Most of us look forward to the festive season. After all “‘tis the season to be jolly”. It is a time for family and friends to be gathered together, often with the accompaniment of special treats and food. However, this may not always be the case for individuals who struggle with eating disorders.
Across various cultures, food is a unifying cultural thread, and eating is a huge and important part of our social lives. Oftentimes we forget the pervasiveness of food in our everyday lives. Have you ever considered how integral the role of food is in building social connectedness and relationships? We catch up with friends over meals and have informal business meetings over coffee. We also celebrate important occasions and milestones over food. The phenomenon of foodstagramming (a term used to describe the act of taking pictures of one’s food and posting it on social media), or “the camera eats first”, also dominates our social media.
As a result of the emphasis that is being placed on food, individuals with an eating disorder may feel tremendous stress and anxiety partaking in food-focused family traditions and gatherings with friends during the holiday season.
What are eating disorders?
Eating disorders are a category of psychological conditions that manifest themselves in persistent and unhealthy relationships between body image, food, eating and exercise. They usually develop in adolescence and young adulthood and are often associated with a whole host of distressing thoughts and emotions. Eating disorders can affect people of all ages and of any race, gender or body type.
Some types of eating disorders include:
An eating disorder characterised by weight loss (or lack of appropriate weight gain in children), unhealthy eating patterns, intense fear of gaining weight and significant body image concerns. This condition is extremely dangerous as it can lead to malnutrition, starvation, and death.
Bulimia is characterised by a cycle of bingeing and purging, where the individual eats large amounts of food (larger than what most people would eat in a similar period of time) in a way that feels out of their control, and then engages in purging which involves self-induced vomiting, fasting, or excessive exercise, Individuals with Bulimia also tend to have significant body image concerns.
Binge-eating disorder involves periods of consuming unusually large amounts of food in a discrete period of time, accompanied by a sense of loss of control over eating. Binge-eating episodes are commonly associated with difficult emotions such as guilt, disgust and shame.
Struggles Faced During the Holiday Season
A daily struggle for someone with an eating disorder is worrying about what and how much they will eat, how to burn off the calories consumed. When faced with an abundance of food choices and especially food that they do not commonly eat or labelled as “bad”, such worries become exacerbated. For example, someone with binge-eating urges may find it difficult to control their eating during such situations, leading to increased feelings of guilt and shame, as well as negative beliefs about themselves that come with these feelings.
Disruption of Routines
Obligations to attend various parties and gatherings will also likely disrupt everyday routines such as meal timings and exercise. In addition, structured meal plans that may be essential for someone at a specific stage of eating disorder recovery may also be impacted when dining with others.
The holiday season is also a time when we are faced with expectations from family and friends to be happy and relaxed, and to indulge in food. However, for individuals with anorexia nervosa, they may find it extremely difficult to finish their food when family is watching what they eat, or may feel pressured when others are encouraging them to eat larger amounts of food, which can lead to feelings of shame and guilt. Asking someone if they have eaten is often a way of showing we care, but for someone with an eating disorder this could potentially trigger a whole slew of body-image related thoughts. Additionally, stress may also come in the form of worrying about how to manage comments from others about how they look or what they are eating or not eating.
Individuals with eating disorders tend to feel isolated as they may withdraw from social gatherings as a way of coping with the deeply rooted fear of being negatively evaluated by others. During the holiday season where gatherings involve many more people, this fear can become intensified. They often find it hard to express their anxieties and struggles to family and friends, while at the same time feel unable to escape such situations, resulting in them feeling overwhelmed and detached.
How One Can Manage The Struggle
Preventive Measures and Coping
Given the challenges that someone with an eating disorder might face during the festive season, it is important to be proactive and plan ahead to make it easier to transition into the holidays. Friends and family can also be a significant source of support.
Adhere to a meal plan as much as possible to avoid binge or restrictive eating habits.
Identify potential triggers. List them down and try to brainstorm appropriate solutions or coping for each one of them.
List down coping statements that you think might be helpful. Remind yourself the reasons to leave the eating disorder out of this meal.
Plan non-food related activities that are fun and relaxing to recharge or bond with loved ones. You might feel most vulnerable during the first hour after meals, so plan to do activities that may help to distract yourself from the difficult thoughts or urges to binge or purge.
Arrange check-in sessions to review your game plan with your psychologist before the holiday season.
Practise how to politely set boundaries and prepare a list of topics in case you need to change the topic for when someone makes comments about your appearance or eating that make you feel uncomfortable.
Speak with family members or other members of your support system before the holidays to help them understand your needs and potential triggers.
Identify a support person or a “buddy” who can help with sticking to your plans as well as provide emotional support when needed. It might help to arrange a code word or signal to indicate that you are feeling overwhelmed and need additional support.
