Journal of Psychosomatic Res

Identifying the eating disorder symptomatic in China: The role of

sociocultural factors and culturally defined appearance concerns

Todd Jacksona, Hong Chenb,c,4

aSchool of Psychology, James Cook University, Townsville, AustraliabKey Laboratory of Cognition and Personality (Southwest University), Ministry of Education, Chongqing, RP China

cSchool of Psychology, Southwest University, Chongqing, RP China

Received 3 March 2006

Abstract

Objectives: This study evaluated the extent to which eating

disorder symptomatic Chinese adolescents and young adults could

be differentiated from demographically similar peers on the basis

of their sociocultural experiences and appearance perceptions.

Methods: Forty-two students who endorsed all criteria for a

Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition eating disorder diagnosis on the Eating Disorder Diag-

nostic Scale [Stice E, Telch CF, Rizvi SL. Development and

validation of the Eating Disorder Diagnostic Scale: a brief self-

report measure of anorexia, bulemia, and binge-eating disorder.

Psychol Assess 2000;12:123–31] and 42 less symptomatic class-

mates completed measures of perceived social pressure, teasing,

social comparison, negative affect, and concern with facial

features. Results: Symptomatic participants reported significantly

more social pressure/teasing, appearance comparison, and concern

0022-3999/07/$ – see front matter D 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.jpsychores.2006.09.010

4 Corresponding author. Key Laboratory of Cognition and Personality

(Southwest University), Ministry of Education, RP China.

with facial appearance than their less symptomatic peers, although

groups did not differ in average levels of negative affect. In a

jackknife discriminant classification analysis using these five

predictors, 76.2% of the symptomatic group and 81.0% of the

comparison group were correctly classified. Within the sympto-

matic group, 95% of respondents who reported either full or partial

criteria for bulimia nervosa or binge-eating disorder were correctly

identified compared to 59.10% of those who endorsed all criteria

for eating disorders not otherwise specified related to anorexia

nervosa. Conclusions: This is the first study to link appearance-

related social pressure and social comparison as well as appearance

concerns not directly reflecting body size or weight with increased

eating disorder symptomatology among young people from the

People’s Republic of China.

D 2007 Elsevier Inc. All rights reserved.

Keywords: Eating disorder; China; Sociocultural; Adolescents; Young adults

Introduction girls from economically developed cities of Hong Kong and

If eating disorders were once characterized as concerns

exclusive to young, affluent, white women in the developed

world [1], during the past two decades they have become a

global phenomenon, found even in rapidly developing

Asian countries such as Mainland China where body types

are typically leaner [2]. Economic development, moderniza-

tion, urbanization, and Westernization are among the

interrelated processes that have been linked to increasing

body image concerns among adolescents and young adults

from China. For example, Lee and Lee [3] found adolescent

Shenzhen reported more fatness concern, body dissatisfac-

tion, and lower desired body mass index (BMI) than their

peers living in less developed, rural Hunan.

Numerous other studies have documented weight pre-

occupation, body dissatisfaction, and disordered eating in

Chinese samples from Hong Kong [4–8], experiences that

extend to developing regions of China [9–11]. For instance,

in a study of more than 9000 3 to 15-year-old children from

the Chinese mainland, Li et al. [11] found respondents were

no more likely than their Western peers to be satisfied with

their bodies. Only 46.5% of boys and 43.0% of girls having

normal weight reported satisfaction with their current body

size. Even lower rates of satisfaction were found among

children considered to be overweight or underweight on

earch 62 (2007) 241–249

T. Jackson, H. Chen / Journal of Psychosomatic Research 62 (2007) 241–249242

the basis of Centers for Disease Control and Prevention

growth charts. Finally, in this sample, preferences for

thinner body ideals increased among adolescents compared

to younger children.

