It's perfectly normal for your daughter to say she's too fat, even when she's not. However, if she starts skipping meals frequently and/or disappears to the toilet after meals, you should be concerned.
If she's starving herself, she could be on the brink of anorexia nervosa. If she keeps going to the toilet after meals to induce vomiting, she could be suffering from bulimia nervosa.
These are two of the main eating disorders.
Psychologist Assoc Prof Dr Hera Lukman explains that there's no single definition for eating disorders as it is actually a group of conditions.
“Until today, we have classified the groups of conditions into anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified (Ednos).
“Those with Ednos have symptoms of AN and BN but not quite fulfilling the classifications for both. That's the general definition,” she informs.
You might think these are conditions you merely read about in the newspaper about kids in the United States or Britain. However, Malaysia is not spared from such conditions and our adolescents and teenagers are also at risk of developing body image issues as well as bulimia and anorexia.
“I think it's certainly present in our society as we do have cases of individuals or children who have problems with their eating. They do present themselves to physicians and psychologists.
“So, definitely, eating disorders occur in Malaysia but we don't have very systematic research on the prevalence like other countries such as Singapore. We don't have such studies here because in Malaysia we don't have a concerted effort to manage eating disorders.
“In fact, individuals who suspect themselves or their children suffering from eating disorders go to a variety of professionals who manage them. As such, it's very difficult to do studies to see how many children, adolescents and adults have eating disorders.
“I wouldn't be able to say if it's a growing problem because we don't have hard facts. But, if the regional studies are of any guide, then I would say it is increasing because the prevalence of eating disorders is increasing throughout the world. The percentage is quite comparable to the one in the West so generally speaking we can expect about 1% of the population to have anorexia nervosa, 3% having bulimia nervosa and within this group of eating disorders 10% involves males.
“The data suggests that it can happen to children as young as six, but that's pretty rare.
“I think the main population we're looking at is adolescents. Anorexia nervosa usually happens in early adolescence, about 14 years old. Bulimia nervosa happens slightly older but still within the young adult population.
“So, we're looking at that pattern. I wouldn't be surprised that if Malaysia had such a systematic research as to prevalence that it would show similar patterns,” says Dr Lukman.
Female more than male
Dr Lukman, who has done some studies on the subject of eating disorders in the past, says that the majority of people who suffer from eating disorders would be female, compared to male.
“There are several reasons for this actually. It's a female condition and body image evaluation is one of the main diagnostic criteria in AN and BN, meaning that individuals who have such eating disorders are very concerned about the way they look. This concern is so pervasive in their life that it takes over everything. When you look at body image, females are usually more affected than males for a variety of reasons.
“Firstly, as females from young we have been socialised to look at our body as an object that we look at and that other people look at. So, it's got to be pretty, presentable, has to conform to some sort of societal ideal. But, for boys, since young they are also taught to focus on their body but not with respect to appearance. They are asked to focus on their body with regards to strength and bravery. So, it's more the function of the body, not about the appearance.
“We are always asked to emulate what is depicted in the media as an idealised body which is very thin. This has become something that adolescent girls would want to emulate. But, adolescent girls go through puberty and that doesn't seem to correspond with this ideal because, during puberty, girls put on weight and fat in different parts of the body. Their body changes. So, they move away from this ideal. For some girls who are really very concerned about the way they look, they want to become thin but their bodies are changing in the opposite direction,” she says.
While the global statistics indicate that it's a bigger problem for girls than boys, Dr Lukman believes it is slowly becoming a problem for boys, too. Because of the media emphasis on men's six-pack abs and rippling muscles, boys these days also find that there is pressure to look muscular.
“They have become a little bit more concerned about the way they look and some of them may resort to unhealthy behaviours to get themselves more muscles. They might take supplements or muscle enhancing products for muscle enhancement which may not be as good for them at this stage,” she adds.
According to her the percentage of eating disorders in the West for boys is actually increasing. In the future, we may even see less discrepancy in the difference between the genders.
Body image
Dr Lukman emphasises that it is perfectly normal for girls and women to not be satisfied with their bodies.
Importantly, not everyone who has body image issues is at risk of having an eating disorder.
“If you look at the figures, the majority of girls are not satisfied with their bodies, but only about 1% gets anorexia nervosa and 3% develop bulimia nervosa, for example, in the West.”
She explains that body dissatisfaction cannot and shouldn't be equated with the development of eating disorders. However, it is one of the major influencing factors.
“I think there's nothing wrong in girls wanting to look a bit more presentable, a bit better, and to not like something about their appearance. I think most of these are quite benign,” says Dr Lukman.
However, she adds, things become more of concern if:
- Your child is looking at themselves in the mirror many times a day;
- Or if they avoid mirrors altogether;
- They avoid wearing clothes that show their body;
- They don't want to go swimming because of the swimsuit;
- They keep weighing themselves excessively;
- Their conversations are all about how fat, big, ugly they are;
- They get extremely upset when you take a photo of them; and
- They avoid anything that makes them uncomfortable about their body.
These are signs that your child is struggling with body image.
Signs of change
What are some of the signs that your child is developing an eating disorder?
Dr Lukman says that children might start to diet a little bit. They might refuse to eat certain things or they might tell you they just want to eat fish, or they don't want meat. It can be a very subtle behavioural change.
Or, if they excessively exercise or if they feel they need to keep moving, refuse to sit down …. These are signs of some kind of distress.
Dr Lukman recommends that parents who notice these changes not confront their child in an accusatory or judgmental manner.
That would really scare them off. Parents need to be very careful how they approach these issues.
