Eating Behaviors 15 (2014) 306–310
Contents lists available at ScienceDirect
Eating Behaviors
Disordered eating & cultural diversity: A focus on Arab Muslim women in Israel Marjorie C. Feinson ⁎, Adi Meir Falk Institute for Behavioral Health Studies, Kfar Shaul Hospital, Givat Shaul, Jerusalem 91060, Israel
a r t i c l e
i n f o
Article history: Received 26 August 2013 Received in revised form 12 February 2014 Accepted 11 March 2014 Available online 26 March 2014 Keywords: Disordered eating Arab Muslims Jews Cultural diversity Israel
a b s t r a c t Context: A dearth of data concerning eating problems among adult women from minority population groups leaves substantial knowledge gaps and constrains evidence-based interventions. Objectives: To examine prevalence and predictors of disordered eating behaviors (DEB) among Arab Muslim women in Israel, whose eating behaviors have not been previously examined and to compare with second generation Israeli-born Jews of European heritage. Design: Community-based study includes sub-samples of Arab Muslims and Israeli-born Jews. DEB is assessed with fourteen DSM-IV related symptoms. Hierarchical regressions examine influence of weight, self-criticism and psychological distress on DEB severity. Results: Relatively high prevalence rates emerge for Muslims (27%) and Jews (20%), a nonsignificant difference. In contrast, regressions reveal substantially different predictor patterns. For Arab Muslims, weight has the strongest association; for Jews, weight is not significant while self-criticism is the strongest predictor. Explained variance also differs considerably: 45% for Muslims and 28% for Jews. Conclusions: Surprising similarities and distinct differences underscore complex patterns of eating disturbances across culturally diverse groups. Culturally sensitive interventions are warranted along with more illuminating explanatory paradigms than ‘one size fits all.’ © 2014 Elsevier Ltd. All rights reserved.
1. Introduction
1.1. Background
Culturally sensitive interventions for eating disturbances are constrained by a dearth of data (Cummins, Simmons, & Zane, 2005; Marcus, Bromberger, Wei, Brown, & Kravitz, 2007), especially for minority population groups. Despite the importance of sociocultural factors, our understanding remains “relatively rudimentary,” (Cummins et al., 2005 p. 570) particularly with regard to adult women (Feinson, 2011). An opportunity to address this knowledge gap is provided by a first-ever, community-based study of adult Arab Muslim1 women in Israel, whose eating behaviors have not been previously assessed. Prevalence and predictors of disordered eating behaviors (DEB) afford intriguing cross-cultural comparisons with second generation Israeli-born Jews of European heritage.
The influence of sociocultural factors on eating problems is complex, fraught with inconsistent findings, and derived primarily from studies of young females (under age 25) (Feinson, 2011). A limited number of studies of young Arab Muslim women also contain mixed findings (Abdollahi & Mann, 2001; Latzer, Tzischinsky, & Geraisy, 2007; Nasser, 1986). Inconsistent findings suggest that exposure to westernized norms may be irrelevant for some eating disturbances, such as BED (Striegel-Moore et al., 2005). Indeed, some research is broadening the sociocultural agenda to include factors such as the subordinate status of women in patriarchal cultures (Douki, Ben Zineb, Nacef, & Halbreich, 2007), minority acculturation processes (Cachelin & Regan, 2006; Mussap, 2009), discrimination and poverty (Halperin-Kaddari & Yadgar, 2010; Striegel-Moore, Dohm, Pike, Wilfley, & Fairburn, 2002), major social transitions (Abu Baker, 2002; Al-Haj, 1995) and stresses from conflicting cultural demands (Haj-Yahia, 1995; Kuba & Harris, 2001; Pessate-Schubert, 2003). Several important sociocultural factors are highlighted by focusing on Arab Muslim women in Israel, a deeply divided society in which almost one-fifth (18%) of the population are Arab citizens. In contrast to minority groups elsewhere, Arabs are not immigrants, but have lived in the country for centuries. They are predominantly Muslim (82%); their language is Arabic, not Hebrew, and their way of life
⁎ Corresponding author. Tel.: +972 02 651 3395; fax: +972 02 651 3292. E-mail addresses: [email protected], [email protected] (M.C. Feinson). 1 A number of terms describe the Arab population including Israeli Arabs, Palestinian Arabs, Palestinians, Palestinian-Arab citizens of Israel, and Arab Muslims, among others. All respondents in this study are Arab Muslims and that is the term that is used.
http://dx.doi.org/10.1016/j.eatbeh.2014.03.004 1471-0153/© 2014 Elsevier Ltd. All rights reserved.
