Anorexia: The epidemic Japan refuses to face up to

Anorexia: The epidemic Japan refuses to face up to

Eating disorders, once unknown in Japan, are now increasingly more rapidly than anywhere in the world. Yet women have to wait seven years for treatment.

Hachiko wants to meet for the first time over breakfast at the Krispy Kreme shop outside Shinjuku station. This is the busiest district in Tokyo, the bit of the city made famous in photographs. Everyday, millions of people commute into Shinjuku to work long hours in high-rise office blocks and to hang out in massive neon-lit department stores and nightclubs.

Like the rest of Japan, Hachiko is mad for Krispy Kreme donuts. It’s the country’s latest fast food craze and she wants to indulge her sweet tooth with her favourite snack.  There’s a queue to get in and the place is packed but its easy to spot her. She’s the only Japanese person sitting in the room with dyed blond hair. She’s also the skinniest.

When I get up close to meet her I catch my breath. Although strikingly pretty, Hachiko’s skin looks whiter than the snow on the ground. Her smile reveals teeth that are decayed and yellower than butter. When shakes my hand for the first time I notice her wrist is half the width of mine.

Its winter and below zero degrees, yet Hachiko is wearing a mini dress over her thin body and no tights. As he gets up to greet me properly her pale skinny legs – each as thin as her wrist – attract worrying glances from customers. Hachiko, however, ignores them. She wants the world to accept her for what she is: a woman struggling with Anorexia – and desperate to get noticed.

“No hiding from now on. I want to show off my body and be honest about who I am and what I’m going through,” she explains in an upbeat voice when we sit down to talk about her eating disorder. “Here in Japan, nobody talks about their problems openly like they do in the west. It’s not our culture. Silence is the golden rule, a Japanese virtue. We have to always pretend nothing is wrong, but I’m tired of hiding.”

Hachiko sips her plain tea but her original-glazed donut remains untouched. Its too early in the morning to be eating so many calories and she’s scared even a bite will kick start a binging spree.

Hachiko is 25 year old and, at 5’2 inches weighs only 33 kilos or 75 pounds. Doctor’s tell her she’s at least 20 kilos below her healthy weight.

Instead she talks about the loneliness of her Anorexia even though there are many like her here fighting the same battle. “If every woman who had an eating disorder in Japan checked herself into a hospital today there would be no room left for any other patients,” says Hachiko with all seriousness. “It’s a very big problem and something needs to happen for sufferers to get their lives back.”


“Anorexia Nervosa and other eating disorders has been around for a long time,” explains Dr. Aya Nishizono-Maher, a psychiatrist specialising in eating disorders at the Tokyo Metropolitan Institute of Medical Science and Department of Clinical Child Psychiatry. “In fact, Japan’s first reported case of Anorexia was in 1788- almost 100 years before the first case was identified in the UK. But there was an Anorexia and Bulimia boom in Europe and America during the 60’s and 70’s that Japan never experienced.”

Fast-forward to the present day and Japan, like other developed countries, is grappling with the increasing number of women developing chronic eating disorders. Dr. Hiroyuki Suematsu, a professor of clinical psychology at Nagoya University, says Japan’s Anorexia Nervosa rate is 10 times higher than it was 30 years ago. There were no reported cases of bulimia 40 years ago. Today, it’s the country’s biggest eating disorder problem.

Unlike the rest of the developed world, however, Japan’s population is getting skinnier- not fatter. Government data show that since 1984, women between the ages of 20 to 59 have become thinner (BMI of less than 18.5). The percentage of those women who are overweight (BMI over 25) has declined, as well. In a bid to stay trim and be accepted in Japanese society, women are consuming lesser calories than they did during the Second World War.

“America’s definition of Anorexia is anyone who is 15 percent under their standard body weight. If you applied the same metrics to the Japanese population, than more than half of the country’s young women would be considered Anorexic,” he says.

Dr. Hiroyuki Suematsu says the obsession to stay slim is profitable business and the diet industry is booming. Its also making the country richer.  “The Japanese government collects 3 billion yen in tax revenue each year from companies selling slimming aids,” he says.

Blessed with good genes and a healthy, low fat diet, most Japanese people stay slim naturally. Even so, its’ difficult to ignore the pressure to be skinnier. Japanese models, singers and celebrities are thinner than they were 30 years ago, and many women look up to them. In many cases, the country’s biggest stars are opening suffering from disorders like Anorexia but they remain very popular, such as the singer Cocco.

More disturbing is the endless billboards and magazine covers of young women-often depicted as little girls with pubescent figures- used to sell everything from milk to mobile phones. This young, innocent girl image is an extension of a unique Japanese obsession with “kawaii” culture. It’s a celebration of all things cute, such as dolls, cartoons and comic book figures, and often these Kawaii images can become sexualized as well.

