Worada Elstow had just entered university when she was recruited for modeling work. Soon she was subsisting only on black coffee and a small plate of suki haeng without noodles or eggs every day. But it wasn’t enough, so some days – especially when the cafeteria was too full – she’d forgo eating for a cigarette instead.

I don’t need this indication of beauty and sexuality anymore, I’m beautiful the way I am

For Worada, eating had become the precursor to self-induced vomiting like the binge-and-purge cycle of many eating disorders.

By her second year at Chulalongkorn University, Worada’s nails had turned purple and she was fainting between classes. Her teeth were decaying from frequent exposure to the acid in her digestive fluids.

With medication, therapy and support from her loved ones, the more extreme habits of her eating disorder – which has symptoms of both anorexia and bulimia – began to subside.

Worada, now 25, might have ended up in the emergency room with her illness undiagnosed – or dead, were it not for her family recognizing she had a problem.

“My uncle noticed I wasn’t eating and took me to the doctor. I got treated for my eating disorder as well as for depression, which I believe was interrelated,” said Worada. “The anti-depression meds really helped.”

She’s gotten help, and even though she is still recovering, Worada wants to talk about a potentially fatal problem she and the medical community worry other young Thai women are suffering untreated.

‘Under the Radar’

A number of doctors and psychologists interviewed for this story said they believe eating disorders are on the rise, particularly among urban youth. But no one knows the scope of the problem because – anecdotal evidence aside – eating disorders in Thailand are under-reported, aren’t tracked and haven’t been studied.

There is no academic research or data concerning the prevalence of eating disorders in the country, according to Kullaya Pisitsungkagarn, a Chulalongkorn University psychology professor.

“By nature, eating disorders are secretive and very personal,” she said. “Since most Thais are petite and want to be thin anyway, they slip under the radar. There has been no substantive research on the number of Thais suffering from eating disorders.”

The Public Health Ministry doesn’t have information either.

“There are definitely eating disorders among Thais, but universities haven’t investigated or researched them yet,” said ministry Chief Advisor Yongyuth Yuthavong. He believed that was because it was relatively new to Thailand.

Without reliable data, practicing doctors can only estimate.

Anuttara Pothikamjorn, a pediatric endocrinologist at Bumrungrad International Hospital, said that generally, private Bangkok hospitals in Bangkok, including where she works, receive five to 10 patients with severe anorexia or bulimia every year.

“But multiply that by all the private hospitals and add them together, and it’s a significant amount,” she said.

And those are only the diagnosed cases.

Many more likely go unreported due to the social stigma against psychological treatment, or undiagnosed because hospitals aren’t trained to recognize it.

Many Thais are too embarrassed to seek therapy, said Aswin Nakpongpan, a child psychiatrist and lecturer at Chiang Mai University’s Faculty of Medicine.

Friends and family usually don’t bring in loved ones suffering from eating disorders until they have physically broken down, partly due to low awareness of the disease, said Adipat Chaichanasakul, a psychologist at BNH Hospital.

“The average person who has fallen ill from an eating disorder will receive electrolytes and have their body mass index checked out at a public hospital. There is no eating disorder hotline, and no hospital has a full support team ready to take care of someone with an eating disorder,” Adipat said. “Many have only their body treated, not their mind.”

Under Pressure

Rather than identifying one monolithic cause to blame, Anuttara said such disorders are nurtured by a set of common factors – abuse from family members or peers, anxiety about puberty, school and even perfectionist behavior types – which can increase one’s vulnerability.

Young Thai women especially are susceptible to “heavy expectations placed on a lack of self-esteem,” Kullaya said.

Worada knows this well. 

“I started modeling in 2012, in my first year at university. All the other models were taller than me. As a petite person with short legs, I thought I’d battle them with my thinness,” she said.

The baht value assigned to her body as a commodity in modeling was psychologically damaging.

“A direct monetary value was assigned to my body. For example, I might charge 3,000 for a photoshoot, but those born-to-be models can get 10,000 baht. I’d think, ‘If only I was this much thinner, I could make a few thousand more,’” she said. “I started to feel guilty whenever I ate. So after eating, I was so stressed that didn’t even have to force myself to purge, it all just came up.”

Worada’s delicate build and doe eyes are belied by her frank recitation of how the disease wracked her body. She speaks casually, almost blithely, when recounting the details in part explanation and part confession.

“Sometimes I puked so much that I had to flush the toilet twice,” she said before smiling and looking off to the side. “You know, I’ve never told anyone that before?”

While she should have been focused on her studies, her life was being taken over by another education.

“Did you know, noodles, including mama noodles are the easiest to puke up? They come out in one lump.”

She said she used cigarettes and spicy tom yum soup piled with chili powder “as hot as I could take it” as intense laxatives. She discovered “Pro-ana” or pro-anorexia communities online that helped her rationalize her disease.

“There’s this whole community online that says that they choose to be like this, that having anorexia is a lifestyle that they want to have,” Worada said.

On pro-ana forums, Worada would chat with others in the community about how many calories a glass of water had, or make inspiration boards with pictures of Kate Moss and her infamous quote, “Nothing tastes as good as skinny feels.”

Her favorite pictures, she would set as her iPhone lock screen: sometimes a photo of a Victoria’s Secret model, others, the words “STOP EATING.”