M.C. Feinson, A. Meir / Eating Behaviors 15 (2014) 306–310
tends to be semi-traditional compared to dominant Israeli culture (Smooha, 2010). A central aspect of Arabs' distinctive status is that as a “national minority” they are “…tied by language, culture, identity, history, collective memory, narratives, and loyalty to Palestinian nationalism and pan-Arabism” (Smooha, 2010 p. 7). These distinguishing characteristics contribute to making Arabs an “…inassimilable minority. Arabs do not intermarry with Jews. They want to keep their existence separate... The cornerstone of the separation is that of residential communities and schools, which affects 90% of the Arabs who live in Arab villages and towns” (Smooha, 2010 p. 7). Accordingly, Muslim respondents in this study live in an Arab village on the outskirts of Jerusalem. Abu Ghosh, one of the only remaining Muslim villages in the area, is named for the Arab clan that settled in the area in the 16th century and its 5700 residents are direct descendants (Moshe, 2000). Abu Ghosh is a village with 13 restaurants that many Israeli Jews visit, especially on weekends, when most Jerusalem restaurants close for the Jewish Sabbath. Despite these contacts, Arab– Jewish relations generally have worsened since the 1995 assassination of Prime Minister Yitzhak Rabin with “a consistent trend of growth in the alienation, deprivation, and fears among the Arabs…” (Smooha, 2010 p. 18). 1.2. The present study In addition, several other sociocultural factors are particularly relevant including the observation that Arab Muslim women “suffer from a three-tiered discrimination: as women in Israel, as Palestinians in Israel, and as women within the Palestinian community” (HalperinKaddari & Yadgar, 2010). Also, during the past three decades, Arab society has been undergoing a complex transition involving changes in women's status within the family and community. Despite increased education and work outside the home, “woman's role as mother and wife continues to be traditional and non-egalitarian” (Haj-Yahia, 1995 p. 439). Thus, forces encouraging modernization and those pulling families toward traditionalism are operating simultaneously, contributing to stresses and conflicts for women (Haj-Yahia, 1995). Finally, there is the issue of bi-cultural conflict that arises when the values, beliefs and practices of minority groups diverge from dominant cultural norms. Arab Muslim women may find comfort in food as they struggle with the conflicting demands of a bi-cultural existence (Kuba & Harris, 2001). A unique opportunity to explore disordered eating and cultural diversity issues exists with a community-based study including two population groups: Arab Muslims, with roots dating back to the 16th century and second generation Israeli-born Jews of European heritage. High rates of disordered eating among Arab Muslim women might be expected due to sociocultural risk factors, including their status within a disadvantaged minority group and as subordinates within a patriarchal culture (Halperin-Kaddari & Yadgar, 2010). Additionally, Arab women's traditional roles within patriarchal families, including meal preparation for large families, may exacerbate eating problems. Alternatively, aspects of Arab Muslim culture may be protective and associated with reduced rates of disordered eating, including the rootedness of Arab communities and the stability provided by history, heritage identification, and deeply embedded religious rituals and traditions (Mussap, 2009). 2. Methods
307
2.2. Measures 2.2.1. Disordered Eating Behaviors—Screening Questionnaire (DEB-SQ) The absence of adequately standardized instruments for assessing eating problems in multicultural, non-clinical samples of women across the life span (Kuba & Harris, 2001; Marcus et al., 2007) is particularly relevant to Israel (Latzer, Witztum, & Stein, 2008). Thus, an easily administered, culturally sensitive self-report questionnaire (SRQ), adapted from several widely-used instruments, was developed to assess 14 behaviors, more than half consistent with DSM-IV symptoms especially binge eating. Higher scores reflect more serious eating problems. The DEB is used categorically for descriptive statistics and in linear form for correlations and regressions (see Feinson & Meir, 2012). 2.2.2. Weight Interviewees indicated if they were underweight (slightly or very) or overweight (slightly or very), a procedure consistent with numerous studies and sufficiently valid for epidemiological and survey studies (Striegel-Moore, Wilson, Wilfley, Elder, & Brownell, 1998). 2.2.3. Emotional well-being Two aspects of emotional well-being are measured. A modified version of the Rosenberg Self-Esteem Scale (Rosenberg, 1979) reflects a more nuanced dimension of self-esteem, namely, self-criticism (CSS). Cronbach's alpha (standardized) is .733 with acceptable alphas for both population groups. Psychological distress is measured with the Brief Symptom Inventory (BSI), an 18 item questionnaire frequently used in epidemiological studies with well-established reliability and validity. Alpha reliability for this sample is .868 with similar alphas for population groups (data available upon request). 2.2.4. Socio-demographic variables Two population groups include Arab Muslims (n = 48) and Israeli Jews (n = 98). Age groups conform to Central Bureau of Statistics categories. Socio-economic status is measured with single questions concerning years of education and income sufficiency. 2.3. Statistical analysis Socio-demographic comparisons utilize Pearson's chi-square, Spearman's Rho and analysis of variance. Bivariate relationships are assessed using Pearson correlation coefficients for continuous variables and Spearman's Rho for categorical variables. Hierarchical regressions measure the contribution of three clinical correlates (weight, selfcriticism, distress) to explaining DEB variance after controlling for demographic variables. DEB, CSS and BSI distress are normally distributed and used in their initial continuous form. 3. Results 3.1. Demographics For the full community sample (n = 567) and two population sub-groups (Table 1a) reveals no significant group differences regarding age or income sufficiency. Arab Muslims are more likely than Jews to be married (68% vs. 49%, p b .05) and to have fewer years of education (12.2 vs. 14.6, p b .001).
