Ethnicity and spirituality as risk factors for eating disorder symptomatology in men.
Eating disorders (Demographic aspects)
Spirituality (Health aspects)
Ethnicity (Health aspects)
Men (Health aspects)
Boisvert, Jennifer A.
Harrell, W. Andrew
|Publication:||Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Men's Studies Press ISSN: 1532-6306|
|Issue:||Date: Spring, 2012 Source Volume: 11 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: New York Geographic Code: 1U2NY New York|
The present study investigated ethnicity, spirituality, body shame,
body mass index (BMI) and age as risk factors for eating disorder
symptomatology in men. A representative nonclinical sample of Canadian
men (N = 603) was surveyed. Body shame and BMI explained a portion of
the variance in eating disorder symptomatology. Ethnicity was indirectly
related to eating disorder symptomatology through spirituality, body
shame and BMI. Aboriginal men had lower spirituality and Asian men had
greater body shame. Older men were at greater risk for eating disorder
symptomatology by virtue of higher BMIs and body shame. These findings
have implications for assessing men's health risk factors and
developing interventions addressing gender, including beliefs about
health and masculinity, and initiatives to promote health.
Keywords: ethnicity, spirituality, body image, eating disorder symptomatology, men
The desire of women and men to attain a trim, fit and youthful appearance is often at a cost to their physical, nutritional and psychological well-being (Bordo, 1993, 1999; Wolf, 1991). Most research on body image concerns and eating disorder symptomatology has focused on women and girls (Grabe & Hyde, 2006), the assumption being that men and boys are immune to concerns over unrealistic cultural standards of attractiveness and achieving an "ideal" body type. In the last decade, however, there has been an increasing awareness that men and boys, too, are susceptible to cultural messages and pressures regarding body appearance that put them at risk for developing eating disorder symptomatology (Cohane & Pope, 2001; Grogan & Richards, 2002; Hatoum & Belle, 2004; McCabe & Ricciardelli, 2001). These cultural messages and pressures may influence men's attitudes and behaviors about masculinity in relation to food, eating and exercise habits (Connell, 1995; Courtenay, 2000a, 2000b; Gough & Connor, 2006). Indeed, eating disorder symptomatology (attitudes and behaviors reflective of eating disorders) has increased among men (Andersen, 1990; Carlat & Camargo, 1991; Drummond, 2002; Olivardia, Pope, Borowiecki, & Cobane, 2004).
Media images are a powerful source of body image concerns, eating disorder symptomatology and risky body change behaviors in women, and increasingly, in men (Duggan & McCreary, 2004; Karazsia & Crowther, 2010; Morrison, Kalin, & Morrison, 2004). In Western society, media images of the male body ideal and masculinity have gradually changed from a muscular, powerful, V-shaped physique (Gray & Ginsberg, 2007; Petrie et al., 1996), to an ideal male body that is increasingly muscular (Leit, Pope, & Gray, 2001). Today's standard of attractiveness and body ideal for men is a muscular build characterized by a well-developed upper body and a slender lower body--a combination of physical strength and leanness (Fan, Dai, Liu, & Wu, 2005; Furnham & Radley, 1989; Maisey, Vale, Cornelissen, & Tovee, 1999; McCreary & Sasse, 2000; Pope, Olivardia, Gruber, & Borowiecki, 1999).
Like women, men may be vulnerable to messages to pursue a thin yet muscular ideal (Bordo, 1993, 1999; Brumberg, 1997; Pope, Philips, & Olivardia, 2000). Constant exposure to an ideal body type (but one that is unrealistic and impossible to achieve) can make men more sensitive and conscious about their bodies (Beren, Hayden, Wilfley, & Grilo, 1996; Hatoum & Belle, 2004), giving rise to a crisis of masculinity, e.g., masculine gender role stress, and a growing preoccupation with men's body weight, size and appearance (Mussap, 2008). Some studies suggest that there are roughly an equal number of men who wish to lose weight as those wishing to gain muscularity (Drewnowski & Yee, 1987; Silberstein, Striegel-Moore, Timko, & Rodin, 1988; Thompson, Heinberg, Altable, & Tantleff-Dunn, 1999). Some groups of men, e.g., younger and underweight men, may display greater drive for muscularity than others (Harmatz, Gronendyke, & Thomas, 1985; Serdula et al., 1993). Male body dissatisfaction associated with feeling too small can lead to negative feelings similar to those felt by women who feel that they are too big (Drewnowski & Yee, 1987; Harmatz et al.; McCreary & Sasse, 2000). Men's body dissatisfaction has been linked to the development of body image disturbance, low self-esteem, depression, and eating disorder symptomatology (Andersen, 1990, 1992; Cafri, Stauss, & Thompson, 2002; Cafri et al., 2005; Lynch & Zellner, 1999; Olivardia et al., 2004; Thompson et al.). Men, particularly those seeking to build muscle mass, may engage in risky behaviors such as compulsive exercise, low- or no-fat diets, and use of anabolic substances (Andersen; Blouin & Goldfield, 1995; Filiault & Drummond, 2010; Pope, Katz, & Hudson, 1993; McCreary, Hildebrandt, Heinberg, Boroughs, & Thompson, 2007; Olivardia, Pope, & Hudson, 2000).
While negative psychological experiences associated with deviation from culturally prescribed standards for the male body, e.g., muscularity, have been observed in men (e.g., Carpenter, Hasin, Allison, & Faith, 2000; Harmatz et al., 1985), body shame is not amongst them. Body shame reflects the degree to which an individual internalizes body-related cultural expectations that are linked to the belief that achieving these standards is realistically possible and that one is a "bad" person if these prescribed standards are not met (McKinley & Hyde, 1996). Body shame has been shown to increase eating disorder symptomatology in women (e.g., Boisvert, 2006; Frederick & Grow, 1996; Fredrickson, Roberts, Noll, Quinn, & Twenge, 1998; Noll & Fredrickson, 1998). The present study will investigate this link in men.
ETHNICITY AND EATING DISORDER SYMPTOMATOLOGY
The way men's body ideals are constructed and prescribed and the meanings men attach to food, eating and emulating body ideals often varies with factors such as ethnicity or immigrant status (Boisvert & HarreI1, 2009a, 2009b), sexual orientation (Boisvert & Harrell, 2009c; Morrison, Morrison, & Sager, 2004; Yelland & Tiggemann, 2003), income or social class (Gough & Conner, 2006), and endorsement of gender roles and masculine norms and ideals, e.g., strength (Kanayama, Barry, Hudson, & Pope, 2006; McCreary, Saucier, & Courtenay, 2005).