Be kind to yourself! Acknowledge that you are stepping outside your comfort zone. It is understandable that this might be difficult and challenging for you, but struggling does not mean you are failing.
Set realistic goals and expectations of yourself. Take things one step at a time.
Catch yourself when you criticise yourself again. Recognise that you are doing the best you can.
Give yourself the gift of enjoying the meal. Remove the idea of treating food as a “reward”, and give yourself permission to enjoy the food and company.
How Family and Loved Ones Can Help
Be there for a loved one who is struggling. Listen to their struggles without making any judgments.
Ask them how they feel and try to validate their feelings, even if you may not fully understand what they are going through.
Avoid being the “food police” unless the treatment team has given you a plan to monitor and portion food for your loved one.
Avoid making comments and judgments about calories, eating and physical appearance.
Refrain from making criticisms and instead offer support and words of encouragement.
Expat life and moving around the world places a great deal of stress on children. DR REBECCA GIESS and DR MARK TOH from Promises Healthcare share how parents can help them adapt to new environments and people.
What issues do children deal with when adjusting to expat life?
Rebecca: They suffer mostly from homesickness, and grief from losing friends, extended family and familiar places. In a new country, they find it difficult to fit in and feel a sense of belonging. They have a fear of missing out (FOMO) on life back home.
Mark: They perceive a threat in relocating. Extended family and friends represent the emotional resources the child depended on, and the disruption in daily routine affects their emotional security and stability. This is an important and largely overlooked stressor. How children experience this, and how prepared they are for the change, is based on their relationship with their parents.
What are the red flags?
Rebecca: It can be difficult for children to know how they are feeling or how to express it. They may exhibit anti-social behaviours by breaking the rules or defying expectations. Tune into your child to uncover the underlying emotional triggers, and what they might need emotionally from you.
Mark: For children under the age of eight, there may be more crying, moodiness and irritability, complaining about school, expressing worry, or becoming withdrawn and clingy. There may also be regressions such as thumb-sucking, temper tantrums or toilet accidents, despite being potty-trained.
Children aged seven to 10 may worry about their health or family and express anger and irritability. They may also pin negative labels on themselves. Some of these behaviours may manifest at school more than at home.
Preteens may be more reactive to the demands and stress of the new school, complaining about the different system or classmates. They could become withdrawn, have more incompleted homework, or have declining grades.
How can we help teenagers adjust?
Mark: Teenagers will miss their friends, prom, graduation and sports pursuits – the rites of passage – and they may feel their sense of identity being stripped away. They may display depression, anxiety, irritability, apathy and withdrawal, which increases their sense of isolation.
Those who feel ready to be independent may feel trapped with their family. They blame their feelings on the relocation and start to resent the family for it.
If the teenager is close to completing Grade 12, consider allowing them to graduate before they relocate.
How can parents navigate their child’s emotions?
Rebecca: Create space and guidance for their emotional experiences. Parents can validate and normalise their emotions by saying things like: “It makes sense.” Or: “It’s normal to feel sad or stressed.”
Don’t place any expectations on how your child “should be feeling”. They feel what they feel. Parents can help them label their emotions and work out how best to manage them.
Talk to your child about becoming a “third culture kid” – someone who spends a portion of their developmental years in another country. There are several benefits and challenges worth understanding and planning for.
I recommend parents read Third Culture Kids: The Experience Of Growing Up Among Worlds (Pollock, Van Reken & Pollock 2017).
What is most important to the child?
Mark: Children are looking for safety and security. With younger children especially, this depends on how close they are to their parents. Pay more attention to any work or social activity that might threaten this bond. Parents must remain accessible to the child, meeting regularly, exploring and discovering the country together and having fun in the process.
They should also assess how they themselves are coping, and if they might be unintentionally neglecting their child’s needs.
What can parents do at home?
Mark: Help children to set up their room. They are more likely to embrace their new home when they know that their needs are being met predictably. Parents should be ready to share their personal feelings and discoveries to encourage their children to communicate as well.
Create routines that bring everyone together. Playing games encourages bonding. Team games, where discoveries can be made individually and shared collectively, are particularly useful. In the process, the family learns about each member together.
How can a therapist help?
Rebecca: Therapists are trained to work with children experiencing anxiety and depressive symptoms due to adjustment difficulties. Children are rarely completely open with their parents and may do better in a non-judgmental safe space.
Mark: A therapist looks at both the child and family’s wellbeing. How is each person in the family coping? If there are individual or collective difficulties uncovered, the therapist could help them get unstuck.
About Dr Giess & Dr Toh
Dr Giess has extensive experience in working with teenagers and parents. She also helps adults address severe and chronic mental and physical health issues, and is trained in couples relationship counselling.
