Historically, eating disorders were perceived as culture-bound syndromes  restricted to the Western culture. Eating disorders were first described in Caucasian females living in Western Europe and North America, leading to the presumption that specific characteristics of their culture must be crucial to the development of an eating disorder. Several decades after the emergence of eating disorders in Western culture, cases of eating disorders have been identified in all cultures to a varying extent, mostly with increasing incidence rates but still lower prevalence rates than in Western countries [2,3].
Recent evidence suggests that the incidence of bulimia nervosa is decreasing in Western countries, but remains stable for anorexia nervosa [4,5]. The point-prevalence for anorexia nervosa in Western Europe and North America ranges from 0 to 0.9% with a mean estimate of 0.29% in the high-risk population of young females [6,7]. For bulimia nervosa, a general point-prevalence of up to 1% among young females is widely recognized [7–9]. Regarding eating disorders in Asia, the prevalence rates in Japan and China are now considered at par with European levels of eating disorders [10,11], whereas eating disorders seem to be at a rise in Arab countries, but still have lower prevalence rates compared with Western nations . The proceeding industrialization, globalization and therefore westernization in these regions are suspected as catalysts for increasing incidence rates of eating disorders [2,13▪]. In consideration of the close proximity of Latin America to the United States, not only in a geographical but also economical manner, research on the epidemiology of eating disorders in these countries could further confirm the westernization theory of rising prevalence rates of eating disorders in developing countries. Recent research suggests that prevalence rates of eating disorders in urbanized regions of Latin America reach similar levels as in Europe and the United States [14,15], and Latin American immigrants in Western countries did not differ from the Caucasian population regarding diagnoses of eating disorders [16,17]. However, English language literature on the epidemiology of eating disorders in Latin America is still rare, as most studies are published in Spanish or Portuguese.
As a first step to better understanding eating disorders in Latin America, this study provides a systematic review of the existing literature on the epidemiology of eating disorders in the general population in Latin America. Its focus is on the prevalence of anorexia nervosa, bulimia nervosa and binge-eating disorder (BED) in Latin American countries in continental South and Central America.
The review was conducted in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement (PRISMA) . This review focuses on the prevalence rates of anorexia nervosa, bulimia nervosa, and BED in Latin American countries. Latin America is defined as all American countries in which Romance languages are spoken. For a more focused review, only continental American countries were considered. Therefore, literature on the prevalence of eating disorders in the following countries was included: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. Suriname, Guyana, and Belize were excluded, as their official languages are not considered Romance. French Guyana was excluded, as it is not a sovereign state.
A systematic literature search was conducted in January 2015 and was updated in May 2016 for recently published articles. The following databases were screened: Medline (via PubMed and DIMDI), Web of Science, SciELO, LILACS, IBECS, INDPSI, HISA, and LIS. The search term was a combination of the disorders of interest (eating disorder, anorexia nervosa, bulimia nervosa, and BED), ‘South America’ and ‘Latin America’, and all names of the countries included. Because of the interest in local literature, SciELO, LILACS, IBECS, INDPSI, HISA, and LIS were searched in Spanish and Portuguese in addition to English.
Data extraction and quality assessment
Records identified in the literature search were evaluated in a two-step approach. A screening of titles and abstracts of all publications found in the databases was conducted by two researchers. Articles fulfilling all of the following eligibility criteria were considered for full-text review: (1) the article was written in English, Spanish, or Portuguese; (2) the article was related to eating disorders; and (3) the article was related to the epidemiology of these disorders. Articles considered as relevant were reviewed in full-text. Articles meeting at least one exclusion criterion of the following were excluded during screening and full-text review: (1) editorials, newspaper articles, literature reviews, study protocols, theory articles, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, and lectures; (2) the article was published in a journal without peer review; (3) samples with overall sample age under 10; (4) studies with biased sample selection; or (5) the article studied a clinical population. Articles fulfilling the inclusion criteria as provided in Table 1 were included in a qualitative analysis.
The screening and full-text review was conducted online using Covidence (Covidence.org, Alfred Health, Melbourne, Australia). Two researchers decided on the inclusion of each article at each stage of the review. If disagreement occurred, resolving was conducted by the principal investigator. The first three authors speak fluent English and Spanish, and the first author speaks Portuguese as well. In the case of difficulties understanding Portuguese language articles, a translation was given by the first author.
Quality assessment of the articles was conducted with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist . Additionally, a methodological scoring system to rate studies adapted from Loney et al.  was used.