Variation in the idealization of the male body ideal may be more pronounced among certain groups of men. For example, heavier male bodies are idealized in lower income and social class individuals, where fatness may be indicative of access to food resources (Gough & Conner, 2006; Swami & Torte, 2005). In the same vein, ethnic minority men with genetic predispositions at odds with thin-muscular ideals, e.g., Aboriginal men, may be at greater risk for eating disorder symptomatology and associated negative psychological experiences than White men. They may also experience greater body dissatisfaction (Lorenzen, Grieve, & Thomas, 2004) and body shame, though body shame has not been studied in ethnic minority men.
A growing interest in the role of culture and ethnicity in the development of eating disorder symptomatology has led to a number of studies examining ethnic group differences in women (e.g., Bisaga et al., 2005; Boigvert & Harrell, 2009a; French et al., 1997; Neumark-Sztainer et al., 2002; Smith, Thompson, Raczynski, & Hilner, 1999). Comparatively, there are far fewer studies of ethnic differences in men. As noted above, ethnic minority men are in particular need of study since virtually nothing is known about factors that might increase their risk for eating disorder symptomatology. With so few studies on eating disorder symptomatology in men, it is generally assumed in the literature that women are more vulnerable to Western cultural values related to diet, thinness and body appearance than men. However, an emerging literature suggests this is not so (e.g., Campbell, Pope, & Filiault, 2005; Yang, Gray, & Pope, 2005).
A few studies have investigated eating disorder symptomatology in Native American Indian women (e.g., Lynch, Heil, Wagner, & Havens, 2007; Neumark-Sztainer et al., 2002; Rosen et al., 1988; Snow & Harris, 1989; Story, French, Resnick, & Blum, 1995). Only a single study has investigated Canadian Aboriginal women (Boisvert & Harrell, 2009a). There are no studies of Canadian Aboriginal men in this area. Native American Indian women and men have a tendency toward overweight and obesity (Broussard et al., 1991; Welty, 1991) as shown by higher body mass index (BMI) and weight-control behaviors, particularly binge eating (Croll, Neumark-Sztainer, Story, & Ireland, 2002; Knowler, Pettitt, Savage, & Bennett, 1981; Mueller et al., 1984; Rosen et al.; Snow & Harris). Compared to White women, Native American Indian women report higher BMI and weight concerns, body dissatisfaction and eating disorder symptomatology (Boisvert & Harrell; Croll et al.; Davis & Lambert, 2000; Neumark-Sztainer et al.; Pumariega, 1986; Rosen et al.; Smith & Krejci, 1991; Snow & Harris; Story et al., 1997). Other studies, however, suggest that Native American Indian women have higher body satisfaction than White, Hispanic and Asian women (e.g., Boisvert & Harrell; Story et al., 1995). Studies have shown high prevalence of body image and eating disorder symptomatology in Native American Indian women and men (Crago, Shisslak, & Estes, 1996; Croll et al.; Smith & Krejci; Story et al., 1997), identifying overweight or obesity as a risk factor for dieting and weight control behavior (e.g., Story et al., 1994, 1997). Native American Indian boys have higher levels of vomiting for weight control than White boys (Croll et al.; Story et al., 1995) and higher prevalence of obesity than Hispanic, Asian American or White boys (Neumark-Sztainer et al.).
Studies comparing Asian American women with White women have found that the former report greater concern with "fatness" and their non-Occidental ethnic features, but lower overall body dissatisfaction (Akan & Grilo, 1995; Harris, 1994; Haudek, Rorty, & Henker, 1999; Miller et al., 2000; Mintz & Kashubeck, 1999; Sanders & Heiss, 1998; Story et al., 1995). Asian American women report more binge eating behavior (Croll et al., 2002; Story et al.). Asian women (in Western and non-Western societies) at the greatest risk for eating disorder symptomatology tend to have high BMI and body image concerns (Bisaga et al., 2005; Mumford & Choudry, 2000). BMI has been strongly correlated with body dissatisfaction among Asian (Filipino) males but less strongly correlated among Asian (Japanese) women (Yates, Edman, & Aruguete, 2004). Asian American boys report higher body dissatisfaction and weight-related concerns/behaviors such as higher levels of dieting and binge eating than White boys (Croll et al.; Neumark-Sztainer et al., 2002; Story et al.).
Hispanic women report higher levels of body dissatisfaction and eating disorder symptomatology than White and Asian American women (Akan & Grilo, 1995; Barry & Grilo, 2002; Demarest & Allen, 2000; Harris, 1994; Miller et al., 2000). The most common explanation for greater body dissatisfaction among Hispanic women is that Latin culture favors a more robust, less thin, ideal female body type (Gil-Kashiwabara, 2002). Studies comparing Hispanic and White women have shown that Hispanic women report higher drive for thinness than White women (McComb & Clopton, 2002), and a greater prevalence of weight-related behaviors such as dieting, binge eating and use of laxatives or diuretics (Croll et al., 2002; Fitzgibbon et al., 1998; Story et al., 1995). Other studies, too, have found more weight loss attempts and eating disorder symptomatology among Hispanic girls and boys (e.g., Chamorro & Flores-Ortiz, 2000; Miller et al.; Neumark-Sztainer et al., 2002; Snow & Harris, 1989), with the severity of this symptomatology related to higher weight and BMI (Bisaga et al., 2005; Fitzgibbon et al.; Neumark-Sztainer et al.). There are no reported studies of Hispanic men in this area.
One explanation for the above findings is a "differential acculturation hypothesis" (Lynch et al., 2007, p. 180) or "two-world hypothesis" (Katzman & Lee, 1997, p. 387)--the idea that cultural conflict associated with affiliation with more than one culture may lead to increased risk for eating disorder symptomatology (Crago et al., 1996; Stice, 2003). For example, Asian and Hispanic women have body dissatisfaction and body shame due to their failure to achieve Western ideals of beauty and thinness (Gil-Kashiwabara, 2002; Mok, 1998). This may also be the case for Native American Indian, Asian and Hispanic men. Studies suggest that ethnic differences in eating disorder symptomatology may be a function of differences in BMI, body dissatisfaction and body shame (e.g., Boisvert & Harrell, 2009a; Lynch et al.; Neumark-Sztainer et al., 2002; Stice; Yates et al., 2004). Based on the literature, in the present study, it was predicted that men with higher BMIs or body shame would report more eating disorder symptomatology.