2.1. Recruitment of respondents 3.2. Frequency distributions A community-based sample was recruited randomly from primary health care clinics in Jerusalem and surrounding areas including Abu Ghosh. All instruments and protocols were reviewed and approved by the appropriate institutional review boards and the medical directors of all participating clinics. (For additional details, see (Feinson & Meir, 2012).)
3.2.1. Clinical correlates Table 1b reveals that just under 20% of individuals in the community sample are obese with no significant differences between the two sub-groups. While a larger proportion of Arab Muslim respondents are highly self-critical (27% vs 16%), the difference is non-significant. In
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Table 1 Characteristics of respondents: Community sample & population sub-groups. Variables
a. Demographics Age (years) Mean (sd) Education (years) Mean (sd) Education (groups) b12 12 13–15 16+ Income sufficiency Insufficient Partially Sufficient Marital status Non-married Married
Community samplea n = 567b
Population groups
t or χ2
Arab Muslims n = 48
Jews n = 98
43.0 (15.2)
31.4 (9.4)
32.1 (9.9)
n.s.
13.7 (3.2) % 17.6 25.4 25.2 30.0
12.2 (2.5) % 22.9 37.5 31.3 8.3
14.6 (2.5) % 3.1 27.6 34.7 34.7
t = 5.56⁎⁎⁎
18.2 33.2 46.0
18.8 33.3 47.9
15.5 30.9 53.6
n.s.
36.6 58.6
31.9 68.1
51.0 49.0
χ2 = 4.67⁎
18.5 27.9 51.5
18.8 12.5 68.8
16.8 26.3 56.8
n.s.
n.s.
χ2 = 23.00⁎⁎⁎
b. Clinical correlates Weight Obese Overweight Healthy weight Self-criticism (CSS) Self-critical Not self-critical Mean (sd) Psychological distress (BSI) Distressed Not distressed Mean (sd)
18.9 79.9 1.55 (0.39)
27.1 72.9 1.65 (0.36)
16.3 83.7 1.53 (0.38)
15.2 84.7 1.72 (0.59)
35.4 64.6 2.14 (0.62)
12.2 87.8 1.65 (0.54)
χ2 = 10.87⁎⁎⁎
c. Dependent variable Disordered eating behaviors (DEB) Serious Considerable Minimal Mean (sd)
15.9 27.5 56.4 2.37 (0.57)
27.1 20.8 52.1 2.52 (0.64)
20.4 36.7 42.9 2.55 (0.53)
n.s.
n.s.
t = 4.90⁎⁎⁎
n.s.
CSS = Critical Self Scale; BSI = Brief Symptom Inventory. a A broadly representative, community-based sample (n = 567) of adult women (age 21+) in Israel. b Categories do not add to 100% due to missing data on some variables. ⁎ p b .05. ⁎⁎⁎ p b .001.
contrast, almost three times as many Muslims as Jews report psychological distress (35.4% vs. 12.2%, p b .001).
Table 2 Hierarchical regression analyses of disordered eating behaviors (DEBs). Variables influencing DEB Change statistics
3.2.2. DEB Table 1c shows that DEB differences are not statistically significant. Substantially more serious DEB reported by both population groups compared to the community sample (27%, 20% vs. 15.9% respectively) is noteworthy. 3.3. Bivariate relationships Bivariate analyses (data not shown) reveal considerably different correlational patterns with DEB. For Arab Muslims, DEB is significantly associated with weight (r = .58, p b .001). In sharp contrast, weight is not significant for Jews. For Arab Muslims, DEB is not associated either with self-criticism or with BSI distress in contrast to significant correlations for Israeli Jews. 3.4. Multivariate analyses Hierarchical regressions uncover strikingly different predictor patterns of DEB severity. For Arab Muslims (Table 2a), weight makes a
A. Arab Muslims (n = 47) Age (years) Marital status (MS) Education (years) Weight Self-criticism (CSS) Distress (BSI) MS ∗ CSS Adjusted R2 = .448
Overall
R2 change F change p
R2
.039 .154 .017 .213 .054 .039 .053
df
F
p
1.804 4.085 .894 7.356 4.041 3.036 2.225
n.s. .024 n.s. .002 .051 n.s. n.s.
.039 1, 45 .192 3, 43 .209 4, 42 .422 6, 40 .476 7, 39 .515 8, 38 .568 10, 36
1.804 3.407 2.773 4.860 5.060 5.038 4.735
n.s. .026 .039 .001 .000 .000 .000
B. 2nd generation Israeli-born Jews (n = 93) Age (years) .010 0.947 Marital status (MS) .037 1.747 Education (years) .002 .199 Weight .032 1.511 Self-criticism (CSS) .154 17.080 Distress (BSI) .003 .323 MS ∗ CSS .120 7.684 2 Adjusted R = .281
n.s. n.s. n.s. n.s. .000 n.s. .001
.010 1, 91 .048 3, 89 .050 4, 88 .082 5, 86 .236 7, 85 .239 8, 84 .359 10, 82
0.947 1.485 1.154 1.282 3.744 3.290 4.588
n.s. n.s. n.s. n.s. .001 .003 .000
DEBs = disordered eating behaviors; MS = marital status; CSS = Critical Self Scale; BSI = Brief Symptom Inventory.