As three disorders were analyzed in this review, separate meta-analyses were conducted for each disorder. Only two studies reported 12-month and lifetime prevalence rates, hence quantitative analyses were conducted for point-prevalence rates only. In many epidemiological studies, prevalence rates are assessed by first screening a larger population with a screening questionnaire to identify people at risk for having an eating disorder. Subsequently, the final diagnosis of an eating disorder is established in a personal interview to which only the high-risk group is invited. The prevalence rates of these so-called two-stage studies included in the meta-analysis were recalculated and based on participants screened at first stage, as not all studies provided response rates for the second stage. If, for example, 2770 patients were included, 2756 participants filled in the screening instrument and 23 cases were detected at the second stage, the prevalence rate would be p = 23/2756. Meta-analyses were conducted with MetaXL 3.0 (epigear.com), which allows analyzing a quality effects model accounting for heterogeneous prevalence studies, by taking the overall quality scores of the studies into account . This model was calculated for each disorder separately. As recommended by Barendregt et al. , prevalence values were normalized and double arcsine transformed to stabilize variance of prevalence estimates near 0. Finally, forest plots presenting the overall and study-specific prevalence, 95% confidence intervals and the study weight were computed.
In our literature search, 2199 articles were identified as shown in the study flow diagram (Fig. 1). After removal of duplicates, 1583 articles were screened and 1361 articles removed as irrelevant. A total of 222 studies were reviewed in full-text, resulting in an inclusion of 17 studies. Reasons for the exclusion of studies are given in Fig. 1. Fifteen of the studies provided point-prevalence rates of eating disorders and were therefore included in the meta-analyses.
Table 2 provides sample characteristics, measures and reported prevalence values of each study included. Of the studies included, five were conducted in Colombia, three in Brazil, three in Mexico, two in Venezuela and one each in Argentina and Chile. One additional study provided data from Colombia, Brazil, and Mexico. Due to the small number of studies, an international comparison of the results was not conducted.
Lifetime and 12-month prevalence rates
Only two of the included studies reported lifetime and 12-month prevalence rates for bulimia nervosa and BED [14,25], and only one study for anorexia nervosa . Regarding Mexico, lifetime prevalence rates for adolescents aged 12–17 years were 0.5% (12 months: 0.1%) for anorexia nervosa, 1.0% (0.7%) for bulimia nervosa, and 1.4% (0.7%) for BED . In a study on adults, lifetime prevalence rates of bulimia nervosa were identified as 0.8% (12 months: 0.3%) in Mexico, 0.4% (0.2%) in Colombia, and 2.0% (0.9%) in Brazil . Regarding BED, the same study identified the lifetime prevalence rates as 1.6% (12 months: 0.5%) for Mexico, 0.9% (0.3%) for Colombia, and 4.7% (1.8%) for Brazil . Lifetime prevalence rates were highest for bulimia nervosa and BED in Brazil, and lowest in Colombia .
Mean point-prevalence and heterogeneity testing for anorexia nervosa
In 10 studies providing 11 distinct samples (N = 10 840) assessing anorexia nervosa, there was a weighed mean prevalence rate of 0.1%, 95% CI (0.02, 0.23) for the general population in Latin America (Fig. 2). The included studies varied regarding their quality index from three to seven points. Heterogeneity of the studies was moderate (I 2 = 51.50). By exclusion of the most extreme outlier Rueda-Jaimes et al. , the heterogeneity can be reduced to almost 0. There was no real difference between the mean prevalence in the general population and that of a meta-analysis with the female subsample only (0.1%, 95% CI [0.02, 0.35]; N = 6 334). Prevalence rates were comparable amongst the different countries included.
Mean point-prevalence and heterogeneity testing for bulimia nervosa
Regarding bulimia nervosa, 14 distinct samples in 13 studies were identified, with an overall sample size of N = 14 816 participants assessed at first stage. In the meta-analysis, a weighed mean prevalence rate of 1.16% (95% CI [0.55, 1.98]) was calculated for Latin America (Fig. 3). Heterogeneity was large (I 2 = 92.28), reflecting the different sample settings and countries included. The highest prevalence rate was found for Chile, and the lowest for Argentina, especially in a male sample [27▪▪]. The prevalence rates for Colombia, Brazil, Venezuela, and Mexico seem comparable. As the Chilean study was conducted as a self-report screening, the high prevalence rate might be due to the study design. However, no study could be determined as a main source of heterogeneity. In consideration of the small number of studies included, no moderator analysis for heterogeneity was conducted.