The line between a reality and a fantasy body is blurred and some doctors believe it can contribute to body obsession among young Japanese girls “There are certain images that young people want to pursue that belong in Kawaii culture,” says Dr. Suematsu, “Young girls especially want to look like their favorite characters, even if they are not real. And, often these characters are unrealistically thin.”

Psychologist Dr.Norio Mori concurs. “Kawaii in Japanese means cute. And for many young girls that’s the ideal.”

Dr. Norio says the influence of the media and Kawaii on young girls means that there are more patients coming in with eating disorders- and they seem to be getting younger. “One of my Anorexic patients is only 9 years old,” he says. If a girl develops an eating disorder in her teens in Japan, she often continues to battle it in the twenties and sometimes even longer.

Hachiko was only 16 years old when she developed her eating disorder. She agrees that kawaii culture has an influence, but she says its not what drives her condition. She thinks its more about acceptance and control.

“When I look in the mirror I see a person that is desperate to disconnect her self value with her weight. I want my body to look healthier. I don’t want to look like the skinny girls in adverts or on the streets. It’s an obsession here Japan to be thin, with a petite little girl body, but this is not my ideal.”

Dr. Nishizono-Maher also believes that body image in the media is just one aspect of the problem and that other factors are contributing to the rise of chronic disorders.

“Like other developed countries, Japan has moved from a pre-feminism to post-feminism society, “ she says. “A woman’s role is no longer defined and she doesn’t have a clear idea of her place in society anymore. The nuclear family has disintegrated and more people are living alone, confined in private spaces. In isolation, sufferers can indulge their addiction.”

Dr. Nishizono-Maher adds that the unique 24-hour lifestyle in Japan- particularly in urban cities- makes it easy for people to continue a destructive eating disorder cycle.

“Japan is one of safest countries in the world. It has a very low crime rate, so women don’t stay in when it’s dark. They go out whenever they want, because they are not afraid. They also work and have money to buy things and access the conveniences of the city. Japan’s major cities are vibrant at night and all the shops are open till late, some never shut. A person with an eating disorder can go into any convenient store –which are on every street corner-to buy binge food whatever time they like. These stores also lack human interaction, so a binger can go into the store over and over again and not be embarrassed about their compulsive behavior.”

Dr Masayuki Yamaoka, the director of the department of psychosomatic internal medicine at Tokyo’s Kudanzaka hospital, has a more controversial theory. He believes the root cause of eating disorders in Japan is the lack of maternal love in the sufferer’s past.

“Forty years ago, mothers stayed at home to raise children. They had grandparents and a husband to provide a support network. Over the past decade, more women are going to work and the entire system of raising children has shifted. Children are not getting enough attention and love from their mothers, who are struggling to balance work and family life. This can cause them to have great stress and insecurity.”

Consequently children are susceptible to developing unhealthy coping mechanisms such as an eating disorder. Dr. Yamaoka’s research coincides with this theory. Hey says the number of eating disorders went up when more women entered the work force.

Dr. Yamaoka further claims that even when mothers are staying at home, they still may not be providing enough maternal love to their children. “Women have no support network to help them raise their children properly. The husband is generally absent in Japan now as well, since they are expected to work long hours, and other family members are not around to educate and show them how to raise a child. Japan also has a dirth of daycare facilities” He says this can cause depression and frustration in a mother, making her incapable of sharing the level of maternal love that the child needs.

“There is definitely a rise in post-natal, mental health problems. I am also seeing more mothers and pregnant women coming in with issues with their body weight,” says Dr. Nishizono-Maher. “This puts new pressures on families.” Some Japanese mothers are also developing Alexi-Theymia- an inability to read emotion properly, which is partly caused by lack of family interaction.

“The number of underweight babies being born in Japan has gone up steadily as a result of women controlling their calories during pregnancy,” she says. “Children and babies are also getting skinnier, because the mother with the eating disorder is also controlling the calorie intake for her children. In most cases she can’t read when her children are hungry because she doesn’t feel hunger herself.”

Dr. Nishizono-Maher highlights the overall breakdown of the Japanese family, and the relationship problems between husband and wife-which can also trigger eating disorders. Neglectful and over-controlling parenting, which is common in Japan, is equally harmful. If the child does not have a stable or nurturing home then they grapple to find a way to gain control over their lives and are in danger of harmful societal influences, such as the media’s perception of beauty.

Hachiko can identify with a lot of these triggers. She still lives at home with her mother in the city she was born, a flishing port in Isakawa, about 300 miles north of Tokyo.  She has an older sister who is married and leading a normal, healthy life. Her dad rents a house nearby and she goes to see him everyday. She says her childhood was fraught with insecurity and that her eating disorder ultimately destroyed her parents’ difficult marriage.