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large and significant contribution of 21.3% followed by marital status, 15.4%. Despite a relatively high rate of BSI distress among Arab women, it is not associated with DEB severity. For Jews (Table 2b), weight is not significant, while self-criticism and the interaction term make significant contributions. Explained variance also differs considerably: 44.8% for Arab Muslims and 28.1% for Israeli Jews.
significant predictor (Fitzgibbon et al., 1998). In brief, these findings reveal different factors associated with eating disturbances for distinctly different population sub-groups. Additional research would help to clarify how growing up in different cultures influences the development of serious eating problems (Smolak & Striegel-Moore, 2002).
4. Discussion
5. Conclusion
The study empirically supports the concept that “growing up in a different culture raises the possibility of different influences regarding the development of eating disturbances” (Smolak & StriegelMoore, 2002 p. 117). Detailed comparisons of culturally distinct groups living in geographic proximity underscore cultural complexities associated with eating disturbances. The discussion focuses on several noteworthy findings: a) similarly high frequency rates of eating disturbances and b) substantially different clinical predictors of DEB severity. More than one-quarter of Muslim respondents have serious problematic eating behaviors (DEB), a disturbing prevalence rate that parallels binge eating frequency of 25.5% among Black women in a community study (Reagan & Hersch, 2005). Additional research, especially qualitative, would shed light on whether high rates are a form of coping with disadvantageous life circumstances. Indeed, several narrative studies underscore a broad range of traumas and injustices that contributed to women turning to food not only for comfort, but also as survival mechanisms (Feinson & Ben Dror, 2010; Thompson, 1994). In a similar vein, high Muslim rates may reflect challenges and conflicts within Israel's Arab community. “Over the past three decades, Arab society in Israel has been undergoing processes of transition. These processes are manifested by changes in the economy, education, the status of women, family structure, and by socio-cultural changes and transformations in patterns of coping with social problems” (Haj-Yahia, 1995 p. 429). Similar to Japanese women, whose eating problems developed within broad social transformations following World War II (Pike & Borovoy, 2004), serious eating problems among Arab Muslims have begun as coping mechanisms. In contrast to similar prevalence rates, distinctly different predictors of DEB severity emerge. For Muslim respondents and consistent with numerous studies, weight is the largest contributor (Alegria et al., 2007; Cachelin, Veisel, Barzegarnazari, & Striegel-Moore, 2000; Grucza, Przybeck, & Cloninger, 2007). For Jews, weight is not significant. These divergent patterns broadly parallel a U.S. study of adult women in which weight significantly predicted binge eating for Hispanics, but not for White or Black respondents (Fitzgibbon et al., 1998). Why obesity is such a strong predictor of disordered eating among Arab Muslim respondents remains unclear. However, future research may reveal more favorable attitudes toward larger body sizes, similar to African Americans (LoveJoy, 2001). Perhaps most striking is the contrast in self-criticism. Despite no significant differences in prevalence rates, sharp differences emerge regarding the relationship with disordered eating. For Arab Muslims, self-criticism barely makes a significant contribution. For Israeli Jews, however, it is the strongest predictor of DEB severity. Although additional research is needed to fully understand these divergent patterns, they parallel a U.S. study in which depression significantly predicted binge eating for the majority population group (Whites), but not for the minority groups (Blacks & Hispanics) (Fitzgibbon et al., 1998). A final difference concerns explained variance. For Arab Muslims, the model accounts for 45% with weight as the largest contributor. Substantially less variance is explained for Israeli Jews, 28%, with a major role for self-criticism. Again, these divergent patterns are broadly comparable to a U.S. study: for Hispanics, 23% of the variance was explained largely by weight and, to a lesser degree, by depression; for Whites, 28% was explained with depression as the only
Surprising similarities and distinct differences highlight the need for culturally sensitive interventions. Expanding the research agenda to include a broad spectrum of risk and protective factors, especially those unique to specific cultural groups is warranted (Harrington, Crowther, Henrickson, & Mickelson, 2006). Of utmost importance is the need for more culturally relevant explanatory models than ‘one size fits all.’ Role of funding sources Funding for this study was provided by The Hadassah Foundation, New York, NY and Geula Charitable Trust, New York, NY. Neither had a role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors Dr. Marjorie C. Feinson designed the study, wrote the protocol, conducted literature searches, provided summaries of previous research studies and wrote the first draft of the manuscript. Adi Meir conducted the statistical analysis. Both authors contributed to and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgments A debt of gratitude goes to more than 800 women in Israel who graciously participated in long and detailed telephone interviews. The authors also wish to thank Lisa (Gold) Margolin and Tamar (Levy) Ben Dror who were outstanding Field Supervisors, responsible for two waves of data collection and a joy to work with. Generous funding from The Hadassah Foundation, New York and Geula Charitable Trust, New York made this work possible. Thank you all.
