Although bulimia nervosa is one of more commonly referenced eating disorder types in popular culture, it, like much in the world of eating disorders, is thoroughly misunderstood.
Bulimia is characterized by episodes of uncontrollable binge eating episodes paired with inappropriate compensatory behaviors to prevent weight gain. The key words to pay attention to are “uncontrollable” and “inappropriate.” Much like in binge eating disorder, these instances of eating are not simple episodes of overeating but usually involve eating several thousand calories at once to the point of physical pain and severe discomfort.
The corresponding compensatory behaviors mirror the severity of the binge eating. Although we typically think of self-induced vomiting, or purging, in bulimia, these compensatory behaviors could also include laxative or diuretic abuse, prolonged fasting or excessive exercise. To give an example, a person with bulimia might compensate for a binge by fasting for several days or running something like 10-15 miles on consecutive days after bingeing.
By nature, bulimia is a disorder of cyclical behaviors, and once an afflicted individual is stuck in that pattern it becomes very challenging to escape. The pattern will likely look something like this:
Strict Dieting Behaviors > >
Tension (“White Knuckling”) > >
Food Cravings > >
Binge Eating Episodes > >
Purging or Other Compensatory Behaviors > >
Feelings of Shame and Guilt > >
Return and Re-Commitment to Strict Eating Behaviors
The key to recovery is to break this cycle, and an important place to start is to look critically at the baseline eating pattern as it’s often unreasonably strict. Fear of weight gain will often create distrust of a more “normalized” eating pattern, but this shift is essential to avoiding relapsing into the familiar cycle of bulimia.
Although the physical signs of bulimia may be less visually apparent than anorexia, the mortality risks of this disorder remain high. In anorexia, severe weight loss and change in physical appearance may alert family and friends to the existence of the problem. In contrast, someone struggling with bulimia may maintain a very normal weight and, although the eating pattern is chaotic, the weight pattern may be stable. Regardless of weight status, poor body image often drives the baseline eating rigidity which drives the rest of the cycle of bulimia.
The practice of purging via self-induced vomiting can lead to severe electrolyte imbalances and potential cardiac arrest. Additionally, repeated episodes of this behavior can damage the lining of the esophagus and risk tears in that tissue; an esophageal bleed is an emergent-level medical problem that can be fatal if not quickly addressed.
Outside of the severe medical risks of bulimia, the social and psychological impact is severe. Instances of bingeing and purging almost always occur in isolation, and the subsequent feelings of shame and guilt become part of the chronic cycle of the disorder.
Although weight changes may or may not be part of the presentation of bulimia, other signs may include fear of eating in public or with groups, disappearances immediately after eating, unusual swelling in the cheek or jaw area from repeated self-induced vomiting, dental damage, extreme concern or preoccupation with body shape and weight, and frequent dieting. Keep in mind that many of these signs are related to purging via self-induced vomiting, but bulimia may also be present with other compensatory behaviors.
“Diabulimia” is a term describing the intentional misuse of insulin in those with type 1 diabetes for the purpose of “purging” calories by not storing glucose. Of course, this leads to dangerously high blood glucose levels that can have severe health consequences.
Those who suffer from bulimia are also statistically more likely to engage in self-harm, substance abuse and impulsive behaviors.
Recovery from bulimia requires patience, persistence and resilience. Friends and family can be supportive, but a treatment team is often needed to provide the necessary framework for recovery. This team may include primary care, a psychiatrist, a therapist and a dietitian. Relapses are common, but viewing these struggles as learning opportunities rather than failures can help maintain a long-term path to recovery.
For more information on bulimia and other types of eating disorders, check out the NEDA website and all of the great information and resources in that space.
If you would like to inquire about virtual nutrition counseling for eating disorders, please check out our First Bite Nutrition page.