SPIRITUALITY AND EATING DISORDER SYMPTOMATOLOGY
There is an extensive literature relating spirituality, religiosity, life satisfaction and physical/mental health (Ellison, 1991; Hill & Pargament, 2003; Mickley, Carson, & Soeken, 1995; Miller & Thoresen, 2003; Powell, Shahabi, & Thoresen, 2003; Seeman, Dubin, & Seeman, 2003). While Judeo-Christian beliefs and religious attendance per se have not been linked to life satisfaction (Ellison) or suicide attempts (Garroutte, Goldberg, Beals, Herrell, & Manson, 2003), other aspects of religiosity have been. For example, existential certainty, i.e., the absence of doubts about matters of faith, was predictive of life satisfaction (Ellison). Literature suggests that religiosity and spirituality may reduce health-risk behavior such as alcohol abuse, morbidity and mortality (e.g., Hill & Pargament; Hill et al., 2000). Native American Indian spirituality is associated with the cessation of alcohol abuse in Native American Indian men (Stone, Whitbeck, Chen, Johnson, & Olson, 2006) and fewer suicide attempts (Garroutte et al.).
While studies suggest that religion and spirituality are important to men's health (e.g., Carson, Soeken, Shanty, & Terry, 1990; McBride, Arthur, Brooks, & Pilkington, 1998), for the most part, these factors have been identified as more important to women's health (e.g., Hintikka, Koskela, Kontula, & Viinamaki, 2000; Mickley & Soeken, 1993; Mickley, Soeken, & Belcher, 1992; Simioni, Martone, & Kerwin, 2002). Research examining gender differences suggests that men more often see themselves as religious but not spiritual, and women more often see themselves as both religious and spiritual (e.g., Maselko & Kubzansky, 2009; Rayburn, 2004). A single study (Boisvert, 2006) has investigated low spirituality as a risk factor for eating disorder symptomatology in women. To our knowledge, no study has examined this relationship in men. Based on the literature, in the present study, it was predicted that men with low spirituality would report more eating disorder symptomatology.
AGE AND EATING DISORDER SYMPTOMATOLOGY
Aging-related concerns may increase women's risk for body dissatisfaction and eating disorder symptomatology (Gupta, 1995; Gupta & Schork, 1993). Studies have shown younger than older women are at greater risk for higher body shame and eating disorder symptomatology (e.g., McKinley, 1999; Tiggemann & Lynch, 2001). These studies do not address the possibility that ethnicity might factor into this relationship. The little literature in this area suggests that younger men may be at greater risk for eating disorder symptomatology (Boisvert & Harrell, 2009c; Harmatz et al., 1985), but this relationship remains largely unexplored, particularly for different ethnic groups. Based on the literature, in the present study, it was predicted that older men, due to due to higher BMIs or body shame, would report more eating disorder symptomatology.
A MODEL OF EATING DISORDER SYMPTOMATOLOGY FOR MEN
The present study addressed the aforementioned gaps in the literature by testing a path model that included ethnicity, spirituality, religiosity, body shame, BMI and age as risk factors for eating disorder symptomatology in men. To our knowledge, no study has yet examined and tested the model shown in Figure 1. Thus, this is the first study to compare ethnically diverse groups of men in a model of eating disorder symptomatology comprised of the above predictors. The model consisted of the predicted direct effects of spirituality, religiosity, body shame, BMI, and age on eating disorder symptomatology. In addition, it was predicted that the indirect effects of ethnicity, religiosity, and age would be mediated by spirituality, body shame and BMI. This study differed from previous research by: (1) testing an original path model of eating disorder symptomatology, (2) examining both spirituality and religiosity as predictors of eating disorder symptomatology, and (3) using a sample of Canadian men of diverse ethnicity and age.
[FIGURE 1 OMITTED]
Sample and Procedure
A community sample of 603 men was recruited as part of a general telephone survey that covered several regions in the Province of Alberta, Canada. To be eligible to participate in the study, participants had to be male, 18 years or older and contacted at home through random digit telephone dialing (RDD). Informed consent was obtained from all respondents. Ethical approval was received from an Institutional Review Board (IRB).
Ethnicity. Respondents reported their ethnicity. For purposes of analysis, ethnicity was classified as: White, Asian, Aboriginal or Hispanic. (1,2) The majority of the men identified themselves as White (86.0%, n = 518) followed by Asian (6.06%, n = 33), Aboriginal (2.4%, n = 14) and Hispanic (2.5%, n = 15))Data on respondent's sexual orientation or social class were not collected. (4,5)
Age. Respondents reported their age. The mean age was 42.33 years (SD = 15.44), ranging from 18 to 80 years.
Religiosity. A single item was used to measure religiosity: "I would describe myself as religious." Response categories varied from one (strongly disagree) to six (strongly agree). This item was adapted from self-report measures cited in the literature (see Kenney, Cromwell, & Vaughan, 1977; King, Speck, & Thomas, 2001). The use of a single item to measure the strength of religiosity in men, including those of diverse ethnicity, is consistent with other studies (e.g., Brown & Gary, 1994; Jurkovic & Walker, 2006; Plante, Yancey, Sherman, & Guertin, 2000).
Spirituality. Spirituality was measured using two items from the Existential Well-Being (EWB) subscale of the Spiritual Well-Being scale (SWB: Paloutzian & Ellison, 1982). The EWB subscale (10 items) reflects psychological and existential dimensions such as sense of life purpose, life satisfaction and transcendence in relation to that which lies beyond the self (Ellison, 1983). The two items used in the present study were, "I feel very fulfilled and satisfied with my life" and "I feel that life is a positive experience." Items were rated on a Likert-style scale with values ranging from one (strongly disagree) to six (strongly agree). A higher score reflects higher life satisfaction, purpose and direction.
The SWBS scale has adequate validity and high reliability (Boivin, Kirby, Underwood, & Silva, 1999; Bufford, Paloutzian, & Ellison, 1991 ; Ellison, 1983; Lukoff, Turner, & Lu, 1993; MacDonald, Friedman, & Kuentzel, 1999; MacDonald, LeClair, Holland, Alter, & Friedman, 1995; Paloutzian & Ellison, 1982). It has been used in samples of women and men of varied age, ethnicity and health status (Bufford et al.; Paloutzian & Ellison). The EWB subscale has been used in studies examining masculine gender role in relation to religiosity and spirituality (e.g., Jurkovic & Walker, 2006; Mahalik & Lagan, 2001).