While levels of body dissatisfaction among the Chinese

may approach those reported in the West, emerging evidence

suggests clinical eating disorders are also a problem. Prelimi-

nary research on Beijing schoolgirls concluded that 1.1% met

Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition (DSM-IV) criteria for bulimia nervosa (BN)

[12]. Huon et al. [10] used a survey to assess features of BN,

anorexia nervosa (AN), and binge eating disorder (BED)

among 1246 junior and senior high school girls from different

metropolitan areas of China. Although none of the girls

endorsed full criteria for AN, 7 reported all criteria for BED

and 9 others endorsed criteria for a partial diagnosis of AN. A

majority of the girls were concerned with weight and about

40% said they had dieted and/or binged, albeit only 25% of

bingers felt highly out of control during such episodes.

These studies highlight how young people from China are

not immune to body dissatisfaction or clinical eating dis-

orders. Presumably, adolescent females are at risk [10], and a

complex array of factors related to economic development and

modernization also have a role [3]. Beyond that, however, no

research has been published on specific psychological or

sociocultural factors that contribute to eating disorder

pathology in China. Determining why particular individuals

are more or less likely to experience features of clinical

eating disorder has important implications for establishing

appropriate targets for prevention and intervention.

In contrast to the dearth of research on sociocultural

predictors of eating pathology in China, related theory and

research has proliferated in the West. Leading theories on the

development of eating pathology [13–16] have implicated

specific psychosocial and sociocultural experiences as

predictors of body image and eating disturbances. For

example, the dual-pathway model [15] posits that pressures

to be thin from family, peers, and media contribute to body

dissatisfaction and disordered eating because repeated

messages that one is not thin enough promote disgruntlement

with one’s appearance. From this perspective, appearance-

based comparisons with and internalizations of thin body

ideals, at least among women, also contribute to body

dissatisfaction because such ideals are not attainable for

most. In theory, increases in body dissatisfaction foster

dietary restraint and negative affect, each of which sub-

sequently can increase risk for eating disorder symptoms.

Considerable evidence has linked disordered eating with

specific facets of the dual-pathway model including

appearance-based social pressure and social comparison

processes, negative affect, and body dissatisfaction. First,

recurring messages from family, media, and peers that one is

not thin enough are related to dieting because such pressures

foster discontent with body size or, in the absence of body

dissatisfaction, because people believe dieting might reduce

social pressures to be thin [17]. Indeed, perceived pressure

to be thin is associated with eating disorder symptoms in

both cross-sectional [18–20] and prospective studies

[21–23]. One form of direct pressure, teasing from family

[24,25] and/or peers [26–28] also predicts eating disorder

behaviors and body dissatisfaction, albeit effects are not

uniformly reliable in longitudinal work [29–31].

Social comparison, the process of evaluating how

personal attributes measure up to those of others [32], is a

second source of influence on body image and eating

disturbances. Social comparisons can enhance self-esteem,

but appearance comparisons with peers, models, and

celebrities are related to body dissatisfaction and eating

pathology in cross-sectional studies of patients with eating

disorder [33], adolescent boys and girls [34,35], and under-

graduate women [36,37]. Recent experimental evidence [38]

has found comparisons with attractive breal-worldQ peers

have effects similar to those observed with idealized media

portrayals, albeit real-world effects may not extend beyond

body dissatisfaction to disordered eating. Preliminary

longitudinal research also suggests social comparisons, in

tandem with conversations with friends on appearance and

body mass, contribute to body dissatisfaction in girls,

although different factors have relevance for boys [32].

Negative affect is a third potential influence on the

development of eating disorder symptoms. From the affect-

regulation perspective, people engage in disturbed eating

behavior such as bingeing and extreme compensatory

activities to distract from adverse emotions, reduce anxiety

about weight gain from overeating, and provide emotional

release [39]. Bolstering this hypothesis, negative affect has

positive associations with caloric intake in experiments of

persons not having an eating disorder [40] and with eating

disorder symptoms [21,41]. Once more, the association is

not as reliable in longitudinal research [42,43].

