Chapter 2: Literature Review
Introduction
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☐ Include an introduction that begins with a summary of the purpose statement,
describes the content, scope, and organization of the review as well as the strategy used
in the literature search. Do not simply cut and paste the Purpose Statement section from
Chapter 1.
Theoretical/Conceptual Framework
The theoretical framework guiding this research is Culturally Responsive Leadership.
Culturally Responsive Leadership (CRL) theory is centered on practices and pedagogy to focus
school policy on creating and maintaining an environment which is inclusive and supportive of
students and families from all ethnicities and cultural backgrounds (Johnson, 2014). It is relevant
to the educational needs of African American girls with anorexia because school leaders assist in
implementing programs for all manner of chronically ill children so that academic and
educational progress is forward moving (Arnett, 2018). Hayes (2017) reported that there is a
scarcity of literature addressing the needs of school leaders when supporting students with
chronic illnesses such as anorexia. The subset of this population, African American girls in
middle and high school who also have anorexia, create and maintain their own sense of culture
and norms within the school setting.(cite) The three main parts of Culturally Responsive
pedagogy are institutional, personal, and instructional, and reflect the leadership focus and
priorities, the emotional and cognitive investment of the teachers, and the materials, classroom
activities, and strategies used (Richard., Brown, & Forde, 2007). How school leaders can
effectively serve minoritized students is a focus of Culturally Responsive School
Leadership (Khalifa, 2018)
According to Andersen (2017) school leadership is critical to student performance and school
achievement. Culturally Responsive Leadership, within the school setting, challenges the
established norms of school leadership practices in order to create better ways to engage
students, including chronically ill students, such as those with anorexia, to take ownership of
and responsibility for harnessing their knowledge, skills, and values to create social change
(Guthrie, 2017). Culturally Responsive Leaders recognize that they possess the power to
influence students through the creation and maintenance of positive institutional culture and
climate for all students, but with special focus on inclusion of the students who become
marginalized for any number of reasons including chronic illness. (cite) For the purposes of this
research, the Culturally Responsive Leadership practices outlined hereafter will focus on the
ways in which school leaders can support and maintain educational growth for African American
girls with Anorexia in the United States. This theory guides the research such that school leaders
may gain insight into possible programs to be implemented to academically support African
American girls with anorexia.
It is important to point out that some of the difficulties faced by African Americans and the
need for this study are already in place due to the existing institutional racism in the United
States’ educational system (citation). Using Culturally Responsive Leadership and Critical Race
theories as the framework for the research will allow the expression of the lived experiences of
African American girls with anorexia to inform school leadership practices such that academic
achievement is maintained for girls with anorexia
Theme or Subtopic
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Anorexia
While Anorexia Nervosa is equally prevalent in all ethnic groups, the utilization of
mental health services is much lower for all ethnic minorities than for non- Latino White persons
(Marques, et al., 2011). The American Psychiatric Association (2018) noted that while the
prevalence of mental health issues is equal across all ethnicities, African Americans may receive
inferior services and often do not have access to care which is sensitive to cultural differences.
According Mental Health America, (2019) the historical adversity African Americans in the US
have experienced, including slavery, sharecropping and race-based exclusion from health,
educational, social and economic resources, has created socioeconomic disparities today, which,
in turn, is linked higher risk for poor mental health.
Girls
with anorexia often have comorbid depression and anxiety, which can interfere with
schoolwork and academic gains over and above the potentially life-threatening consequences of
the anorexia (Sinbourne & Touyz, 2007). The National Eating Disorders Association (2018)
studied more than 2,400 eating disorder patients and found that 94% also suffered from a mood
disorder and 92% suffered with a depressive disorder. It was discovered that 32-39% of the
patients presenting with anorexia also struggled with Major Depressive Disorder and that 4851% were also diagnosed with an anxiety disorder, including 20% with OCD (National Eating
Disorders Association, 2018). Children and adolescents with a chronic illness such as anorexia
tend to demonstrate diminished physical and social functioning and often have school attendance
issues, which can lead to diminishment of achievement (Emerson, et al., 2015).