Body mass index (BMI). The measures of height and weight used in the calculation of BMI were based on self-report. Most studies have concluded there is only a small discrepancy between observed and self-reported height and weight measures and that self-reports of height and weight can be considered as reasonably reliable measures for research purposes, i.e., 2-3 pound discrepancy (e.g., Betz, Mintz, & Speakmon, 1994; Brownell, 1982; Gupta, Schork, & Dhaliwal, 1993). Using self-reported height and weight, BMI was calculated as weight (kg) by height squared (m2): BMI = weight (kg)/height ([m.sup.2]) (Garrow & Webster, 1985). In the present study, the mean BMI of the sample was 26.78 (SD = 4.36).
Body shame. Body shame was measured using two items from the body shame (BS) subscale of the Objectified Body Consciousness scale (OBC: McKinley & Hyde, 1996). The BS subscale (8 items) reflects the degree to which an individual believes s/he is a bad person if s/he does not fulfill sociocultural expectations concerning body shape and appearance. The two items used in the present study were, "I feel like I must be a bad person when I don't look as good as I could" and "When I am not exercising enough, I question whether I am a good enough person." Items were rated on a Likert-style scale with response categories ranging from a value of one (strongly disagree) to seven (strongly agree). A higher score reflects higher body shame.
The OBC scale has good validity and reliability (McKinley, 1998; McKinley & Hyde). Initially developed for women, it has also been proven useful for men (McKinley, 1998, 1999; McKinley & Hyde). The BS subscale has been used in studies examining gender and body shame in relation to eating disorder symptomatology and health-related behavior in women and men of diverse ethnicity and age (e.g., Boisvert & Harrell, 2009a; John & Ebbeck, 2008; Lowery et al., 2005; McKinley, 1999, 2006; Sanftner, 2011; Tiggemann & Slater, 2004).
Eating disorder symptomatology. Eating disorder symptomatology was measured using one item from each of the drive for thinness (DT), bulimia (B) and body dissatisfaction (BD) subscales of the Eating Disorder Inventory (EDI: Garner, Olmstead, & Polivy, 1983). The DT subscale (8 items) describes an excessive concern with dieting, preoccupation with weight, and fear of weight gain. The item used in the present study used was, "I think about dieting." The B subscale (8 items) describes a tendency towards episodes of uncontrollable overeating and self-induced vomiting. The item used in the present study was, "I stuff myself with food." The BD subscale (8 items) describes a general dissatisfaction with the body. The item used in the present study was, "I feel satisfied with the shape of my body." A higher score reflects higher eating disorder symptomatology in the aforementioned dimensions. Items were rated on a Likert-style scale with response categories ranging from a value of one (never) to six (always) (for example, see Frederick & Grow, 1996; for scoring, see Schoemaker, van Strien, & van der Staak, 1994).
The EDI has good validity and reliability (Crowther, Lilly, Crawford, & Shepherd, 1992; Garner et al., 1983; Kashubeck-West, Mintz, & Saunders, 2001; Schoemaker et al., 1994; Shore & Porter, 1990; Wear & Pratz, 1987). Initially developed for women, it has been proven useful for men (e.g., Kinzl, Mangweth, Traweger, & Biebl, 1997; Olivardia, Mangweth, & Hudson, 1995; Shore & Porter; Wolf & Akamatsu, 1994; Yelland & Tiggemann, 2003). The EDI has been used in samples of women and men of diverse ethnicity, culture, age, and clinical status (e.g., Crowther & Sherwood, 1984; Kashubeck-West et al.; Klemchuk, Hutchinson, & Frank, 1990; Norring & Sohlberg, 1988; Podar & Allik, 2009). The DT, B and BD subscales have been used in studies examining gender in relation to eating disorder symptomatology in men (e.g., Boisvert & Harrell, 2009c; Cantrell & Ellis, 1991; Lewinsohn, Seeley, Moerk, & Striegel-Moore, 2002; Loosemore et al., 1989; Oliosi, Grave & Burlini, 1999; Thiel, Gottfried, & Hesse, 1993; Yelland & Tiggemann).
All analyses were performed using SPSS. Ordinary least squares (OLS) regression analyses were performed to test the predicted prediction model shown in Figure 1, which postulates direct effects of spirituality, body shame and BMI, on eating disorder symptomatology, and indirect effects of ethnicity, religiosity and age on eating disorder symptomatology. As recommended by Kline (1998), all insignificant paths were "trimmed," i.e., that is, those not being statistically significant at the .05 level or better were dropped. All indirect effects were calculated by adding the products of the significant path coefficients.
Descriptive Statistics Table 1 presents a comparison between ethnic groups on each of the variables. There were no significant differences between the five ethnic classifications for EDI and spirituality.
White men had the lowest mean score for body shame (M = 3.64, SD = 1.80) and were significantly different from Asian men (M = 4.48, SD = 2.14) who had the greatest body shame.
Aboriginal men had the highest BMIs (M = 28.52, SD = 5.81) and were significantly different from Hispanic and Asian men. White men (M = 26.91, SD = 4.34) had the second highest BMIs and were significantly heavier than Asian men (M = 24.58, SD = 3.11).
In Table 2, EDI scores were significantly related to body shame (r = .15, p < .01) and BMI (r = -.28, p < .01), with men having higher body shame and BMI reporting more eating disorder symptomatology. EDI scores were not significantly related to any of the ethnic classifications to spirituality, religiosity or age.
Body shame was significantly related to lower spirituality (r = -.16, p < .01), older age (r =. 14, p < .01) and being non-White (r = -. 12, p < .01). Spirituality was only significantly correlated with being non-Aboriginal (r = -.08, p < .05). Religiosity was significantly related to being older (r = .14,p < .01) and being non-White (r = -.10, p < .05). Higher BMIs were related to being older (r = .19, p < .05), being White (r = .09, p < .05) and being non-Asian (r = -.12, p < .01).
