The extant literature indicated this was the first study to systematically review, consolidate and critically examine familial stressors in Asian students living in Anglosphere countries. This systematic review critically examined the evidence for relationships between familial stressors and disordered eating, in Asian students from Anglosphere countries. Eight themes in familial pressures were identified across the 14 included studies including (1) intergenerational conflict; (2) lack of familial cohesion; (3) parental overprotection; (4) low parental care; (5) achievement orientation; (6) parental criticism; (7) parental expectations; and (8) direct parental influence. The results indicated that intergenerational conflict, maternal overprotection, and familial achievement orientation were the most noted familial pressures significantly associated with eating pathology in this population.
Intergenerational conflict
Intergenerational conflict over cultural values is a distinct familial pressure encountered by Asian students in the Anglosphere, as their adoption of Western values of assertiveness and individual desire comes into conflict with Asian cultural values of filial piety and collectivism [39]. The findings of this review aligned with a meta-analysis which found the conflicting demands of Anglosphere and non-Western cultures creates an acculturation mismatch between traditional parents and acculturated children, which correlates with intergenerational cultural conflict [51]. The same meta-analysis found intergenerational conflict worsened as immigrant children aged and increasingly assimilated, which could highlight why cultural conflicts are still potent for university subsamples. Similarly, Mumford et al. demonstrated that the traditional orientation of parents was significantly associated with higher eating attitudes test (EAT) scores in British-Asian girls [52], in alignment with the review’s findings. Given that a greater acculturation gap is predictive of intergenerational conflict, this can leave immigrant Asian children from traditional families vulnerable to developing disordered eating, particularly when they reach adolescence and begin to internalise the derogatory stereotyping of Asians in Western culture which encourages them to separate from their family’s culture and assimilate into the white mainstream [52,53,54]. The resentment and emotional distress that Asian youth experience from conflict with parents who fundamentally do not understand their children’s desire to individuate and assimilate, has additionally been linked by Asian patients to ED development as a coping mechanism [55]. Thus, intergenerational conflicts can serve as a continual stressor that maintains EDs in Asian patients, which are challenging to address without culturally appropriate interventions [53].
Lack of familial cohesion
Dysfunctional familial cohesion is known to influence the development and maintenance of eating pathology, as families of ED patients have been commonly characterised as having high enmeshment and a lack of familial cohesion [56, 57]. However, the findings of this review have exhibited an opposing view [30, 41], where familial enmeshment and insecure parental attachment has not been pathological for Asian youth. Kirschner [58] found familial enmeshment may be more culturally normative in collectivist Asian cultures, than for independence-oriented Western cultures where such interactions can increase psychological stress. These findings align with a study in Korean-American families by Jin and Roopnarine, which hypothesised that enmeshment may not be pathological in collectivistic-oriented families that embrace close proximity in family relationships as culturally normal [59]. Familial enmeshment may be perceived by Asians as signalling unconditional commitment to well-being whilst white individuals culturally perceive the negative aspects of enmeshment including the suffocating lack of boundaries and over-dependence on family [60]. In contrast, low family connectedness does not align with the family-oriented values of Asian cultures, which could underlie its significant association with pathological eating in Asian-American students in French et al. [42]. However findings by Soh, Touyz and Surgenor found a conflicting overview of the relationship between familial cohesion and disordered eating in Asians [58, 61]. The latter review hypothesised that the level of satisfaction with the perceived family environment could be linked to more disordered eating [61]. Thus, cultural differences that influence a patient’s perception of their family relationships could explain why Asian students do not significantly exhibit eating disturbances in response to traditional ED risk factors like familial enmeshment and insecure attachment [30, 41].
Parental overprotection
Parental overprotection is common in Asian family dynamics, for parents to express care and support to their children’s development [62], and can extend into adulthood for young Asians [28]. In the context of Anglosphere countries, Asian students may conversely believe that their non-Asian peers are often offered more agency and independence. Consequently, this parenting style has been suggested to be maladaptive to young Asians who grow up internalising the Anglosphere’s values of autonomy and individual freedom [63]. While traditional Asian parents may believe increased parental monitoring is important in preparing their children for success in predominantly white environments [62, 64], this may foster resentment and psychological distress in their adult children who perceive this parenting behaviour as abnormally intrusive in the context of Anglosphere culture [28, 65]. The link between maternal overprotection and eating disturbances could be explained by an Asian child’s attempt at claiming control of their lives [38, 44] or to compensate for psychological distress [65]. However, adolescents with overprotective parents may suppress their need for autonomy to avoid intergenerational conflict, which has been related to emotional dysregulation and psychological risk factors [66, 67]. Asian mothers tend to be protective and highly involved in their children’s daily activities, especially in the upbringing of their daughters [17]. This could explain why maternal control was linked to disordered eating in all the included studies that examined this familial pressure, while paternal control has a more conflicting relationship. It is important to note that no paper that assessed parental control included males, and Asian men typically view their fathers as more controlling and influential than Asian women [17].
