenues for women to escape unless systemic changes are made in how beauty and success are marketed.9
However, socio-cultural factors cannot be viewed independent of the individual psychological and genetic predispositions that heighten the risk of AN development. Research indicates that genetic influences account for over 40% of the variance in thin-ideal internalization.4 This genetic inclination combined with persistent socio-cultural messaging creates a fertile breeding ground for anorexia to thrive. While society may normalize thinness as beauty, not everyone will internalize this standard to the same pathological extent, illustrating an interesting battle between nature and nurture in the development of eating disorders. The differences in how individuals internalize beauty standards highlight the influence of diverse socio-cultural environments. In recent years, researchers have explored programs aimed at attempts to mitigate the development of AN.
A 2022 study conducted in the Netherlands found that positive body exposure, administered with the Positive Body Experience protocol, leads to “significant positive changes in attitudinal body image, eating pathology and depressive symptoms in female participants with eating disorders”, including anorexia nervosa “in a clinical setting”.10 However, what happens when the patients go back to their pre-clinical lives? Will the eating disorder return given the exposure to the same environments, social pressures, and media? Ultimately, resolving the pervasive issue of anorexia nervosa requires a holistic approach, addressing not only the individual psychological predispositions and AN patient’s environments but also the societal structures that engender these disorders.
The cost of thinness—embodied in the experiences of those struggling with anorexia nervosa—reveals a mixture of socio-cultural forces and individual genetic vulnerabilities. Acknowledging the complexity of these influences is an important step towards creating a more empathetic, informed, and equitable society where individuals are valued for their intrinsic worth rather than their adherence to unrealistic and harmful body ideals. The road to recovery and prevention is not short, nor is it without its challenges. Fundamental societal change necessitates systemic solutions that go beyond individual therapy but rather incorporate economic, political, and educational reform, reshaping the way beauty is perceived in our cultures. The ethical implications are clear. Healthcare providers must address both the biological and sociocultural dimensions of AN, while society at large must recognize its role in contributing to environmental conditions that can activate genetic vulnerabilities. Only by confronting the deeply ingrained socio-cultural forces and challenging the lucrative industries that benefit from persistent body dissatisfaction can we hope to alleviate the suffering of those grappling with AN and prevent future generations from falling into these unhealthy norms.
Reviewed by Anna Chen
Graphic by Eugene Cho
References
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Uchôa FNM, Uchôa NM, Daniele TM da C, et al. Influence of the Mass Media and Body Dissatisfaction on the Risk in Adolescents of Developing Eating Disorders. Int J Environ Res Public Health. 2019;16(9):1508. doi:10.3390/ijerph16091508
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Rekkers ME, Aardenburg L, Scheffers M, Elburg AA van, Busschbach JT van. Shifting the Focus: A Pilot Study on the Effects of Positive Body Exposure on Body Satisfaction, Body Attitude, Eating Pathology and Depressive Symptoms in Female Patients with Eating Disorders. Int J Environ Res Public Health. 2022;19(18):11794. doi:10.3390/ijerph191811794