Figure 2 shows the "trimmed" path model. Ten percent of the variance in EDI was explained by BMI (b = .28, p < .001) and body shame (b = .15, p < .001), with higher BMI and body shame resulting in greater eating disorder symptomatology. Six percent of the variance in body shame was explained by age (older men had higher EDI) (b = .15, p < .001), being Asian (b =. 11, p < .01) and lower spirituality (b = -. 15, p < .001). Five percent of the variance in BMI was explained by age (older men had higher BMIs) (b = .18, p < .001) and being Asian (b = -.11, p < .01). Asians had lower BMIs (M = 24.58, SD = 3.11) than non-Asians. The only significant predictor of spirituality was Aboriginal ethnicity (b = -.08, p < .05), with Aboriginal men reporting lower spirituality (M = 7.22, SD = 1.38) than non-Aboriginal men.
While spirituality did not have a significant direct effect on EDI, it had a significant indirect effect (b = -.02) that was mediated by body shame. This suggests that men lower in spirituality also tended to have higher levels of body shame and, in turn, increased eating disorder symptomatology. Age also had an indirect effect (b = .07), suggesting that older men tended to have higher BMIs and higher body shame; each variable, in turn, increased EDI.
[FIGURE 2 OMITTED]
Aboriginal ethnicity had a small positive indirect effect on EDI (b = .01) due to lower spirituality. In contrast, Asian ethnicity had a negative indirect effect (b = -.01) due to lower BMIs. These results suggest ethnicity is indirectly related to eating disorder symptomatology.
In summary, a respectable 10% of the variance in EDI was explained by two variables--body shame and BMI--for this sample of men. As predicted, BMI and body shame were the dominant mediators, with men reporting higher BMI and body shame reporting greater eating disorder symptomatology. Interestingly, the mediating role of BMI versus body shame on eating disorder symptomatology was influenced by ethnicity. As predicted, lower spirituality increased risk for eating disorder symptomatology, but spirituality was not influenced by age. Age only influenced BMI and body shame, suggesting that older men may be at increased risk for eating disorder symptomatology because of higher BMI and body shame. Finally, belonging to certain ethnic classifications, particularly Aboriginal, appears to be a risk factor, as this group of men had, on average, lower spirituality and, subsequently, higher EDI scores than all other groups of men.
Body Shame and BMI
Body shame and BMI were the strongest predictors of eating disorder symptomatology, with men reporting higher level of body shame and higher BMI reporting more eating disorder symptomatology. This is consistent with a number of studies that have examined the influence of BMI and body shame on eating disorder symptomatology in women (e.g., Boisvert, 2006; Frederick & Grow, 1996; Fredrickson et al., 1998; Noll & Fredrickson, 1998).
While spirituality did not have a direct effect on eating disorder symptomatology, it was strongly related through the mediator body shame. Thus, men who reported lower spirituality also tended to have greater body shame; this, in turn, increased eating disorder symptomatology. To our knowledge, this is the first study of men in which spirituality plays a role in eating disorder symptomatology.
The significant effect of age was also indirect, mediated by both BMI and body shame. Older men tended to have both higher body shame and greater BMI that in turn, increased eating disorder symptomatology. The finding that older age and higher BMIs predicts eating disorder symptomatology supports previous research in women (e.g., Tiggemann, 1994; Tiggemann & Rothblum, 1988). Since there is virtually no literature on the influence of age on eating disorder symptomatology in ethnically diverse groups of men, there is little explanation of how the aging process may lead to higher body shame, and in turn, increased risk for eating disorder symptomatology. The paucity of literature in this area suggests it is ripe for future study.
Ethnicity and Eating Disorder Symptomatology: Asian Men
There were no direct effects of ethnicity on eating disorder symptomatology. However, Asian ethnicity had significant indirect effects on eating disorder symptomatology that were mediated by BMI and body shame. Asian men tended to have lower BMIs than other men. Asian men also had higher body shame. Our study suggests that Asian men's relationship to eating disorder symptomatology was complicated. These men reported lower BMIs, which, in turn, reduced their risk for eating disorder symptomatology. However, Asian men also reported higher body shame that subsequently increased their risk for eating disorder symptomatology. Future research needs to explore the impact of these two "pathways" to eating disorder symptomatology for Asian men as well as for men of other ethnic groups. It may be that the influence of body shame will be greatest for those Asian men who have recently immigrated to North America, experiencing the greatest shock when trying to conform to a new Western culture that places importance on a thin yet muscular body ideal for men.
The finding that Asian men reported higher body shame than White men is consistent with research comparing Asian and White women's level of body shame (Boisvert & Harrell, 2009a). It is also in line with research showing that Asian men demonstrate a similar pattern to Asian women of strong body/self-dislike and preference for a smaller body (Yates et al., 2004).
Asian men, upon immigrating to North America, may find themselves constitutionally less able to conform to a culture that idealizes men's attainment of a thin muscular body. They may also lack the benefit of an insulating indigenous subculture. It may be that Asian men are more likely than other ethnic groups of men to encounter cultural conflict, experienced as body shame, because of their inability to achieve Western ideals of the male body. That is, differential acculturation or two-world hypotheses (Katzman & Lee, 1997; Lynch et al., 2007) may account for Asian men's reporting of higher body shame. Indeed, cross-cultural research in Western and non-Western regions has documented the role of media exposure in Asian men's body dissatisfaction (e.g., Yang et al., 2005). Previous research examining male body image in Western and non-Western societies, and relationships of immigration and acculturation status and eating disorder symptomatology suggests the need to study further the influence of culture in men's health (e.g., Boisvert & Harrell, 2009b; Davis & Katzman, 1999; Yang et al.).
Ethnicity and Eating Disorder Symptomatology: Aboriginal Men
Aboriginal men had the highest BMIs of all men and the lowest spirituality. Both of the relationships tended to have an indirect, positive effect leading to higher eating disorder symptomatology. The finding that Aboriginal men reported higher BMIs than White, Hispanic and Asian men is consistent with research comparing Aboriginal and White, Hispanic and Asian women's BMIs (Boisvert & Harrell, 2009a). Native American boys and men have also been shown to engage in dieting and purging behavior, and have a tendency towards overweight and obesity (Knowler et al., 1981; Neumark-Sztainer et al., 2002, Story et al., 1997).
