Obsessing about body weight can be a debilitating, even fatal, condition, and it is affecting more and more of China's young. Liu Zhihua examines the worrying trend.
Obesity is a hot issue in China. In the last couple of years, the issue of fat has hogged the headlines time and time again. But even as China grows bigger around the waistline, there is another eating disorder that is plaguing many of its young - anorexia nervosa.
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Anorexia is an eating disorder that can get in the way of a normal social life at best. At its worst, it can take away life.
Experts say it's all in the mind, and they categorize anorexia as a symptom of mental imbalance, usually among teenage girls and young women. The fear of weight gain becomes pathological and the suppression of hunger and the avoidance of food can lead to metabolic and hormonal disorders.
Some victims may consequently die from malnutrition and the resulting organ failure.
"The incidence rate of anorexia nervosa has increased very quickly in China in the past decade, but society is apparently not ready to deal with it," says Zhang Darong, a mental illness specialist with Peking University No 6 Hospital, one of the most famous psychiatric hospitals in China.
"Most Chinese are unfamiliar with the term, and many patients hear about it for the first time when they are diagnosed."
Zhang was one of the first specialists in China on the eating disorder, since the early 1980s. According to her, there were only 52 eating disorder cases in the hospital from 1983 to 2001.
By 2006, the hospital was already dealing with the same number of patients in a year. These days, they see about 20 patients every month.
At the Shanghai Mental Health Center, the number of anorexia nervosa patients is four times higher than 10 years ago, according to reports by the city's Youth Daily newspaper.
"Anorexia nervosa is a 'fashion' disease," Zhang says. "In a society obsessed with thin figures and a market flooded with advertisements for slimming products, the disorder is almost inevitable."
The causes of anorexia nervosa are not specific, although studies have put forward the theory that starving feeds the vicious cycle of destructive eating patterns, caused by changes in the neuro-endocrine system.
The numbers get truly alarming when you realise that almost half of young Chinese girls go on diets to try to lose weight, and that the incidence rate for anorexia among dieters is eight times more likely, according to Zhang.
"I'm abnormal. You cannot imagine how much I regret it," says Guo Yue, 27, an inpatient at the Peking University No 6 Hospital. Her real name has been changed to protect her privacy.
Guo, from Hubei's provincial capital Wuhan, started dieting in 2004 when she was just 19. She thought she was too fat. She cut down food to a minimum, drank coffee without food every morning, and tried to still her hunger pangs by drinking just water.
She also found out that if she pressed down on her stomach after eating, she could induce vomiting, and she started doing that after every meal.
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Her weight dropped rapidly from 56 kg to 48 kg, and for her height at 1.6 meters tall, she became underweight. Still, she considered herself too fat and she weighed every bite of food and exercised rigorously.
"I was addicted to throwing up," Guo says, describing her bulimic condition. "But I felt I had achieved something. I didn't realise I was ruining myself."
Her personality soon changed, battered by constant hunger and plagued by fears of being overweight. Although she was a naturally gentle person, she started yelling at people all of a sudden. At other times, she would fall totally silent.
In 2010, her worried family forced her to seek treatment and she was diagnosed with anorexia nervosa. She gradually recovered after a course of medication and psychotherapy sessions, but she suffered from many relapses.
After being hospitalized in Wuhan five times, she was sent to the Peking University No 6 Hospital a few months ago. By then, she weighed only 35 kg, and her food intake was only a fourth that of the average adult.
"If time could turn back, I would never do these silly things," Guo says. "It's so hard to get rid of the illness."
Guo was lucky to be diagnosed early before more comorbid mental disorders set in - such as depression, anxiety disorders and obsessive-compulsive disorder.
"Many patients have other mental disorders and physical complications when diagnosed," says Han Xueqing, a mental health specialist with Tongren Hospital in Beijing. "It is hard to recover when the condition becomes complicated. Unfortunately, getting an early diagnosis of anorexia nervosa in China is like winning a lottery."
The odds are poor because the disorder is relatively "new", and it develops so slowly that both the patient and those around her may not be aware in the initial stages.
When the excessive weight loss and avoidance of eating finally become obvious to family members, they may seek medical help. But very often, because they are not aware that anorexia is actually more a mental than a physical disorder, the patient may be brought to a digestive tract or neurological diseases specialist, Han explains.
Yu Xiao, 22, is one such patient who was wrongly diagnosed.
The Yangzhou native developed anorexia in her freshman year in college in 2008. She dieted so vigorously that by her second year at college, she was suffering from amenorrhea due to severe weight loss.
Her family sought treatment in Yangzhou, Jiangsu province, and Shanghai, and she was medicated for irregular menstruation and digestive tract diseases. The medication proved ineffective and only made her more uncomfortable.
"Eating is easy for other people, but for me, it was very hard," Yu says. "I was hungry, but I didn't want to eat. I was afraid of putting things into my stomach, because I thought it would make me ill."
And even after food, she would exercise rigorously, thinking that exercise would help expel the food.
Her family did everything they could to tempt her to eat. Her mother thought she was being capricious, and conversation between them was concentrated on eating and gaining weight - so much so that they were quarreling about it.
"There was nothing left in my life except eating or not eating," Yu says. "I wanted to please them, but I couldn't persuade myself to eat. Life seemed hopeless and I gradually changed into another person. I was like the walking dead, but sometimes I would shout at people."
In late 2011, she was finally diagnosed with anorexia in a hospital in Yangzhou, and in early 2012, she was admitted to Beijing Huilongguan Hospital for treatment, at 1.7 meters tall and weighing less than 40 kg. She was extremely underweight, and suffering from depression and obsessive-compulsive disorder.
After being treated for about two months, she gained 10 kg and started eating again.
"I don't blame the doctors in Yangzhou and Shanghai. Few people are aware of this disorder. Who would think of such a thing?" Yu says.
"Our society is more tolerant of people who are thin rather than fat. But if I had known there was such a disorder, I would never have hurt myself in the first place."