Hellbent on Anorexia in Asia
The Health eZine - Eating Disorders

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Hell-bent on looking thin


(Names have been changed to protect their identity)

When being thin becomes an obsession, eating disorder takes root. But it is a complex psychological problem and causes are difficult to pinpoint. Among the “contributing factors” include the person's personality, genetic make-up and pressure from society for girls to be thin.

AT 13, Lillian* is a bubbly teenager with a bright future ahead. Born to an upper middle-income family and, most of all, loving parents, she is not deprived of emotional or physical needs.

Although slightly underweight, she is otherwise a picture of health and beauty, and perhaps the source of envy among her peers.

Sweet, responsible and soft-spoken, she is well liked by family and friends.

But there is a skeleton in her closet; for six months last year, she was a totally different person. She suffered from anorexia nervosa, a complex psychological problem that is commonly referred to as an eating disorder.

Besides displaying all the symptoms – abstaining from certain types of food she thought would make her fat and skipping meals – Lillian also turned violent physically and verbally towards herself and her family. She was also secretly exercising in her bedroom or bathroom constantly.

When Lillian started to suffer from the condition, her parents withdrew her and her younger sister, Anna*, 11, from their dance classes. While trying to figure out what was wrong with their daughter, they kept a close watch on her. Her parents were having sleepless nights ensuring that she did not hurt herself physically, and had to hold her when she was uncontrollable.

“We were living on thin ice and being on guard each minute of the day,” says a family member.

The parents' anguish and helplessness were exacerbated by the lack of information from consultations with local medical practitioners and non-governmental organisations.

They read books and surfed the Internet in desperation. Time was not on their side, as the weight of their daughter, who was 1.7m tall, was plunging. It dropped to below 35 kg when she was finally admitted to an overseas hospital for treatment.

Observations of Lillian during her stay at the hospital shed light on the gravity of her condition. One night, she was seen standing on one leg while doing the crossword puzzle, and in between she did squats just to ensure she would lose weight. Her leg was swollen the next day.

Her “relentless efforts” to lose weight also saw her taking the longest route to get her toothbrush before taking another long way around to reach the bathroom.

She would even use the excuse of forgetting to take something to the bathroom, just to make another trip!

After six months of treatment by all the relevant specialists, which cost about RM1,000 per day, and her parents unconditional love and support throughout her ordeal, Lillian regained her health and her weight.

On hindsight, it is not difficult to see indirect links between Lillian's condition, her upbringing and pressure from modern society. According to Dr Hera Lukman from the International Medical University (IMU), parents of those with anorexia nervosa were highly nurturing and at times over-protective.

But Dr Lukman, who is attached to the IMU's Community Medicine and Behavioural Sciences in the Faculty of Medicine, is also quick to point out that eating disorders are complex psychological problems and it is thus difficult to pinpoint the cause or causes.

She says the “contributing factors” to eating disorders would include the person's personality, genetic make-up and pressure from society for girls to become thinner and thinner.

Citing examples, Dr Lukman shares that professionals such as athletes, ballerinas, gymnasts and models who are under constant demand to maintain a certain physique and performance are prone to eating disorders.

Last but not least, society also compels individuals to measure themselves according to their looks. A very slim figure has often been portrayed as one of the basic traits of an attractive, popular and successful woman.

“Now we are looking at size zero, meaning the waist measurement is 23 inches, similar to the average girth of an eightyear- old girl. It is biologically impossible for a young woman to have such body size unless harm has been done to the body,” warns Dr Lukman.

And perhaps the over-zealousness to fight obesity may also backfire as studies have also identified some “possible indirect links” between measures to cut obesity and eating disorders like anorexia and bulimia.

For instance, singling out overweight children and subjecting them for measures like exercise regimes and control on food intake could lead to stigmatisation, especially when the children are also subjected to teasing and name-calling.

The Singapore Government has been successful in cutting down the incidence of obesity among children – from 14% in 1992 when they introduced the Trim and Fit (TAF) programme to 9.5% in 2006. Under TAF, the overweight children would be subjected to, among other measures, exercise regimes before and after school.

But a study by the National University of Singapore in 2005 involving 4,400 female students (many of whom are either former or currently under the TAF programme) showed that 7% of them were at high risk of disorders like anorexia and bulimia.

