Prof. Anna Brytek-Matera discusses eating disorders in Japan
Prof. dr hab. Anna Brytek-Matera from the Institute of Psychology at the University of Wrocław is developing a scientific project concerning the analysis of factors sustaining the symptoms of eating disorders. The research is being conducted at the University of Tokyo Medical School Hospital, which ranked 17th in the World’s Best Hospitals 2024 ranking and was named the best hospital in Japan.
The project is being implemented along with the head of the Department of Psychosomatic Medicine and a professor at the Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, University of Tokyo, prof. Kazuhiro Yoshiuchi.
What is the aim of the project? What does the project concern?
Our research aims to establish the relationship between eating disorders and psychological and physical factors in patients with anorexia nervosa and bulimia nervosa with the use of Ecological Momentary Assessment (EMA). EMA refers to an evaluation procedure conducted via technology to gain data from participants in their natural environments (“ecological” aspect) at various times (“momentary” aspect). All examined use the mobile application for the following 14 days. They answer questions concerning their mental health, as well as register meal consumption. During the research, we also use special devices, which establish the level of glycemia, physical activity and heart function. The research is going to help us identify the factors that contribute to unhealthy eating behaviours in patients with eating disorders in natural conditions.
When were eating disorders first mentioned in Japan? How broad is the topic in Japan?
The first research concerning anorexia nervosa in Japanese emerged at the beginning of the 40s of the 20th century; however, Japanese records from the 17th-18th century describe the disease of “not eating” comprehensively. During the Edo period, dating from 1603 to 1867, about thirty patients were described as “mentally ill” (over 90% were women from 15 to 40 years old), who did not consume meals regularly, rice for example. They only ate low-calorie products such as seaweed or tofu for extended periods. Modern scientists believe that these patients had early symptoms of eating disorders similar to today’s perception of anorexia nervosa. However, in the mentioned patients, there were no observed key factors of eating disorder development, namely the internalisation of the ideal of a slim body and a distorted body image. Some scientists suggest the possibility that those clinical cases would be classified today as indefinite cases of eating disorders or as disorders with food intake restriction/avoidance according to the currently applicable diagnostic criteria of DSM-5.
The first empirical research in the international scientific literature concerning eating disorders from Eastern cultures was first mentioned in the 70s of the 20th century. The prevalence of eating disorders in Eastern societies is less common than in Western cultures, however, it has significantly increased during the last three decades. For comparison, in 1997 in Japan, the prevalence of anorexia nervosa was estimated at 0,017%, while in 2015 it varied between 0,025% to 0,031%. It is estimated that the frequency of eating disorders among people in Poland is over 0,2%, while in Australia, it occurs in 4,5% of the population (i.e. over 1 100 000 people).
It used to be thought that eating disorders were exclusive to Western cultures. However, research findings and documented case reports that challenge accepted theories regarding the aetiology of eating disorders show that eating disorders are common across all cultural groups.
Are there any existing cultural differences concerning the diagnosis of eating disorders?
Certainly, the cultural differences pertain to the diagnostic criteria of anorexia nervosa. Research elaborated by the Committee for Research on Eating Disorders of the Japanese Ministry of Health, Labour and Welfare, concerns weight loss that remains over 20% below normal for more than 3 months, wrong eating behaviours involving food restrictions, bulimic episodes and eating in secret. The next criteria are body, shape, image distortion and intense anxieties about gaining weight, even in cases of underweight. Anorexia nervosa is diagnosed in patients among whom the disorder appeared before turning 30 years old, and in women with primary or secondary amenorrhea (the formers refer to the absence of menstruation in girls who, due to their age, should have already started menstruating, the latter refers to women who previously had regular menstruation cycles), as well as other symptoms, such as lanugo hair (thick, fluffy, pigmented hair all over the body, occurring in patients diagnosed with anorexia nervosa as an outcome of great body loss, and consequently malnutrition, hormonal imbalance and thermobalance), bradycardia (heart rate tempo below 60 beats per minute), constipation, hypotension, hypothermia (a drop in body temperature below 35℃), or oedema. The last criterion is the negation of the prevalence of the disease, including other mental disorders connected to anorexia nervosa and loss of body weight. In contrast, in Western cultures, to fulfil the criteria of anorexia nervosa elaborated by The American Psychiatric Association, the symptoms must include food restrictions, which lead to loss of body weight, and also a fear of an increase in body weight or persistent behaviour influencing its loss. The last criterion is the wrong perception of body weight or shame influencing one’s self-esteem, or the failure to recognise the insufficient body weight.
