Journals    
Present Issue 
Past Issues 
 

THESMANEWS   
Present Issue 
Past Issues 
 

SMJ Editorial Board 

Letters to the Editor

Instructions to Authors 
 

Singapore Med J 1999; Vol 40(08):

Thin Desires and Fat Realities
E K Ung, D S-W Lee

INTRODUCTION

The pursuit of thinness is no longer a Western monopoly. As countries become more industrialised, rates of excessive thinness and fatness rise and preference for thinness becomes more pronounced. Changing concepts and attitudes towards body shape and desirability have made the relentless pursuit of thinness commonplace in Singapore.

Winds of change appear to be sweeping across all of Asia. Even the Japan Sumo Association has started fat testing for the first time in the 2000-year-old sport. The message bombarding young women is, "be thin and be lean" as the passport to happiness, success and desirability. Mirroring this has been an increase in advertising related to slimming, fitness and beauty; an increase in the number of slimming and fitness centers; the introduction of mandatory weight control programmes in schools as well as thin and lean actresses and models representing the body ideal. For example, popular actresses Fann Wong, Ann Kok and Zoe Tay have a body mass index of 17.1, 17.1 and 17.4 respectively. The corresponding "average" Singapore Chinese female of the same height and age range (based on weight for height reference charts for Singapore) would have a BMI of 19.5, 19.9 and 19.7 respectively. The truth is that girls do not ask, "I wonder if it is unhealthy to be too thin" but "how can I look like that?". In the latest national survey, rates of obesity have increased for Malay and Indian females, adding to the pressures to be thinner. Data comparing average weights of Playboy centerfolds and Miss America contestants against the average weight of American females from 1959 to 1988 show a progressive increase in the latter and decrease in the former(1). Studies have also shown an increase in the number of dieting manuals and slimming products. These findings lend credence to the feminist theory of eating disorder which suggests that environmental pressures towards the thin ideal are the key explanation for the increase in eating disorders.

In the Wang et al study(2) presented in this month’s journal, 53% of females and 28% of males wanted to be thinner. 11.4% of females in the lowest tertile of BMI (less than 18.7 kg/m2) are "underweight" (WHO recommends 18.5 to 24.99 as the healthy range) but still want to be thinner. Such figures, though routine in the West, are cause for concern as such attitudes are often the harbinger of future eating disorders. Data from the United States, Israel and Australia show such weight concerns in much younger cohorts, with about half of pre-adolescent girls sampled voicing concerns about weight, appearance and diet. As early as 6 - 7 years old, 42% of girls preferred body figures thinner than their own(3). Another finding of the Wang et al study was a link between "Westernisation" (based on English being the main language spoken at home) and body dissatisfaction. Studies looking at ethnic differences in rates of eating disorder yield discrepant findings but more studies than not show higher rates of eating disorders, body dissatisfaction and dieting behaviour in Caucasians (compared to Black or Asian). Studies also show a positive correlation with social class which may act as a confounding factor. A lack of correlation between parental education level and preference for thinness in the current study lends weight to the authors’ contention that ‘Westernisation" is the key factor and not social class. Some studies of young Asian immigrants assimilated into Western cultures show that they are more prone to developing eating disorders and dietary restraint than even their local counterparts, suggesting the presence of powerful factors related to cultural transition. Some studies, however, show no such ethnic variations in weight concerns and further research is necessary to explain the discordant findings.

In a pilot study of 26 fourth year female medical students in the National University Hospital(4), the mean BMI was 18.7 (50% below 18.5, 77% below 20). Fifty-eight percent reported feeling very or moderately fat and only 12% reported not feeling fat. Just under half (46%) expressed slight or moderate dissatisfaction with their bodies and 42% had dieted to lose weight. Four of the 10 with BMI’s below 18 reported feeling very fat. This data is consistent with the findings of Wang et al.

The factors which relate to "Westernisation" and weight concerns can be categorised into "push and pull factors". "Push factors" stem from societal perception of the undesirability of fatness and "pull factors" from the desirability of thinness. Society gives the message that fat people should not be taken seriously, (when was the last time you came across a fat actor or actress who was not a comedian?). Studies show children as young as 6 using derogative terms such as "lazy, stupid, ugly" to describe the silhouette of an overweight child. Doctors are not exempt from such behaviour. It is not uncommon to hear of stories where doctors have made sarcastic and cynical comments to their overweight female patients. Some teachers in mandatory school weight loss programmes may be more insulting and punitive than encouraging, thus further eroding the self-esteem of their young charges. Advertisements conjure up an illusion of quick, effective and lasting weight loss. The reality of dismally low long-term success rates create further pressure in an increasingly heavier society. Other advances which parallel "Westernisation" such as improved access to information and increased health-consciousness may also lead to body dissatisfaction. Television, advertisements and print media would seem to be reasonable "pull factor" culprits. In a study of preadolescent and adolescent schoolgirls, 69% reported that fashion and women’s magazines influenced their idea of the perfect body shape and 47% wanted to lose weight because of magazine pictures(5). Watching soap operas and movies is positively correlated with body dissatisfaction and watching music videos, drive to thinness(6).

How should the medical profession respond? It is futile to attempt to change societal concepts of beauty. Advertising budgets of health organisations pale into comparison with that of entertainment and corporate entities. The thin ideal is here to stay - at least for the time being. Girls just want to be thin. Men want their girls thin. Supply follows demand. Obesity is a rising problem and obesity is a genuine health hazard. Promoting healthy methods of weight control and avoiding extreme or inappropriate weight-control behaviours is a reasonable aim. Pertinent issues revolve around awareness, empowerment and promotion of healthy selfesteem. Early and wise psycho-education and intervention is likely to yield the best results. Mandatory school weight and wellness programmes should be monitored and reviewed. Teachers running such programmes would benefit from better training and support. The importance of pooling together the expertise of various disciplines to try to identify and protect those at greatest risk of developing eating disorders in such programmes cannot be overstated, nor the authors’ call for well-designed epidemiological studies of eating disorders in our young.

In conclusion, fat is no longer just a feminist issue. It is a personal, familial and societal issue cutting through all strata of society. Ideas of beauty, desirability, thinness and fatness have to some extent become "universal" with our modern day ease of communication. ‘Ally McBeal’ is as much a cover story in the pages of Sunday Plus as in the New York Times.

Department of Psychological Medicine
National University Hospital
5 Lower Kent Rdige Road
Singapore 119074

E K Ung
MBBS, MPCPsych, FAMS
Consultant Psychiatrist

D S-W Lee
Research Assistant

Correspondence to: Dr E K Ung