Reports earlier this year stated the Singapore government had decided to scrap the 15- year-old TAF next year and put in place another healthy lifestyle programme that involved all students.

Muffins saved Heidi Klum

LONDON: Supermodel Heidi Klum was saved from developing anorexia by her fondness for muffins.

The German beauty admits that the pressures to stay thin during her catwalk career were intense but she never wanted to be skinny to score over others on the ramp, contactmusic.com reported.

"I was never a skinny, skinny type - the more I tried, the worse it was. I'd think about food more than ever," she said.

"They'd say, 'You have to lose weight', and I'd be like, 'All I can think about is muffins!' I wasn't prepared to starve myself to be edgy."

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Gisele blame Families For Anorexia

Gisele Bundchen has entered Brazil's growing debate over anorexia, saying families are to blame - not the fashion industry.

"I never suffered this problem because I had a very strong family base," the supermodel told the local Globo newspaper on Friday. "The parents are responsible, not fashion."

The 26-year-old model was in Brazil for the annual Fashion Rio, a weeklong showcase for some of the country's top designers.

Anorexia became a hot issue in Brazil after the deaths of four young women last month, including 21-year-old model Ana Carolina Reston.

Splashed across the front pages of newspapers nationwide, the subject has held morbid fascination for Brazilians, and was even the theme of a popular TV soap opera. It also sparked a debate within Brazil's fashion industry.

"Everybody knows the standard for models is to be thin," Bundchen said. "But you can't generalize and say that all models are anorexic."

Other countries, too, have begun to address what they see as the dangerous link between high fashion glamour and an unhealthy image of women. In September, Madrid's Fashion week banned underweight models. Italy's designers followed suit in December, requiring models to submit proof that they do no suffer from an eating disorder.

Bundchen, who left home for a three-month modeling job in Japan when she was 14, said family support was key to her.

"You leave home, the protection of your parents, but you still know you have their support," said the Brazilian, who has five sisters.

Expert: One in 10 young girls are prone to eating disorders


KUALA LUMPUR: Walk into any urban campus and there will be hordes of young girls who are slim and dressed in clothes that reveal their figure. Being thin is in and many are dying to be thin. They want to emulate weight-conscious celebrities like Paris Hilton and Lindsay Lohan.

And this is one of the reasons for a rising problem among young females - eating disorder. About 70% of them are not satisfied with the shape - and size - of their bodies.

In a study conducted by chartered psychologist Dr Hera Lukman, it was revealed that about one in 10 young urban female college students is prone to eating disorders in their quest for a perfect body shape.

Dr Lukman, a senior lecturer at the Faculty of Medicine at the International Medical University’s (IMU) Community Medicine and Behavioural Sciences Section, conducted the recent survey among 578 female college students aged between 18 and 25 in the Klang Valley.

Although there are signs that this problem is on the rise, there has been no study to determine the number, as those suffering from the problem rarely seek help voluntarily.

Nevertheless, Dr Lukman said studies have shown that the prevalence of eating disorders in Asian countries was comparable to that in the West, where between 1% and 4% of girls aged between 14 and 18 have an eating disorder.

In Singapore, a National University of Singapore’s (NUS) study of 4,400 female students in 2005 also showed that 7% of them were found to be at high risk of disorders like anorexia and bulimia.

Penang Hospital’s child and adolescent psychiatrist Dr Lai Fong Hwa said there was a six-fold increase in the incidence of eating disorders in Singapore in the last 10 years.

On her survey, Dr Lukman said those affected were usually terrified of gaining weight though they were underweight or emaciated.

“The students in my survey had, among others, displayed behaviour, attitude and thoughts which were associated with eating disorders. Only 28% of them were satisfied with the shape of their bodies,” she said in an interview.

The two most common eating disorders are anorexia nervosa (when one engages in self-induced food restrictions and excessive exercise although underweight) and bulimia nervosa (uncontrollable overeating or bingeing, followed by self-induced vomiting and purging via the use of laxatives). The medical fraternity usually terms them as a “complex psychological problem” with “possible indirect links” with the environment.

Dr Lukman said interviews with some of the respondents revealed that they would induce vomiting after eating. Some of them would feel guilty about eating and subsequently resort to eating in isolation or “secretive eating”.

