REVIEW

CURRENT
OPINION Updates in the epidemiology of eating disorders in
Asia and the Pacific
Jennifer J. Thomas a,b, Sing Lee c, and Anne E. Becker b,d

Purpose of review
This review summarizes and contextualizes the recent epidemiologic data on eating disorders in the Asia
and Pacific regions.
Recent findings
Gaps in epidemiologic data on eating disorders from the Asia and Pacific regions stem, in part, from
omission of eating disorder-specific assessments in large nationally representative cohort studies of mental
disorders. Available data – often from clinical and school-going cohorts – support that the prevalence of
both eating disorders and associated attitudes and behaviors in many Asian and Pacific regions studied
may be comparable to those reported in Europe and North America. Moreover, the prevalence of eating
disorders in some regions of Asia may be increasing. Some of the national and subnational regions with
the highest annual percent increases in disability-adjusted life years per 100 000 caused by eating
disorders over the past two decades are located in Asia.
Summary
Notwithstanding sparse epidemiologic data concerning eating disorders in Asia and the Pacific, available
evidence supports comparable prevalence to other global regions and that associated health burdens in
some regions of Asia may be rising. This further supports that eating disorders are trans-national in
distribution and challenges the previous understanding that they were primarily culture-bound to the Global
North.
Keywords
Asia, China, eating disorders, Pacific Islander

INTRODUCTION subnational regions in Asia (Fig. 2a and b) [1 ].

&&

Epidemiologic data on eating disorders from Asia
and the Pacific are comparatively limited, with
recent systematic prevalence data being limited to
countries located in the Global North, with the
exception of China. Other epidemiologic data that
establish prevalent attitudes and behaviors associ-
ated with eating disorders risk in regions within Asia
and the Pacific have uncertain clinical and public
health significance. We begin by situating the
limitations of these data in the global context of
estimates of health burden caused by eating dis-
orders as measured by disability-adjusted life years
(DALYs).
Although rates of DALYs per 100 000 caused by
eating disorders remain highest in regions of
Europe, Australia, New Zealand, and the Americas
&&
(Fig. 1) [1 ], regions with the highest annual per-
cent increase in DALYs per 100 000 caused by eating
disorders over the past two decades are located in
the Global South; these include national and
Metrics of disease burden such as DALYs per
100 000 are, of course, highly salient to setting
public health priorities locally. Likewise, patterns
of change in disease burden signal potentially
emerging local health needs but can also be broadly
informative to etiologic models. Moreover, despite
their comparatively low rates of DALYs per 100 000
caused by eating disorders, by virtue of the massive
a
Eating Disorders Clinical and Research Program, Massachusetts
General Hospital, bDepartment of Psychiatry, Massachusetts General
Hospital/Harvard Medical School, Boston, Massachusetts, USA,
c
Department of Psychiatry, The Chinese University of Hong Kong, Hong
Kong, China and dDepartment of Global Health and Social Medicine,
Harvard Medical School, Boston, Massachusetts, USA
Correspondence to Dr Anne E. Becker, MD, PhD, SM, Department of
Global Health and Social Medicine, Harvard Medical School, 641
Huntington Avenue, Boston, MA 02115, USA. Tel: +1 617 432 1009;
e-mail: Anne_becker@hms.harvard.edu
Curr Opin Psychiatry 2016, 29:354–362
DOI:10.1097/YCO.0000000000000288

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

 Epidemiology of eating disorders in Asia Thomas et al.