DSM Criteria
DSM-5 Criteria for Anorexia Nervosa
A person must meet all of the current DSM criteria to be diagnosed with anorexia nervosa:
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Restriction of food intake leading to weight loss or a failure to gain weight resulting in a
"significantly low body weight" of what would be expected for someone's age, sex, and
height.
Fear of becoming fat or gaining weight.
Have a distorted view of themselves and of their condition (Examples of this might
include the person thinking that they are overweight when they are actually underweight,
or believing that they will gain weight from eating one single meal. A person with
anorexia might also not believe there is a problem with being at a low body weight; these
thoughts are known to professionals as "distortions.")
The DSM-5 also allows professionals to specify subcategories of anorexia nervosa:5
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Restricting type: This is a subtype typically associated with the stereotypical view of
anorexia nervosa. The person does not regularly engage in binge eating.
Binge-eating/purging type: The person regularly engages in binge eating and purging
behaviors, such as self-induced vomiting and/or the misuse of laxatives or diuretics. The
binge eating/purging subtype is similar to bulimia nervosa, however, there is no weightloss criterion for bulimia nervosa. As in previous editions of the DSM, anorexia nervosa
"trumps" bulimia nervosa, meaning that if a person meets criteria for both anorexia
nervosa and bulimia nervosa, then anorexia nervosa (binge-eating/purging type) is
diagnosed.
Diagnostic guidelines in the DSM-5 also allow professionals to specify if the person is in partial
remission or full remission (recovery), as well as to specify the current severity of the disorder,
based on BMI.6
https://blackdoctor.org/bmi-and-african-american-women/
African-Americans tend to have less visceral fat (fat around their organs)
and more muscle mass. An African-American with a BMI of 28, considered
overweight by the standard chart, may be as healthy as a Caucasian person
with a BMI of 25. There are a lot of differences in BMI and health risk among
multicultural groups according to Richard L. Atkinson, MD, a researcher
and editor of the International Journal of Obesity.
For Black women in particular, here are five interesting aspects to consider
regarding BMI: Home / BMI: Is This Scale Broken For Black Women?
… the density of lean mass in different ethnic groups.
 Based on direct measures of body fat, such as dual energy x-ray absorptiometry (DXA),
researchers found that an African American woman may not be overweight or obese even though
the BMI formula indicates that she is.
 The statistical risk for disease; high cholesterol, diabetes and high blood pressure would
increase at BMI of 30 /180 pounds in a Caucasian women and at BMI 33 /198 pounds in an
African American women according to researchers.
 According to researchers in the study Body Size Perception Among African American Women,
56% of overweight women (BMI 25 or greater) and 40% of obese women (BMI 30 or greater)
did not classify their body size as overweight, obese, or too fat. The cultural threshold for
overweight was determined to be about a BMI of 35, which is higher than the medical definition
of ≥25.
 African American women have the highest obesity prevalence of any demographic group and
are more likely to underestimate their body weight than white women. According to new
research from Rush University Medical Center, cultural norms for body size may prevent
awareness among many African American women about the potential health benefits they and
others in their cultural group might achieve through weight loss.
