SCMP Monday, June 26, 2000

Dying to be thin
DAWN GOLDSMITH

Two years ago Molly, a 40-year-old Hong Kong Chinese, weighed just 29 kilograms. At 1.55 metres tall she was so weak she could barely walk. "If I tried to climb just one stair I felt like my heart was breaking," she recalls. But despite her skeletal appearance and frail health, Molly was convinced she was overweight.

"I used to weigh myself 20 times a day. Even if I had only drunk a glass of water I would jump on the scales to see if I had put on weight," she remembers. "I thought I was very fat." Repeatedly weighing herself was just one symptom of what, for a desperately unhappy Molly, was a long-undiagnosed eating disorder.

While it is estimated that up to eight million people suffer from eating disorders in the United States, figures for Asia are much harder to come by. Until recently the problem was thought to be confined to the West. Asian societies, with their often naturally slim female body type, were considered immune from problems such as anorexia and bulimia.

The opening of a new Hong Kong Eating Disorder Centre today, however, sends a clear signal to the public and the medical profession that eating disorders are very much a reality for an increasing number of Hong Kong women.

Director of the Hong Kong Eating Disorder Centre, Professor Sing Lee from the Chinese University of Hong Kong, department of psychiatry, explains: "Ten years ago, when talking to my Western colleagues I used to say, 'Asian women are so slim. They don't diet, so there are unlikely to be any eating disorders here'. Back then I perhaps saw one or two eating disorder patients a year. Today I see one a week." Another alarming trend, according to Lee is that eating disorders, typically affecting young women in their late teens and early 20s, are now starting to affect younger and younger girls. "My youngest patient is 10," he admits. "And the problems with eating disorders setting in at so young an age is that dwarfism can occur." Eating disorders were first brought to Lee's attention in the early 1990s and confirmed by a 1995 survey of 1,581 college undergraduates.

Asking participants to rate their body image of 25 different body parts, Lee was alarmed to find that 80 to 90 per cent were unhappy with their body shape and weight, despite being within the healthy weight range.

Lee attributes this to growing pressure on young women to emulate thin role models and to perform well in all areas of their lives such as school and career and family life. "There are also many Hong Kong celebrities who are themselves very thin and send a negative message to young girls - their fans - that they must be thin to be successful. Being thin symbolises self-control, attractiveness and success," he says.

Anorexia, bulimia, and compulsive eating wreak their own psychological and physical damage on both the patient and her family. If unchecked, anorexics can literally starve themselves to death. Bulimia sufferers, meanwhile, induce vomiting, putting themselves at increased risk of heart attack.

"One of my patients, who was five-foot four [1.63 metres tall] dropped to a weight of just 18 kg," says Lee. "She died about six years ago." Lee also recounts the tale of one bulimia patient who swallowed a toothbrush after she had been using it to induce vomiting. "We had to perform surgery to remove it from her throat."

Vivid cases aside, perhaps the most disturbing element of eating disorders is that they can remain hidden for many years before help is sought. The shame of exposing something wrong with a family member coupled with an ignorance of what eating disorders are often stops friends and family offering help. A common misconception is that eating disorders arise out of a patient's wish to be thin. While thinness is certainly the objective and the preoccupation, experts agree that the root of such disorders lies in a loss of control over life in general.

Says Carmen Liau, therapist at the Hong Kong Eating Disorder Clinic: "Often the girl has problems with the family or with her peers. Sometimes there is sexual abuse. In most cases, girls experience a loss of control over their lives and turn to the one thing they can control - food and weight." A need for control was certainly what motivated Molly. Returning to Hong Kong after obtaining a degree at university in Toronto, Molly found she had lost direction. Her parents pressured her to join the family garment business. "I felt that because I was the eldest and also because my family had paid for my education, I should repay them in some way." Working for the family was far from Molly's ideal, however. "I had to work in the dyeing factory, moving up to 1,000 pounds [450 kg] of fabric in excessive temperatures. I hated it. I thought, 'Wait a minute, why am I here? I'm a college graduate, I worked hard and here I am, working like this'. I really, really hated it, but I couldn't talk to my parents and I really didn't have any friends I could share my feelings with.