review, we summarize the most recent published

KEY POINTS
 Although few representative epidemiologic data are
available for Asian and Pacific Island populations,
available evidence supports that eating disorders and
associated attitudes and behaviors are prevalent across
these regions.
 Longitudinal data suggest that eating-disorder
prevalence is increasing in Japan and Singapore, and
that regions with the highest annual percent increase in
DALYs per 100 000 caused by eating disorders
globally include national and subnational locations
in Asia.
 Local phenomenological variations in eating disorders
presentation present challenges to diagnostic
assessment and detection that may, in turn, result in
underestimates of their prevalence.
size of their populations, India and China lead the
world as countries (along with the United States)
with the highest contributions to global DALYs
caused by eating disorders in absolute numbers
&&
(Fig. 3) [1 ]. In other words, whereas the contri-
bution of eating disorders to the overall health
burden is small at the country level in India and
China, at a global level their contributions to the
health burdens caused by eating disorders are pro-
portionally and substantively large. These regions,
nonetheless, remain relatively neglected within the
scope of eating disorders research, highlighting both
a critical scientific gap and opportunity. In this
data relevant to eating disorder epidemiology in
Asia and the Pacific by region, recap key founda-
tional studies, and comment further on data gaps
and limitations.
EAST ASIA
The most robust epidemiologic data on eating dis-
orders in Asia come from East Asia, including large
cohort studies from China, Japan, and South Korea.
However, we were unable to identify relevant data
from North Korea, Mongolia, Bhutan, or Macau.
China, Taiwan, and Hong Kong
Most epidemiological surveys on mental disorders
in China have not included eating disorders. Pub-
lished studies on eating disorders in China have
slowly increased from the 1990s. Initially, these
mostly comprised small clinical descriptive studies
which were then followed by cross-sectional studies
of self-reported disordered eating attitudes and their
correlates in student samples. These studies pro-
vided important empirical support for prevalent
fat concern and other maladaptive eating attitudes
among young females in China. More recent studies
suggest these attitudes and behaviors may even be
more common than among some of their Western
counterparts [2,3]. How ‘pathogenic’ these attitudes
and concern are in the development of eating dis-
orders in China has become clearer in recent years.

Eating disorders
Both sexes, all ages, 2013, DALYs per 100 000

10 20 30 40 50 60 70 80 90

FIGURE 1. Global rate of DALYs per 100 000 caused by eating disorders, by country. Reproduced with permission [1 ]. &&

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Eating disorders

(a)

Eating disorders
Both sexes, all ages, annual % change, 1990 to 2013, DALYs per 100 000

–1.4% –1.2% –1.0% –0.8% –0.6% –0.4% –0.2% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4%

(b)

Eating disorders
Both sexes, all ages, annual % change, 1990 to 2013, DALYs per 100 000

–1.4% –1.2% –1.0% –0.8% –0.6% –0.4% –0.2% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4%

FIGURE 2. (a) Global annual percent change in DALYs per 100 000 from 1990 to 2013 caused by eating disorders, by
country (national level). Reproduced with permission [1 ]. (b) Global annual percent change in DALYs per 100 000 from
&&

1990 to 2013 caused by eating disorders (subnational level). Reproduced with permission [1 ]. &&

In this regard, a methodologically rigorous
study of eating disorder prevalence in university
students in Wuhan used the Eating Disorder Inven-
tory (EDI-1) for screening in stage 1 (N ¼ 8521) and
the Structured Clinical Interview for DSM-IV Axis I
disorders (SCID-I, Section H) for eating disorder
diagnosis in stage 2 (N ¼ 569) [4]. Despite the unsat-
isfactory sensitivity and discriminant ability of the
EDI-1 and a high rate of refusal (39% of EDI-1
positive screens) for stage 2, the study found that
eating disorder prevalence among female students
was high by previous Chinese standards [1.05, 2.98,

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 Epidemiology of eating disorders in Asia Thomas et al.