Why BMI Is Still Important For Black Women
BMI is not the only way to size up your shape. However, the BMI ranges are
based on the relationship between body weight and disease and death, and
knowing your number can be life-saving. Overweight and obese individuals
are at increased risk for many diseases and health conditions, including the
following:
1. Discrepancies in BMI may be due to variations in bone mineral content,
hydration state and…
https://www.quora.com/What-is-a-good-weight-for-a-teenage-girl-that-is5%E2%80%B23%E2%80%B3-What-would-be-considered-underweight
Epperson, Song, Wallander, Markham, Cuccaro, Elliott, and Schuster, (2014) found that
methods for promoting healthy weight control and for correcting disordered eating in youth may
need to target racial and ethnic groups differently. The National Heart, Lung, and Blood Institute
(2013) suggests portion control as a method for maintaining a healthy weight but reports that
serving sizes and portion sizes have increased over the last 20 years causing the American
population to have a great deal of confusion over how healthy eating really looks (We Can,
2013). They also recommend limiting fats and sugar and increasing the intake of fresh fruits and
vegetables and carefully reading the labels on foods to determine true nutritional content and
correct portioning. The Institute for the Psychology of Eating recommends 3 step process for
correcting disordered eating: observing and investigating eating personal behaviors without
judgement, listening to and identifying the reasons for the disordered eating, and finding and
securing a community of support for eliminating negative behaviors and replacing them with
more positive ones (3 Steps for Healing from Disordered Eating, 2014). However, Salinas, Wang
and DeWan (2016) conducted a genome-wide association study of body mass indexes in
Hispanics and African Americans and concluded that there are genetic differences in the ways
body mass is maintained in these populations, most specifically for African Americans,
indicating the need for ethnicity dependent differences in the treatment of conditions such as
obesity and underweight. The results of this study signal that the bodies of African Americans
function differently than other ethnicities in terms of creating and maintaining body mass and
that previous comparisons of healthy weight norms across ethnicities may be erroneous. Further
study is needed to determine the more accurate measure of healthy and unhealthy weights in
African Americans as criteria for determining and ameliorating eating disorders such as
anorexia.
Differences exist among racial and ethnic groups of youth in how they perceive the size
of their bodies in relation to acceptable body norms and the need to lose weight (Adams et al.,
2000; Martin, May, & Frisco, 2010; Mikolajczyk, Iannotti, Farhat, & Thomas, 2012). The
addition of standards of measurement which are more reflective of the experience of non -White
anorexic patients is needed, as the criteria used to determine disordered eating, i.e. weight
relative to height and age, may not be accurate for all due to cultural differences in which eating
disorder symptoms present themselves in a given population; (Alegria, Woo, Cao, Torres, &
Meng, 2007). African Americans were at higher risk of developing eating disorders than are
Hispanic and Asian Americans (Walcott, 2003). Minorities, such as Latina and Native
American women, despite the severity of their symptoms, were less likely than Caucasians to
receive a referral for further evaluation (Edwards, 2010).
The criteria for diagnosing and treating anorexia and other eating disorders may not be
accurate for all ethnic groups (Conger, 2009) The Diagnostic and Statistical Manual, 5th Edition,
details the criteria necessary for diagnosing anorexia as: the reduction of caloric intake to the
degree of causing significantly lower than expected body weight relative to age, sex, physical
health and developmental expectations; an intense fear of gaining weight or becoming
overweight and behavior that interferes with weight gain even at lower weights than considered
healthy; a persistent disturbance in one’s perception of body size and weight coupled with
overfocus on body size and weight as a measure of worth and a lack of comprehension of the
seriousness of maintaining less than minimal weight (American Psychiatric Association, 2013).
These criteria are less easily indicated in the absence of a generalizable definition of “healthy
weight” for all ethnicities. However, more study is needed to determine racial/ethnic differences
in body shape and size, and there need to be more racial and ethnically specific ways to
determine health and normalcy for weight and size (Heymsfield, Peterson, Thomas, Heo, &
Schuna, Jr., 2016).
African Americans
African American women are underrepresented in eating disorder research (Bell, 2013),
leading to the conclusion that anorexia is a relatively new phenomena in African American
women and girls (Konstntinovsky, 2014). The prevalence of eating disorders within the U.S.
African American population varies by type of disorder, age cohort, gender, and ethnic group
among adults, and by type of disorder among adolescents, and treatment providers require
specialized training to recognize and treat eating disorders in ethnically-diverse patient
populations. (Taylor, Caldwell, Baser, Faison, & Jackson, 2013). African American patients are
often subjected to unnecessary and invasive tests before the diagnosis of anorexia is established
and, by the time proper treatment is made available, patients are often very ill with conditions
such as: emaciation, bradycardia, insomnia, cold intolerance and hyperactivity (Becker, 2003).