To our knowledge, this is the first study to find that lower spirituality may increase risk for eating disorder symptomatology in an ethnically diverse sample of men. Aboriginal ethnicity was significantly related to eating disorder symptomatology through spirituality and body shame. Aboriginal men, overall, had the lowest levels of spirituality. This absence of spirituality was associated with higher body shame, and in turn, risk for eating disorder symptomatology. Spirituality has been identified as an important factor for risk of suicide and alcoholism in Native American Indian groups (Garroutte et al., 2005; Stone et al., 2006). The present study suggests that the absence of spirituality in Aboriginal men may increase their risk of higher eating disorder symptomatology.
These findings are particularly interesting when gender is considered since Aboriginal women may be less at risk for eating disorder symptomatology than Aboriginal men. Research has shown that Aboriginal women have higher body satisfaction than White, Hispanic and Asian women despite higher BMIs (Boisvert & Harrell, 2009a; Story et al., 1995). Just as Aboriginal women may be "insulated" from Western culture beauty ideals because of their ethnic identity, e.g., a strong attachment to Aboriginal culture beliefs, traditions or spirituality (Boisvert & Harrell), Aboriginal men may be less insulated from Western cultural male body ideals by embracing their ethnic identity. Other research on Black women also suggests positive and moderating relationships between ethnicity, ethnic identity, body image concerns and eating disorder symptomatology (Harrington, Crowther, Hendrickson, & Mickelson, 2006; Henrickson, Crowther, & Harrington, 2010; Story et al.). Further research should examine how ethnic identity and spirituality may relate to the severity and typology of eating disorder symptomatology.
Another explanation for our findings is that Aboriginal men's reporting of lower levels of spirituality and its association with body shame and eating disorder symptomatology may reflect their belief that they have failed to achieve the male body ideal that confers power and status in Western society. As with Aboriginal women, this group of men might be at particular risk for psychological problems such as alcohol abuse or eating disorder symptomatology given a cultural history of marginalization, discrimination, oppression, colonization and poverty (Malone, 2000). It would be expected that Aboriginal men, too, might be at greater risk for low self-esteem or depression because of the loss of cultural or traditional roots, inter-generational differences or low income and social class (Malone), with low self-esteem or depression being associated with eating disorder symptomatology (Olivardia et al., 2004; Thompson et al., 1999). Although Aboriginal men's beliefs about masculinity and health, or income or social class were not measured, it is possible that this group of men compensates for their lower position in the hegemonic hierarchy or differently expresses their masculinity by engaging in other forms of perceived masculine behavior such as eating red meat, engaging in criminal activity, drinking alcohol in excess, or purchasing low-cost, unhealthy foods, e.g., junk food, due to economic constraints (Courtenay, 2000a; Gough & Connor, 2006). Because socioeconomic status has been linked to health (Adler et al., 1994), including eating disorder symptomatology (Boisvert & Harrell, 2009b; Story et al., 1995) along with the construction of masculine gender in relation to food and eating (Gough & Conner), it will be important for future research to examine these linkages to reveal how they play out for Aboriginal men. Future research should also examine Aboriginal men's beliefs about masculinity and health, and their relation to spirituality.
The Importance of Causal Model Analysis
The present study demonstrates the importance of using causal model analysis to show that factors such as ethnicity, while not directly influencing eating disorder symptomatology, can be important variables appearing earlier in a causal chain. The findings have implications for future modeling efforts specific to the causal ordering, i.e., sequencing of predictors. The importance of causal modeling is also apparent with respect to the role of ethnicity as a predictor of eating disorder symptomatology, mediated by BMI and body shame. The literature has often reported mixed and contradictory results with respect to ethnic differences in eating disorder symptomatology (e.g., Grabe & Hyde, 2006). Our results suggest that ethnicity can be a power predictor of variations in BMI and body shame. Indeed, BMI and body shame are significant mediators for a number of variables, including ethnicity. In the case of body shame, it was a significant mediator for Asian men. These men tended to have a greater risk for eating disorder symptomatology than Aboriginal men because of higher body shame. Aboriginal men, in contrast, tended to be at greater risk for eating disorder symptomatology because of lower spirituality and higher body shame.
The Importance of Gender Analysis
The present study also demonstrates the importance of incorporating gender analysis to illuminate how men's concept of masculinity and health, in terms of achieving a male body ideal or outwardly appearing "masculine," "muscular," "fit" and/or "healthy" may influence their risk for eating disorder symptomatology. The fact that this research did not specifically investigate relationships of masculinities, body shame and eating disorder symptomatology, suggests further study in this area is needed. While this research did not investigate the role of sexual orientation, it is possible that being gay or bisexual played a role in the results, with older men of color who have sex with men being at higher risk for eating disorder symptomatology (Halkitis, Moeller, & DeRaleau, 2008; Heinberg, Pike, & Loue, 2009; Kaminski, Chapman, Haynes, & Own, 2005). While messages from the dominant heterosexual culture prescribe men to self-evaluate in aesthetic and erotic terms (Rohlinger, 2002), the same messages emanating from gay culture may put gay men at greater risk for eating disorder symptomatology than heterosexual men because of a focus on weight and physical appearance (Duggan & McCreary, 2004; Kimmel & Mahalik, 2005; Tiggemann, Martins, & Kirkbride, 2007). Gay men, in striving to be physically attractive to other men, may have a "higher valuation on thinness" (Andersen, 1999, p. 208) and a body ideal that significantly differs from heterosexual men (Swami & Tovee, 2008). Previous research suggests that the gay male body ideal of thin yet muscular places gay men at risk for eating disorder symptomatology (e.g., Boisvert & Harrell, 2000c; Yelland & Tiggemann, 2003), as might stigmatization and "internalized homonegativity" (Williamson & Hartley, 1998, p. 162). Future research will need to examine the role of sexual orientation eating disorder symptomatology in men to elucidate these relationships.
Furthermore, the present study did not examine the influence of income or class on eating disorder symptomatology. Previous research examining income in relation to eating disorder symptomatology in women and men suggests that it may be a factor (e.g., Boisvert & Harrell, 2009b; Story et al., 1995). It is possible that some of the men in our sample such as Aboriginal have impoverished backgrounds or low income or social class where they may encounter racism or marginalization. These experiences might have played a role in lowering spirituality and increasing risk for eating disorder symptomatology via body shame. As aforementioned, some of the factors associated with racism such as low self-worth, social isolation, and feeling pressured to look or act a certain way to be accepted by the dominant culture, may increase individual vulnerability to eating disorder symptomatology (Crago et al., 1996; Stice, 2003). Future research will need to examine closely spirituality and body shame factors as mediating or moderating variables, taking into account sociocultural influences such as income and social class, along with experiences of racism or marginalization. This is important given that previous research has identified sociocultural and psychological links to men's engagement in risky body change behaviors (e.g., Karazsia & Crowther, 2010).