Eating disorders
Both sexes, all ages, 2013, DALYs

50k 100k 150k 200k 250k 300k

FIGURE 3. Global absolute number of DALYs caused by eating disorders in 2013, by country. Reproduced with
permission [1 ].
&&

and 3.58% for anorexia nervosa, bulimia nervosa, Japan

and binge-eating disorder (BED) respectively]. These
findings require replication, but suggest that high
rates of fat concern and the desire for weight control
found among young people in China today [2,3] may
no longer be confined to a ‘cognitive’ level as was
apparently the case in Hong Kong as recently as two
to three decades ago [5]. In the presence of rapid
social change and the emergence of developmentally
Epidemiological studies in Japan suggest that eating
disorder prevalence is increasing. In a multicohort
study of 10 499 female high-school and university
students ages 16–23, between 1982 and 2002, the
prevalence of anorexia nervosa increased from 0.11
to 0.43%, bulimia nervosa increased from 0 to
2.32%, and eating disorder not otherwise specified
(EDNOS) increased from 0.89 to 3.32% [11 ]. This
&&

relevant risk factors, these concerns appear to be
driving actual weight control behavior. Thus, such
attitudes may be exhibiting more pathogenic poten-
tiality than before, resulting in eating disorders in
vulnerable individuals. This possibility is supported
by a 2-year longitudinal study in Chong-qing, China,
showing that body dissatisfaction and negative affect
were fairly robust risk factors for exacerbations in
eating disturbances during adolescence [6].
Similarly high rates of fat concern and/or mal-
adaptive eating attitudes have been found among
young people in Taiwan. A recent cross-sectional
survey using the Children’s Eating Attitudes Test
found that 39% of grades 4–6 children wanted to
be thinner, and that 10.5% of children were at high
risk for disturbed eating tendencies [7]. Although
epidemiological studies of eating disorder preva-
lence are lacking in Taiwan, available data suggest
that dance students are at increased risk [8,9]. In a
&
two-phase survey, Liu et al. [10 ] further demon-
strated that 15.4% of 442 female high-school dance
students had an eating disorder.
trend contrasts with data from the U.S. from the
same timeframe, during which the prevalence of
bulimia nervosa significantly decreased [12]. Sim-
ilarly, an epidemiological study of seven school
prefectures in Japan estimated the point prevalence
of anorexia nervosa among girls in three grades of
junior high school and three grades of senior high
school at 0–0.17, 0–0.21, 0.17–0.40 (junior high
school), and 0.05–0.56, 0.17–0.42, 0.09–0.43%
&
(senior high school), respectively [13 ], comparable
to estimates in North America and Europe.
South Korea
Data from 6027 adults in the 2011 Korean Epide-
miologic Catchment Area Study indicate that eating
disorders are rare in South Korea, with a lifetime
prevalence of 0.0% for anorexia nervosa and 0.1%
&
for bulimia nervosa [14 ]. However, clinical investi-
gations suggest that these may be underestimates.
One study reported 67 incident cases of anorexia
nervosa at the Seoul Paik Hospital eating disorder