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Contents lists available at ScienceDirect
Eating Behaviors
Disordered eating & cultural diversity: A focus on Arab Muslim women in Israel Marjorie C. Feinson ⁎, Adi Meir Falk Institute for Behavioral Health Studies, Kfar Shaul Hospital, Givat Shaul, Jerusalem 91060, Israel
a r t i c l e
i n f o
Article history: Received 26 August 2013 Received in revised form 12 February 2014 Accepted 11 March 2014 Available online 26 March 2014 Keywords: Disordered eating Arab Muslims Jews Cultural diversity Israel
a b s t r a c t Context: A dearth of data concerning eating problems among adult women from minority population groups leaves substantial knowledge gaps and constrains evidence-based interventions. Objectives: To examine prevalence and predictors of disordered eating behaviors (DEB) among Arab Muslim women in Israel, whose eating behaviors have not been previously examined and to compare with second generation Israeli-born Jews of European heritage. Design: Community-based study includes sub-samples of Arab Muslims and Israeli-born Jews. DEB is assessed with fourteen DSM-IV related symptoms. Hierarchical regressions examine influence of weight, self-criticism and psychological distress on DEB severity. Results: Relatively high prevalence rates emerge for Muslims (27%) and Jews (20%), a nonsignificant difference. In contrast, regressions reveal substantially different predictor patterns. For Arab Muslims, weight has the strongest association; for Jews, weight is not significant while self-criticism is the strongest predictor. Explained variance also differs considerably: 45% for Muslims and 28% for Jews. Conclusions: Surprising similarities and distinct differences underscore complex patterns of eating disturbances across culturally diverse groups. Culturally sensitive interventions are warranted along with more illuminating explanatory paradigms than ‘one size fits all.’ © 2014 Elsevier Ltd. All rights reserved.
1. Introduction
1.1. Background
Culturally sensitive interventions for eating disturbances are constrained by a dearth of data (Cummins, Simmons, & Zane, 2005; Marcus, Bromberger, Wei, Brown, & Kravitz, 2007), especially for minority population groups. Despite the importance of sociocultural factors, our understanding remains “relatively rudimentary,” (Cummins et al., 2005 p. 570) particularly with regard to adult women (Feinson, 2011). An opportunity to address this knowledge gap is provided by a first-ever, community-based study of adult Arab Muslim1 women in Israel, whose eating behaviors have not been previously assessed. Prevalence and predictors of disordered eating behaviors (DEB) afford intriguing cross-cultural comparisons with second generation Israeli-born Jews of European heritage.
The influence of sociocultural factors on eating problems is complex, fraught with inconsistent findings, and derived primarily from studies of young females (under age 25) (Feinson, 2011). A limited number of studies of young Arab Muslim women also contain mixed findings (Abdollahi & Mann, 2001; Latzer, Tzischinsky, & Geraisy, 2007; Nasser, 1986). Inconsistent findings suggest that exposure to westernized norms may be irrelevant for some eating disturbances, such as BED (Striegel-Moore et al., 2005). Indeed, some research is broadening the sociocultural agenda to include factors such as the subordinate status of women in patriarchal cultures (Douki, Ben Zineb, Nacef, & Halbreich, 2007), minority acculturation processes (Cachelin & Regan, 2006; Mussap, 2009), discrimination and poverty (Halperin-Kaddari & Yadgar, 2010; Striegel-Moore, Dohm, Pike, Wilfley, & Fairburn, 2002), major social transitions (Abu Baker, 2002; Al-Haj, 1995) and stresses from conflicting cultural demands (Haj-Yahia, 1995; Kuba & Harris, 2001; Pessate-Schubert, 2003). Several important sociocultural factors are highlighted by focusing on Arab Muslim women in Israel, a deeply divided society in which almost one-fifth (18%) of the population are Arab citizens. In contrast to minority groups elsewhere, Arabs are not immigrants, but have lived in the country for centuries. They are predominantly Muslim (82%); their language is Arabic, not Hebrew, and their way of life
⁎ Corresponding author. Tel.: +972 02 651 3395; fax: +972 02 651 3292. E-mail addresses: [email protected], [email protected] (M.C. Feinson). 1 A number of terms describe the Arab population including Israeli Arabs, Palestinian Arabs, Palestinians, Palestinian-Arab citizens of Israel, and Arab Muslims, among others. All respondents in this study are Arab Muslims and that is the term that is used.
http://dx.doi.org/10.1016/j.eatbeh.2014.03.004 1471-0153/© 2014 Elsevier Ltd. All rights reserved.
