Ms Lee Yue-Er, 21, developed an eating disorder when she was in Primary 5 amid challenging family circumstances. ST PHOTO SHINTARO TAY
SINGAPORE - Ms Lee Yue Er’s most striking childhood memory was that of her parents shouting and fighting while she sat on the floor crying.
As an only child, she had no one to turn to for help. She was in lower primary school then. A sense of abandonment and confusion plagued her childhood, said Ms Lee, now a 21-year-old nursing student, in an interview with The Straits Times.
At the age of 11, her emotional turmoil churned into a more destructive force. A self-professed “shy kid”, she faced friendship problems in school.
She began starving herself because food was the only thing she felt she could control.
“Hunger was a source of comfort. When my weight dropped, I felt satisfaction,” said Ms Lee, who was diagnosed with anorexia nervosa when she was 14.
The mental health condition is characterised by an abnormally low body weight and an intense fear of gaining weight. Another common eating disorder is bulimia nervosa, which involves binge eating, then purging.
Stressors such as family conflicts, academic stress, bullying and low self-esteem can contribute to the development of an eating disorder, said Dr Courtney Davis from the adolescent medicine service at KK Women’s and Children’s Hospital (KKH).
Other factors that put one at risk of developing an eating disorder include being female, having other psychiatric conditions like mood disorders and being a perfectionist, she added.
Although eating disorders can affect people at any age, they commonly develop in adolescence.
In Singapore, anorexia nervosa and bulimia nervosa begin at 14 years old on average.
One of the main contributing factors is puberty, said Dr Ng Kah Wee, director of the eating disorder programme at Singapore General Hospital (SGH).
“There’s more awareness of a person’s body as it changes, like body size, shape and image – which are the main domains that patients have struggles with in eating disorders,” said Dr Ng.
In line with global trends in recent years, Singapore is also seeing a rising number of youngsters being diagnosed with eating disorders.
In 2023, 140 youngsters aged 11 to 18 were newly diagnosed with eating disorders at KKH, more than double the 50 to 70 cases in 2017. Of these cases, 6 per cent to 15 per cent involve male patients.
Dr Davis said that while research is ongoing to better understand the phenomenon, possible factors include the after-effects of a jump in eating disorders during the pandemic, and “increased access (via social media) to information about dieting and other unhealthy behaviours”.
That was the case for Ms Lee, whose dieting habits worsened after she got her first cellphone when she was 13.
“I was able to search on things like calories, and different diets. With social media, there were more resources that caused me to spiral down,” she said.
She started keeping a diary to log every morsel of food she allowed herself to eat. On average, she ate around 700 to 900 calories daily, significantly less than the recommended intake of 1,960 to 2,660 calories daily for 13-year-old females, according to HealthHub.
On average, Ms Lee ate around 700 to 900 calories daily, significantly less than the recommended intake of 1,960 to 2,660 calories daily for 13-year-old females ST PHOTO: SHINTARO TAY
At 14, she was referred to KKH and then admitted there for inpatient treatment in end-2017, after a school health examination raised alarm bells. Standing at 1.5m and weighing 25.5kg, she had a body mass index (BMI) of just 11. A healthy BMI for a girl of that age is between 15.6 and 24.6.
During her three-week stay at KKH, she was closely monitored and coaxed to eat about six meals a day in order to recover. She also met mental health professionals, including psychologists and psychiatrists, to address the root causes of her eating disorder.
While she managed to gain weight when hospitalised, she struggled to do so after being discharged due to the lack of constant supervision. She was readmitted seven times between 2018 and 2019, spending about two weeks each time.
“Anorexia was my best friend. Whenever something inconvenient happened, I would go back to it,” said Ms Lee.
Addressing the misconceptions that eating disorders are “just about diet” and patients can just “choose to get better”, Dr Davis said eating disorders lead to changes to the structure and function of the brain, perpetuating the symptoms.
“Nutrition is an important part of recovery to reverse these brain changes, and recovery commonly requires specialised, structured treatment,” she said.
Sharing an anecdote of a patient who had an extreme fear of gaining weight, and would suffer heart palpitations and break out in cold sweat near mealtimes, Dr Ng said patients often face many psychological barriers.
“Statements like ‘Why can’t you just eat more’ can be quite disparaging, as it invalidates the patient who is struggling,” said Dr Ng.
Ms Lee’s turning point was when her mother was diagnosed with colon cancer around 2018.