Finally, cross-sectional research has found associations

between eating disorders and body dissatisfaction in both

Western [44] and Chinese samples [5,6,10,11]. Some West-

ern studies have observed this association over longer

intervals [15,22,23], but findings are not always consistent

[45,46]. Differences in ages of samples, outcome measures,

and length of interval between assessment points are among

the factors that may contribute to discrepancies. Despite

their relatively robust relations, overlaps between measures

of body dissatisfaction and features of eating disorder (e.g.,

intense fear of becoming fat, body shape, and weight as

undue influences on self-evaluation) might artificially inflate

strengths of relation. Furthermore, although some Chinese

patients with eating disorder report fat phobia, others deny

fear of fatness [4,47]. Among the Chinese, self-starvation

may also be motivated by complaints of abdominal bloating

or pain, loss of appetite, no hunger, distaste for food, or bnotknowingQ why one does not want to eat [47].

On a related note, eating disturbances may be precipitated

by stigmatizing physical appearance concerns not directly

associated with weight or body size. For example, concern

with facial appearance has no obvious overlap with eating

T. Jackson, H. Chen / Journal of Psychosomatic Research 62 (2007) 241–249 243

disorder criteria but may be central to judgments of attrac-

tiveness in China. Lee et al. [6] observed that a substantial

portion of undergraduate women (15.2%) endorsed a specific

facial feature as the body part with which they were most

dissatisfied. Other research on judgments of Hong Kong job

candidates found facial attractiveness was more important

than either grade point average or public examination

performance in observer ratings of work-related skills [48].

With growing affluence, increasing numbers of Chinese

undertake surgery to lengthen the nose, reshape the jaw, and,

most commonly, to put an extra fold of skin in eyelids to

enhance the odds of success in the workplace and love [49].

Finally, facial acne has been linked to risk for clinical eating

disorder among the Chinese. As explained by Lee et al. [50],

facial acne is associated with excess bhotQ energy and may be

treated by reducing intake of hot foods such as oily, fried or

spicy food, red meat, and chocolate. Subsequent weight loss,

which can improve acne, may reinforce such beliefs and

precipitate AN [50]. If such ideas are intriguing, they remain

highly speculative and are based on limited case study

evidence. Nonetheless, the research above suggests concerns

with facial appearance may be a culturally specific factor

related to eating disorder risk in China.

In summary, although disordered eating behavior has been

observed in adolescent and young adult samples from China

and researchers have suggested sociodemographic factors

such as gender [10] and economic development/urbanization

[3] contribute to risk, no past studies have examined potential

sociocultural and appearance-related correlates of eating

disturbances in this population. The purpose of this inves-

tigation was to assess the degree to which self-reported social

pressure and social comparison about physical appearance,

negative affect, and dissatisfaction with facial features could

differentiate eating-disorder symptomatic Chinese adoles-

cents from peers expressing relatively lower levels of eating

pathology. In light of evidence that sociodemographic factors

influence relative risk for disordered eating among the

Chinese, these between-group comparisons were made only

after matching each symptomatic participant with a classmate

of the same gender, region, or residence (urban vs. rural), and

age (within 1 year). It was hypothesized that symptomatic

adolescents would report more appearance-based pressure,

teasing, and social comparison with others, negative affect,

and dissatisfaction with facial features compared with peers

endorsing fewer eating disorder symptoms. It was also

expected that participants would be classified correctly into

their respective group at better than chance levels on the basis

of responses on these measures.

Method

Participants

An initial sample of 1297 females and 754 males

was recruited from 10 Chinese cities (Zunyi, Chongqing,

Kunming, Chengdu, Guiyang, Liuzhou, Xinzhou, Qianjiang,

Neijiang, and Xichang) representing North, South, Central,

and Southwest China. The sample ranged in age from 12 to

21 years (mean=15.81 years, S.D.=2.43) and was composed

of 522 middle school (25.45%), 852 high school (41.54%),

and 677 college and university (33.00%) students. Partic-

ipants resided in both urban (48.2%) and rural (51.5%)

regions of China, with 0.3% not providing this information.