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Eating disorders
clinic between August 2010 and February 2012 [15]
and another study identified 359 cases of anorexia
nervosa, bulimia nervosa, and EDNOS presenting to
another eating disorder clinic from 2010 to 2012
[16].
SOUTHEAST ASIA
We did not identify any recent epidemiologic studies
in Southeast Asia. Nor did we identify recent epide-
miological, clinical, school-based, or case studies on
eating disorders in Cambodia, Laos, Myanmar, or the
Philippines from 2014 to 2016. Absent recent
relevant epidemiological data from Malaysia, Viet-
nam, and Thailand, case studies and school or uni-
versity-based studies establish prevalent attitudes
and behaviors associated with eating disorders.
Singapore
The most recent Singaporean epidemiological
study – the Singapore Mental Health Study – did
not assess eating disorders [17]. However, clinical
studies suggest that eating disorder prevalence in
Singapore is increasing. Of the 271 total patients with
anorexia nervosa treated in the Department of Psy-
chiatry at Singapore General Hospital from 2003 to
2010, the number of incident cases per year doubled
&
from just 19 in 2003 to 41 in 2010 [18 ]. Available
data also highlight the role of sociocultural factors
in eating disorder etiology or maintenance. For
example, in one study, 10.3% of anorexia nervosa
patients had previously participated in Singapore’s
‘Trim and Fit’ obesity prevention programme, which
required overweight schoolchildren to do intense
physical exercise and limit the calorie content of
foods purchased at school, before being discontinued
&
in 2007 [18 ].
Malaysia
Among 329 urban school-going boys and girls in
Sarawak, 18.5% scored above the clinical cut-off
on the 26-item Eating Attitudes Test (EAT-26),
suggesting risk for a possible eating disorder [19].
The proportion scoring above the EAT-26 cut-off
was lower among 206 female students from a private
university, at just 6.3% [20].
Vietnam
A survey of 203 female university students in Hanoi
found that nearly half (48.8%) screened positive for
a possible eating disorder by responding affirma-
tively to at least two of five items on the SCOFF
(an eating disorder screening instrument named for
the first letter of each the five symptoms queried)
[21]. The SCOFF has uncertain validity in this
358 www.co-psychiatry.com
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population as it correlated negatively with EDI-2
[21], and findings highlight need for further
research.
Thailand
A report of a 13-year-old girl from Khon Kaen pre-
sented the first published case meeting full DSM-IV-
TR anorexia nervosa criteria in Thailand [22]. Two
additional studies of female undergraduates in
Thailand report a relatively low prevalence of high
EAT-26 scores in a one-stage screening [23,24].
SOUTH ASIA
The relevant epidemiologic data in South Asia
remain sparse compared with East Asia. In the
absence of representative epidemiologic studies
from Pakistan, Bangladesh, and Nepal, school-based
studies demonstrate prevalent attitudes and behav-
iors associated with eating disorders. Limited clinic-
based data support the presence of eating disorders
in both India and Sri Lanka.
India
Clinician observation supports a rise in eating dis-
order prevalence in India. Whereas psychiatrists’
encounters with anorexia nervosa were previously
reported as rare [25], a 2012 study found that two
thirds of psychiatrists surveyed in Bangalore (n ¼ 66)
had seen a case of anorexia nervosa, bulimia nerv-
osa, and/or EDNOS within the past year [26]. Sim-
ilarly, a large retrospective chart review of 3274
children and adolescents seeking treatment in a
psychiatric clinic from 2000 through 2005 ident-
ified six cases of anorexia nervosa, resulting in a 6-
year prevalence of 0.18% [27]. Finally, a small
school-based study of female adolescents in Uttar
Pradesh found 26.6% of respondents scored above
the cut-off score on the EAT-26 [28].
Pakistan
Comparative data suggest that eating disorder atti-
tudes and behaviors (as measured by the EAT-26) are
becoming increasingly prevalent in Pakistan. For
example, two 1992 studies in school-going adoles-
cent female populations, Mirpur and Lahore, found
7 and 10.3% respectively scored above the study cut-
point [29,30]. In contrast, a 2014 study in an Islam-
abad-based population of medical students that
included 51 women, found that 21.6% scored above
the cut-point [31] 20 years later.
Nepal
A study of body dissatisfaction in a mixed
gender study sample of school-going adolescents
Volume 29  Number 6  November 2016