While Worada’s health has returned, the pressures of life are still there, and it’s clear her struggle isn’t over. She admits as much. 

“You know, I have an underwear photoshoot tonight? I know I said I was mostly cured of this disease, but if I’m taking people’s cash for a shoot, then I still can’t eat normally,” she said.

At another point, she reached for her phone, where “STOP EATING” still screamed at her from the screen.

“You know I’m planning to shave my head Saturday? I’m telling everyone I don’t give a fuck anymore. It’ll be good for me. I don’t need this indication of beauty and sexuality anymore, I’m beautiful the way I am,” she said, giving voice to her internal dialogue.

Common Causes

Similar to Worada’s case, medical experts agree that Thailand’s social veneration of thin, intense parental pressure and changing urban lifestyles make conditions ripe for women to develop eating disorders.

“This pressure to be thin, combined with the social practice of commenting on people’s bodies can make one feel as if they lack personal space,” Kullaya said. “This can make one feel uncomfortable, and for people with low self esteem … can lead to harmful behaviors.”

While “fit is the new skinny” may be in vogue in the West, skinny is still the same old skinny in Thailand.

“When someone gets thin, they get complimented, and the thinner they keep getting, the more compliments pile on.” Adipat said. “However, this may put pressure – not just women, but also men – to purge, restrict their food intake too much or overexercise.”

Anuttara of Bumrungrad said Thai media doesn’t just represent hyper-thin women as normal, but also hits them with marketing for all manner of diet products.

“Even a NatureGift ad would trigger me,” Worada said, referring to the diet coffee brand advertised with gaunt models. “Later in the bathroom, I’d tell myself that I was fat and ugly and fat and ugly, and then everything would all come up.”

Overbearing parents can factor into eating disorders, Anuttara said, as the ability to binge and purge or not eat is a means for children to gain a sense of control. At Bumrungrad, she says she gets young people from well-off families that have developed eating disorders due to helicopter parents.

“As a kid, my mother was always hard on me. I never felt like I was good enough for anything, and I would act out by seeking attention or self-harm,” Worada said. As she matured and eventually enrolled as a French major, this manifested into depression and ultimately her eating disorder.

Rapidly changing lifestyles – enabled by technology, addicted to unhealthy food and susceptible to fads – are another force at play.

But doctors say it’s mostly a city thing.

Affluent, urban Thais are generally more the vulnerable to eating disorders.

“Only comparatively small groups of urban-dwellers are the most prone to eating disorders. The spread to countryside lifestyle has been rather slow,”  said Chiang Mai psychotherapist Aswin.

And though the disease has a gender-bias, it’s not only women suffering.

“Some suffering from eating disorders are gay men concerned about their bodies, as well as straight men, who are usually intense muscle builders,” Anuttara said. Hanging out with a group of body image-focused peers, such as ballet dancers or body builders, can also be pressures for teens.

Anuttara said she’s even treated Bangkok youth with orthorexia, a lesser-known eating disorder in which someone is so obsessed with eating healthy or – as the trend is now – “clean” food, that it creates similar problems.

Shifts in eating habits – from eating for survival to feasting on cheese tarts – also sees eating disorders more prevalent in urban centers.

“Not too long ago, the problem for many Thais was, ‘Do we have enough food to eat?’ Now, it’s shifted quite rapidly to, ‘We have enough food, but how do we eat in a smart and beneficial way?’” Kullaya said.

Not Alone

There are also social norms that counter the pressures that can produce eating disorders.

Aswin, the child psychiatrist in Chiang Mai, said there is relatively less obsession over body image in Thailand than there is elsewhere, as families in Asia are more likely to link self-worth to education and social status.

“The teenagers I treat mostly suffer from other conditions, such as stress from too much studying, engaging in drugs, risky behavior or unprotected sex. I can remember by name the ones who come in for eating disorders,” he said.

BNH psychologist Adipat said communal eating habits, with friends and family sharing dishes and scooping food for each, may discourage some development of eating disorders, compared to the solitary Western dining experience.

Worada remembers how her peers and loved ones came through in that regard.

I began to associate food with joy again.

“During lunch break, my friends who knew about my eating disorder would drag me to the cafeteria. They’d sit across me and made sure I ate,” Worada said. “The people around you really affect your recovery. When they took me out for food, I felt like I was loved. If you can’t love yourself just yet, find someone to help.”

Her boyfriend then would mash chili into rice for her to eat or take her out for meals she couldn’t refuse.

“Once he got me to eat the ramen at Bankara Ramen, and the pork was amazing. I still remember that.”  Worada said. “I began to associate food with joy again.”

She worries about others suffering silently.

“This self-harm just isn’t worth it, trust me. You have more to offer than just your body. Don’t feel like you’re not good enough or that you’re unloved. Please go get help from a doctor, or even come talk to me,” she said when asked about advice she would give to those currently suffering from eating disorders.

As for herself, Worada plans to make good on her promise to quit modeling – she hasn’t yet – and pursue a master’s degree in psychology.

As our interview ended, she jumped atop a concrete pedestal – a popular spot for taking photos at Chulalongkorn’s Faculty of Arts.

“How about a picture of me up here? I want people to know that this human is well again,” Worada said.