Understanding Eating Disorders in Singapore

Date

27.12.22
by Fiona Yassin

A Generation Affected by Eating Disorders and the Parents Who Care

In Singapore, the likelihood of an eating disorder diagnosis among teenagers and young adults is higher than ever. Eating disorders among children, tweens, teens, and young adults continue to rise at an alarming rate in expatriate and local communities.

Prevalence of Eating Disorders in Singapore

The recent periods of restricted movement, school closures, and the loss of day-to-day routines have led to a significant rise in young people seeking mental health advice in Singapore.

A growing number of those seeking psychiatric support are concerned about eating disorders and their appearance. Struggles with food during isolation, together with increased feelings of anxiety and depression, have created fertile ground for disordered eating and eating disorders to take hold in Singapore’s younger generation.

53% of 12-year-old girls report dissatisfaction with their body, while over 80% of 10-year-olds report a fear of being ‘fat’.

With increasing numbers of young people seeking help for eating disorders, mental health professionals are assessing children at much earlier ages than previously encountered. Concerned parents of children as young as nine are contacting Child and Adolescents Psychiatrists for advice, support, and access to eating disorder treatment.

Eating Disorder Diagnosis: 8% (and rising) of Young People in Singapore Are at Risk

A study in Singapore revealed that the number of young people seeking help for eating disorders is steadily increasing, with almost 8% of 12–26-year-olds at risk.

40–70% of Middle-School Girls Dislike Two Or More Areas Of Their Body.

Anorexia nervosa, bulimia nervosa, and binge eating disorder have a mean onset age of f 12–13 years.

Avoidant restrictive food intake disorder (ARFID) has a slightly lower median age of onset at 11 years.

Eating Disorders Also Challenge Boys and Men in Singapore

Eating disorders have often (wrongly) been considered a female-only concern.

While eating disorders are more often diagnosed in girls and women, the rise of eating disorders in boys and men in Singapore (and in the Asia region) is significant.

25% of boys in primary school report wishing to be ‘thinner’.

The quest for a certain body shape and social media are reported as highly influential in male body dissatisfaction.

Education and Advice for Parents and Schools

Some parents reaching out for advice and support typically have a gap in their knowledge of eating disorders, given they have only become well-documented more recently.

As eating disorder research in the region becomes more readily available, parents, families, and educators are becoming more aware of the severity and complexity of the issue in teenagers and young adults.

The Wave is a constant advocate for greater education among psychiatrists and dieticians in the region and for eating disorders to be included in core competencies for mental health professionals. The team has partnered with the Malaysia Psychological Association (PSIMA) to increase education, research, and available treatment options to local families.

Diet Culture in Singapore: Dying to Be Thin

It is reported that almost 60% of people in Singapore are currently on a diet’.

Eating disorders manifest where diets exist. That is one fact we know to be true about complex and sometimes fatal mental health conditions.

Ditch the Diet

Restriction or dieting of different types in family settings is not unusual. Dietary restrictions, cultural food, and body messaging can impact vulnerable teenagers and may become a contributing factor.

Direct instruction that certain food groups should be limited or omitted is unhelpful and can lead to children labelling food as ‘good’ or ‘bad’, ‘healthy’ or ‘unhealthy’. This can reinforce rigid, rule-based eating, which underpins disordered eating.

Advice for young people to restrict carbs, fats, or sugars is common but unhelpful. Instructing children, teenagers, and young adults about food intake can create a pathway to a disordered relationship with both food and body image. They should be encouraged to experiment with food and enjoy lots of variety.

Weight bias and stigma are evident in every corner of society, and Singapore is no exception. Families often need to explore each member’s relationship with food while looking at the weight bias or stigma that we may all carry.

Family Influence in the Treatment of Eating Disorders in Singapore

Parents sometimes ask if they are responsible for their child’s eating disorder. The short answer is that eating disorders are incredibly complex, and no single factor is responsible for eating disorders in young people.

