# Fundamentals of Human Nutrition/Bulemia Nervosa
## Introduction and Background

Bulimia Nervosa is distinct from anorexia nervosa and it occurs more often than anorexia nervosa. ‘Bulimia’ is actually derived from the Greek language and means “ox hunger” and “connotes a state in which an individual repetitively consumes a feast-like quantity of food” (Gwirtsman & Mitchell, 2008). Unlike anorexia nervosa, bulimia nervosa is less noticeable physically, making it harder to detect (Rolfes & Whitney 2013). Bulimia nervosa is considered a psychiatric disorder because there is an emotional stress component to the cycle of binge eating and purging (Gwirtsman & Mitchell, 2008). It is also found to be more common in females than in males, 10:1. Out of all women, about 2% experience bulimia nervosa during their lifetime (Reus, 2015). The common typical person that suffers from bulimia nervosa is white, female, single, educated, and within a few pounds of her ideal body weight. Even people who are a little overweight can suffer from bulimia nervosa (Rolfes & Whitney 2013).
The start of this disorder normally begins in adolescence and can last for any number of years depending on the individual. Dieting is often a precursor to bulimia nervosa and can be seen to lead to the cycles of out of control eating and compensating actions. These cycles occur about once a week for 3 months at a time and both the binge eating and the compensatory behaviors have to be present in order for the patient to be diagnosed with bulimia nervosa (Radin, Ranzenhofer, & Tanofsky-Kraff, 2015). The secrecy of bulimia nervosa is caused by an obsession with thinking about their body image and food. People who suffer from bulimia nervosa have multiple episodes of binge eating that are followed by actions that compensate for the excessive eating, like laxatives, purging, enemas, or extensive exercise (Reus, 2015).
A bulimic binge is where an individual feels they do not have control over what they are eating and will not have a gauge of how much they are eating or what they are eating. Often, this occurs because it acts as an action that brings about emotional comfort. The purge part of the cycle can be done by either a cathartic or an emetic. A cathartic is a very strong laxative that has the ability to injure part of the lower intestinal tract. On the other hand, an emetic can be used to help induce vomiting and is a drug intended to combat poisoning. The consequences of this vicious cycle are mineral imbalances, abnormal heart rhythms, and battered kidneys. Vomiting can cause sores in the mouth, dental caries and erosion of the teeth, and callused hands. Not only are there physical consequences, but there are also mental consequences and effects. After the purge, the individual often feels ashamed or guilty. Treatment for bulimia nervosa includes establishing a regular eating planned schedule and a regular exercise regimen. Maintaining a healthy weight is key to recovering from bulimia nervosa (Rolfes &Whitney 2013).

## Overview and Definition

Bulimia Nervosa is a life-threatening eating disorder in which episodes of binge eating (the consumption of large quantities of food in a short period of time) are met with behaviors utilized in an attempt to lose weight. Those who binge often don’t have any feeling of control during their binging episodes. According to the updated DSM-V, to be diagnosed with Bulimia Nervosa, the minimum frequency of “binge-purge” incidents needed is once a week. Many people suffering from Bulimia Nervosa usually partake in these activities more often than this. There are actually two categories of Bulimia Nervosa: • (1) Purging Bulimia Nervosa: This is a form that uses physical methods to actually rid oneself of the binged food. Examples of purging include vomiting or the use of laxatives, diuretics, or enemas. • (2) Non-purging Bulimia Nervosa: This is a form that uses methods such as excessive exercise, fasting, or dieting to prevent weight gain from the previous binge eating. Many people tend to overlap with these two separate categories of Bulimia Nervosa, using dangerous weight loss methods from both. Approximately 1.5% of women and 0.5% of men suffer from Bulimia Nervosa at some point in their life. Women are much more likely to develop bulimia nervosa, but it should not be forgotten that it still occurs in males as well. It is also more prominent in certain populations, especially college students. Bulimia Nervosa can be life threatening due to the physical effects that it takes on one’s body. It also has a mortality rate of approximately 3.9%.

