the HAES® files: Covered But Not Immune: Body Image, Eating Behaviours, and Weight Stigma in the Middle East

by Health At Every Size® Blog

by Lily O’Hara BSc, Postgrad Dip Hlth Prom, MPH, PhD

Long before I even thought about moving to the Middle East, I read Geraldine Brooks’ Nine Parts of Desire, and agreed with the blurb that it was ‘a rich and riveting account of her six years living among the women of the Muslim mideast’. Until then I had made a whole lot of assumptions about the reasons why women, whom I had only seen on TV, might wear the abaya (loose fitting black covering dress), cover their faces with a shayla (black headscarf), or wear the niqab (the piece of cloth that covers the face from under the eyes) or the burqa (the stiff metallic looking leather piece that is tied across the face). Brooks’ book opened my eyes to the notion that wearing such clothing, which I had previously thought of as oppressive to women, may actually be a matter of choice, and for some women may even be empowering. Some of the women in Brooks’ book talked about how being covered enabled them to be taken seriously at work or even in general everyday life, because their bodies, and for some women their faces, were ‘invisible’ and so there was nothing else for others to concentrate on but their intellect and their personality.

Some years later my family and I moved to Abu Dhabi in the United Arab Emirates (UAE) for work and adventure. Based on my insights from Brooks, I assumed that women in this region who wear the abaya would be more likely to have a healthy body image, and not be invested in what I thought of as the western ‘slim ideal’ or beauty standards. I also assumed that because food is so much a part of local hospitality, that the women would also have a comfortable and healthy relationship with food and eating. I was happy with the anticipation that my then early teenage and younger daughters would experience a culture that was at least body neutral, if not body positive. And then I discovered how utterly and devastatingly wrong I was.

The first hint I had of the sheer chasmic depth of my ignorance was when I encountered some work colleagues in the bathroom. They had removed their abayas and shaylas, and I hadn’t even recognised them. Women that I had thought of as demure and conservative were wearing extremely glamorous and tight fitting clothing, full makeup, and killer heels. More shockingly, they were complaining about their bodies and talking diets and weight loss. I could have been in the bathroom in any western country.

Sometime later I was invited to a wedding of another work colleague. Weddings in the UAE are gender separate occasions so almost all of the women at the wedding did not have their abayas on. I was taken aback at the gorgeous glitz and glamour of the women, and although there was fabulous free spirited dancing and all manner of diva dresses and full on professional makeup and hair on display, (after all, who doesn’t love dressing up for a wedding?) I was dismayed to hear many women engaged in negative body talk.

These experiences gave me some hints about the situation here, but it was only when I came to work at a teachers college that I began to realise the full scale of body negativity among the women in this region. In the college bathrooms, I noticed the same glamour, makeup and killer heels that I’d seen on my work colleagues. I talked to students about how they felt about their own bodies, and how their bodies are viewed in their culture. They wistfully told me stories about how there used to be less emphasis on their bodies, but now it was their number one issue and that it consumed many of their lives. Many expressed dire concerns about the impact of these ‘toxic’ ideas on their younger siblings or children. A number of faculty asked me for resources and strategies to help them deal with body dissatisfaction and disordered eating, and with the terrible meanness they were witnessing between students based on their bodies. I was increasingly aware that cosmetic surgery and even bariatric surgery were ruthlessly promoted and widely available in the country. The situation really shocked me; so like any good academic, I decided to go beyond talking to people and do some research.

I started reading the literature and discovered that since the early 1990s, researchers have documented increasing rates of body dissatisfaction and eating disorders in the UAE and other countries in the Gulf region. In one study, almost 80% of a sample of female undergraduate students in the UAE had high levels of body image dissatisfaction. In various studies with adolescents in the Gulf, up to a third had eating disturbances consistent with clinical eating disorders. And these figures appear to be increasing. The latest study with adolescents showed that nearly 40% had disordered eating behaviours and attitudes. So I knew that body image dissatisfaction and disordered eating were big issues here, and that some researchers were putting the blame for these spiraling rates on exposure to western culture. I also found that no one had looked at the concept of weight stigma. So together with colleagues from other universities, we conducted some studies on body image, eating behaviours, weight stigma, and cultural identity. And what have we found?

In the first two studies, we explored the relationship between how much people identify with their Emirati identity (in-group preference) and their levels of disordered eating attitudes and behaviours, which I’ll refer to as ‘disordered eating’ as short hand from here on. For these studies we tested both implicit and explicit in-group preference in over 200 female Emirati undergraduate students. One of my colleagues, who is an IT guru as well as a great researcher, had developed a very cool way of assessing implicit in-group preference. Names (study 1) or images (study 2) associated with Emirati culture or western culture flashed momentarily on the computer screen, followed by a positive word such as fun, pleasure or praise, or a negative word such as danger, harm, or insult. Participants had to classify the word as positive or negative as quickly as they could by pressing P or Q respectively on the keyboard. The theory is that when a name or image from the group you identify with flashes on the screen, you will be faster at correctly classifying the word than when a name or image from the culture you don’t identify with flashes on the screen. Participants also completed some questionnaires that assessed explicit in-group preference. We found that higher levels of implicit in-group preference were associated with lower levels of disordered eating, and conversely, that higher levels of implicit out-group preference were associated with higher levels of disordered eating. There were no relationships between explicit in-group or out-group preferences and disordered eating. From a disordered eating perspective, these results suggest that implicit in-group preference may be protective and implicit out-group preference may be detrimental.