"I realise now that I survived by creating another lifestyle for myself that I could control," says Molly. Too busy to eat throughout the day, the evening meal was the one time she could relax. " Eating was a way for me to turn off and not think. I used to eat solidly for two hours. I loved the food and how it made me feel." Horrified by the amount she ate and terrified of putting on weight, Molly forced herself into a gruelling exercise regime. "I used to climb the stairs every night for four hours. We live on the 24th floor so I would climb up and down at least six or seven times, about 1,000 stairs each time. I was afraid that otherwise all the food would make me fat." Not surprisingly, Molly's weight started to plummet from her usual 45 kg to a final low of less than 29 kg. A turning point came when she realised her 60-year-old father could walk faster than she could. "I thought, do I want my elderly parents looking after me until I die? I realised it was time to get help." At that time, there was little experience of treating eating disorders in Hong Kong. Molly was placed in the psychiatric ward of the Prince of Wales Hospital where she spent the next four months. There she found staff as ignorant of her condition as her parents were. "They thought they could just yell at me to eat and I would get better." She discharged herself and was put in touch with Lee's Eating Disorders Association where she began family therapy. "In the beginning my parents came to counselling with me because they knew I could die if I did not get help. But family therapy exposed a lot of what was wrong in our family, so they stopped coming." Gradually, Molly battled to get better. "In the end I realised that it was about me. Only I could make the changes, only I could make myself eat." First she threw away her scales, then cut down on exercise, from four hours a night to just 10 minutes every day. "It was very, very hard. I didn't even know what a normal amount of food to eat was." Today she is back to her original weight of 45 kg.

Molly now plans to use her experience to help others. She is a member of the board of the Eating Disorder Clinic and taking courses to become a qualified counsellor. "Now I think about the future. Before, food and exercise took up so much of my time, it was a way of not thinking about the future and what I wanted to do."

Lee is as much amazed by Molly's transformation as she is.

"She was one of the most difficult cases to crack. Her disease lasted 14 years," he said. "I really thought Molly was not going to make it. She has been the biggest surprise to me of all."

Women aren't the only victims

If you thought it was just women who suffered from eating disorders such as bulimia and anorexia, you're wrong, and new studies show the effect of eating disorders on men could be more severe than on women.

A study of patients admitted to an eating disorders unit at the University of Iowa Hospital and Clinics, in the United States, between July 1991 and June 1998 showed 14 per cent of cases were men. One of the common side effects of eating disorders is a decrease in bone mass leading to osteoporosis. The researchers found loss of bone mass in men with anorexia or bulimia is significantly higher than in women with similar disorders.

Meanwhile, the British Medical Association has demanded the media play a more responsible role in promoting a healthy body image. A report in the British Medical Journal states the BMA is sending a clear message to broadcasters and magazine publishers to "adopt a more responsible editorial attitude towards the depiction of extremely thin women as role models".

Information: Hong Kong Eating Disorder Centre. The new 2,800 square foot facility is located in a residential block near the Prince of Wales Hospital. The centre has an in-house therapist and soon will appoint a clinical psychologist. Women's Growth Groups as well as individual counselling are offered to sufferers.
Tel: 2144 5838.
E-mail: hedc@cuhk.edu.hk
Web site: www.hedc.med.cuhk.edu.hk

Other useful Web sites:
St Joseph's Eating Disorder Center: www.eating-disorder.com

UC Davis Eating Disorder Site: http://eating.ucdavis.edu

Eating Disorders Online: www.twu.ca/eating

Recommended reading:
The Secret Language Of Eating Disorders: The Revolutionary New Approach To - Peggy Claude Pierre.
Breaking Free From Compulsive Eating - Geneen Roth.
Bulimia - A Guide To Recovery - Lindsey Hall.
Afraid To Eat: Children And Teens In Weight Crisis - Francie M Berg.

Self is edited by Dominic Biggs (dbiggs@scmp.com).