She wears extra sweaters and jumpers when the air-conditioning is turned on, her complexion is dry and flaky with red blotches, and the sight of food repulses her.
Her 15-year-old body is breaking down. She suffers from constant exhaustion, feels light headed and cannot focus.
If she is bulimic and purges, her saliva glands may swell from the strain of vomiting, causing her to have “chipmunk cheeks”. Her heart beats irregularly – a symptom that can lead to death.
Her behaviour changes – she is overly suspicious of friends and family, thinking that people are watching and waiting to confront her about her “shameful” self-purging.
In order to stick to her starvation ritual, she develops a fixed schedule dictating almost every movement in her daily life, from the mandatory half an hour purging session after dinner to the three precise slices of apple she allows herself to eat for lunch.
She will eventually lose bone mass and suffer from low blood pressure. Most frighteningly, she may develop brain atrophy – her brain will shrink.
Her signs are just the tip of the iceberg of the emotional, psychological and physical deterioration that people with an eating disorder display.
She is just one out of 120 other Singaporean youths who seek treatment for eating disorders at Singapore General Hospital’s Eating Disorders (ED) Programme every year, a three-fold increase from just a decade ago.
About half of the youths seeking treatment suffer from anorexia nervosa, and a third have bulimia. The rest suffer from other eating disorders like binge-eating.
They are the lucky ones – doctors here say that hundreds of others go undiagnosed and untreated.
In 2006, a survey of 4,000 females aged between 12 and 26 found that females at risk faced a 7 out of 100 chance of developing an eating disorder – meaning that the 100 who come forward each year for treatment form only a fraction of those who are suffering from anorexia or bulimia here.
“People with eating disorders can be secretive about their illness .. it is not necessary that all people with disorders look extremely thin,” says Zahra Hoodbhoy, a prevention coordinator with the SGH programme.
“At SGH, the number of patients has definitely been on a rising trend every year.”
Hoodbhoy attributes the rising numbers to the Internet – and the wealth of pro-anorexia and pro-bulimia information available at the click of any impressionable teenagers’ mouse.
“There are lots of websites and blogs available on the Internet that promote unhealthy eating behavior. Youths today are definitely exposed to a lot of such information that may hinder them from seeking help for their disorder,” she said.
That leaves it to the friends and families of eating disorder victims to spot the tell-tale signs before they escalate.
Lydia Toh is only 10 years old, but her keen observation of her sister Vivian’s downward spiral into early anorexia saved her health from long-term damage.
In 2011, she noticed that her older sister, 16, was secretly throwing away her home-cooked lunch and dinners when their parents were not paying attention.
Lydia also told her parents that Vivian "needed a wig".
“She told me to bring Vivian to buy a wig because all her hair was falling out and clogging their shared bathroom’s drainage hole,” said the girls’ mother, who only wanted to be known as Mrs Toh. “Lydia would tell me that she could hear her jie jie crying every night and punching her tummy.”
It turned out that Vivian had started starving herself five months earlier when the boy she liked at school rejected her for being “chubby” – and punching her stomach was a “tip” she had picked up from the Thinspo blogs and forums she would frequent that was supposed to help curb hunger pangs.
She was diagnosed with anorexia and received intensive counseling for a year before being given the all-clear, but Mrs Toh and Lydia continue to keep a close watch on Vivian for any signs of a relapse.
“The doctors said that the diagnosis is the easiest part, and it’s true. Vivian only got better because we were there for her 24/7, eating with her, cooking with her, and reminding her that she was beautiful and that we cared about her,” said Mrs Toh, who quit her job as a human resource manager to help her daughter get her life back on track.
Youth counsellors told Yahoo! Singapore that the emotional and social fallout eating disorder victims experience are more obvious than the physical signs, which can take months to spot if the sufferer is careful enough.
“An eating disorder is a psychological illness,” said Dr Lee Huei Yen, director of SGH’s eating disorder programme and a senior psychiatric consultant. “In vulnerable individuals all it can take is a precipitating factor – external stress, or comments from others, to trigger an ED.”
Short tempers and erratic, secretive behaviour are also giveaway symptoms of eating disorder sufferers.