An eating disorder is a severe psychiatric condition that is made up of many parts. It is often referred to as the ‘Perfect Storm’. Biological factors such as genetics, environment, education, friends, family, and individual personality can all play a part in developing an eating disorder in those more vulnerable. Social media is also highly influential in body dissatisfaction. As one of the possible risk factors, it emphasises physical appearance and the pursuit of thinness.

Families can play a crucial part in eating disorder prevention, treatment and sustained recovery.

Avoid discussing weight, shape or size; for yourself and others.
Parents, ditch the diet. Diet culture is not only harmful to children and young people, but it is also harmful to you.
Focus less on weight, shape and size and more on humility, kindness and body positivity.
Explain that social media images aren’t always an accurate representation of someone due to many being edited.
Perfectionism and obsession with straight ‘As’ is not more important than health. Put your child’s mental health before grades. Every. Single. Time.
Help your child to separate self-esteem from body image. Often the number on the scale relates to how valuable we believe we are, so reassure your child that this is not true.
Children and teenagers do not need scales in their bedrooms or bathrooms, nor do the parents.

Why more teenagers are suffering from anxiety than before

Eating Disorder Treatment in Singapore

Hospital and residential treatment admissions have increased by more than 40% during the past two years. The diagnoses of anorexia nervosa and bulimia nervosa in Singapore continue to rise steadily, particularly in the 13–24-year-old age group.

Singapore’s mental health professionals and dieticians report increased assessments for disordered eating in the 9–12-year-old age group.

Singapore has some medical interventions available and admission into Eating Disorder Units with General Hospitals (Singapore General Hospital, Eating Disorder Unit +65 6321 4377. Outpatient Unit, Level 3).

The region’s only specialist Eating Disorder Program for teenagers and young adults in Malaysia is based just outside Kuala Lumpur. Combining psychiatry, education, medical interventions, dieticians and psychotherapists, The Wave Clinic provides one of the world’s leading evidence-based Eating Disorder Programmes for teenagers and young adults.

The Wave is trusted by expatriates and receives over 85% of international admissions. The benefit for young people is that all aspects of treatment fall into one programme. Furthermore, medical supervision in a home environment avoids hospital stays and possible trauma.

When Teens Lose More Than Weight: A Childhood Lost to Eating Disorders

Parents often begin to notice the outward signs and symptoms of their child’s eating disorder quite late in the illness. The mental conditions that affect a young person’s eating habits are not necessarily tied to a specific body type; someone suffering may appear very thin, with a healthy weight. Young adults who suffer from eating disorders don’t always have a significantly low body mass index.

Children and teenagers preoccupied with their physical appearance can become withdrawn and may stop participating in activities they previously enjoyed. Their focus on their body image and eating habits can overwhelm their daily life.

As the eating disorder begins, other areas may suffer, including friendships and family relationships.

Many families wrongly assume the situation cannot be problematic if education and studies are unaffected. This can lead to a delay in reaching out for support and treatment, which can have catastrophic effects in the longer term.

Eating disorders are also associated with other psychiatric disorders, such as obsessive-compulsive disorder (OCD) and anxiety disorders. Young people challenged by eating disorders may display obsessive and compulsive behaviours as a means of coping. One of the areas affected can be academic life. This may manifest as perfectionism, leading to overwork and excessive concern about grades. Perfection can infiltrate all areas of a young person’s life and become restrictive. Achievement often becomes more important than enjoyment, with anxiety and feelings of low self-worth interfering with how a person lives their life.

While experiencing a loss of control, young adults may use their body image struggles and an obsessive focus on their eating habits to regain control. This may come from disordered eating, self-induced vomiting, or misusing laxatives or diet pills. The extensive worry, and compulsive behaviour, to prevent weight gain can trigger food restriction and excessive exercising, which in turn furthers the development of an eating disorder. Persistent disturbances in eating behaviour and an intense fear of gaining weight can lead to self-starvation and create a further distorted body image.