Dr Toh treats troubled children and their families and helps them to address their challenges. Helping parents to parent well is also a concern for him. He also works with couples and individual adults, as well as individuals with personality disorders.
Promises Healthcare is at #09-22/23 Novena Medical Center, 10 Sinaran Drive. Contact the team at 6397 7309.
She shared that gaming addictions often develop in the context of underlying issues, such as struggles with schoolwork, bullying, or tensions at home. Children hence turn to gaming as a coping mechanism, she added.
*Visions by Promises is the addiction treatment arm of Promises Healthcare. This interview was done before its formation.
The Straits Times reached out to Henny Tan, Senior Clinical Psychologist to get her thoughts on the BMI classification.
She shared that “Having the BMI classification in the report book may unintentionally encourage children to consider weight as an important indicator of self-worth, and some may also view being outside the “acceptable” range as being a failure”
Youths these days have a lot on their plate. Teenagers have to cope with the highly competitive education system, and the fresh graduates are worried about employment opportunities or career advancement. Coupled with the need to maintain good relationships with their friends and family, these individuals may be experiencing high levels of stress. Some people do thrive well under stress, but what happens when stress levels exceed the healthy range? For those who are unable to cope, chances are their mental wellbeing would take a toll.
With young people unable to attend school in person regularly or go into the workplace during the circuit breaker, they might have felt increasingly isolated due to the lack of face-to-face social interaction over this extended period of time. Furthermore, having to fight for their own space while at home with their family members may have caused some conflict and frustration for some. Undoubtedly, cabin fever may have also kicked in for some of them. Although circuit breaker measures have recently been eased, youths may not be able to adjust back to the norms as easily as one might expect. Reports have shown thatit is expected that more youths will be prone to developing mental health issues such as depression due to the various implemented COVID 19 pandemic coping measures.
Depression is one of the world’s leading mental health disorders, and youths have become increasingly prone to it. Studies have shown that depression affects up to 18% of Singaporean youths. People with depression may turn to self-harm or experience thoughts of suicide. These are often methods they adopt in order to cope with their difficult emotions. According to the suicide prevention agency Samaritans of Singapore (SOS), suicide remains the leading cause of death among youths aged 10 to 29 in Singapore, and as of 2018, 94 of them had succumbed to suicide. In order to curb the rise of depression cases among youths, it is important that we are able to identify the early stages of depression. Doing so will allow them to seek treatment earlier and to help them get back onto their feet. Depression, if left untreated, will severely impact people’s lives in a negative light, causing personal, educational and familial difficulties.
Here are some of the most common symptoms of depression that you should look out for (not exhaustive):
Extreme sadness and low mood
Lack of interest in activities once enjoyed
Lack of self-worth
Experiences sleep disturbances and loss of appetite
But how can we first better support troubled youths? When it comes to dealing with depression, individuals with mild depressive conditions could adopt self-help strategies such as trying to maintain a balanced diet, to pick up on relaxation techniques, embark on daily gratitude journaling exercises (e.g. 3 things I can be thankful for today) and get some exercise in, even if it’s just a stroll around the estate or exercises from ATHLEAN-X™ or Athlean-XX for Women. Try encouraging them to live a healthy lifestyle and maybe create a ‘Daily Wellness Plan’ – a list of little and big things they can accomplish on a daily basis to comfort and keep their moods up. However, it is key to take note that even though their depression may be perceived to be mild from a third person’s point of view, we should never make assumptions as to what they truly feel on the inside. We should never, under any circumstance, tell them to “snap out of it”. It is very important for us to be patient and listen to what they have to say if they do approach and confide in you. Stay empathetic and show your concern for the individual. Acknowledge and respect their feelings and worries. Listen actively by using active listening skills. Encourage them to join mental health support groups like those conducted by PSALTCare – journeying with others that are going through similar struggles can encourage social healing.
On the other hand, for those coping with moderate to severe conditions, we might need to encourage them to seek a multidisciplinary approach to recovery like psychiatric help and look to taking medications, with supporting psychotherapy or counselling sessions and support groups. They might also be afraid of the stigma attached to seeing a Psychiatrist or what would transpire in that session. Try to assure them that there is nothing to be ashamed of. In fact, it is a lot more common in Singapore now, and a trip to the Psychiatrist is as straightforward as seeing your family doctor. Alternatively, these youths can book appointments for psychotherapy first. With appropriate treatment and support, it is entirely possible for them to move on and lead a more productive and happier life. Here’s a questionnaire that is widely used by Psychiatrists to help determine depression to help you with next steps decisions: www.mdcalc.com/phq-9-patient-health-questionnaire-9