The present study has a number of limitations that require consideration and discussion. First, the study design is nonexperimental, thus causal conclusions may not be drawn. This study was cross-sectional in its design. Given the correlational method of analysis, causal inferences cannot be made with certainty. It is possible that recursive relationships exist between study variables, e.g., eating disorder symptomatology may feedback to BMI over time. Longitudinal studies are needed to confirm the causal sequencing of predictors.
Second, this study sample primarily consisted of middle-aged White men. Thus, generalizing the findings is appropriate for men with these characteristics and not others, e.g., ethnic groups beyond those examined here. Future studies should include other ethnic groups of men as well as immigrant men in order to examine acculturation as a specific risk factor for eating disorder symptomatology.
Third, we utilized a nonclinical sample. It would be useful to examine the severity and typology of eating disorder symptomatology among diverse subgroups of men, such as men of color, gay or bisexual, or low income or social class, in both Western and non-Western regions. There is a need for more research using nonclinical, subclinical and clinical populations to explain why select subgroups of men across the globe are more vulnerable to eating disorder symptomatology than others, taking into consideration the role of masculine gender, hegemonic masculinity and men's beliefs about masculinity, health and diet, and their health risk behavior.
Fourth, generalizations to other populations of men, particularly those of other ethnicities that were not included in this study or those non-Western regions, need to be made cautiously, since the present data were from a community sample of men aged 18 years and older in Alberta, Canada; a province with a predominantly White population, located in the Western world. As well, our findings cannot be directly extrapolated to a larger population of men who have subclinical disordered eating or clinical eating disorders.
Fifth, the present study focused on selected variables within a single theoretical framework. There are other variables (e.g., masculinity, beliefs about health, attitudes about food, eating and exercise, self-esteem, depression, gender role orientation, income or social class) that could influence the relationships examined in the present study that will need to be studied in future. For example, while variables such as income and class were not considered in the present study due to the greater focus on examining relationships of ethnicity, spirituality and eating disorder symptomatology, these should be considered in future studies that use samples of ethnically diverse men, e.g., Aboriginal, as they might yield important findings. Further, incorporating a social constructionist framework and masculine-related concepts such as hegemonic masculinity into future research may increase our understanding of how gender and masculinities influence men's health and engendered health (Connell, 1993, 1995; Connell & Messerschmidt, 2005; Courtenay, 2000a, 2000b).
Sixth, the measuring of constructs used in this study might have influenced the results. Because only a few dimensions of eating disorder symptomatology were measured using EDI subscale items, with this specificity capturing some aspects of this phenomenon in men, it nevertheless provides a limited view. Thus, future studies should consider measuring a broader range of subclinical disordered eating and clinical eating disorders in addition to the predictors proposed in the model in order to tease out differences or nuances. The measures used to assess body shame and eating disorder symptomatology in men, especially men of color, may not tap these constructs in the same manner as they do in women. While these measures are increasingly used with men, further research is needed to determine their suitability for use with ethnically and sexually diverse groups of men, since little is known about these groups. The EDI, despite being used in several studies with men (see Morrison et al., 2004), has been criticized for not appropriately tapping "male" forms of eating disorder symptomatology (Kaminski et al., 2005). However, the value of using the EDI, specifically subscale items, in the present study is that it has been widely used with many different populations, possesses good psychometric properties of validity and reliability (Garner et al., 1983), and permits comparisons of men and women in this area. The refinement of measures of body shame and eating disorder symptomatology constructs to incorporate aspects beyond body weight and appearance is an area for further study. Also, measuring of BMI and eating disorder symptomatology may be limited by self-report. While research has shown that self-reported weight is accurate, but where errors are made, they tend to be underestimates--on the order of 2-3 pounds (Brownell, 1982). It is possible that some respondents might have been less accurate in their self-report, i.e., underestimate their weight or self-perceiving as overweight (Betz et al., 1994; Tiggemann, 1994). In the present sample, men's self-reports may not accurately reflect the reality of gendered risks (Courtenay, 2000a); it may be that underweight men in the present study inflated their weight to appear "masculine" and "muscular," or similarly, overweight men deflated it to appear "masculine" and "fit."
These limitations notwithstanding, the present study has unique findings and strengths. One unique finding is that there may be two "pathways" to eating disorder symptomatology, via BMI and body shame, for Asian men. This finding and others yielded suggests a strength of this study is it provides an opportunity for making comparisons to disordered eating in women. For example, the present study supports earlier studies that have found evidence of pathways to eating disorder symptomatology via BMI and body shame in women (e.g., Boisvert, 2006; Frederick & Grow, 1996). There is a need to examine further these linkages in order to make accurate comparisons based on gender as well as ethnicity.
A major strength was the large sample size and broad age range and ethnic variation that permitted valid statistical comparisons across the various categories of these variables. To date, many studies have used considerably small samples to examine ethnic and age differences in men and women (e.g., Demarest & Allen, 2000).
Because the large majority of studies in this area have been conducted in the United States, samples drawn from a U.S. population may not validly be generalized to the greater ethnic diversity of Alberta and Canada as a whole, e.g., Aboriginal men. These population differences need to be considered when comparing, contrasting and generalizing our results in terms of studies conducted in the United States that draw samples from a U.S. population, or in other Western or non-Western regions of the world such as Australia and India, respectively.
Several implications for future study can be drawn from the preceding discussion. While researchers have examined eating disorder symptomatology in men and boys, few attempts have been made to examine what it is about gender, exactly, that influences health, and specifically, men's developing of eating disorder symptomatology. One mediating factor may be men's beliefs about masculinity. Constructs and measures that assess beliefs about masculinity and concepts such as gender roles, masculine norms or ideals, e.g., drive for muscularity attitudes, should be considered in future research (see Eisler, 1995; McCreary & Sasse, 2000; Morrison, Morrison, & Hopkins, 2003; Thompson, Pleck, & Ferrera, 1992). In addition, the influences of factors such as ethnicity, sexual orientation, income, social class, and their interaction with masculinity, should be further examined. Future research should also address the methodological limitations and issues outlined earlier.
