Most people suffering with eating disorders in Japan are not receiving any medical or psychological support, according to doctors.
The Japan Society for Eating Disorders claims the health system is failing hundreds of thousands of sufferers.
It also says the pressure on girls, in particular, to be thin has “gone too far”.
The government says it’s trying to set up more services and has tried to discover the extent of the problem.
“I hated being chubby when I was a kid,” says Motoko – who is using a different name to hide her identity.
“The other kids bullied me so I always wanted to change.”
Motoko was 16 years old when her eating disorder started. She would severely limit how much she ate and then started exercising excessively.
By the time she was 19, Motoko was dangerously underweight. She says her parents didn’t know how to help her.
“They were negative about my illness,” she says. “When I tried to see my doctor, they told me not to.
“My mother felt responsible, perhaps my father blamed her too.”
Fear of ‘wasting food’
Motoko’s story is a familiar one. Stigma around eating disorders – for both sufferers and their families – prevent many people from coming forward.
“They see actions such as binging on food and then vomiting (bulimia) as shameful,” says clinical psychiatrist Dr Aya Nishizono-Maher, a member of The Japan Society for Eating Disorders.
“They feel they have to hide it. Parents may think they are wasting food so that might stop them seeking help.”
After more than 10 years, Motoko finally started getting the help she needed and she now attends one of the few eating disorder community support groups which receives money from the government.
She is now married and has a young son and says her life is much better since she started treatment.
But her experience as a teenager was very different.
“The school nurse saw me when I was so thin (but there still wasn’t any help). Maybe it’s something you cannot do anything about, but I wish I could have got the help I needed sooner.”
• Serious mental illnesses
• Treatable – full recovery possible
• Affects men and women of all ages and cultural backgrounds
• But young women are most at risk.
The Japanese government said it was difficult to get an accurate picture of how many people are suffering with eating disorders because so few come forward for treatment.
Doctors say the prevalence in Japan is “comparable with that of the UK”.
However, in 2014 only 10,000 people were getting treatment for eating disorders according to Japan’s Ministry of Health, Labour and Welfare. That’s compared to 725,000 people in the UK, a country with almost half the population of Japan.
There is no family doctor referral system, so it’s largely up to sufferers and their families to understand what’s happening and to find psychiatric support themselves.
Doctors say that is a big ask for people desperately trying to hide their illness, or not even recognising they are unwell.
“The medical system is failing people with eating disorders,” says Dr Nishizono-Maher.
“Hundreds of thousands of people are suffering in silence. There are very few services available to help people.”
‘Close to death’
The president of the Japan Society for Eating Disorders, Dr. Toshio Ishikwa, said: “It’s often too late by the time the patient is seen in a hospital.
“Their condition is very severe. Sometimes they are even close to death.”
The government acknowledges it has a huge challenge on its hands.
It set up a project in 2014 to try and establish the extent of the problem and how best to deal with it.
Takanobu Matsuzaki, Deputy Director of the Ministry of Health, Labour and Welfare, said: “We want to achieve widespread public recognition of eating disorders.
“We hold symposiums for the public and we publish information on our website to tell people about the programmes we offer.”
The government partly funds only a handful of community support groups. Mr Matsuzaki says he wants more of these services to be made available.
“We want to set up local systems of support where their illness can be picked up early so people can be helped sooner,” he explains.
Another major concern is the immense pressure women and girls in particular face to be very slim. Eating disorders are complex and rarely down to one thing, but there are concerns as to whether that pressure is having an impact.
Dr Ishikwa said: “Although the causes of eating disorders are unknown, there is the predominant cultural ideal that ‘skinny is beautiful’. That has gone too far and we need to address it.”
Japan’s first and only magazine aimed at so called “plus-size” girls is trying to encourage people to acknowledge and celebrate different shapes and sizes, not just the “skinny ideal” portrayed in the mass media.
Harumi Kon, editor-in-chief of La Farfa magazine, started the publication two years ago after her own battles with accepting her body.
She said: “When I was a teenager I was so embarrassed and ashamed of myself… Because I was big.
“Now it’s been 15-20 years but girls still feel like this. It’s just not right. I want to tell girls ‘just be yourself, be happy, be healthy’.”