Low parental care
In classical ED literature, bulimia and anorexia nervosa patients have commonly reported low parental care [68, 69], which is traditionally mediated by internalised shame [70]. Asian students are generally raised by authoritarian and low-warmth parenting [71], in contrast to Western cultures where parental love is equated with high parental care [45]. The literature has typically described parental care as a protective factor against health-risk behaviours in white children, including eating pathology [72, 73]. However, in Asian cultures, parental care is typically expressed indirectly through acts of services and parental sacrifice, rather than through warm parenting [74]. Furthermore, the media stereotyping of Asian parents as controlling and emotionally unavailable, can further contribute to internalised shame in acculturated Asians, and lead to entrenched ideas of the specific behaviours that constitute warm parenting [62].
Hahm et al. [72] hypothesised that highly acculturated Asian adolescents may feel separated from their family’s cultural values, leading to a failure to accept low-warmth parenting as their peers with more traditional cultural orientations. Conversely, a study of Chinese-Australian women found high parental care was positively correlated with eating pathology in traditional women, in contrast with previous findings of its protective value [75]. Overall, the extant literature seems to align with the conflicted findings on the relationship between low parental care and eating pathology in Asians in the Anglosphere. Drawing on the mediating factors of internalised shame may explain the heterogeneity of findings, where low parental care may manifest in psychological distress and eating pathology when its perception is abnormal. In contrast, the traditional notion of low parental warmth is shown to manifest differently in Asians who perceive such parenting styles as culturally normative, and equate their parent’s behaviour with emotional care.
Family achievement orientation
Traditional literature on white families have supported higher levels of achievement orientation in the family environments of individuals with anorexia nervosa or binge eating disorder [18, 76], though Lee and Lock found Asian anorexia patients had a significantly higher frequency of an achievement-oriented family background [47]. Academic success is viewed commonly by immigrant Asian families as the only guaranteed pathway for their children to be shielded from poverty and racial discrimination in white-dominant societies [77]. Hence, Asian parents strive to secure their children’s upward mobility in Anglosphere countries by installing a commitment to school and life success, but these achievement pressures have been linked to perfectionistic strivings and emotional distress [78]. The findings of this systematic review are supported by a qualitative study conducted by Smart et al. [55] where ED therapists reported their female Asian-American patients were significantly impacted by their desire to appease parents with their achievement. Smart et al. affirmed that female Asian-American patients were inclined to meet their parent’s standards on appearance to preserve familial pride and avoid shame [55]. The failure to meet parental standards on appearance, can manifest in shame for young Asians. Asian women with ED were described as motivated by an avoidance of shame, to prevent themselves from disappointing their families and continue striving for ideals of thinness [55].
Other studies have hypothesised that the emotional distress created from heightened achievement pressures in Asian families may drive young girls to compensate through disordered eating [30, 79]. The perceived social pressures may carry more weight for female Asian students, who become predisposed to developing pathological eating habits to preserve familial pride and strive for an ideal appearance.
Parental expectations
Multiple studies have demonstrated that Asians report higher levels of perfectionism than white people [48, 80, 81], which has been linked to authoritarian parenting styles and higher parental expectations in Asian families [15, 82]. The findings of this systematic review conflicted with other Asian-American studies, which demonstrated a correlation between high parental expectations and disordered eating in participants [81, 83]. However, a more recent study by Brosoft, Calebs and Levinson found that although perfectionism was higher in Asian-Americans, it was more strongly associated with ED symptoms in European-Americans [80]. This could explain why perfectionism has been traditionally linked with eating pathology. The same study by Brosoft, Calebs and Levinson demonstrated that social appearance anxiety was predictive of ED symptoms in Asian-American undergraduates.
Goel et al. found a focus group of South Asian-American women internalized high parental expectations for appearance, in addition to academic success [84]. These heightened parental expectations of appearance ideals were linked with body dissatisfaction, a significant risk factor for eating disturbances as shown in Fig. 1 [85]. Unrealistic parental expectations of body image may be internalised by Asian children, who are raised in a culture of filial piety to become obliged to desire familial approval [55, 84]. This is further concerning in Anglosphere countries, where Asian students internalise Eurocentric beauty standards from Anglosphere media and peer influences, which can be inconsistent with familial expectations of appearance [86]. A study of Asian-American women suggested that bicultural stresses contribute to higher levels of body dissatisfaction and disordered eating, while pressure from Western or Asian cultures alone may not increase risk [78]. Similarly, a qualitative study on Asian-American women reported most participants felt their body image was negatively impacted by their limitations to achieve Eurocentric beauty standards and the pressure to conform to familial expectations of attractiveness [86]. This conflict in beauty ideals may fuel a constant dissatisfaction with one’s body shape and weight, driving pathological eating behaviours in Asian students experiencing high parental expectations in the context of bicultural pressures.