Apart from compensatory behaviour, those suffering from eating disorders face various physical health challenges and medical conditions. Disordered eating behaviours such as skipping meals, binge eating or purging behaviour to lose weight come with gastrointestinal problems, poor appetite, fatigue, constipation, bloating, hair loss and nutritional deficiencies. It can also cause low blood pressure, cardiac complications such as bradycardia and arrhythmia, brain atrophy, and lead to significant electrolyte abnormalities.

Common Eating Disorders in Singapore

Life-threatening eating disorders can affect young adults who do not meet the strict diagnostic criteria of common eating disorders such as bulimia nervosa, anorexia nervosa or binge eating disorder. Examples include atypical anorexia nervosa, which does not involve significant weight loss. Avoidant restrictive food intake eating disorder can present similar but is not necessarily related to body image issues, size or shape concerns. Night eating syndrome – which involves excessive and recurrent episodes of food consumption at night – affects weight gain and is related to sleep.

Binge Eating Disorder

Binge eating disorder involves recurrent episodes of consuming large amounts of food within a short or specific time frame. A person suffering from this disorder may eat despite being hungry, eat very fast during binging episodes, and eat to the point of discomfort or extreme fullness. Those who battle with binge eating may lose control over their eating habits. Unlike bulimia nervosa, binge eating disorder does not involve compensatory behaviours but is accompanied by feelings of shame, guilt or disgust. It is also common for a young adult struggling with this eating disorder to suffer from depression.

Bulimia Nervosa

Bulimia nervosa involves binge eating but is followed by behaviour that a person uses to rid themselves of unwanted calories and prevent weight gain. These behaviours may include fasting, following strict diets or doing excessive exercise. It may also cause self-induced vomiting, using weight-loss supplements or laxatives.

Young people suffering from bulimia nervosa may judge themselves harshly for their self-perceived flaws. Strongly related to self-image, bulimia nervosa can be very hard to overcome without treatment and support.

Anorexia Nervosa

Anorexia Nervosa involves a persistent restriction of food. As this restriction is below the minimal energy intake required by the body, it can lead to significantly low weight and comes with a severe fear of weight gain. Anorexia nervosa could mean that a distorted body image drives a person to abstain from solids or liquids because they believe any amount of food will lead to weight gain.

Many sufferers of this condition perceive themself as overweight regardless of how lean or skinny they are, which is reflected in their unhealthy preoccupation with food intake.

Comparisons in Eating Disorders

Comparing oneself with others is, in part, a developmental stage. We begin to compare ourselves with others at around the age of four. We can often developmentally compare ourselves to peers and siblings. In Singapore, an affluent, mobile society where comparisons are made in many areas of life, young people report increased levels of stress and pressure. Teenagers describe placing a great deal of importance on studies and exams.

As eating disorders progress, the comparisons made between the self and others return in the most unhelpful ways, whether in education, relationships, clothes or body shape.

Comparisons in eating disorders are the killjoy in the room: fuelling self-doubt and self-loathing, causing decreased confidence and extreme social anxiety. Comparisons can become incredibly powerful in young people with a degree of clinical perfectionism and severely affect their ability to function at home, work or school. Clinical perfectionism can follow, often with rigid – and ultimately unhelpful – rules for life.

The Importance of Early Intervention

Early intervention is essential. A family member noticing mood changes and abnormal eating behaviours in a child or teen can make a difference.All research indicates that the sooner treatment begins, the more likelihood of sustained and long-term recovery.

FREED, the early intervention in eating disorders model, developed by King’s College in London, is designed to help young people access treatment within two weeks of reaching out for assistance.

Mental Health in Singapore

In 2019, over 12,600 young people in Singapore contacted mental health services for advice, support and intervention.