Delays to proper diagnosis for African American patients mean greater misdiagnosis, and longer,
more medically focused treatment before psychological interventions are put into place
(Smedley, 2003) The result of the delay in proper treatment is longer periods of time out of
school for school aged sufferers of anorexia, leading to more significant deficits in learning
outcomes (Lindstedt, Kjellin, and Gustafsson, 2017.) A gap in the research can be found in the
differences in the manifestations of disordered eating behaviors based on race and ethnicity,
such as African American woman and girls (Reba-Harrelson, et al., 2009; Edwards, 2010; Sala,
Reyes-Rodriguez, Bulik and Bardone-Cone, 2013).
Educating African Americans
According to Brownstein (2016) under the same educational conditions as any other group,
only 73% of African American students graduate on time. This demonstrates the already existing
difficulties for African American students and creates a markedly less optimistic future for
African American students with anorexia. Steele (2011) noted that educational mediocrity has
stigmatized African American children for more than a generation and is an offshoot of the ways
in which the society at large views and treats children of color in both the educational and
political arenas. It can be concluded that African American do not share the same educational
supports and opportunities as do other groups and therefore struggle to achieve and acquire the
same societal advantages (Andersen, 2016.) Despite the gap in research regarding anorexia and
ethnicity, it can be cited through Rose, Lindsey, Xiao, Finnegan-Carr, & Joe (2017) that African
American girls with a chronic and debilitating mental health conditions such as anorexia will
face even greater difficulties in educational achievement.
Societal Views of the Black Woman
Even as Black women report emotional eating as a means of coping with strong feelings
associated with traumas stemming from abuses suffered in childhood, clinicians deny that Black
women experience anorexia (Ross, 2019). Because clinicians are less likely to conform the
prevalence of anorexia in the Black community, Black women are equally unlikely to believe the
condition is prevalent (Ives, 2017). In 2003, NIMH studied 985 white women and 1,061 black
women and concluded that that health professionals need to be more alert to the possibility of
eating disorders in all women, even as eating disorders, especially anorexia nervosa, are more
common among white women than among black women(Striegel-Moore, Dohm, Kraemer,
Taylor, Daniels , Crawford, and Schreiber, 2003).
Ross (2019) reported that African-American women are more likely to experience
pervasive stress associated with poverty, than their white counterparts. She further reports that
Black women experience racism and daily microaggressions, including: discrimination and
sexual harassment in the workplace with limited mean to effectively redress the issues recourse.
She advanced that disordered eating can become the coping mechanism for handling these
stresses. Striegel-Moore RH, Wilfley DE, Pike KM, et al. (2017) report that Black women
experience higher rates of depression that their white counterparts. In addition to the trauma of
abuse and neglect, foster care placement , the lack of one or more viable parents or other strong
caregiver, and recurrent domestic abuse are also traumatic and can lead to attachment disorders
and repeating relational turbulence for many women (Ross, 2019). Clinicians will improve their
ability to treat Black women with anorexia when they can conceptualize the disorder as an
explicable strategy for coping with ongoing stress and trauma rather than as a reflection of the
desire to reflect thinness as a body ideal (Ross, 2019)
How black women have been conditioned to cope with stress from life experiences relies heavily
on this strong black woman archetype, or Superwoman role. (Ross,2019)
The Hottentot Venus
Recy Taylor
Annette Butler
Medical Exploitation of Black Women
1840s, James Marion Sims
Anita Hill
Omerosa
https://theundefeated.com/features/our-patriarchal-society-doesnt-always-tell-thestories-of-black-women/
The Voice of the Black Woman
Summary
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Checklist:
☐ Briefly restate the key points that were discussed in the chapter. Review the headings
and/or table of contents to ensure that all the key points are covered.
☐ Highlight areas of convergence and divergence as well as gaps in the literature that
support the need for the study. This discussion should logically lead to Chapter 3, where
the research methodology and design will be discussed.