In terms of ethnicity, 74.3% of respondents were Han, while

substantially fewer were Miao (5.8%), Buyi (5.6%), Yi

(3.9%), Tu (2.7%), Zhuang (2.2%), or botherQ (5.3%). The

mean Body Mass Index of the sample was 19.10

(S.D.=2.32). A majority of respondents reported educational

attainment levels of their mother (63.6%) and/or father

(51.0%) to be less than high school completion and a small

minority (11.7%) reported a monthly household income in

excess of 3000 yuan.

Based on their responses on the Eating Disorder

Diagnostic Scale (EDDS) [51], 42 participants (36 females,

6 males) from the initial sample composed the eating

disorder symptomatic group. Each respondent endorsed all

criteria for a DSM-IV eating disorder (ED) or eating disorder

not otherwise specified (EDNOS) on the EDDS. The group

included 7 girls who endorsed all criteria for BN, 8 girls

who endorsed all criteria for BED, 16 girls and 6 boys who

endorsed all diagnostic criteria for AN with the exception of

the amenorrhea criterion, and five girls who endorsed all BN

criteria except that they engaged in compensatory behaviors

at levels lower than the DSM-IV threshold. Consistent with

past work on demographic correlates of disordered eating

[3,10], highly symptomatic respondents were more likely to

be female (85.7%), from an urban region (66.7%), and from

a higher income household (35.7%) compared to the sample

from which they were drawn, although similar proportions

were Han (83.3%) and reported their mother (52.4%) and/or

father (59.5%) had a bless than high school completionQeducation level.

Subsequently, each symptomatic adolescent was matched

a priori for gender and residence (urban vs. rural) with a

classmate who had also completed the survey. Hence, the

comparison sample (n=42) was also composed of 36 females

and 6 males, of whom two thirds were from urban regions.

No one in the comparison group endorsed all criteria for an

ED or EDNOS. With only one exception, each symptomatic

participant was also matched with a classmate of exactly the

same age; there was only a 1-year age difference in the

mismatched pair. Finally, with the exception of one pair

mismatched on ethnicity (a symptomatic Han participant

paired with a Buri classmate), all other symptomatic–less

symptomatic pairs were matched for ethnicity.

Measures

Back translation

Survey items were translated into Chinese by the

corresponding author and back-translated into English by a

T. Jackson, H. Chen / Journal of Psychosomatic Research 62 (2007) 241–249244

faculty member in the English Department at Southwest

University in Chongqing, China. Minor deviations from

English-language versions were discussed by the researchers

and changed to better approximate meanings from ori-

ginal scales.

Eating Disorder Diagnostic Scale [51]

The EDDS is a 22-item self-report screening measure-

based on DSM-IV criteria for AN, BN, and BED. The scale

has high internal consistency, satisfactory test–retest reli-

ability, excellent concordance with structured clinical inter-

views, and convergence with validated measures of eating

disturbances (i.e., dietary restraint, hunger, disinhibited

eating, and eating, weight, and shape concerns and rituals),

eating disorder risk factors, and social impairment [51,52].

The EDDS is sensitive in detecting intervention effects

and predicting risk for subsequent binge eating, com-

pensatory behaviors, and onset of depression [52]. In this

study, the standardized EDDS had an alpha coefficient

(a=.86), that was comparable with past work on American

samples [51,52].

The Perception of Teasing Scale (POTS) [53]

The 22-item POTS assesses frequency and impact of

teasing about weight (e.g., bHow often have people made

jokes about the way your body looks? Q ) and competence

(e.g., bHow often have people teased you by repeating

something you say because they think what you said is

stupid?Q) on the individual. For this study, only the six-item

weight teasing frequency subscale was used. Its alpha was

.75 in the current sample.

