You walk past two women on the street. Both are tiny, but one is Caucasian and the other is Asian. You're told that one of them is anorexic and the other is naturally thin. Which one has the eating disorder?

You'd probably say the Caucasian woman. And according to the National Association of Eating Disorders , eating disorders are historically associated with white women. But recent research on the steady rise of eating disorders in Asia is challenging conventional assumptions of how cultural influences trigger their occurrence in Asian and Asian-American women.

The United States and Western Europe were the first to report anorexia as a medical syndrome in the late 19th century, and along with bulimia, it became prevalent in the West in the late 1960s. Eating disorders started to appear in Asia in the 1970s, and before 1990, Japan was the only Asian country to report their incidence . Eating disorders are a mental illness, a fact substantiated by the addition of binge eating disorder to the DSM-5 in 2013, whose previous editions only included anorexia and bulimia.

In a review published in September , Columbia psychology professor Kathleen M. Pike argues that eating disorders in Asia develop independently of the West and are instead reactive to the cultures in which they're found. Pike's research is one of many pieces of evidence that illustrates the paradox of eating disorders in rapidly industrializing East Asian countries: Native cultural values not only explain why they emerge, but why they aren't recognized as problems.

Economic growth indirectly explains the emergence of eating disorders across cultures. In the West, the rise of the consumer economy in the second half of the 20th century and its subsequent emphasis on individual achievement coincided with the rise of eating disorders. This trend became evident in Asia later on: Japan was the first Asian country to undergo modern economic transformation and report eating disorders, China and Vietnam are the most recent to report significant instances of eating disorders.

"As Asian countries become more affluent and economically engaged in the global community, eating disorders are increasing," explains Dr. Pike. During the first decade of 2000, rates of anorexia in Japan were four times as great as they were in the 1990s. A study published in March 2014 found that the occurrence of eating disorders among Chinese university students was beginning to rival that of Western university students. A 2009 study in Taiwan found that habits like binge eating and the use of laxatives to lose weight were spreading among college women and identified 43 percent of them to be at risk for an eating disorder.

That China, Japan and Korea all share a foundation in Confucian values may explain how certain societal attitudes enforce and ignore eating disorders at once. These include the subordination of women to men, a collectivistic mindset that emphasizes obligation to the family, and the importance of maintaining social harmony. As East Asian societies become more consumer-driven, Asian-American women accustomed to the individualism of the West feel conflicted by these conventional values.

Some Asian women feel that a pressure to be thin is rooted in traditional beliefs of how women should behave. "Asians want women to be small, thin, and quiet, and I think that has a lot to do with sexist ideals that say women should be docile and obedient," says Juliana Chang, a Chinese-American who moved from California to Taiwan when she was 11 and had disordered eating habits throughout high school. "Being thin isn't just an aspect of body image, but how you're supposed to behave as an Asian woman," explains Lisa Lee, who along with fellow Taiwanese-American Lynn Chen, co-founded Thick Dumpling Skin , a website for Asian and Asian-American women to discuss body image.

In Asian cultures, thin is the default body type, and there's collective pressure to maintain it. "It's a given that women are supposed to be thin, and people think it's your fault if you're not," says Chang. In 2008, Japan established a national limit on waistlines , and in South Korea, appearance is considered more important than ability or talent in determining a woman's success in marriage or career.

"Being overweight felt like a public display of my lack of discipline," says Joyce Kwon, a Korean-American who recently moved to Seoul from New York and writes about the transition on her blog, Plus Size Fairy . Kwon has found the direct emphasis on thinness invasive. "I was shopping at a Korean department store years ago, and the salesperson recommended outfits but suggested that they'd look better on me if I lost a bit a weight," she says.

In Chinese and Taiwanese culture, an overarching obligation to family rituals affects an individual's control over food . "A lot of my issues towards eating arose when I was with my family," Lynn Chen tells me. "At family get-togethers, we sit at these huge round tables for hours on end and people keep putting food on your plate," Chang says of her own experiences in Taiwan. "You're constantly expected to eat and if you aren't super thin, people judge you for eating but still expect you to not gain weight," she explains. "It's paradoxical." Lee notes a similar pressure. "A big part of our lifestyle is being around food and our family. The way your relatives show their love is by serving you food and encouraging you to eat more, even if you're full. If you say no, it's like a rejection of their love," she tells me.

A lot of this family pressure comes from the older generations. The historical memory of food shortage and famine in China and Korea has left behind an attitude that eating is a sign of well-being, and "Have you eaten?" is synonymous with "How are you?" Kwon has found that her grandmother's stigma toward wasting food has trickled down to her. "I have a tendency to make sure I finish all of my food, as does my mom, even when I'm already full."

"In the stories our readers have shared, some of them say, 'how can I recover if when I talk to my parents about it, they don't see it as a real problem?'" explains Lee of the ignorance toward eating disorders in the Asian community. Mental illness is considered a personal weakness, and Confucian tradition considers the exposure of such weaknesses a disruption in the social harmony ."Getting professional help through a therapist is seen as strange and construed as a sign of weakness," affirms Chen. "The unwillingness to admit that it's a problem is why it's a problem."

All the women I spoke to agreed that their Asian identity affects their relationship with food and body image. Chang tells me that since weight was always discussed in her family, she didn't think her eating attitudes were extreme. " I started to become obsessive. I was always thinking about my next meal and I always wanted to eat alone. I realized that there was something very wrong with how I approached food," she says of her personal decision to seek treatment.

Knowing that other Asian women suffer from the same pressures has helped many of the women overcome their eating disorders. Removing a feeling of isolated suffering is why Chen and Lee encourage Asian women to share their experiences on Thick Dumpling Skin. "So many women feel like they're alone in this. It's a sad fact that many Asian families aren't that supportive, and so much of the first step of recovery is the feeling that you aren't alone," says Chen.

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