M.C. Feinson, A. Meir / Eating Behaviors 15 (2014) 306–310
tends to be semi-traditional compared to dominant Israeli culture (Smooha, 2010). A central aspect of Arabs' distinctive status is that as a “national minority” they are “…tied by language, culture, identity, history, collective memory, narratives, and loyalty to Palestinian nationalism and pan-Arabism” (Smooha, 2010 p. 7). These distinguishing characteristics contribute to making Arabs an “…inassimilable minority. Arabs do not intermarry with Jews. They want to keep their existence separate... The cornerstone of the separation is that of residential communities and schools, which affects 90% of the Arabs who live in Arab villages and towns” (Smooha, 2010 p. 7). Accordingly, Muslim respondents in this study live in an Arab village on the outskirts of Jerusalem. Abu Ghosh, one of the only remaining Muslim villages in the area, is named for the Arab clan that settled in the area in the 16th century and its 5700 residents are direct descendants (Moshe, 2000). Abu Ghosh is a village with 13 restaurants that many Israeli Jews visit, especially on weekends, when most Jerusalem restaurants close for the Jewish Sabbath. Despite these contacts, Arab– Jewish relations generally have worsened since the 1995 assassination of Prime Minister Yitzhak Rabin with “a consistent trend of growth in the alienation, deprivation, and fears among the Arabs…” (Smooha, 2010 p. 18). 1.2. The present study In addition, several other sociocultural factors are particularly relevant including the observation that Arab Muslim women “suffer from a three-tiered discrimination: as women in Israel, as Palestinians in Israel, and as women within the Palestinian community” (HalperinKaddari & Yadgar, 2010). Also, during the past three decades, Arab society has been undergoing a complex transition involving changes in women's status within the family and community. Despite increased education and work outside the home, “woman's role as mother and wife continues to be traditional and non-egalitarian” (Haj-Yahia, 1995 p. 439). Thus, forces encouraging modernization and those pulling families toward traditionalism are operating simultaneously, contributing to stresses and conflicts for women (Haj-Yahia, 1995). Finally, there is the issue of bi-cultural conflict that arises when the values, beliefs and practices of minority groups diverge from dominant cultural norms. Arab Muslim women may find comfort in food as they struggle with the conflicting demands of a bi-cultural existence (Kuba & Harris, 2001). A unique opportunity to explore disordered eating and cultural diversity issues exists with a community-based study including two population groups: Arab Muslims, with roots dating back to the 16th century and second generation Israeli-born Jews of European heritage. High rates of disordered eating among Arab Muslim women might be expected due to sociocultural risk factors, including their status within a disadvantaged minority group and as subordinates within a patriarchal culture (Halperin-Kaddari & Yadgar, 2010). Additionally, Arab women's traditional roles within patriarchal families, including meal preparation for large families, may exacerbate eating problems. Alternatively, aspects of Arab Muslim culture may be protective and associated with reduced rates of disordered eating, including the rootedness of Arab communities and the stability provided by history, heritage identification, and deeply embedded religious rituals and traditions (Mussap, 2009). 2. Methods
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2.2. Measures 2.2.1. Disordered Eating Behaviors—Screening Questionnaire (DEB-SQ) The absence of adequately standardized instruments for assessing eating problems in multicultural, non-clinical samples of women across the life span (Kuba & Harris, 2001; Marcus et al., 2007) is particularly relevant to Israel (Latzer, Witztum, & Stein, 2008). Thus, an easily administered, culturally sensitive self-report questionnaire (SRQ), adapted from several widely-used instruments, was developed to assess 14 behaviors, more than half consistent with DSM-IV symptoms especially binge eating. Higher scores reflect more serious eating problems. The DEB is used categorically for descriptive statistics and in linear form for correlations and regressions (see Feinson & Meir, 2012). 2.2.2. Weight Interviewees indicated if they were underweight (slightly or very) or overweight (slightly or very), a procedure consistent with numerous studies and sufficiently valid for epidemiological and survey studies (Striegel-Moore, Wilson, Wilfley, Elder, & Brownell, 1998). 2.2.3. Emotional well-being Two aspects of emotional well-being are measured. A modified version of the Rosenberg Self-Esteem Scale (Rosenberg, 1979) reflects a more nuanced dimension of self-esteem, namely, self-criticism (CSS). Cronbach's alpha (standardized) is .733 with acceptable alphas for both population groups. Psychological distress is measured with the Brief Symptom Inventory (BSI), an 18 item questionnaire frequently used in epidemiological studies with well-established reliability and validity. Alpha reliability for this sample is .868 with similar alphas for population groups (data available upon request). 2.2.4. Socio-demographic variables Two population groups include Arab Muslims (n = 48) and Israeli Jews (n = 98). Age groups conform to Central Bureau of Statistics categories. Socio-economic status is measured with single questions concerning years of education and income sufficiency. 2.3. Statistical analysis Socio-demographic comparisons utilize Pearson's chi-square, Spearman's Rho and analysis of variance. Bivariate relationships are assessed using Pearson correlation coefficients for continuous variables and Spearman's Rho for categorical variables. Hierarchical regressions measure the contribution of three clinical correlates (weight, selfcriticism, distress) to explaining DEB variance after controlling for demographic variables. DEB, CSS and BSI distress are normally distributed and used in their initial continuous form. 3. Results 3.1. Demographics For the full community sample (n = 567) and two population sub-groups (Table 1a) reveals no significant group differences regarding age or income sufficiency. Arab Muslims are more likely than Jews to be married (68% vs. 49%, p b .05) and to have fewer years of education (12.2 vs. 14.6, p b .001).
