Victoria Beckham, Princess Diana and Oprah Winfrey admitted to it. Kate Moss denied having the condition and Keira Knightley sued the newspaper that accused her of lying about it - and won a settlement payout. As celebrities obsess about eating disorders in memoirs, confessions and television chat shows, incidence rates in the United States have reached epidemic levels, according to the National Association for Anorexia Nervosa and Associated Eating Disorders. Seven million women and a million men in the US are suffering from some form of eating disorder, with 86 per cent aged under 21 when the illness starts and 43 per cent aged under 16. They and other sufferers around the world can feed their dreams at more than 400 'pro-ana' websites that display 'thinspiration' photos of emaciated stars to show what can be achieved, and offer tips and support on living with anorexia. The sites, many of which carry warnings that people enter at their own risk, have drawn criticism from health advocacy groups for rejecting the fact that anorexia nervosa is an eating disorder. Controversy over standards of thinness also hit the fashion industry last year after Uruguayan teenage sisters Eliana and Luisel Ramos - both models - died of heart attacks within six months of each other. Spain banned ultra-thin models from the catwalks and the French National Assembly moved legislation in April to make it illegal for anyone - including fashion magazines, advertisers and websites - to publicly encourage extreme thinness. The Australian government is considering a similar move over pro-ana websites as part of an internet censorship plan. Hongkongers are bombarded with images of super-thin fashion models from giant hoardings across the city's shopping districts but public debate over any link with eating disorders - and the support provided for sufferers - has been muted. That could change, however, following the tragic death of 16-year-old Megan Farrell, a student at West Island School - part of the English Schools Foundation - who was believed to have been suffering from anorexia. The Year 12 student died at her home two weeks ago of a viral infection after becoming increasingly ill over several months, according to the Pok Fu Lam school. The tragedy has triggered intense mourning at the school, with hundreds of students joining a memorial group on Facebook, but West Island has also moved swiftly on preventative action following discussions with ESF leaders. The school has set up a student-led monitoring group to look out for signs of eating disorders among students so sufferers can be identified early on and offered appropriate support and treatment. Philippa Yu Man-wai, head of the Hong Kong Eating Disorders Association, the only dedicated support group in the territory for people with anorexia, bulimia nervosa and related conditions, welcomed the move. 'I have not heard of any other school setting up a student-led monitoring group on eating disorders,' she said. 'It is a good idea as dieting behaviour is quite common for the youngsters. But it is important that there is training for the students who take part.' Ms Yu said the association ran information sessions on eating disorders in about 100 schools a year - mainly across the government and aided sector - but there was a great need for additional advice and support services. A study of more than 3,500 students aged 11 to 20 carried out by the association in 2005 showed that more than 40 per cent had 'body dissatisfaction', 44 per cent engaged in unhealthy weight-control behaviour and more than 6 per cent were at risk of developing eating disorders. Exposure to pro-ana websites among teenagers in Hong Kong was limited but the launch of a wide range of slimming products in the territory in 2003 had been a big influence on youngsters, as were celebrity magazines, advertisements and pop culture. 'There is quite a lot of demand for our services,' Ms Yu said. 'Almost all of the cases request psychological support and sometimes dietetic consultations as well. Because it is a life-threatening illness, we normally see patients for one to two weeks and it is very intensive treatment.' Clinical psychology services were the responsibility of public hospitals but since the provision was not meeting the needs of patients with eating disorders, the association had employed two clinical psychologists of its own to offer treatment. It received an annual grant of HK$260,000 from the Social Welfare Department but met the remainder of its total HK$1.5 million to HK$2 million annual expenditure through fund-raising activities. There have been three registered deaths due to anorexia over the past seven years, according to the Centre for Health Protection but neither it nor the Hospital Authority had figures available on the number of patients with the condition. A centre spokeswoman said the student health service run by the Department of Health promoted healthy eating, proper diets and physical activity through service centres and outreach teams. Students found to have an abnormal body weight would be assessed by doctors and dietitians, and then referred to specialists. A spokeswoman for the Hospital Authority said doctors referred patients with eating disorders to the psychiatric services for follow-up action and the most recent psychiatric outpatient figures - from 2003-2005 - showed there were 280 to 295 per year with eating disorders. 'The Hospital Authority will continue to closely monitor the demand for such treatment and will arrange for redeployment of resources to meet the needs of patients if necessary,' she said. But Sing Lee, director of the Hong Kong Eating Disorders Centre at Chinese University, said there were waiting lists of three to 18 months for psychiatric services and outpatient appointments, which lasted eight to 15 minutes on average - too short to meet the needs of patients with eating disorders. 'This is a level of provision that would be totally ineffective,' he said. 'The only treatment with proven effectiveness for anorexia nervosa is intensive psychotherapy - but that is barely available in our health services. 'A low rate of help-seeking is typical for people with anorexia in general and particularly with Asian kids in Hong Kong. Subjectively, they don't feel that they have a problem. 'And there is a tremendous amount of resistance amongst teenagers to attending a psychiatric outpatient service because of the sense of stigma associated with psychiatry. They don't feel that they have a psychiatric problem.' Professor Lee said the eating disorders were now 'probably one of the most common problems among young women in Hong Kong' and early intervention was essential to prevent the condition becoming life-threatening. Measures such as biannual body weight screening and group counselling sessions on eating disorders should be introduced across all schools to help identify students who were at a high risk. But this needed to be led by a central agency, which could also provide user-friendly clinical psychology services and should receive government support, because school principals were 'already quite busy with teacher stress and educational reforms'. Elaine Leung, a parent member of the ESF's new governing board, said: 'People are being bombarded with images of people slimming and being successful. 'I think these cases are more noticed in schools that serve the more affluent sections of the community but I think it is prevalent everywhere. I don't think that schools in any sector really have the resources or the time to come up with their own policies and programmes on eating disorders. 'We need one organisation to take the lead and set up a centre to co-ordinate support for schools.' Such a centre, which could be based in a medical school, teaching hospital or a government agency, should organise seminars and briefings, provide information for schools and offer individual counselling, advice and referrals. But Michael Wong Wai-yu, chairman of the Association of Heads of Secondary Schools, said: 'School principals in my association never mention this as an issue in their schools. So I don't think this is a common problem in government and aided schools.' The Hong Kong Eating Disorders Association can be contacted on 2850 4448 ( http://www.heda-hk.org )