Dr Lukman added that eating disorders were chronic conditions with devastating physical, psychological and social consequences when not given immediate attention and multi-disciplinary approach treatment by experts like physicians, psychiatrists, dieticians and family therapists.

The dangers of eating disorders usually make headlines when a celebrity or prominent figure dies from it. In November last year, Brazilian model Ana Carolina Reston, 21, was reported to have died of anorexia nervosa. She was 1.74m tall and weighed only 40kg when she died. Many Tinseltown celebrities like Nicole Richie and Mary-Kate Olsen are constantly under the media glare for losing weight and looking unhealthily thin.

On treatment for eating disorders, Dr Lukman said Malaysia has yet to have a centre for such patients and she had to refer her patients for treatment overseas, with the nearest centre in Singapore. There was dire need for such a centre to provide proper and affordable treatment for eating disorders and conduct more in-depth research on the problem.

She said patients could not seek treatment overseas due to the high costs incurred.

Dr Lai said it costs about RM1,000 a day for an eating disorder patient to get treatment in Singapore. The high cost of treatment was because of the number of professionals involved in the care.

“If Malaysia were to set up an eating disorder centre, treatment would still cost a few hundred ringgit a day, although patients who seek help at government hospitals at the moment are treated free,” he said.

“The problem in Malaysia may not be as serious (compared to Singapore), but I am seeing and hearing of more such cases these days,” he said.

She said it was also difficult to identify a person with eating disorders, especially Asians, because the females tend to be thinner and have a smaller frame.

Countries where eating disorders are common include Japan, South Korea, Thailand, China, Taiwan, Hong Kong, Singapore, India, Pakistan, Egypt and Israel, she added.

Dr Lukman said eating disorders are more common among females than males. For every 10 to 20 females with eating disorders, there would be one male with similar problem.

Lack of awareness on eating disorders

MANY victims of eating disorders usually go undetected until their problems are manifested in severe health conditions, like drastic weight loss and disruption or secondary amenorrhea (when menstruation stops).

For instance, patients admitted to the Penang Hospital for eating disorders are reported to have a body mass index (BMI) of below 12 when a healthy BMI for Asians is anything between 18.5 and 24.

Malaysia's head of psychiatry Datuk Dr Suarn Singh says parents are also hesitant to seek professional help because of the fear of stigmatisation – having their child being recorded as a psychiatric case.

“Eating disorders are psychiatric problems and the patients must be referred for treatment by experts including psychiatrists,” he says.

He also laments the lack of awareness on eating disorder among Malaysians, including professionals.

“There are no seminars or conferences that address the issue specifically. I hope the media will do more write-ups on the condition so that the public will understand the problem better,” he says.

Although the incidence of eating disorders in the country has yet to reach an alarming stage, nevertheless Dr Suarn says there must be concerted effort to address the problem – from creating public awareness to getting parents and medical practitioners to be on the look out for signs and symptoms of the problem and referring the patients for proper treatment.

On the profile of patients with eating disorder, he says: “Most of them are in fact quite intelligent and have been performing well in school. Their academic performance would be hardly affected, at least not at the early stage of their problem.

That is why most parents tend to think that their child will grow out of the problem.”

Dr Suarn says many patients seek professional help only when their condition has reached a critical stage.

“For instance, parents are only worried when the menstruation of their children are affected,” he says.

Penang Hospital child and adolescent psychiatrist Dr Lai Fong Hwa says Malaysia is yet to have an eating disorder unit. Nevertheless, the hospital has an adhoc multidisciplinary team of specialists comprising psychiatrists, staff nurses, occupational therapists and physiotherapists to handle such cases.

Dr Lai says the hospital submitted a proposal to the Health Ministry a few months ago requesting a few beds for patients with eating disorders. Such patients admitted to the hospital would be taught how to exercise and relax and this would not only relieve their anxiety over eating but also help tone up their muscles.

Chartered psychologist Dr Hera Lukman from the International Medical University says Malaysia is in dire need of an eating disorder unit.

“We definitely need one here. There are people with eating disorders who come and talk to me but I can only refer them to the closest centre, which is in Singapore,” she says.

However, she adds, the cost and distance of going to the centre deter them from seeking help.

“When help is delayed, the condition can become severe and death can happen.”

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