“My mother fought through so many rounds of chemotherapy and operations for me. So I feel like I should also fight my eating disorder for her,” she said, adding that her friends also supported her by eating with her.
She eventually reached a healthy weight of around 46kg in 2019.
When her mother died in July 2023, she made herself eat a proper meal even when she did not have the appetite.
“I know my mum’s biggest worry would be me not eating. So I must let her rest in peace,” said Ms Lee.
While the bulk of patients with eating disorders is female, more males are coming forward with their struggles.
SGH says that over the past few years, around 10 per cent of the new patients in its eating disorder programme have been male, up from about 8 per cent a decade ago.
At KKH, the number of male patients has risen in line with the increase in its total cases. The overall percentage of male patients varies between 6 per cent and 15 per cent each year.
Awareness that eating disorders can affect anyone and increased pressure for young men to conform to appearance ideals are some possible reasons for the increase, said Dr Davis.
Ms Henny Tan, a senior clinical psychologist at Promises Healthcare, said she has seen five cases of males with eating disorders in 2024, compared with three in 2023.
Males are less likely to engage in behaviours like self-induced vomiting, but they are more likely to overtrain in the gym and consume nutritional supplements like protein powders to achieve the idealised lean and muscular look, said Ms Tan.
Undergraduate Yeo Shin Loong, 23, who was officially diagnosed with anorexia in 2023, recalled making himself exercise up to three times a day when he was in national service.
Undergraduate Yeo Shin Loong, 23, believes his unhealthy ideas about food and exercise started in primary school. ST PHOTO: ARIFFIN JAMAR
“My mind was heavily preoccupied with exercise... I had a routine where I must do it, and I cannot let go of it,” said Mr Yeo, adding that he had a fear of being fat, especially as he was slightly overweight and dissatisfied with his body image in his primary school years.
He believes his unhealthy ideas about food and exercise started in primary school.
During his NS stint, he had a fear of feeling too full, and was not eating enough to compensate for his excessive exercise. Over time, he lost weight.
It was only when his feet swelled to the point where he could not wear his army boots that he realised something was seriously amiss. In 2021, Mr Yeo was admitted to hospital for two weeks, and a battery of tests revealed that his heart rate and white blood cell count were very low.
Doctors found that he was underweight and malnourished, and referred him to a dietitian to help him gain weight. He managed to gain 5kg in six months, and his feet-swelling went away.
But he was not given an eating disorder diagnosis then, despite him raising concern that he might have one.
Through regular sessions with psychologists and support from his parents, Mr Yeo has since developed a healthier relationship with food. ST PHOTO: ARIFFIN JAMAR
His disordered relationship with food and exercise reared its ugly head again in 2023 when he was in university, fuelled by academic stress and his perfectionist tendency. As he stayed at his university hostel, his parents could not supervise his mealtimes.
“Food was like a reward, and I could have it only after I finished all my work... So I had only one meal a day,” said Mr Yeo.
His weight dipped to 39kg. With his height at 1.71m, his BMI was 13. A healthy adult’s BMI is between 18.5 and 22.9.
He decided to seek help again when his feet-swelling returned. This time, he was admitted to Mount Elizabeth Novena Hospital, where he was finally diagnosed with anorexia.
“I felt a sense of relief,” said Mr Yeo of his diagnosis, instead of having doubts about his condition.
His mother, who wanted to be known only as Mrs Yeo, said: “If he had been diagnosed when he was in the army, he would have gone on an earlier journey of recovery, rather than suffering more.”
She hopes there can be more awareness raised of eating disorders impacting males.
With regular sessions with his psychologists and the support of his parents, who accompany him to the park for meditation, Mr Yeo has been able to build a healthier relationship with food since.
“I’ve learnt that food is not a form of self-control, and can be a form of self-love,” he said, adding that he now enjoys occasional treats like doughnuts and biscuits, something he would not allow himself to do previously.
Looking visibly energetic and healthy, Mr Yeo said he is in a much better place, though his journey to recovery is still ongoing. He declined to reveal his current weight.
Mr Yeo also urged those who are suffering to seek help.
“Guys may avoid seeking help for an eating disorder because it doesn’t feel manly to be restricting their food choices, and they don’t want to have that feminine label on them. But regardless of your gender, everyone can have the same struggles. Don’t discount your right to have a struggle just because you don’t fit that gender role,” he said.