Physical Appearance Comparison Scale (PACS) [54]

The PACS has five items that assess the tendency to

compare one’s own appearance with that of others (e.g., bAtparties or other social events, I compare my physical

appearance to the physical appearance of othersQ). Responseoptions ranged from 1 (never) to 5 (always). Thompson et

al. [54] found the psychometric characteristics of the PACS

to be adequate in an early study. However, consistent

with recent work [55], item four of the scale was dropped

due to its low correlations with all other PACS items. The

internal consistency of the four-item PACS was a=.87 in thepresent research.

Perceived Sociocultural Pressure Scale (PSPS) [12]

The eight-item PSPS assesses perceived pressure to

change physical appearance from four sources: friends

(e.g., bI’ve felt pressure from my friends to change my

physical appearanceQ), media (e.g., bI’ve felt pressure from

the media to change my physical appearanceQ), dating partner(e.g., bI’ve felt pressure from people I would like to date or

have dated to change my physical appearanceQ), and family

(e.g., bI’ve felt pressure from my family to change my

physical appearanceQ). Itemswere rated between 1 (none) and

5 (a lot). Stice andAgras [12] conclude the scale has adequate

internal consistency, stability, and predictive validity. The

total PSPS had an alpha of .91 in this study.

Positive and Negative Affect Scale (PANAS) [56]

The 10-item Negative Affect subscale of the PANAS

assessed experiences of negative affect. Participants were

asked to how often they experienced a number of relevant

mood states (e.g., guilty, distressed, nervous) during the past

week between 1 (none of the time) and 4 (most of the time).

Negative affect had an alpha of .88 in this research.

Negative Physical Self-Scale (NPS) [57,58]

The NPS is a 42-item multidimensional measure of body

image concerns (i.e., General Appearance, Facial Features,

Shortness, Fatness) developed specifically for use with

Chinese adolescents and adults. Each NPS dimension has a

stable factor structure, in addition to satisfactory reliability

and validity. The 12-item Facial Features concern subscale

was used in the main analyses. Sample items on the

subscale include, bI am ashamed about my facial appear-

anceQ and bPeople around me don’t like the way my face

looks.Q Facial Features Concern had an alpha coefficient

of .82 in this study.

Background data

Information was solicited about participants’ age, gender,

weight, height, region of residence, and ethnicity. Because

self-reported weight correlates (r =.97) with confederate-

measured weight [59], BMI was calculated from participant

reports. Finally, in relation to socioeconomic indicators,

participants provided information about parents’ educational

levels and estimated monthly household income. Specifi-

cally, educational level of each parent was measured as

bless than high school completion,Q bhigh school graduate,Qor bmore than high school graduate (e.g., college or

university degree).Q Income was also-based on three

options: less than 1000 yuan per month, 1000–3000 yuan

per month, or more than 3000 yuan per month (1 US dollar

is worth about 8.0 Yuan).

Procedure

The corresponding author contacted colleagues working

in middle schools, high schools, colleges, and universities

from the above cities, seeking permission to conduct a study

on body image and eating concerns. All contacted settings

granted permission. Subsequently, one class from each

setting was randomly selected for the research. Teachers

from the class gave prospective research volunteers a

survey packet that included a cover page outlining the

research purposes (to foster knowledge about body image and

eating behavior among students from China), and an

informed consent form that included information about the

time involved (30–40min), the voluntary, anonymous nature

Table 1

Comparisons of sociodemographic factors among eating disorder symptomatic and comparison samples (N =84)

Measures

Eating disorder sample

Difference value P Effect sizeSymptomatic Less symptomatic

Gender

Male 6 6 – – –

Female 36 36

Area

Urban 28 28 – – –

Rural 14 14

Ethnicity

Han 35 34

Miao 3 3 v2(3)=0.21 b.98 Phi= .05

Zhuang 2 2

Buyi 2 3

Age 15.71 (2.40) 15.74 (2.38) F(1,82)=0.01 b.96 g = .01Body Mass Index 18.03 (2.56) 18.52 (1.80) F(1,82)=1.01 b.32 g = .11Father’s education 1.60 (0.80) 1.71 (0.83) F(1,82)=0.45 b.51 g = .07Mother’s education 1.55 (0.63) 1.50 (0.63) F(1,82)=0.12 b.73 g = .04Family income 2.19 (1.04) 2.02 (0.84) F(1,82)=0.65 b.42 g = .09