Parental criticism and direct parental influence
Parental criticism has traditionally been correlated with disordered eating in the literature [19], particularly with bulimia [87, 88]. In Asian cultures, parental criticism is culturally normative where it is employed in families to promote behaviour change in children [84, 89]. This systematic review observed conflicting findings on the association of parental criticism with eating pathology. Yu and Perez focused specifically on maternal criticism of appearance and weight, demonstrating a significant association with disordered eating. This aligned with previous studies where active parental criticism centred on body shape or size were predictive of disordered eating [19, 90], along with studies indicating maternal pressures are more potent in influencing eating behaviours [90, 91]. Similarly, Chang, Yu and Lin, also identified by this systematic review, found parental criticism framed as a direct influence on dieting and weight loss was significantly associated with eating pathology in Asian-American college students [48].
Culturally, blunt interactions in Asian families have been related to enforcing weight standards and expressing judgement on a child’s eating behaviours [50, 84]. Also, there are Asian parental beliefs that children have better chances of success in an Anglosphere country when conforming to Western ideals of beauty [89]. Asian parents intend to use criticism to exhibit their care and to shield their children from further shame [92], but immigrant Asian students may associate increased parental criticism with Western-influenced connotations of being unloved and inadequate, rather than the parents’ intentions of expressing support and care [93]. Kawamura found that the contribution of parental criticism to body dissatisfaction, was mediated by whether Asian children perceived these comments as supportive or overcritical [92]. This hypothesis has been supported by qualitative studies, where Asian-American women reported interpreting parental criticisms about appearance as hurtful and directly related to negative body image and eating concerns [79, 93]. That parental comments carry more weight for Anglosphere Asian students [15], combined with parental criticism in Asian families being culturally normative, may render parental criticism a potentially potent risk factor for disordered eating in the Anglosphere Asian diaspora.
Limitations and strengths
This review has several limitations. Almost all included studies were cross-sectional and could not demonstrate whether familial pressures cause eating pathology. The review covered students of Asian descent, but Asia is highly culturally and ethnically diverse. Future studies could focus on intra-Asian differences in factors that determine disordered eating. The review excluded American studies that combined Pacific Islanders with the Asian-American group as the focus was on Anglosphere students of Asian descent, although this led to the exclusion of studies that examined the relationship between familial stressors and eating pathology of Asian participants.
The studies included in this systematic review encompassed Asian participants of all generational status, though the level of acculturation differs between Asian families headed by first and third-generation immigrants. Hence, the findings may be less applicable to Asian students raised by Westernised parents that lack collectivist orientation.
The quality of studies was another limitation, as most studies did not calculate statistical power or adjust for confounding. Furthermore, the exclusion of men in 11 of the studies, meant most included studies were unrepresentative of the general population of Asian students.
Eligible studies were from the UK and US, and none were identified from Australia, Canada, or New Zealand. This reduces the scope of the review’s coverage of Asian students in the Anglosphere. As the included studies were conducted in students, this could reduce the generalisability to young Asians not enrolled in studies.
This review’s methodology was also skewed towards studies that examined the contribution of familial pressures to eating pathology as opposed to protective factors for healthy eating behaviours in student-aged Asians in Anglosphere countries.
The strengths of the current review include the extensive range of familial pressures that were critically examined in the context of eating pathology in acculturating Asian students. The review consolidates 30 years of research to comprehensively explore the intersection of culture and disordered eating to address the dearth in literature regarding the bicultural pressures faced by Asians in Anglosphere countries. This review contextualises the familial pressures which could potentially contribute to eating pathology in this understudied demographic, and can facilitate for clinicians to consider cultural factors when treating Asian patients in Anglosphere countries. The included studies encompass a broad age range which has greater applicability to Asian adolescents enrolled in secondary and tertiary education when compared to studies focused on a narrow age category. Another strength is the validity and reliability of outcome measures in all cross-sectional studies.
Future directions and implications
Future intervention studies should test whether addressing mediating psychological factors, such as internalised shame and social appearance anxiety, can mitigate the association of specific familial pressures and eating pathology in young Asians. The cultural nuances of parent-child relationships in immigrant Asian families require additional examination, specifically in exploring how perceptions of familial cohesion, low parental care and gender comparisons in parental control are related to eating pathology. Future studies should also focus on the relationship between familial pressures and eating pathology in Asian students living in Canada, Australia and New Zealand, as the extant literature on Anglosphere Asian students is limited to the United States and United Kingdom. Future studies may wish to further examine the influences of racial discrimination and internalised racism on eating pathology and familial pressures in the Anglosphere Asian diaspora.
Finally, future studies should address quality issues in the existing literature by increasing Asian male representation, adjusting for confounders and calculating statistical power.
The findings of this review can provide a foundational understanding of culturally-specific familial stressors, to enable future studies to address the dearth of knowledge in treatment of Asian patients [94]. The practice of culturally-sensitive ED assessment can mitigate the historic underscreening and underdiagnosis of Asian ED patients, while lowering barriers for patients concerned about clinician discrimination or misunderstanding [1].