SINGAPORE – During a weight-taking exercise in school in 2019, Ms Angela Tan’s 11-year-old daughter was mistakenly handed a slip with the weight of a boy who had used the machine before her.

Even though the number did not make much sense for her small frame, the girl called her mother and burst into tears.

Ms Tan, 48, said: “I had never seen her cry like that before.”

During the school holidays that year, her daughter stopped eating. Her weight dropped drastically and her hair started falling out.

Ms Tan took the girl to seek help, and she was hospitalised.

After her daughter was diagnosed with an eating disorder, Ms Tan quit her marketing job to become a full-time caregiver for her only child.

She made the tough decision so that she could handle her daughter’s home-based therapy treatment, which included serving three portion-controlled meals and three snacks throughout the day.

Eating disorders include anorexia nervosa, characterised by an abnormally low body weight and an intense fear of gaining weight, and bulimia nervosa, which involves binge eating, then purging.

Dr Courtney Davis from KK Women’s and Children’s Hospital (KKH) told The Straits Times that the hospital saw an increasing number of new cases related to eating disorders among patients aged 11 to 18 – from 50 to 70 cases in 2017 to 140 in 2023.

Psychiatrist Lee Ee Lian from Mount Elizabeth Novena Hospital said that developing an eating disorder at a young age impacts physical, mental and social development.

Stunted growth is the most obvious complication, and poor nutrition affects the neurological development of the young brain, she added.

Dr Davis said caregivers are critical to the recovery of children with eating disorders. They play an essential role in the renourishment of their child by supporting proper consumption and providing emotional support during the recovery process.

In April 2021, KKH collaborated with non-profit organisation Caregivers Alliance (CAL) to offer better support to caregivers of those with eating disorders.

Through the programme, caregivers learn how to better care for their loved ones who are on the road to recovery, and develop a network of support with other caregivers.

The programme has had six runs since then and trained more than 120 caregivers, CAL outreach manager Nandita Nalawala told ST.

She said: “When you have a room full of caregivers looking after individuals with similar conditions, everyone speaks the same language. They don’t need to explain themselves – everyone empathises and is on the same page.”

She said most participants have been parents of children as young as 11, while others include siblings, spouses and friends of those with eating disorders.

IHH Healthcare Singapore, which manages private healthcare institutes like Mount Elizabeth, will also be piloting a support programme for caregivers of patients with eating disorders in the third quarter of 2024.

Ms Patricia Jin, a senior medical social worker at Singapore General Hospital, said parents often feel guilty, sad, helpless and confused when their child is diagnosed with an eating disorder.

She added: “It can be challenging for parents to accept the diagnosis, since a child’s food refusal might be mistaken as them being fussy or going through a developmental phase – and especially if the child had previously enjoyed eating.”

Ms Nandita said many parents may blame themselves, thinking they did not pay enough attention or neglected the eating disorder while it was developing.

The parents of 14-year-old Jenny (not her real name) mistook her eating disorder traits, such as imposing strict portions on herself, as part of normal teen behaviour.

They felt frustrated and helpless when they attempted to encourage Jenny to eat more but she refused.

Ms Jin said: “Food refusal, sometimes coupled with strong emotional reactions, is common among patients with anorexia.

“It was challenging for Jenny’s parents to recognise anorexic behaviours as separate from her. They had to manage their own emotions when anorexic behaviours were pushing their buttons and resisting their interventions.”

As part of CAL’s programme, Ms Nandita said, caregivers are taught to separate or externalise the eating disorder from their loved one who is struggling with it.

This helps them understand that it was not a failure on their part as a caregiver – the person does not have a choice in developing the eating disorder, nor stopping it.

Ms Nandita added that caregiving for children with eating disorders is often overwhelming, as there is a relationship between food and parenting.

“Parents love to feed their children, and it becomes a focal point at family gatherings. So you can imagine the alarm that sets in when there are distorted eating patterns or if a child refuses to eat.”

Many caregivers are also working professionals, and have to perform at work despite the emotional burden they are carrying.

“I’ve known parents who had to run around and schedule their work around mealtimes so that they are around to monitor the feeding process of their child, which is often broken up into five or six times a day.” 

For Ms Tan, quitting her job did not mean that taking care of her daughter’s mealtimes was always easy.

“There were times when I was really tired or frustrated with her, and I had to ask my husband to take over.”

She added that living in a household with extended family, like her in-laws, added to the challenge sometimes.

“Getting her to sit down at the dining table to eat with everyone was hard, and it was also tough to convince her grandparents that she was dealing with a condition as they may not understand.”

Ms Tan was referred to CAL’s programme in 2021, after her daughter’s doctor realised she needed support.

There, she made friends whom she could lean on during tough times. Her husband also made the effort to sit in during some sessions, which gave her support.

“My daughter could also feel it. She saw that mummy and daddy would be in the room once a week in a Zoom call doing something for her. She could see our effort and I feel that it also motivated her in her recovery journey.”

Ms Tan’s daughter, now 17, made a full recovery after six years.

Things to look out for

Dr Lee from Mount Elizabeth Novena Hospital said some subtle changes in behaviour may point to an eating disorder. These include:

  • Making excuses to not eat, like always saying that they have eaten before coming home
  • Insisting to eat later instead of with family
  • Covert removal or reduction of food from the dinner plate
  • Unexplained disappearance of food from the kitchen, and finding food debris in the bedroom
  • Rushing to the bathroom after meals and staying in there for a long time 
  • Excessive exercising and sticking to a rigid schedule regardless of illness, and becoming upset or refusing to eat if they are unable to exercise