T. Jackson, H. Chen / Journal of Psychosomatic Research 62 (2007) 241–249 245

of participation, and the right to withdraw from the research at

any point. The research measures were included in the packet

followed by information regarding referral sources should a

student experience body image concerns or eating disturban-

ces. Participants were encouraged to read each question

carefully and to answer all questions if possible. The survey

was completed during class time and handed back to teachers

separately from informed consent forms. All data were

collected during September and October, 2005.

Results

Preliminary analyses

Due to a priori matching, each of the 42 eating disorder

symptomatic–less symptomatic pairs was identical for

gender and region of residence in addition to being

nearly equivalent for age. Chi-square analyses and t tests

indicated symptomatic and less symptomatic groups did

not differ from one another on any other sociodemographic

factor (Table 1).

Main analyses

Prior to performing the discriminant classification

analysis (DCA), a multivariate analysis of variance was

Table 2

Group differences in measures of sociocultural influence and facial appearance c

Measures

Symptomatic Less symptom

Mean S.D. Mean

Social Pressure 14.57 7.64 6.19

Teasing Frequency 11.29 3.92 8.83

Social Comparison 11.60 4.36 8.40

Negative Affect 17.81 4.52 16.21

Facial Concerns 22.79 12.15 9.48

conducted to assess group differences in sociocultural

experiences and facial features concerns. A significant

multivariate effect was obtained from the analysis,

F(6,77)=7.70, Pb.001, g=.38. Table 2 provides group

means, univariate F values, and effect sizes on each

measure. Symptomatic students had higher scores than

comparison sample participants on all measures with the

exception of negative affect. The most prominent difference

was for concerns with facial features. Due to moderately

high correlations between this dimension, Fatness Concern,

and General Appearance Concern [57], a supplementary

univariate analysis of covariance was performed on dif-

ferences in facial features concerns while controlling for

these other two dimensions. A highly significant differ-

ence remained, F(3,80)=19.95, Pb.001, illustrating that

the difference in degree of concern with facial features

was at least somewhat independent of other facets of

body dissatisfaction.

Subsequently, a standard DCA examined group member-

ship of students on the basis of responses to the five

psychosocial measures. The analysis resulted in a significant

discriminant function, v2(6, N=84)=37.11, Pb.001. The

loading matrix of correlations between predictors and the

discriminant function indicated facial features concern and

social pressure differentiated most strongly between groups

(Table 3). Compared to a 50% rate of classification that

would be found by chance alone, 79.80% of the sample

oncerns (N=84)

atic

Difference value P gS.D.

5.61 F(1,82)=32.81 b.001 .54

3.66 F(1,82)=8.77 b.01 .10

3.30 F(1,82)=14.30 b.001 .39

4.27 F(1,82)=2.76 b.10 .03

6.65 F(1,82)=38.78 b.001 .32

Table 3

Results of discriminant classification analyses for eating disorder symptom groups (N=84)

Predictor

Predictor correlations

with function

Standardized function

coefficients

Pooled within-group correlations among predictors

2 3 4 5

1. Facial Concerns .90 .70 .62 .47 .30 .48

2. Social Pressure .83 .39 – .42 .35 .32

3. Social Comparison .55 .13 – .21 .35

4. Teasing .43 .12 – .22

5. Negative Affect .24 �.29 –

Predicted group

Eating disorder symptoms Higher Lower

Initial classification results, n (%)a

Higher 32 (76.2) 10 (23.8)

Lower 7 (16.7) 35 (83.3)

Cross-validation results, n (%)b,c

Higher 32 (76.2) 10 (23.8)

Lower 8 (19.0.7) 34 (81.0)

a Of total cases, 79.8% were correctly classified.b Each case was classified by functions derived from all cases except its own.c Of total cases, 78.6% were correctly classified.