Mental health services and specialist practitioners in Singapore continually seek to improve the treatment options available for young people. Seeking support for mental health concerns in Asia is becoming more commonplace, with government initiatives and remote services becoming readily available in both the private and public sectors.

Eating disorders are often diagnosed alongside other mental health conditions, and it is not unusual for young people to have one or more co-occurring diagnoses.

Eating disorders have a high rate of fatality in their later stages. The complications and early death rate from eating disorders are greater than any other psychiatric diagnosis. This can be further complicated by an increased risk of self-harm (cutting, burning, hair pulling, skin picking and other self-injurious behaviours) and thoughts of suicide. Many young people diagnosed with an eating disorder describe episodes of extremely low mood, irritability, anxiety, obsessive and compulsive behaviours and clinical perfectionism – leading to low self-esteem and depression.

Adolescent suicide in Singapore continues to be the leading cause of death in the 10–29 age group. Seventy-one young people completed suicide in Singapore in 2019, with numbers rising year after year.

Anxiety, depression, isolation, and increased mental health concerns amongst young people have seen services receive 40 times the previous rates of referrals in the past year.

Eating Disorder Treatment is Much More Than Weight Restoration

Parents may have noticed changes in their children’s and teenagers’ body shape and weight. Any significant changes should be discussed with their family doctor (as long as they have experience treating eating disorders), an eating disorder specialist or a registered dietician.

An eating disorder cannot be diagnosed from a single indicator; it can certainly open discussions and warrant further investigation. An Eating Disorder Specialist and trained psychotherapist can be a great support throughout. Nutritional rehabilitation can be more successful for young people and their families if they continue treatment with an eating disorder specialist team.

For those who have reached medical instability, such as having a dangerously low body weight, there is a medical urgency to begin weight restoration carefully. During this time, a registered dietician will join the medical team overseeing the delicate balance of physical and nutritional needs.

Food is indeed medicine in eating disorder treatment. Many young people will have extensive rules, rituals and restrictions that have become ingrained in their eating habits. When teenagers and young people receive adequate treatment for their eating disorders and other co-occurring conditions or mental disorders, they will be gently challenged on the behaviours that have developed as part of the eating disorder.

Individual and group therapy sessions can help a young person understand the root causes of eating disorders. Mental health professionals help develop healthy coping mechanisms and associations with food in individual treatment and become part of a peer support network in group therapy. Hearing from others who have battled an eating disorder can provide a sense of community and relatability while reassuring individuals that recovery is possible.

Apart from the cessation of disordered eating patterns, the initiation of healthy eating and the addressing of body image distortion, a young person’s relationship with food is vital. By developing healthy habits, young people can take ownership of their bodies and change this relationship.

At The Wave, young people will have the chance to become involved in activities and programmes that promote healthy eating, helping them develop a better relationship with food. These include Cookery School, whereby being around food and learning to nourish the body through cooking can gently help young people form healthy associations with eating. This can also make it a fun experience rather than a scary one.

Other activities may include Gardening Groups, where young people can plant fruits and vegetables, enabling them to be involved with food from the moment it’s planted. They have the chance to look after their bed of plants which provides ownership and empowers them to look after the seeds they’ve sown. These skills can be directly translated into how they look after themselves.

Emotional awareness and trust in a young person’s body can be beneficial. Alternative therapies may range from dance and art therapy to reiki and mindfulness, aimed at enhancing wellness and promoting healing from the inside out. These treatment approaches allow young people to seek emotional expression and help them to let go of negative associations with food.

It can also be difficult for loved ones to truly understand what a young person is going through when they suffer from an eating disorder. It can take a toll on the whole family, which is why family-based therapy provides an essential, safe space for everyone to express their feelings and concerns and understand one another better.

Full Recovery From an Eating Disorder is Possible

Hope is the mainstay of excellent treatment for eating disorders. At The Wave, we know that full recovery is possible. It is certainly not easy and can take a long time, so it is important to reiterate that recovery is never a race.