Bulimia is an eating disorder characterised by eating large volumes of food (bingeing) and then compensating for this by purging (using laxatives, vomiting, diuretics, fasting or overexercising to “purge” the calories). Bingeing is hugely different to simply indulging or consciously and positively enjoying eating more. Instead, it is a negative out of control rapid and self-harming act where a person eats whatever they can find, very fast, often secretly in a bid to use food to cope with negative thoughts, emotions, or situations. A binge is followed by incredible guilt and subsequent purging.  

As with Anorexia Nervosa, a person with Bulimia will often entwine self-worth with weight and body image. This eating disorder also has genetic causes and is linked to those high at risk of anxiety and depression. This disorder is more linked to depression than Anorexia Nervosa, with a larger body again seen as failure and low self-worth. It is also often more undetectable, as it often does not necessarily come with low BMI, and so diagnosis and treatment are much harder to achieve, and recovery is on average much longer.  

Signs of Bulimia Nervosa 

• Evidence of binge eating with food missing from cupboards, wrappers present and larger food bills.  
• Hoarding food in strange places and purchasing large quantities of high-sugar foods or foods that are believed to be forbidden and keeping them in a specific place (snack jar/a cupboard, special drawer).  
• Experiencing difficulties going to the loo (due to digestive issues) and feeling bloated or experiencing heartburn. 
• Evidence of purging (vomiting) or use of laxatives. 
• Skipping meals (or avoiding eating in front of people). 
• Using gum, mouthwash, or mints excessively. 
• Irregular mensuration. 
• Constantly dieting. Skipping meals and trying to go without food for prolonged periods of time. 
• Binge eaters may steal food (as food and money behaviours are often very entwined with eating disorders. Anorexic behaviour is often linked to hoarding or saving money, with a fear of spending money, as they “don’t deserve it,” on self and food, and binge mentalities the opposite).  
• Unable to stop eating once started negatively. The “I might as well eat and eat and never stop as I am so fat and worthless” mentality.  
• Wearing baggy clothes to hide the body. 
• Fluctuations in mood and emotions.  
• Withdrawal from usual friends and activities. 
• Suppressed immune system- at high risk of colds and infections. 
• A history of anorexia. 
• Dental issues from vomiting including acid enamel erosion and yellowing of teeth.  
• Expresses a need to “burn off” calories taken in 
• Thoughts about self-harm or suicide.  
• Diabulimia. This is a fear that “insulin makes me fat.” Restricting certain food or food groups to lower insulin dosages, missing treatment appointments and not taking diabetes medication in order to lose weight. This can be life-threatening.  

Causes 

1. Genetics: As with Anorexia Nervosa, scientific research shows (Himney, 2013; Bulik 2019) considerable evidence for a genetic causation of bulimia 
2. Anxiety and depression: Anxiety and stress can alter a person’s satiety signals (hunger and fullness brain and gut signals), stopping hunger initially, making a person eat less. When the stress has gone, the low blood sugar can trigger extreme hunger and a binge as the body attempts to homeostatically balance the missing nutrition with a rapid intake of food. Tiredness, illness, anger, loneliness, and hunger are all triggers for eating disorders as they put the body and person under physical and emotional stress.  
3. Dietary restriction: cycles of bingeing and purging often start as a person denies themselves sufficient food or certain foods (often highly satiating food they enjoy) as they wish to lose weight or out of fear of weight gain. Insufficient food causes low blood sugar, putting the body and brain into stress “famine mode.” In famine mode, the brain will demand a quick energy source to increase blood sugar, often in the form of high simple carbohydrate and fat foods. The person will crave the foods they deny themselves. A binge happens rapidly as the brain and body is quickly trying to restore blood sugar. A patient will feel almost not present during the binge, as if their brain had taken over. They will break food rules and feel considerable distress and guilt for this and a sense of worthlessness. In a bid to feel wholesome and rid themselves of these negative emotions, they will purge the foods from their bodies. High sugar and fat foods cause a surge in Dopamine neurotransmitter brain chemical, and so imbibing large quantities of these foods in a rapid way can rapidly increase Dopamine. Dopamine is the pleasure and reward chemical, which cements habits, and so bulimia binge/purge cycles can rapidly become habitual coping mechanisms.  

Long term effects 

As with Anorexia Nervosa, the long-term effects depend on the severity of the disorder. If persistent for many years, Bulimia can cause osteoporosis (brittle bone disease) as the body fails to absorb sufficient calcium, rotten teeth (if purging with vomiting) and gastrointestinal disorders and liver, kidney, and heart problems.  

Interventions

There are many treatments for Bulimia Nervosa, all patient specific. Often the best treatment is to find the root cause of the behaviour, the thoughts and feelings surrounding the link between weight and self-esteem and the cause of the anxiety or depression. Then the stages of nutritional support treatment can begin. Treatments focus on identifying and reducing the triggers of binges, preventing an individual from getting energy deficient and too hungry, angry, lonely, tired, or ill (illness can reduce blood sugar as your body requires additional energy to fight disease) and providing them with sufficient negative emotional distress tolerance coping mechanisms to adapt to challenges, without the need to binge and purge. This can involve the use of nutritional support to ensure they always have sufficiently balanced blood sugar levels, CBT, and therapy to help them examine the flawed thinking patterns that trigger binges and behaviour (balanced exercise, yoga and increased social support) and environmental changes (removal from a stressful job or home environment), to help them feel more at ease.  

Distraction techniques for triggering situations or distressing emotions, providing alternative ways of reducing stress and getting the Dopamine surge other than food, are essential in preventing a binge. This can involve exercise to increase (they are Cortisol stress reducing brain chemicals) Endorphins (not overexercising or using exercise to purge calories, but in a balanced way such as a walk-in nature or a sociable dance class), seeing friends or family, creativity (reading, art, theatre, tv, hot baths, massages, sex, gardening), or anything else that brings you pleasure in order to increase Dopamine without food.  

As with Anorexia binges and sometimes in Binge eating disorder, an individual with bulimia will get a sense of self-pride with others from eating little, “good food” meals and denying themselves treats in public. This creates cycles of secret binges, at home often at night when a person is tired, energy deficient and so has low blood sugar and may feel hungry (even if had sufficient food- it is common to confuse hunger and tiredness in eating disorders). Recovery is about ceasing the bingeing, purging behaviour, and restoring a healthy relationship with food and their bodies.  

Nutritional support 

1. Stop the binges: this can involve putting the individual on a nutritional plan with three meals a day and three snacks, where they receive sufficient nutrition to prevent the energy lows which cause hunger. It can also involve the individual being encouraged to mindfully enjoy a portion of foods they deem “fear foods” as part of a normal meal or snack with other people, so the individual is desensitised to the food and is less likely to go “oh I have had a slice of cake, now I will get obese, I feel so bad, I might as well eat the whole cake.” A treatment facility will help a patient relearn their favourite foods and prevent the food denial and restriction that causes cravings and triggers secret binges.  
2. Restore mineral deficiencies: binge eating disorder can cause electrolyte unbalance and nutrient and mineral (such as calcium or ion) deficiencies. To reverse this, certain vitamin and mineral containing foods can be prescribed and supplementation can be given to prevent conditions such as osteoporosis.  

Researched by: Laurentia (Laura) Campbell. Neuroscience and Nutrition scientist (with focus on the gut microbiota and omega 3) and writer. Former anorexic and binge eater turned gourmet food connoisseur, researcher, writer, marketer, and evidence-based nutritionist. See https://www.linkedin.com/in/lauracampbell007/ and https://medium.com/@laurentiacampbell.