in Kathmandu (n ¼ 239) reported that 29% of girls
and 16% of boys scored above the study cut-point on
the EAT-26 [32].
Sri Lanka
A case series reported four adolescent patients (two
of them male) presenting to a psychiatric clinic in Sri
Lanka met full DSM criteria for anorexia nervosa
[33].
Bangladesh
A large convenience sample of male and female
undergraduates in Dhaka found a high prevalence
of EAT-26 scores above the study cut-point (37.6%).
Notably, female respondents were not more likely
than men to score above the cut-point [34].
PACIFIC ISLANDER POPULATIONS
Epidemiologic data relevant to eating disorders from
Pacific Islander populations are extremely sparse. In
the absence of any recent studies, we summarize
relevant data from New Zealand, Fiji, and Guam
reported in the last 15 years. We did not identify
any epidemiologic data relevant to eating disorders
in Indonesia, Timor-Leste, East Timor, New Guinea,
Micronesia, Tahiti, Samoa, the Cook Islands, New
Caledonia, or Vanuatu.
Maori and Pacific peoples in New Zealand
The New Zealand Mental Health Survey was a large-
scale, nationally representative household survey of
New Zealanders (ages 16 and over) that utilized the
Composite International Diagnostic Interview to
assess mental disorders in 2003 and 2004. This
survey comprised New Zealanders who identified
ethnicity as first, of predominantly European
descent (n ¼ 8161), second, Maori (n ¼ 2457), third,
(other) Pacific people (including Samoan, Tongan,
and Cook Islander ethnicity) (n ¼ 2236), and finally,
mixed Maori and other Pacific ethnicity (n ¼ 138).
Maori and other Pacific people were oversampled
and eating disorders were assessed in a subsample
(n ¼ 7435). Whereas the 12-month prevalence of
any eating disorder in the overall subsample was
0.5% [95% confidence interval (CI): 0.3, 0.6], the
prevalence of both bulimia nervosa and any eating
disorder was higher among women at 0.6% (95% CI:
0.4, 0.9) than men at 0.3% (95% CI: 0.1, 0.5).
Anorexia nervosa prevalence was low at <0.1 among
both women and men (95% CI: 0.0, 0.2 and 95% CI:
0.0, 0.1, respectively) [35]. The lifetime prevalence
of any eating disorder across groups was 1.7% (95%
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Epidemiology of eating disorders in Asia Thomas et al.
CI: 1.5, 2.1). Adjusted hazard ratios for lifetime risk
for any eating disorder were significantly higher in
both Maori (adjusted HR ¼ 1.6; 95%CI 1.1, 2.4) and
other Pacific people (adjusted HR ¼ 2.5; 95% CI: 1.6,
3.9) compared to the reference New Zealand Euro-
pean descent group [36]. The 12-month and lifetime
prevalences of bulimia nervosa among Pacific
people were comparatively high at 1.5% (95% CI:
0.7, 2.6) and 3.9% (95% CI: 2.7, 5.5), respectively.
Similarly, the 12-month and lifetime prevalence of
any eating disorder in the Pacific people subsample
was 1.5% (95% CI: 0.7, 2.6) and 4.4% (95% CI: 3.1,
6.2), respectively [37].
Fiji
Evidence supports increasing prevalence of attitudes
and behaviors associated with eating disorders
among females in Fiji’s iTaukei population in the
setting of globalizing cultural exposures [38–41]. A
large representative school-based study sample of
iTaukei adolescent girls in 2007 (N ¼ 523) docu-
mented prevalent purging behaviors (using a
modified Fijian version of the Eating Disorders
Examination Questionnaire) [42] with 42% of
respondents self-reporting an episode of vomiting
or herbal purgative use within the preceding month
[43]. Another study assessing binge eating in a com-
munity sample of iTaukei adult women (n ¼ 50) with
a Fijian version of the Questionnaire on Eating and
Weight Patterns-Revised, found 4% of respondents
endorsed symptoms consistent with BED [44].
Guam
A study in a large school-based sample of 9–12th
graders (N ¼ 1386) using Guam’s version of the
Youth Risk Behavior Survey assessed purging by
vomiting or laxative use in the past 30 days and
found a prevalence of 10.9 and 5.1% among female
and male students, respectively [45].
LIMITATIONS OF EPIDEMIOLOGIC
ASSESSMENT OF EATING DISORDERS IN
ASIA AND THE PACIFIC
A major challenge to epidemiologic assessment of
eating disorders in these regions is the uncertain
validity of diagnostic assessment. Although cross-
national comparisons are facilitated by utilization of
standardized eating disorder assessments, these may
fail to identify local eating disorder variants [29,42].