Hachiko’s eating disorder began when her classmate was made captain of the tennis club. It was a position she wanted, and she thought that if she looked and acted like her classmate she would achieve this goal, and gain more approval from her family.

“I was very competitive and wanted to be like her. She was very skinny and kept losing weight and I thought I would be accepted as captain one day if I did the same.”

They both drastically reduced their calories, and quickly became alarmingly thin. Within a year she dropped nearly 10 kilos. But she says everyone ignored the problem at school, while teachers dismissed it as a phase when she tried to get help. Hachiko’s parents were also in denial.

By the time she turned 18 years old, she had lost 10 kilos, mainly from starving herself on less than 1000 calories a day. “When I first became anorexic I barely ate anything,” she says. “I would skip breakfast and then for lunch and dinner I’d have a handful of rice and some vegetables and that’s it.”

These days, Hachiko prefers to have two big meals at lunch and dinner followed by a vast amount of snack food. A lot of what she eats is a typical Japanese diet, which is nutritious and packed with vitamins, such as green vegetables, rice and fish. Sadly she binges and purges every time she eats.  This is what keeps her weight down.

One of her rituals is eating raw okra during her meal. It’s a popular vegetable in Japan and Hachiko buys it chopped and vacuum packed in snack size bags. “Okra is slimy when its fresh and it makes it easier to throw up,” she explains. “There is other slippery foods in the Japanese diet I stick too, like seaweed with Miso soup, tofu and yams.”

Overwhelmed by her disorder, Hiroko has shoplifted for food and has tried to kill herself. She wants to get better but doesn’t know how. She blames her family for ignoring her condition, and the lack of medical expertise she gets in Japan. “Nobody ever talked to me about my problem. Not even the doctors. They don’t know anything,” she says. Hachiko has been hospitalised 6 times and discharged after a few weeks. “Doctors just made polite conversation with me, asking me how I am and how my day has been. I have to a find a solution to my own problem.”

“The treatment of Anorexia and other eating disorders is inadequate in Japan,” agrees Dr. Maher. “Unlike the UK, people aren’t registered at a local GP. They go to independently run clinics that don’t even have the complete medical record of a patient. Most of these doctors are also not trained to assess psychiatric issues and to refer patients to a specialist like they are in Britain. Also, to make things worse, there are very few specialists to be referred to that can actually deal with the problem.”

Consequently, the onus is on the sufferer to find a doctor who can either help the patient or refer them to someone else If a doctor agrees to see a patient they only have 10 minutes for the consultation.

“Often the waiting list to see an eating disorder specialist is 7 years, and doctors usually only take patients that other doctors couldn’t treat,” says Dr. Yamaoka. “There are simply not enough professionals who are trained to deal with the issue,” says Dr. Yamaoka.

Dr. Maher says a multi-disciplinary team of experts should work together to deal with the problem, such as psychologists, nutritionists and psychoanalysts. She says that Cognitive Behaviour Therapy (CBT), which is used widely to treat disorders in the west, could be very effective in Japan, but the government hasn’t approved it as a medical treatment. Even psychologists are not properly recognised professionals.  She says the UK’s B-EAT organisation is good model to copy but Japan is still far behind in achieving this goal.

In the meantime there is only a disparate number of independent support groups that sufferers can turn to for help. The biggest of these organisations is the Nippon Bulimia and Anorexia Association (NABA), a self-help group made up of chronic and recovering sufferers of anorexia and bulimia.  They meet regularly and offer emotional support and to run a support line. It has several independent chapters across Japan but the main office is located inside a cramped, two-room apartment in a bland low-rise, concrete apartment block in Tokyo.

When you walk in, the air is stale and boxes of papers block most of the halllway space. The main sitting area is filled with more paper work and office equipment and there is no place to stretch your legs when you sit.

Despite the organisations many good intentions to improve the look of the centre with teddy bears and drawings, the place looks like its run on very little budget. Its messy, chaotic and claustrophobic. There is simply not enough space to run an office- let alone host regular meet ups where people with serious psychological issues can relax and talk comfortably about their feelings.

The moment you meet Mome Tsuruda and her team, all these impressions about NABA are melted by her warmth and charm. She greets you with a hug and constantly makes eye contact with her guests. She offers green tea and chocolate. She laughs a lot and listens even more. Her kindness is what keeps people coming back. Its like she’s invited you to her own home and you’re a person she truly care about.

“We are not here to fix problems, but we bring people together to share stories and to let people know what’s really happening in our lives,” explains Momoe Tsuruda, She herself has struggled with Anorexia and Bulimia for over 20 years, and, like Hachiko, says it was a lonely and frightening experience. “We are always putting up appearances that we are fine in Japan, but we are not being honest about our lives. When you are with others with similar problems you can be yourself and tell the truth.”

