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Calories that Control

Driven by social pressure and skewed body image standards, more Chinese girls and women are developing eating disorders, a mental health condition that often goes undiagnosed, with death rates as high as 20 percent

By NewsChina Updated Feb.1

Waking up in a daze, Zhang Qinwen found herself lying on the ground, her head covered in blood. People told her she had fainted. She was sent to hospital, but doctors said Zhang was too malnourished for anesthesia. In the end, they stitched up her head wounds without anesthetic.  

Zhang was anorexic. By the time she fainted, Zhang said she had not eaten regular meals in two years.  

“It was like falling into a huge black hole where the food looked like a monster,” she told NewsChina of the incident in Shanghai. “I really wanted to eat, but if I ate something, I’d get so depressed that I’d want to kill myself. I heard a voice shouting inside me: ‘it’s a monster,’” she said. 

In her early 20s, Zhang was already losing her hair. She had stopped menstruating, her skin was peeling and she had developed age spots.  

She was too weak to walk up a flight of stairs. Zhang’s parents tried to force her to eat, but she would cry for a whole afternoon for having eaten two small cookies and half a glass of skim milk.  

She hated how she looked, and she hid under tables, behind curtains and in corners. 

“I was miserable,” Zhang said, “I couldn’t find a way to fix it. The disease was extremely horrible.”  

Zhang was taken to an ICU, where doctors found she had wasted away to only 28 kilograms. Tests showed that her organs were failing. During treatment, Zhang blogged about her fight on Sina Weibo, where she set up a support group with others struggling with eating disorders to raise public awareness.  

Chen Jue, a clinician at the Shanghai Mental Health Center, said that between 5 and 20 percent of eating disorder cases end in death. 
Addicted to Dieting
The exact causes of eating disorders are still unknown. Research indicates genetic and environmental factors, such as mental health, family and social pressures. Chen told NewsChina that studies conducted in Western nations found that 90-95 percent of those diagnosed with eating disorders are females between ages 12 and 35.  

Chen found that in China, most are between 13 and 18 years old, and that vacation periods following national high school and college entrance exams are peak times for students to go on extreme diets.  

Zhang decided to lose weight when she was 18. Although 1.62 meters tall and weighing less than 50 kilograms at that time, she wanted to have slimmer legs. She worked out a strict diet using a calorie tracker app. Zhang set her maximum calorie intake at 800 calories a day, with a daily target of 500 calories. She followed the diet to the letter - even a single, between-meal bean would be counted.  

Zhang became addicted to dieting. She reduced her daily portions from three to two: one-fourth of a sweet potato for breakfast and a small bowl of green vegetables for lunch. She eventually dropped below 40 kilograms but could not stop dieting. Food became her enemy.  

“Nothing could make me happy. Every day, I hoped time would pass more quickly, yet I was afraid of tomorrow,” she told NewsChina.  

Yang Yang (pseudonym), 22, suffered through similar misery. She was 18 and attending university in Shanghai in 2016 when she began fixating on her figure. Coming from a city in Central China, Yang hoped to be more like the slimmer, petite women she saw in China’s coastal regions.  

She started a regimen of diet and exercise, which at first energized Yang. She continued to eat less and less.  

Yang said she lost control over her dieting while on a yearlong study abroad program in the US. The constant pressure of living in a foreign country had taken away her appetite. “I wanted to vomit every day,” she told NewsChina. “Sometimes I found my mind was stuck, and I couldn’t recall or think about anything. [When] I did eat something, I’d soon feel a strong sense of guilt,” she said.  

When Yang returned home in January 2019, she weighed little more than 40 kilograms. Due to her emaciated state, she developed a short fuse. She lost her temper easily and flew off the handle over trivial things. She was often confused, speaking incoherently.  

She longed for death. “Dad, when I fall asleep, please suffocate me with a pillow. I really want to die,” she once told her father.  

“Eating disorders, especially anorexia, cause emotional disorders such as depression and anxiety, so many patients suffer from depression as well,” Chen said.  