Findings from this study and previous studies (e.g., Bisaga et al., 2005; Croll et al., 2002; Lynch et al., 2007; Neumark-Sztainer et al., 2002) suggest the value of incorporating a gender approach when treating eating disorder symptomatology in men. New psychological interventions for men should be developed to address gender in relation to health, taking into account men's beliefs about health and masculinity (Addis & Mahalik, 2003; Smart, 2006). These interventions need to be tailored for men of different ethnicity, spirituality, religion and age. Practitioners may consider incorporating a spiritual aspect when using a multicultural therapeutic approach, particularly with Aboriginal men (Malone, 2000).
In addition, the development and implementation of prevention initiatives such as media literacy programs or media exposure in attitudes about male body image appears to be a key strategy (Campbell et al., 2005; Wilksch, Tiggemann, & Wade, 2006). Along the same line, the development of prevention programs on men's health and more resources to help professionals work with men who have eating disorder symptomatology would be useful, given that the treatment literature largely focuses exclusively on women. Outcome research is needed to measure the effectiveness of these and other gender-specific interventions in promoting men's mental and physical health, and reducing their risk for eating disorder symptomatology.
In conclusion, the present study findings suggest a need for interventions addressing eating disorder symptomatology in men, especially those of diverse ethnicity and spirituality. Prevention research and programming offering strategies for reducing body shame and eating disorder symptomatology is needed. More research adopting a masculinity or gender analysis approach is needed to uncover men's experience of body shame and its relationship to BMI and eating disorder symptomatology, the personal meanings men attach to food and eating, and their engaging in risky behavior or eating disorder symptomatology in order to achieve a male body ideal and outwardly appear "masculine," "muscular," "fit" and/or "healthy." Further study of how ethnicity or spirituality in selected groups of men, e.g., men of color, gay or bisexual men, may be a risk factor for eating disorder symptomatology may provide important information for understanding men's health beliefs, health-related behavior and body experience.
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JENNIFER A. BOISVERT, Ph.D.  and W. ANDREW HARRELL, Ph.D. 
 Independent Practice.
 Professor Emeritus, Department of Sociology, University of Alberta.
The authors thank the two anonymous reviewers for their comments and suggestions on this article.
Correspondence concerning this article should be addressed to Jennifer A. Boisvert, Ph.D., Independent Practice, 1241 Johnson Ave., Box 323, San Luis Obispo, CA, 93401. Email: email@example.com
(1) The Aboriginal subsample included: Aboriginal, M6tis, Inuit, and North American Indian. The Asian subsample included: Asian, Chinese, Vietnamese, Japanese, Korean, Indian (Asian and East), Pakistani, PunjaN, Sri Lankan, and Sikh. The Hispanic subsample included: Mexican, Brazilian, Chilean, Central/South American, Filipino, Spanish, and Portuguese. The White suhsample included: Canadian, American and a multitude of White-skinned ethnic groups, e.g., Dutch, Greek, Polish.
(2) Consistent with the literature (e.g., Griffith, Moy, Reischl, & Dayton, 2006; Mays, Ponce, Washington, & Cochran, 2003), the present study refers to men of color in terms of ethnicity, recognizing the trend in the literature to use the term "ethnicity" rather than "race," recognizing the difficulty of measuring and classifying race and ethnicity as separate, distinct constructs that may influence health status and inequalities.
(3) It is important to note that despite the relatively small numbers of men in each ethnic group, these numbers are statistically sufficient for the performance of the present analyses.
(4) We believed that including additional questions about income, social class or sexual orientation to our telephone survey would have been burdensome on respondents, and that such questions, particularly those pertaining to sexuality, may have evoked invalid or inaccurate responses. We also believed that collecting data on sexual orientation might have been difficult due to the disputed definitions of homosexuality (see Strong, Williamson, Netemeyer, & Geer, 2000).
(5) A variety of factors may influence physical health, longevity and inequity, including ethnicity, income and social class (LaVeist, 1993; Pappas, Queen, Hadden, & Fisher, 1993). While factors of income and social class appear to be associated with diet and nutrition (Gough & Conner, 2006) and risk for eating disorder symptomatology in certain groups of ethnic minority men, e.g., Aboriginal men, the present study placed more emphasis on illuminating the relationship between ethnicity and psychological factors that have not been examined in men to date, notably body shame and spirituality.
Table 1 Comparison of Means of Variables and Measures for Different Ethnic Groups Ethnicity EDI BS BMI SPIR REL AL 7.92 3.75 28.52 (a,b) 7.22 3.72 (a) [2.92] [1.78] [5.81] [1.38] [2.05] AN 7.67 4.48a 24.58b (c) 7.61 4.19 [2.83] [2.14] [3.11] [1.75] [2.26] WE 7.80 3.64a 265.91 (a) 8.09 3.63 (b) [2.56] [1.80] [4.34] [1.60] [1.98] HP 7.03 4.24 24.94 (a) 8.38 4.32 [2.55] [1.82] [3.11] [l.56] [1.62] F=.35,ns. F=2.75 * F=3.44 ** F=1.85,ns. F=2.42 * * p<.05, ** p<.01, *** p<.001. Notes: Means with the same superscript are significantly different at the .05 level. EDI = Eating Disorder Inventory; BS = Body Shame; BMI = Body Mass Index; SPIR = Spirituality; REL = Religiosity; AL = Aboriginal; AN = Asian; WH = White; HP = Hispanic. Table 2 Correlations of All Variables and Measures BS BMI SPIR REL Age EDI .15 ** .28 ** -.07 .08 .03 BS .00 -.16 ** .03 .14 ** BMI .00 .00 .19 ** SPIR .05 -.03 REL .14 ** Age AL AN WH HP AL AN WH HP EDI .01 -.01 .03 -0.05 BS .00 .10 * -.12 ** 0.05 BMI .06 -.12 ** .09 -0.07 SPIR -.08 * -.07 .08 0.03 REL .00 .06 -.10 * 0.05 Age -.08 -.07 .12 ** -0.05 AL -.04 -.44 ** -0.03 AN -.68 ** -0.02 WH -26 ** HP * p<.05, ** p<.01, *** p<.001. Note: EDI = Eating Disorder Inventory; BS = Body Shame; BMI = Body Mass Index; SPIR = Spirituality; REL = Religiosity; AL = Aboriginal; AN = Asian; WH = White; HP = Hispanic.
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