T. Jackson, H. Chen / Journal of Psychosomatic Research 62 (2007) 241–249246

correctly classified from patterns of response on psychoso-

cial measures including 76.2% of symptomatic students and

83.3% of less symptomatic students. In a cross-validation

analysis wherein each case was classified from functions

derived from all cases except its own, 78.6% of the sample

was correctly classified. Accuracy rates of 76.2% and 81.0%

were found for eating disorder symptomatic and less

symptomatic samples, respectively.

Finally, variability in patterns of endorsing eating

disorder diagnoses provided the opportunity to examine

whether misclassified symptomatic cases differed as a

function of diagnostic subgroup. All participants who

endorsed full criteria for BN (n=7) or BED (n=8) were

correctly classified into the eating disorder symptomatic

group, as were 80% of those endorsing EDNOS criteria for

subclinical BN. In contrast, the rate of correct classification

for students endorsing all criteria for EDNOS related to

subclinical AN was much lower (13/22 or 59.1%), v2(3)=

8.27, Pb.04. Because all symptomatic males were in the AN

symptomatic subgroup, a supplementary analysis was

performed to assess whether classification accuracy within

this subgroup was affected by gender. Rates of misclassi-

fication did not differ between males (33.3%) and females

(43.8%), v2(1)= 0.20, Pb.65.

Discussion

To our knowledge this is the first study to show how

eating disorder symptomatic Chinese young people can be

differentiated from their demographically similar, less

symptomatic peers on the basis of their perceptions of

appearance-related pressure and social comparison as well

as concerns about facial appearance. More than 75% of

respondents in each group were correctly classified into

their respective groups from their responses on these five

measures. Although the study did not fully test a particular

explanation of eating pathology [12,19,35], it did support

the utility of extending facets of the dual-pathway model

[15,22] to understanding eating disorder symptomatology of

young people in China. Like their neighbors from the West,

Chinese adolescents and young adults who report relatively

heightened appearance-related pressure from peers, parents,

and media as well as proclivities to compare their own

appearance with that of others express more eating disorder

pathology than their less symptomatic peers.

The study was also the first to extend past research on the

link between dissatisfaction with body weight/size and

disordered eating among the Chinese [4–6,11] to a possible

culture-specific facet of appearance dissatisfaction and

eating pathology. Specifically, preoccupations with facial

appearance emerged as one of the strongest individual

factors discriminating between symptomatic and less

symptomatic groups. If this finding does not directly

support hypothesis that changes in dietary practices due to

facial acne contribute to eating disorder [47], it does provide

empirical underpinnings for the contention that eating

disorder symptoms among the Chinese can arise in concert

with appearance concerns not directly related to fatness and

body size [44,47]. Although specific preventive interven-

tions do not follow easily from this discovery, the finding

does suggest that concern expressed about facial appearance

is a potential marker for corresponding eating disturbances

among Chinese adolescents and young adults. Nonetheless,

given its novelty, replication of this finding is warranted to

better evaluate its stability.

Contrary to expectations, groups differed only margin-

ally on the measure of negative affect. Although future

work is also needed to assess whether this pattern is a

reliable one, two factors may have contributed to the

T. Jackson, H. Chen / Journal of Psychosomatic Research 62 (2007) 241–249 247

attenuated group difference in negative affect. First, because

our eating disorder symptomatic group was not obtained in

a clinical setting, its mean level of negative affect may have

been attenuated relative to what might be found among

patients with eating disorder in treatment. Second, negative

affect, as measured here, may simply not be as relevant to

Chinese samples, in light of evidence that depression is

expressed more strongly through somatic concerns among

the Chinese and through affective distress among Western-

ers [60]. This potential cultural difference suggests links

between body dissatisfaction and eating pathology may not

be mediated by overt negative affect among the Chinese

compared to some Western samples [21,40,41]. Hence,

theoretical accounts may need to be modified in extensions

to non-Western cultures.