This is reflected in a 2014 report from Ghent University in Belgium, which listed suicide as a major cause of death for sufferers of eating disorders. Among those surveyed, 11.8 percent had attempted suicide and 43.3 percent had considered suicide. A report from the US Suicide Prevention Resource Center released in February 2020 showed that among a sample of more than 36,000 respondents, 24.9 percent of adults with a history of eating disorders had attempted suicide. The researchers, the report said, found that 31.4 percent of those with a history of bulimia and 22.9 percent of those with a history of binge eating had attempted suicide.  

Despite her depression, Yang refused medical help until her father begged her. By that time, she weighed a little more than 30 kilograms and had a heart rate at night of 30 beats per minute - a normal adult has a resting heart rate of 60-100 bpm. 
From Anorexia to Bulimia
Yang recovered after being discharged from hospital. Zhang was not so fortunate. Following her treatment for anorexia, she put on 10 kilograms and left China to attend university overseas. But after years of extreme dieting, her long-starved body began to overcompensate. Zhang turned to binge eating.  

At first, Zhang would gorge on six bowls of ice cream and more than 10 meals a day. Before long, she was skipping class to stay in her room and eat. She wolfed down several extra-large bags of potato chips and more than 10 loaves of bread in one sitting. Her stomach became so bloated that she appeared pregnant. Sometimes, she ate to the point that she had trouble breathing.  

Worried about her health, Zhang’s mother applied for an emergency visa to live with her in the UK where she was attending school. But she struggled to help. During the night, Zhang ate everything in the fridge. One day, she wrestled half a frozen pizza from her mother’s grip as she pleaded with her not to eat it.  

“I couldn’t control myself... I wanted to eat anything the moment I saw it. I once even ate a half-cooked chicken... It was like I wasn’t human,” Zhang said.  

Zhang returned to China for a second round of treatment. To prevent her from overeating, her parents installed alarms on their front door and the refrigerator. 

Similarly, another woman, who asked to be identified as “Ice Cube,” did not think her dieting would eventually make her bulimic.  

She did not have three meals a day. She ate all the time, mostly high-fat, high-calorie foods. She said she once gobbled down three 500-gram loaves of bread, and on another occasion, eight buns covered with fried pork flakes, a salad and two cheese tarts. Her constant binging left her feeling disgusted with herself. She was full, yet could not stop eating. In her diary, she called herself a pig.  

“It’s hard to understand, isn’t it? Nobody can understand unless they experience it themselves,” she told NewsChina.  

Li Xueni, an physician who treats eating disorders at Peking University Sixth Hospital, told NewsChina that sufferers of anorexia often shift to binge eating or bulimia.  

“It is part of the tortuous path to recovery from anorexia,” Li said.  

“Bulimics that use emetics [to induce vomiting] or laxatives are the most difficult to treat, since these methods exacerbate harm to the patients’ health and make it even harder to address their malnutrition,” she added. 
Cries for Help
According to Chen, people with eating disorders are at high risk of dying from organ failure caused by malnutrition or suicide due to depression. 

Chen said three months earlier, she had seen a young woman who was 1.7 meters tall but weighed only 25 kilograms. The woman did not have enough strength to stand from a squatting position. Chen immediately referred her to nutritionists and gastroenterologists to begin treatment. However, the woman died one week later.  

“She came to us too late,” Chen said.  

Unfortunately, this is a common issue. According to a paper published in medical journal The Lancet in March 2020, only 20 percent of people with eating disorders seek medical treatment, and mostly only in the later stages of their condition. 

In many cases, parents do not recognize the seriousness of the disease. When Ice Cube realized she was obsessed with eating, she expressed interest in seeing a doctor - only to face ridicule from her mother. “Why do you eat so much if you don’t want to? Just throw up,” Ice Cube recalled her mother saying. “You just lack self-discipline. It’s ridiculous that you want to see a doctor about something like eating.”  

“Most parents are unaware of eating disorders and don’t understand [what their children are going through]. They criticize their children with anorexia for being vain or those with bulimia for being gluttonous. Once they learn it’s actually a disease, they blame themselves. So eating disorders bring misery to the whole family,” Li told NewsChina.  