2.1. Recruitment of respondents 3.2. Frequency distributions A community-based sample was recruited randomly from primary health care clinics in Jerusalem and surrounding areas including Abu Ghosh. All instruments and protocols were reviewed and approved by the appropriate institutional review boards and the medical directors of all participating clinics. (For additional details, see (Feinson & Meir, 2012).)
3.2.1. Clinical correlates Table 1b reveals that just under 20% of individuals in the community sample are obese with no significant differences between the two sub-groups. While a larger proportion of Arab Muslim respondents are highly self-critical (27% vs 16%), the difference is non-significant. In
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Table 1 Characteristics of respondents: Community sample & population sub-groups. Variables
a. Demographics Age (years) Mean (sd) Education (years) Mean (sd) Education (groups) b12 12 13–15 16+ Income sufficiency Insufficient Partially Sufficient Marital status Non-married Married
Community samplea n = 567b
Population groups
t or χ2
Arab Muslims n = 48
Jews n = 98
43.0 (15.2)
31.4 (9.4)
32.1 (9.9)
n.s.
13.7 (3.2) % 17.6 25.4 25.2 30.0
12.2 (2.5) % 22.9 37.5 31.3 8.3
14.6 (2.5) % 3.1 27.6 34.7 34.7
t = 5.56⁎⁎⁎
18.2 33.2 46.0
18.8 33.3 47.9
15.5 30.9 53.6
n.s.
36.6 58.6
31.9 68.1
51.0 49.0
χ2 = 4.67⁎
18.5 27.9 51.5
18.8 12.5 68.8
16.8 26.3 56.8
n.s.
n.s.
χ2 = 23.00⁎⁎⁎
b. Clinical correlates Weight Obese Overweight Healthy weight Self-criticism (CSS) Self-critical Not self-critical Mean (sd) Psychological distress (BSI) Distressed Not distressed Mean (sd)
18.9 79.9 1.55 (0.39)
27.1 72.9 1.65 (0.36)
16.3 83.7 1.53 (0.38)
15.2 84.7 1.72 (0.59)
35.4 64.6 2.14 (0.62)
12.2 87.8 1.65 (0.54)
χ2 = 10.87⁎⁎⁎
c. Dependent variable Disordered eating behaviors (DEB) Serious Considerable Minimal Mean (sd)
15.9 27.5 56.4 2.37 (0.57)
27.1 20.8 52.1 2.52 (0.64)
20.4 36.7 42.9 2.55 (0.53)
n.s.
n.s.
t = 4.90⁎⁎⁎
n.s.
CSS = Critical Self Scale; BSI = Brief Symptom Inventory. a A broadly representative, community-based sample (n = 567) of adult women (age 21+) in Israel. b Categories do not add to 100% due to missing data on some variables. ⁎ p b .05. ⁎⁎⁎ p b .001.
contrast, almost three times as many Muslims as Jews report psychological distress (35.4% vs. 12.2%, p b .001).
Table 2 Hierarchical regression analyses of disordered eating behaviors (DEBs). Variables influencing DEB Change statistics
3.2.2. DEB Table 1c shows that DEB differences are not statistically significant. Substantially more serious DEB reported by both population groups compared to the community sample (27%, 20% vs. 15.9% respectively) is noteworthy. 3.3. Bivariate relationships Bivariate analyses (data not shown) reveal considerably different correlational patterns with DEB. For Arab Muslims, DEB is significantly associated with weight (r = .58, p b .001). In sharp contrast, weight is not significant for Jews. For Arab Muslims, DEB is not associated either with self-criticism or with BSI distress in contrast to significant correlations for Israeli Jews. 3.4. Multivariate analyses Hierarchical regressions uncover strikingly different predictor patterns of DEB severity. For Arab Muslims (Table 2a), weight makes a
A. Arab Muslims (n = 47) Age (years) Marital status (MS) Education (years) Weight Self-criticism (CSS) Distress (BSI) MS ∗ CSS Adjusted R2 = .448
Overall
R2 change F change p
R2
.039 .154 .017 .213 .054 .039 .053
df
F
p
1.804 4.085 .894 7.356 4.041 3.036 2.225
n.s. .024 n.s. .002 .051 n.s. n.s.
.039 1, 45 .192 3, 43 .209 4, 42 .422 6, 40 .476 7, 39 .515 8, 38 .568 10, 36
1.804 3.407 2.773 4.860 5.060 5.038 4.735
n.s. .026 .039 .001 .000 .000 .000
B. 2nd generation Israeli-born Jews (n = 93) Age (years) .010 0.947 Marital status (MS) .037 1.747 Education (years) .002 .199 Weight .032 1.511 Self-criticism (CSS) .154 17.080 Distress (BSI) .003 .323 MS ∗ CSS .120 7.684 2 Adjusted R = .281
n.s. n.s. n.s. n.s. .000 n.s. .001
.010 1, 91 .048 3, 89 .050 4, 88 .082 5, 86 .236 7, 85 .239 8, 84 .359 10, 82
0.947 1.485 1.154 1.282 3.744 3.290 4.588
n.s. n.s. n.s. n.s. .001 .003 .000
DEBs = disordered eating behaviors; MS = marital status; CSS = Critical Self Scale; BSI = Brief Symptom Inventory.