Mean point-prevalence and heterogeneity testing for binge-eating disorder
Within nine studies analyzing point-prevalence rates for BED, N = 10 363 persons were screened at first stage. A weighed mean prevalence rate of 3.53% (95% CI [1.60, 6.13]) was identified (Fig. 4). Heterogeneity was large (I 2 = 97.00). Regarding potential sources of heterogeneity, one study was identified assessing the occurrence of two binges per week for the shorter time range of 3 instead of 6 months as proposed by the DSM-IV criteria for this disorder . However, exclusion of this study did not reduce heterogeneity meaningfully. Possible moderator variables for heterogeneity were age and sex, as studies differed notably regarding age ranges. Due to the restricted number of studies included, no moderator analysis was conducted. Regarding country differences, no conclusion could be drawn as the prevalence rates varied strongly depending on the study.
The present systematic review and meta-analysis evaluated the epidemiology of anorexia nervosa, bulimia nervosa, and BED in Latin America, by assessing not only English literature published in international journals, but also by considering high-quality studies published in Spanish or Portuguese in Latin American journals. We computed mean point-prevalence rates for the specific disorders and compared the prevalence rates of the different countries.
Epidemiology of anorexia nervosa in Latin America
Our findings demonstrate that the prevalence rates for anorexia nervosa are comparable among the different countries in Latin America, and significantly lower compared to European or North American samples [4,6–9]. Similar prevalence rates were found in Hispanic immigrants in the United States . This might be due to the different body ideal of Latinas and Latinos compared to other ethnicities, which idealizes a ‘curvier’ shape and higher weight of the body than in Western countries [44▪▪,45,46], and might be a protective factor in adolescence. As recent research highlights the influence of other etiological factors besides culture contributing to the development and maintenance of anorexia nervosa, genetic variations , or emotion dysregulation  might play an important part in the observed cases of anorexia nervosa in Latin America.
Epidemiology of bulimia nervosa in Latin America
The point-prevalence of bulimia nervosa is mostly reported as 1% in two-stage studies of young females . In this meta-analysis, the heterogeneity of the studies was large. However, most of the studies found prevalence rates of at least the same range or higher than in Western Europe, but assessed eating disorders of both genders. Additionally, half of the samples were younger than 20 years of age. As the peak incidence rate of bulimia nervosa is slightly later than that of anorexia nervosa and females are at a higher risk for developing any eating disorder, this indicates that the general point-prevalence rate in Latin America is most likely underestimated in our study. This is in line with cross-cultural studies conducted in the United States, indicating that the prevalence rate of bulimia nervosa is at least in the same range or even slightly higher in Hispanic immigrants than in Caucasian residents [43,49].
Epidemiology of binge-eating disorder in Latin America
We identified a higher BED point-prevalence in Latin America than previous studies in Western populations [50,51]. Recent studies comparing eating disorder prevalence rates of ethnic minorities with Caucasian habitants identified higher prevalence rates of Hispanic females in the United States [43,49,52]. A possible explanation might be that food has a high emotional value in many Latin American cultures which reflects in the language (e.g., ‘Las penas con pan duelen menos’, – the sorrows with bread hurt less, ‘barriga llena, corazón contento’ – a full belly is a pleased heart), and addressing the cultural assumptions regarding food is of importance in nutritional interventions for Latinas [53▪▪]. Additionally, BED occurs more often in overweight and obese individuals [54,55]. As most of the Latin American countries have higher prevalence rates of obesity and overweight than Western European countries especially in females , a high prevalence of BED might be a concomitant phenomenon of the obesity epidemic in these countries.
Limitations of the study
One of the main difficulties in reviewing the literature regarding Latin American studies on eating disorders is the wide range of instruments used to assess the prevalence rates. The studies included varied heavily regarding the study design (self-administered questionnaire to two-phase designs) and the instruments used. Hence, heterogeneity was large and the mean prevalence rates of the meta-analyses remain difficult to interpret. Furthermore, the studies included were conducted during a time span of 13 years. Because only few studies were from Argentina, Chile, and Venezuela, we did not conduct cultural comparisons within Latin America and the influence of specific countries on the prevalence rates remains unexplored.
Eating disorders are common in Latin America, with a lower prevalence rate for anorexia nervosa and a higher rate for bulimia nervosa and BED, when compared to Western Europe or the United States. These findings might reflect a stronger cultural bond of anorexia nervosa to a Western lifestyle than of bulimia nervosa and BED. However, we could not analyze cultural differences within Latin America as most of the studies included were conducted either in Brazil, Mexico, or Colombia. Therefore, further research assessing the epidemiology and cultural factors of eating disorders in developing countries such as Ecuador, Suriname, or Guyana are needed to draw conclusions regarding the cultural factors of eating disorders in Latin America.
We are thankful to Jochem König and Ekkehart Jenetzky for their valuable comments on the methodology of this study. Patricia Meinhardt conducted proof-reading of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
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