When Hiroyuki Suematsu left medical school in the early 1960s eating disorders were still rare in Japan. During his own childhood after the Pacific war binge eating would have been almost unthinkable.

“When I was at elementary school we didn’t have enough food to eat. No-one knew what bulimia was.”

Even just ten or twenty years ago eating disorders were thought to be much less common in Japan than in other developed countries. But recently Japan appears to have caught up, and the number of sufferers may still be increasing.

A government survey in 2002 found that 2 percent of female high school students in Japan were anorexic. Doctors say that cases of bulimia are even more common. As in Europe and North America, many sufferers in Japan are women in their teens and twenties.

Dr Suematsu deals treats patients suffering from eating disorders and is Director of the Graduate School of Human Sciences at Kawamura Gakuen Woman’s University. He says that, while men and middle-aged and elderly women are generally putting on weight, young women are getting slimmer.

“For young women, obesity simply isn’t an issue . . . being underweight is the problem. When surveys have been done asking young Japanese people ‘do you want to be slimmer’, most say yes — even young people with a standard body weight.”

Foreign residents too can be surprised at perceptions of beauty. “I get a lot of these papers in my mailbox for beauty salons. They have pictures of girls before and after (slimming) treatment,” says one 28 year old Austrian student in Tokyo. “The pictures of before look fine to me, but in Japan they are already overweight.”

A 2002 survey by the Ministry of Health Labour and Welfare found that a quarter of Japanese women in their twenties were underweight. And doctors say that for every person who suffers from anorexia or bulimia there are many more at potential risk of developing an eating disorder.

“What is increasing is the number of ‘sub-clinical’ cases,” says Dr Aya Nishizono-Maher, a research psychiatrist at the Tokyo Institute of Psychiatry. “They don’t fit the diagnostic criteria of anorexia and bulimia, but sometimes (sufferers) diet, sometimes they vomit, sometimes they eat normally, sometimes they binge.”

Girls as young as their early teens face strong peer pressure to diet. “When girls bring school lunches to school from home they compete to bring the smallest lunch boxes possible,” says Nishizono-Maher. “In magazines (for children) there is information about how to diet, calorie calculations, et cetera. Even junior-high school girls know how to calculate their body mass index.”

“There is no way to measure the number of children at potential risk of developing eating disorders,” explains Dr Masayuki Yamaoka, the director of the department of psycho-somatic internal medicine in Tokyo’s Kudanzaka hospital.

However, small scale studies in schools and anecdotal evidence suggest that moderate to severe dieting is common among young teenagers.

Girls at schools with high entry requirements are often most at risk. “We know that eating disorders are common among hardworking and intelligent students,” says Dr Yamaoka. “There’s a possibility that if some students are put in a situation of stress they can stop eating and develop a full-blown eating disorder.”

Some children turn to self-induced vomiting, laxatives, excessive exercise or fasting.

Those who do become ill with anorexia or bulimia may have a long struggle ahead of them. “Psychological counseling and self-help is just as important as medication,” says a representative of the Nippon Bulimia and Anorexia Association. NABA is a collection of self-help groups for recovering sufferers of anorexia and bulimia to meet for mutual support.

“People suffering from anorexia and bulimia can return to a stable weight, and to others they look as if they have recovered. But it doesn’t mean that their psychological struggle is finished.”

It is crucial to detect eating disorders at an early stage, says Doctor Suematsu: “It’s a fact that if you treat anorexia in its early stages people get quicker better.”

The introduction of counselors into Japan’s middle schools has helped teachers and parents pick up early warning signs. But he still believes that more help for sufferers is needed.

“The necessary measures to detect eating disorders are not taken over the whole country and treatment is not always available quickly.” Treatment is easier to find in the cities than in the countries, and patients can be left waiting months for an appointment.

Meanwhile, children, adults and the media continue to equate thinness with beauty.

“When I was at middle-school girls were worried about their weight too, but I still feel that there are more slim children now,” says one 28-year-old Japanese counselor who visits Tokyo elementary and middle schools.

“Actresses are slimmer than they used to be. There is an actress on TV sometimes who I think has suffered from anorexia. She’s so thin that I feel uncomfortable looking at her.”

“I was surprised when my students saw her on TV and told me that they want to be as slim as she is. They think she is beautiful.”

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