When cultural-specific presentations are not cap-
tured by existing diagnostic criteria or conventional
assessments, prevalence and disease burden may be
underestimated. Notable challenges to establishing
www.co-psychiatry.com 359
Eating disorders
anorexia nervosa caseness are lower mean BMIs
and the preponderance of non-fat-phobic anorexia
nervosa in some Asian populations.
Low mean BMI
The average BMI in South Asia is among the lowest
globally, with 23.4% of men and 24.0% of women
classified as underweight (i.e., BMI < 18.5) in 2014
&&
[46 ]. Whereas the World Health Organization
recommends more stringent cut-offs for overweight
and obesity in Asia [47] it does not provide alterna-
tive guidelines for defining underweight. Earlier
studies on Asian populations have used lower BMI
&&
cut points of 16.5 [48] or 17.5 [11 ] for anorexia
nervosa, whereas more recent studies have
applied BMI less than 18.5 [49]. Available data
suggest that BMI categorization may vary by
country, but may need to be adjusted for some
Asian populations.
Non-fat-phobic anorexia nervosa
Early reports on eating disorder phenomenology in
Hong Kong described an anorexia nervosa variant
characterized by an absent fear of weight gain [50].
Epidemiological studies based on DSM-IV criteria
may have underestimated eating disorder preva-
lence in Asia, where non-fat-phobic anorexia
nervosa is more prevalent. Although one clinical
longitudinal study [50] suggested that the pro-
portion of non-fat-phobic cases in Hong Kong have
decreased in tandem with increasing cultural press-
ures for thinness (from 50.0% in 1987–1997, to just
22.4% in 1998–2007), a recent cross-sectional study
[51] of 383 anorexia nervosa cases in Japan high-
lighted that 22.5% presented as non-fat-phobic and
a further 25.3% presented without body image
disturbance. A study in Fiji also described a novel
local variant of weight gain concerns among four
low-weight adolescent girls that differed from con-
ventional fat phobia, illustrating how cultural vari-
ation may reduce visibility of clinically salient
&
presentations [52 ]. Given important differences in
clinical presentation between conventional and non-
fat-phobic anorexia nervosa – a recent taxometric
study in a Hong Kong clinical population highlighted
the difference as categorically distinct [53] – future
epidemiological studies applying DSM-5 criteria will
likely provide more accurate estimates of eating dis-
order prevalence in Asia and the Pacific.
CONCLUSION
Epidemiologic data support the broad distribution
of eating disorder attitudes and behaviors across
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Asia and the Pacific, many regions of which are
highly populous and have undergone rapid modern-
ization and social change in the recent few decades.
However, more representative prevalence data
for eating disorders are only available for China,
Japan, South Korea, and New Zealand. Although
the recently revised DSM-5 criteria for eating
disorders may capture more heterogeneous presen-
tations of anorexia nervosa, bulimia nervosa, and
BED, eating disorders are frequently omitted from
large-scale psychiatric epidemiologic studies
conducted worldwide. Unsurprisingly, rigorous
epidemiologic data from Asia and the Pacific
are incomplete. Although anorexia nervosa and
bulimia nervosa were previously considered
Western culture-bound syndromes, available
evidence underscores the public health relevance
of eating disorders in Asia as well as the scientific
relevance of Asia to advancing the etiologic under-
standing of eating disorders.
Acknowledgements
The authors would like to thank Ms. Lauren Claus for her
assistance with the literature review.
Financial support and sponsorship
None.
Conflicts of interest
A.E.B. and J.J.T. have received honoraria originating
from John Wiley & Sons, Inc. for service as associate
editors for the International Journal of Eating Disorders.
A.E.B. has received a speaker’s honorarium from the
Academy for Eating Disorders (AED), the American
Psychiatric Association (APA), and the Global Founda-
tion for Eating Disorders. She has received in kind confer-
ence registration from the AED and APA and association
membership from the AED. J.J.T. has received travel
reimbursement and in kind conference registration from
the AED. S.L. has no conflicts of interest.
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Volume 29  Number 6  November 2016