How to deal with a victim
“One way to find out is to monitor your child’s finances closely – you’ll find out what motivates them. I had a case where the parents found out their daughter was starving herself after she bought $500 worth of clothes that were two sizes too small for her and charged it to her supplementary credit card,” said one counsellor who declined to be named to protect the confidentiality of the young girls she helps.
She added that those who suspect their friends or family members of suffering from an eating disorder should never start off by confronting them directly.
“These girls know what they are doing is wrong – most are ashamed of it. If you call them out, they are going to clam up and suddenly pull away, making it more difficult to reach them.”
Instead, she suggested keeping in close contact with the victim and showing empathy for their situation before raising it to a person in authority – a counsellor, teacher, or parent.
Jamie (not her real name), 17, lashed out at her friends when they told her parents that she was starving, purging and bingeing to cope with exam stress and a failed relationship.
“I cut them off and refused to answer their SMSes. I was so filled with anger that I didn’t understand myself,” said the polytechnic nursing student.
She would shout and scream and throw things at her parents every time they barred her from regurgitating her dinner in the toilet.
“I would tell them I hated them, and I really felt that I did, I asked them, why do you want me to be fat? If you stop me, I’ll be fat, and I will never forgive you. I accused them of not loving me and wanting me to be ugly – it didn’t make sense, but I blamed them for my problems,” said Jamie.
Her parents had confronted her when they realised that she had been repeatedly stealing $20 to $30 from their wallets to finance her bingeing sprees. The sprees could add up to $40 each time spent on bags of potato chips, pints of ice cream, and bottles of sugary soft drinks – a weekly expense she could ill afford on her allowance.
Still, they had no idea that she was suffering from an eating disorder until her mother called her friends up and they told her that Jamie was abusing her body, a move that Jamie admits may have saved her life.
So if you know someone who has an eating disorder but are holding back because you “don’t want to interfere” you are slowly but surely abetting your loved one’s destruction of her own body, say experts.
“Starvation... affects almost all the bodily systems – nervous, cardiovascular, haematological, gastrointestinal, metabolic and endocrine system. Everything in the body will slowly start shutting down,” said Dr Lee.
SGH offers both inpatient and outpatient treatment for victims of eating disorders.
Patients are assessed by psychiatrists and put through medical tests to establish if they are medically stable. If their BMI is too low (less than 13.5), they will be admitted.
Those warded will go through a structured programme that includes supervised meals, daily group therapy that includes art classes and cooking lessons and body-image sessions to improve their self esteem.
And while the fight against eating disorders may be over for the girls featured in this three-part Seeking Thinspiration series, many others continue to struggle without help or support.
Figures from SGH, National University Hospital, and KK Women’s and Children’s Hospital show that victims suffering from eating disorders were getting younger and younger.
In 2010, an estimated 24 out of 200 cases of anorexia treated at these three hospitals were found to be primary school pupils aged 12 and below, with some as young as just 8.
Jamie’s friends, who have since reconciled with her and are supporting her on her journey back to the pink of health, said that reading up about reading disorders and the consequences helped them convince Jamie that she was sick and needed help.
In particular, one of them chanced upon the story of French actress Isabelle Caro, who died in 2011 aged 28 after 15 year battle with anorexia. At her skinniest, the 1.65 m model weighed only 25 kilograms.
"My friend printed out the article and wrote a note that she passed to my mum for me to read,” said Jamie.
The note said “You’re perfect and beautiful. We love you and we want to make sure you will never end up like Isabelle.”
Isabelle Caro became one of the most public faces of anorexia when she appeared naked in an Italian ad campaign in 2007 for a fashion house.Looking barely human and so stick thin that her eyeballs looked as if they were bulging out, the image shocked the world into action, prompting many fashion houses to ban anorexic or overly skinny models from walking on their runways.
For Jamie, that note represented one of the psychological turning points in her fight against her eating disorders, especially when she found out that Caro’s mother committed suicide after being overcome by guilt over her daughter’s tragic and slow death.
“I realised that it was not about me – if something really bad happened to me, my friends, my parents, my siblings would all suffer. Knowing how much they loved me really helped my self-esteem, and I decided I wanted to get better for their sake too,” she said.
Read Part One and Part Two of the Seeking Thinspiration series.