“I think a lot of the time teenagers who are having issues with body image or have eating disorders, are really calling out for help. They are not coping very well in their circumstances for whatever reasons. And, I think in that state, it's worse if parents were to corner them and try to find out why they are having these issues.
“I think that would really create a huge unmovable barrier. One of the main things I observe parents doing is that they form a lot of barriers of conversation. They don't listen; they judge their children immediately. I think that's something that you don't want to do. The first thing parents need to do when they see these symptoms and behavioural changes is to sit the child down, take them somewhere, have some quality time with them and ask them about the daily things.
“Don't ask them about why they are not eating or why they are exercising so much. It's not a confrontation. It's a conversation to find out more about their lives. Just listen to them, ask them how is school, how are their friends, let them talk and bring out these issues.
“I think a lot of parents make a mistake. I know they are very concerned and they want solutions immediately but in so doing if you confront and judge, that will be the end of the conversation and you will never get to the bottom of it. You will find that your children will not open up to you. I think that's the worst thing you can do and you become their enemy rather than somebody who can support them.”
Watch what you say and do
Parents are a big influencing factor in how their children view their bodies. It is up to parents to let kids know that the body serves many functions and it is not just there for us and others to look at.
Mothers who are constantly dieting or those who keep exaggerating that they are fat or have a preoccupation with body shape will impact how their daughters view their own bodies.
“We need to be a little bit more aware as to what's going on in our family conversations, which is not to say that you shouldn't talk about it but you should have a much more holistic view of what the body is.
“I think all of us are affected by the way the media portrays the body and therefore we need to have that alternative perspective. You cannot stop the media. The media will have all sorts of messages, but we as parents will need to provide the other perspective - that the body is not just to look at and the body is not just about eating. The body is just part of us. There's so much more to us.
“We also need to tell our children how much we value the other aspects of them – that they have their talents and their inner beauty. We need to reinforce again and again these good values in them.
“These are things that parents need to take time to do so that children don't get overwhelmed by what the media and their friends say about the body,” says Dr Lukman.
She emphasises that parents need to understand that they play a huge role in developing their children's sense of self and appearance.
Dr Lukman encourages mothers who themselves struggle with body image to share their struggles with their daughters.
“I think there's no harm in telling your daughter that 'Hey, you know what, being a woman, I also struggle with the way I look. Every woman struggles to a certain extent about the way they look and sometimes I also think I should be a lot thinner than I am but I don't really think this is what we should do so let's make it better by eating healthy.'
“So, you're letting your children know that you are also struggling and that it is actually quite normal to struggle with these things so it doesn't have to be a secret. It doesn't have to be something that they feel they have to go through alone.
“An eating disorder is a very secretive condition. The reason why it's a secretive condition is because people don't talk about it. This is again about what goes on in the family. If children cannot talk about anything in the family because it's not a safe place to talk about things then I don't know where they are going to go for a safe haven to express themselves. They might go to Facebook and other social networks for comfort which you don't really know about and you can't really control.
“I encourage mothers especially to talk to their daughters, because what mothers do and say has more impact on their girls in terms of how they look at themselves and their bodies.
“So, mothers should talk about it and should share, particularly with adolescents because they do understand. You can share as women in the family having this struggle and how could you as a mother and daughter deal with the issue together. So, the children won't have a misconception that it's just them going through this and that their mother doesn't have any issues.”
When is it serious?
One of the signs that this is not just a phase and that a child's eating disorder is serious is when there is extreme weight loss and extreme exercising, as a combination.
That's when parents should bring their child to a professional. However, as soon as parents notice their child is not eating or is disappearing to the toilet after meals, they should already start talking to their child.
“Of course, when things get terribly bad, you really need to see a professional. You cannot deal with it on your own. Sometimes family members can only play that healing role to a certain extent. So, you do need professionals to come and help you out. If the child has already lost a lot of weight rapidly, then the first professional to see would be a doctor to check the child's physical health,” she says.
Dr Lukman suggests parents take their child to a paediatrician if the child is an adolescent to assess the child's health. Then talk to the paediatrician about the problem, engage a good psychologist, psychiatrist and dietitian to talk about it because an eating disorder is a multi-disciplinary condition.
She recommends the whole family go for counselling as it almost invariably involves the family – its dynamics and communication. This is especially so if the child is an adolescent, as he or she would still be under the guidance of family members.
“I think this is something that is necessary but a lot of families find it hard because again it's very stigmatised. There is a misconception that if your family goes to see a psychologist or psychiatrist, there is something really wrong with your family.”
She explains that if one daughter has an eating disorder, there is a risk of the other daughters also suffering from it.
There is a risk because there is a genetic component to eating disorders. In fact, it's not just eating disorders, but any psychological disorder in the family – depression, obsessive compulsive and schizophrenia.
“So, I suggest parents who have children with symptoms of eating disorders or those who already have eating disorders to also focus on their other children.”
Conclusion
Dr Lukman says that parents should know that they play a very important role and they are part of a component that contributes to their children's way of looking at themselves. However, they are not the cause of it.
“Some parents feel very guilty when they find that their children have developed these issues. The guilt becomes an impediment rather than something that spurs them on to look at what the issue is.
“Don't let guilt stop you from helping your children. There's always a new beginning. If you think your conversations with your children don't seem to work out, there's always a new start. That is better than just giving up. Never give up. Nobody teaches us how to parent. It is a journey and hopefully you can let your children know that this is a journey and that you need to learn how to parent as much as they need to learn how to live their lives. This is the kind of connection we need between parents and children.”
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