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large and significant contribution of 21.3% followed by marital status, 15.4%. Despite a relatively high rate of BSI distress among Arab women, it is not associated with DEB severity. For Jews (Table 2b), weight is not significant, while self-criticism and the interaction term make significant contributions. Explained variance also differs considerably: 44.8% for Arab Muslims and 28.1% for Israeli Jews.
significant predictor (Fitzgibbon et al., 1998). In brief, these findings reveal different factors associated with eating disturbances for distinctly different population sub-groups. Additional research would help to clarify how growing up in different cultures influences the development of serious eating problems (Smolak & Striegel-Moore, 2002).
4. Discussion
5. Conclusion
The study empirically supports the concept that “growing up in a different culture raises the possibility of different influences regarding the development of eating disturbances” (Smolak & StriegelMoore, 2002 p. 117). Detailed comparisons of culturally distinct groups living in geographic proximity underscore cultural complexities associated with eating disturbances. The discussion focuses on several noteworthy findings: a) similarly high frequency rates of eating disturbances and b) substantially different clinical predictors of DEB severity. More than one-quarter of Muslim respondents have serious problematic eating behaviors (DEB), a disturbing prevalence rate that parallels binge eating frequency of 25.5% among Black women in a community study (Reagan & Hersch, 2005). Additional research, especially qualitative, would shed light on whether high rates are a form of coping with disadvantageous life circumstances. Indeed, several narrative studies underscore a broad range of traumas and injustices that contributed to women turning to food not only for comfort, but also as survival mechanisms (Feinson & Ben Dror, 2010; Thompson, 1994). In a similar vein, high Muslim rates may reflect challenges and conflicts within Israel's Arab community. “Over the past three decades, Arab society in Israel has been undergoing processes of transition. These processes are manifested by changes in the economy, education, the status of women, family structure, and by socio-cultural changes and transformations in patterns of coping with social problems” (Haj-Yahia, 1995 p. 429). Similar to Japanese women, whose eating problems developed within broad social transformations following World War II (Pike & Borovoy, 2004), serious eating problems among Arab Muslims have begun as coping mechanisms. In contrast to similar prevalence rates, distinctly different predictors of DEB severity emerge. For Muslim respondents and consistent with numerous studies, weight is the largest contributor (Alegria et al., 2007; Cachelin, Veisel, Barzegarnazari, & Striegel-Moore, 2000; Grucza, Przybeck, & Cloninger, 2007). For Jews, weight is not significant. These divergent patterns broadly parallel a U.S. study of adult women in which weight significantly predicted binge eating for Hispanics, but not for White or Black respondents (Fitzgibbon et al., 1998). Why obesity is such a strong predictor of disordered eating among Arab Muslim respondents remains unclear. However, future research may reveal more favorable attitudes toward larger body sizes, similar to African Americans (LoveJoy, 2001). Perhaps most striking is the contrast in self-criticism. Despite no significant differences in prevalence rates, sharp differences emerge regarding the relationship with disordered eating. For Arab Muslims, self-criticism barely makes a significant contribution. For Israeli Jews, however, it is the strongest predictor of DEB severity. Although additional research is needed to fully understand these divergent patterns, they parallel a U.S. study in which depression significantly predicted binge eating for the majority population group (Whites), but not for the minority groups (Blacks & Hispanics) (Fitzgibbon et al., 1998). A final difference concerns explained variance. For Arab Muslims, the model accounts for 45% with weight as the largest contributor. Substantially less variance is explained for Israeli Jews, 28%, with a major role for self-criticism. Again, these divergent patterns are broadly comparable to a U.S. study: for Hispanics, 23% of the variance was explained largely by weight and, to a lesser degree, by depression; for Whites, 28% was explained with depression as the only
Surprising similarities and distinct differences highlight the need for culturally sensitive interventions. Expanding the research agenda to include a broad spectrum of risk and protective factors, especially those unique to specific cultural groups is warranted (Harrington, Crowther, Henrickson, & Mickelson, 2006). Of utmost importance is the need for more culturally relevant explanatory models than ‘one size fits all.’ Role of funding sources Funding for this study was provided by The Hadassah Foundation, New York, NY and Geula Charitable Trust, New York, NY. Neither had a role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors Dr. Marjorie C. Feinson designed the study, wrote the protocol, conducted literature searches, provided summaries of previous research studies and wrote the first draft of the manuscript. Adi Meir conducted the statistical analysis. Both authors contributed to and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgments A debt of gratitude goes to more than 800 women in Israel who graciously participated in long and detailed telephone interviews. The authors also wish to thank Lisa (Gold) Margolin and Tamar (Levy) Ben Dror who were outstanding Field Supervisors, responsible for two waves of data collection and a joy to work with. Generous funding from The Hadassah Foundation, New York and Geula Charitable Trust, New York made this work possible. Thank you all.
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