What does the healthcare system and the treatment of eating disorders look like in Japan?
In Japan, there are 4 kinds of inpatient treatment due to the prevalence of physical illness; first, voluntary hospitalization; second, hospitalization to provide medical health and life protection, with the consent of a family member; third, mandatory hospitalization, which includes hospitalization by the authorization of the governor of the prefecture; and lastly, emergency cases hospitalization. If a patient with anorexia nervosa refuses the treatment, despite the body depletion, the doctor is the decision-maker regarding involuntary hospitalization.
Interestingly, until 2010 there was a lack of official support from the healthcare in Japan for the range of prevention and treatment of anorexia nervosa. However, in recent years, the Japanese Medical Payment System allocated an amount of 2000 yen per day for 30 days and 1000 yen per day for 60 days for the intensive daily care of hospitalized patients struggling with anorexia nervosa, but only for those whose body weight index was below 15 kg/m², signifying a life-threatening condition. Patients between 6 and 69 years old have to cover only 30% of the treatment costs.
In Japan, there is almost a fourfold difference in the range or cost refund concerning the treatment of patients with eating disorders within the speciality. The doctor’s refund for conducting psychosomatic therapy is 1,100 yen for new patients (800 yen for follow-up appointments); however, for psychiatrists, who typically provide outpatient psychotherapy, the reimbursement is 4,000 yen for a 30-minute (or longer) consultation, or 3,300 yen for a session lasting less than half an hour.
Research conducted by prof. Kazuhiro Yoshiuchiego has shown that the annual cost of outpatient treatment was approximately 92,500 yen in 2017, which equals 754 euros or 794 American dollars. For comparison, the results of the systemic review from 2014 indicated that in the United States, the annual cost of patients’ treatment with eating disorders, such as anorexia nervosa or bulimia nervosa and overeating disorders, ranged from 2,993 to 55,270 euros (since the research was conducted across several countries, the authors decided to depict the costs in euros). Whereas, economic costs connected to eating disorders were established for 67,4 billion dollars in the tax year 2018-2019, which gave 11,808 dollars per person affected by the disease. Unfortunately, public data concerning eating disorder cost treatment is unavailable in Poland. The lack of reports on economic costs may be due to the limited availability of facilities offering treatment for eating disorders across Japan. I believe we face a similar matter in our country.
You are currently carrying out the research. Do you plan to continue the collaboration?
Thanks to the scientific scholarship received as a part of the Walczak NAWA programme, which is realised in collaboration with the Medical Research Agency, I will begin conducting research at the University of Tokyo starting April 2025. Our focus will be on the evaluation of a mobile health intervention for treating patients with binge eating disorders and obesity. We will be using mobile apps to monitor various variables, such as quality of life, body weight, and mood several times a day for the following 28 days. We will also measure the influence of Ecological Momentary Intervention on the suppression of binge eating episodes.
What benefits does your stay at the University of Tokyo provide?
As a beneficiary of the III edition of the program supporting academic scholars of the University of Wrocław in their departures to the world’s best global universities as a part of the “Excellence Initiative – Research University (2020-2026)” program, I have the opportunity to collaborate with outstanding scientists from Japan in one of the best research centre in the whole world. I believe that our university creates very favourable conditions for scientific development. Thanks to the exchange of experiences, we, as researchers from Poland, have the opportunity to gain the latest knowledge in our fields and, most importantly, apply it in future research and clinical practice.
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Prof. dr hab. Anna Brytek-Matera is listed among the most quoted scientists in the World’s TOP 2% of Scientists; the single-year impact list. She lectured at numerous universities, such as the University of Padova, the University of Nantes, and Stanford University. She was a sessional instructor at Western Sydney University and the University of Bordeaux. She is currently a visiting professor at the University of Tokyo.
Translated by Jakub Bucholc (student of English Studies at the University of Wrocław) as part of the translation practice.