For me, ever the Health At Every Size® (HAES) practitioner, I wonder what we do with these findings. What are the cultural and ethical implications of trying to manipulate implicit in-group or out-group preference as a strategy to decrease disordered eating? This is very tricky ground, and maybe these findings are best viewed as illuminating rather than stimulating.

In the next study, we examined the relationship between disordered eating, weight teasing, internalized weight stigma, and self-esteem in over 400 female Emirati undergraduate students. This time we had participants complete an online survey. As with previous studies, almost a third of respondents had disordered eating, and almost half reported being frequently teased about their weight. Perhaps not surprisingly, disordered eating was positively correlated with being bothered by teasing from family, friends and others, and internalized weight stigma. Weight- and body-related shame and guilt were the strongest predictors of disordered eating. There were no relationships between body mass index and any of the factors measured, meaning that these results were true for participants across the weight spectrum.

Because these studies are cross sectional, we don’t know what comes first in this population, the teasing, the internalized stigma, or the disordered eating. However longitudinal studies from elsewhere indicate that internal and external weight stigma predict the development of disordered eating. So now that we have some idea about the prevalence of and relationships between these factors in this region, we have moved on to taking action and have piloted a brief HAES program for students, based on the HAES Curriculum (www.haescurriculum.com). Early results are encouraging but we need larger and longer term studies before we can claim that it is effective at improving health and wellbeing. So that’s the next step in our plan.

We can also use the findings from these studies to advocate for a HAES approach in public health and medical services more broadly. It is absolutely vital that health authorities and practitioners everywhere do not inadvertently (or worse, deliberately) condone weight-based teasing, weight stigma and shame, or disordered eating. The HAES approach offers a great alternative and one that is just as applicable here in the Middle East as it is anywhere in the world. Wherever people are hurting as a result of weight wars, body hatred, and size oppression, HAES provides an option for peace, love and human rights.

 


Related publications:

Thomas, J., Quadflieg, S., & O’Hara, L. (2016). Implicit out-group preference is associated with eating disorders symptoms amongst Emirati females. Eating Behaviors, 21, 48-53. doi:10.1016/j.eatbeh.2015.12.005

O’Hara, L., Tahboub-Schulte, S., & Thomas, J. (2016). Weight-related teasing and internalized weight stigma predict abnormal eating attitudes and behaviours in Emirati female university students. Appetite. doi:10.1016/j.appet.2016.01.019

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Lily O’Hara is a health promotion and public health academic and practitioner with experience in Australia and the United Arab Emirates (UAE). She is currently an Assistant Professor at Emirates College for Advanced Education. Lily is passionate about social justice and the need for health promotion initiatives to actually result in health gain. Lily’s two main scholarly interests are the development of critical health promotion practice, and critical weight studies and the Health at Every (HAES) approach. Together with a colleague, Lily developed the Red Lotus Health Promotion Model, which is the first health promotion model to incorporate a system of values and principles that underpins all stages of critical health promotion activity, from assessing health and wellbeing needs, to planning, implementation and evaluation of health promotion initiatives. The model has been used over the past eight years in teaching, research, and practice in Australia, UAE, USA, and UK. With respect to critical weight studies, Lily conducts research on the weight-centred health paradigm, and has developed, implemented and evaluated HAES programs at the community, school and university levels.

Contact email: lilyohara@ecae.ac.ae

8 Comments to “the HAES® files: Covered But Not Immune: Body Image, Eating Behaviours, and Weight Stigma in the Middle East”

  1. Lily, it’s fascinating to read about your recent research, and encouraging to see those in the in-group preference with lower levels of disordered eating. Might there be “culture champions” within the in-group preference cohort who could help you with implementing the HAES curriculum from a culturally-specific lens, to leverage that positive effect of identifying with Emirati culture by celebrating and promoting its many components?

    So exciting to read your work! I can’t say I’m surprised with the findings about the out-group preference, but I’m really encouraged by the in-group preference results and what you can do with that information!

  2. Interesting that body SIZE/ higher weight can still be determined and stigmatized even with the abaya, burka, etc. Sad that for the FEW women who actually have a choice what to wear can not hide from weight stigma in long, hot, black dresses over top a full set of clothes. These coverings still represent soul chilling obvious oppression for women and the fact that they don’t protect from weight stigma makes me see no woman positive use for them at all.

    • Thanks for your comment Rev E-K Daufin. It is indeed sad that it seems as though no-one is immune from the crushing oppression of weight stigma, and I have learnt not to assume that any particular clothing will protect people from that. However I think we need to be very careful about assuming that the clothing itself is automatically oppressive. Certainly many of my colleagues and friends do not see it this way, and indeed make active and informed choices about wearing the abaya and shayla or other types of hijab. I think we need to focus on breaking down the adipophobicogenic (fat hating) environment and build an environment in which all bodies are respected and valued, irrespective of the clothing choices of their owners.

  3. Thanks for your comments and suggestions Amy. I’m really not sure what we can or should do with the in-group/out-group results. There is certainly a strong emphasis on cultural identity here, with many fabulous events celebrating Emirati culture and traditions. However we’d have to do more formative research before even thinking about proactively integrating this into a HAES program.

  4. Here’s great write-up from a Muslim woman on eating disorders that I thought others who commented on this post might be interested in: http://www.worldeatingdisordersday.org/#!Muslims-Get-Eating-Disorders-Too/dfw4q/571bd12c0cf28d4bbf520232

    • Thanks for this link declifford. It’s great to hear from a Muslim woman about her own journey and the work she’s doing to address eating disorders in various countries.

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