While there are no nationwide studies on eating disorders in China, experts said cases were very rare in the country before the 2000s. For a very long time, there were only two hospitals on the Chinese mainland with dedicated departments for eating disorders: Peking University Sixth Hospital and Shanghai Mental Health Center.
Morbid Aesthetics
In 2002, Shanghai Mental Health Center admitted only one patient for eating disorders, with another eight seen as outpatients. Those numbers began to increase in 2005 and have surged since 2012. In 2016, the hospital saw 1,100 people for eating disorders, and 2,700 in 2019. 

Li told NewsChina that during the 1990s, Peking University Sixth Hospital treated less than 10 patients for eating disorders annually. That changed in the 2000s. In one of her papers, Li wrote that her hospital treated 104 people with eating disorders between 2001 and 2005, three times the total from 1993 to 2004. In 2011, the hospital opened a department specializing in eating disorders.  

“Several years ago, cases peaked generally during summer and winter school vacations and we’d have space once the semester started... but in the last two years it’s been constant. There are so many patients,” she told NewsChina.  

Chen Jue at Shanghai Mental Health Center attributed the increase to China’s growing economic development, distorted values regarding appearance and biased societal beauty standards. Body image trends that went viral in 2015 and 2016 only perpetuated these distortions. In the #A4waist challenge, women photographed themselves holding a piece of A4 paper vertically to hide their waists, a width of only 21 centimeters. Another viral challenge involved women balancing stacks of coins on their protruding collarbones. 

These body image biases are prevalent on Chinese campuses. The mother of a junior middle school student told China National Radio this April that her daughter had always been sporty, but she scored low on the physical education portion of the national high school entrance exam because she had a higher than average BMI (body mass index), which damaged her daughter’s self-esteem. According to the report, many local governments include student BMI among the criteria for school evaluations. As a result, schools are encouraged to factor the BMI into students’ physical education scores.  

Under these pressures, more Chinese girls and women are developing eating disorders, a trend reinforced by the use of devices and non-prescription emetic drugs to induce vomiting that are readily available online. Meanwhile, those who are overweight increasingly face fat-shaming and are criticized for lacking self-discipline. In a 2019 survey of 265 female university students, psychologists Ren Fen and Wang Yanxue with the University of Jinan in Shandong Province found a positive correlation between anxiety over physical appearance and eating disorders. 
The disorder is starting to affect younger age groups and people in rural areas. Li and Chen told NewsChina they have treated patients as young as seven years old. China National Radio cited a 2012 study in Shanghai which found that among the children and teenagers surveyed, 1.3 percent of primary students, 1.1 percent of middle school students and 2.3 percent of high school students suffer from eating disorders.  

Prevailing standards of beauty are a big obstacle for treating disorders, according to Li. One of her patients refused further treatment when her weight increased to 42.5 kilograms. She told Li that she could not accept being heavier than 42.5 kilograms because that is the exact weight of a pop star she likes. Li warned that social pressures, combined with lack of awareness, makes those with eating disorders reluctant to seek medical help. 

Many are working hard to reverse the trend. Recently, Zhang and others created a support group on Sina Weibo that saw over 1,000 members join in the first few months. Some members with backgrounds in nutrition, psychology and medicine volunteer to give regular consultations and encourage sufferers to seek early treatment. 

Doctors like Li are also making efforts to combat eating disorders by providing online diagnoses and through public awareness campaigns, especially at schools, to spread the message that weight does not equate to health.  

Zhang recently held a photo exhibition that tells the personal stories of people struggling with eating disorders.  

Yang recently was accepted to a graduate program for psychology, and in the future hopes to help those with eating disorders emerge from the darkness of depression, helplessness and self-reproach.  

After receiving the good news, Yang posted to her WeChat: “The tall and sturdy banyan tree grows from closely woven roots that run deep into dark crevices in the ground. [Like those trees], I hope you can emerge from the darkness of eating disorders and live a flourishing life.”