Sakura, a 31-year-old waitress living in Tokyo, regularly attends NABA meetings. She says her eating disorder was brought on by a stressful home life, and exacerbated by the images of beauty she watched on television.

Growing up, Sakura’s father, a truck driver, bullied the family and intimidated them by throwing objects on the ground and screaming abuse. “His anger was a part of the daily routine, like brushing our teeth,” she confesses. “He was a small man with no power outside the home, yet he ruled the family with violence. He had all the control in the family.”

Turning to the media to escape her sadness, Sakura began watching programmes on television and was drawn to the beautiful girls she saw, especially the Korean pop stars. She wanted to be skinny and slim like them.

“Most women in Japan want to look like Asian celebrities,” says Sakura. “Unfortunately, Asian models and celebrities are a lot skinnier than they used to be, and this sends the wrong messages for emotionally vulnerable people like me.” The more exposure Sakura has with the media and television, the greater her desire to look as skinny as a little girl and to control her weight.

“There is pressure to be skinny in Japan among girls. We talk about it a lot here at NABA. The culture here is to be thin. People are generally ostracised when they are fat. Its good to discuss it and to keep telling ourselves its wrong.”

Sakura and Tsuruda credit NABA for saving their lives. However, several doctors are concerned about the way in which the organisation operates. Dr. Yamaoka believes that these groups aren’t helping sufferers with their illness, but encouraging them to accept their problem and to go on battling the condition without the necessary medical treatment.

Mother and Daughter Therapy- Japanese Style
Dr. Yamaoka solution is one that he says is not accepted by western doctors as an effective treatment for their societies but is extremely successful in Japan. It is called “Reparenting Therapy” which involves training willing mothers to interpret and respond to their children’s emotional signals- regardless of the child’s age. This helps to restore the basic trust level and repairs the psychopathology of the patient’s family.

“In western cultures, if you are over 18 years old, you don’t have the same attachment with your parents as you did when you were younger,” explains Dr. Yamaoka. “In Asian countries like Japan, however, we don’t create a distant barrier between the mother and daughter. It is still acceptable for a mother to sleep in the same bed or have a bath with her daughter if she is over 18 years old.

In his therapy Dr. Yamaoka asks the mother and daughter to agree to a therapy contract to regain trust between them and to give the mother a chance to train herself to respond to her daughters emotional needs with role play. Mothers are encouraged to express their love for their child through hugging and hand holding and tucking their daughters into bed. Dr. Yamaoka claims that the success rate for this programme is very high.

Dr. Suematsu is also interested in this form of therapy, but due to the financial restraints of hospitals, Its difficult to treat a patient for longer than one month and this requires more time.

Other creative and cost effective ways are being introduced, among them the “Lunch Session”, pioneered by Dr. Matsubayashi. The therapy involves filming families having lunch together at a hospital and then discussing how they communicate with one another.

Dr. Nishizono-Maher encourages monitoring and guided-self help, and involving patients with the therapy.

All the doctors interviewed agreed that an institution devoted to treating chronically ill patients would be ideal and a proposal has been drafted to open am eating disorders hospital in Tokyo. The recent earthquake, tsunami and Fukushima nuclear crisis, however, has left the government cash strapped. Getting the facility set up in the near future seems unlikely.

Raising awareness and treating patients early on is the most feasible option, and luckily Japan’s younger generation is finding a way to become more open about themselves and their feelings.

“In Japan, there is no equivalent phrase to say I am hurt, I’m suffering or I am sad in Japanese,” says Hachiko. Without the words or the companionship to share her problems, Hachiko spends a lot of her time boosting her own confidence by making etegami. This is a Japanese picture letter that includes sentences expressing one’s feelings direct from the heart.  She makes them for herself, with phrases that implore her to be true to herself and to love herself for who she is. Hachiko also seeks comfort anonymously with other suffers on a site called Mixi, Japan’s equivalent to Facebook.

She hasn’t had a boyfriend since she was 19 and her only encounter with men is through random guys she meets online, whom she uses to buy food for her binging.

“I would like to be with someone and have a baby, but I don’t know if I’ll ever be able to have one. Because I am so thin I haven’t had my period since I was 16 years old. Hopefully that will change if I get better.”

Dr. Nishizono-Maher sees some positive change in Japan, mainly from the younger generation. “Adolescents are getting used to talking to counselors at schools and our clinics are full of patients wanting to talk,” she says.  “When there is communication, there is a chance for recovery.”


This article appeared in the June 2012 issue of Marie Claire.
Photographs by Kayo Yamawaki.