Finally, examination of misclassified cases revealed that

students endorsing all criteria for BN, BED, or subclinical

BN were detected with striking accuracy via their patterns of

response on sociocultural and appearance scales. In contrast,

over 40% of those endorsing all AN criteria except for

amenorrhea were misidentified as less symptomatic. Similar

to Western studies linking features of the dual-pathway

model specifically to bulimic symptoms [15,21,22], this

pattern suggests sociocultural influences and perceived

personal appearance concerns are more useful in identifying

eating disorders among the Chinese that involve bingeing

and/or compensatory behaviors than those that emphasize

underweight and fear of weight gain/fatness. The less

accurate classification of adolescents fulfilling a subclinical

AN diagnosis may reflect, in part, the fact that a number of

respondents in the lower risk comparison sample also

fulfilled the underweight criterion. As well, early [47] and

recent [2] commentaries have questioned the use of DSM

eating disorder diagnoses in Asian samples, noting, for

example, that core diagnostic criteria for AN, such as fat

phobia, do not account fully for self-starvation in Asians.

In summary, findings suggest that clinicians and research-

ers working with eating disorder symptomatic adolescents

and young adults in China must be sensitive not only to overt

eating pathology but also to perceptions of social pressure,

comparison about physical appearance, and personal con-

cerns about physical features that do not correspond directly

to weight or body size. The present findings help to justify

future resource allocation to assess the impact of socio-

cultural pressure and appearance concerns over extended

intervals and suggest several of these factors might be useful

targets in eating disorder prevention efforts in China.

Notwithstanding its implications, the main caveats of this

research must be acknowledged as well as directions for

further investigation. First, symptomatic participants may

have been higher functioning than clinical inpatient samples.

Consequently, it is not clear how findings generalize to

clinical samples. Future research should examine whether

classification accuracy is even more pronounced when

comparing clinical patient samples with less symptomatic

controls. Second, if their satisfactory alpha coefficients and

patterns of intercorrelation with one another suggest the

measures used in this research are reliable and valid in

Chinese samples, further work should be undertaken to

bolster their validity in this cultural context. Third, this

research is a necessary first step in differentiating Chinese

students with heterogeneous patterns of eating disorder

features from those reporting few symptoms, but further

research is needed to identify potential psychosocial differ-

ences between larger AN, BN, and BED samples in China.

On a related note, it remains to be seen whether social

pressure, teasing, and social comparison about appearance

are specific to eating disorder symptoms or are general risk

factors for diverse forms of psychopathology including social

anxiety and depression [61]. Inclusion of clinical comparison

groups in future studies can elucidate specificity in effects of

such experiences. Fifth, following from prospective research

done in the West [12–14,19,20] and the present cross-

sectional findings, the hypothesis that measures of socio-

cultural pressure and appearance concern predict increases in

bulimic symptoms over time now merits consideration in

Chinese samples. Finally, because this and other studies

[62,63] suggest body image concerns of Chinese andWestern

samples have commonalities, future work might explore how

best to adapt eating disorder prevention programs deemed

effective in the West [64] to Chinese cultural contexts.

Acknowledgments

This research was supported by grants from the China

National Key Subject Foundation of Fundamental Psychology

(SNKSF04016), the Humanistic and Social Science Research

Foundation of the Chongqing government (05JWSK192), and

a Visiting Scholar grant from James Cook University. We

thank Liu Yanmei, Chen Fuguo, Wang Ruiqiang, Zhang

Xiaohong, and Chen Yanlei for assistance with data entry, and

Zhai Lihong, Jiang Tingzhi, He Yulan, Shuai Shun, and Zhou

Tianmei for assistance with data collection.

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