## Signs and Symptoms

Symptoms commonly associated with Bulimia Nervosa include: • Self-esteem issues relating to body image • Episodes of binge eating followed by purging (at least once a week) • Changes in personality/social behavior • Extreme fear of gaining weight • Feelings of loss of control pertaining to food consumption Signs that someone may be suffering from Bulimia Nervosa: • Constant negativity about one’s body image/weight • Possible fluctuations in weight (however, people suffering with Bulimia typically do not gain large amounts of weight) • Evidence of possible binge eating (wrappers, empty containers, etc.) • Unnecessary trips to the restroom after meals (occurs often) • Avoiding meals, especially in social settings • Hiding or hoarding food • Symptoms of depression or anxiety • Fatigue Criteria needed to diagnose Bulimia Nervosa (According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition): • Frequent episodes of binge eating • Compensating “purging” behaviors to prevent weight gain from binge eating •Episodes of binging and purging must occur at least once a week for at least three months •Very self-aware about body shape and/or weight •Episodes do not occur solely during episodes of anorexia nervosa

## Causes

Bulimia Nervosa can be caused by a number of factors, but these factors typically revolve around one’s psychological wellbeing. A person with Bulimia Nervosa has a fear of gaining weight, desperately wants to lose weight, or is simply extremely unhappy/uncomfortable with their body. This unhappiness can stem from bullying, social media, comparison to others, or real psychological disorders such as body dysmorphia, depression, and anxiety. There are many factors that come into play when talking about what causes bulimia, although an exact cause has not been determined and some of them having been mentioned above. Certain situations that could cause a person to develop bulimia nervosa include: previous trauma/abuse, stressful life changes and even culture. Many people who suffer or have suffered from bulimia have a history of abuse, whether it is physical, emotional or sexual. A person with an abusive history could be left with lasting psychological trauma, leaving them to feel as though binging and purging is the only thing they could control. Some people with eating disorders have a ‘coping skills deficit.’ Traumatic events may affect those at risk differently than those not at risk, which could cause the development of an eating disorder. So, instead of dealing with things such as depression and anxiety by using positive coping skills, they resort to actions such as binging and purging. There are also a high percentage of athletes that suffer from eating disorders, particularly bulimia nervosa. Sports that put a lot of emphasis on appearance or muscularity could put certain athletes at risk. Some examples of these types of sports include: gymnastics, wrestling, etc. Biology also comes into play. While this hasn't proved to be a direct cause, some say genetics could play a big role. Those with first-degree relatives suffering from an eating disorder have an increased chance of developing one themselves, 7-12% more likely. It has also been said that a decreased level of serotonin in the brain could also be linked with the development of bulimia nervosa. Another cause of bulimia nervosa could be sociocultural ideals. Currently, our media has increased people’s obsession with the “perfect body” therefore contributing to unrealistic body ideals, which really negatively harm people. While it may not be possible to say that social media directly causes an eating disorder, those who are considered at risk of developing an eating disorder could be increasingly vulnerable to these ideals. Another contributing factor to developing an eating disorder is the notion of ‘dieting.’ This country has made a $60 billion industry off of dieting and dieting products. One of the major factors of dieting that could be a cause of bulimia nervosa is that it instills a feeling of guilt and shame in relation to food. Because many diets emphasize restrictive eating, people often come to associate food with negative thoughts. “Should I be eating this right now?” or “No I already had carbs this morning, I can’t eat anymore now.” When dieting is gone about the wrong way, it could have the potential to lead to developing an eating disorder like bulimia nervosa. As it was mentioned before, a single cause of bulimia nervosa has not yet been discovered, however all of these factors play a large role in causing it.

## Effects

Although the causes of bulimia are mostly psychological, the effects can be as well. This eating disorder can cause the person to be even unhappier with their body than they originally were, thus increasing the levels of depression and anxiety that may in turn promote isolation and a feeling of emptiness. In addition, one is being forced to combat the physical effects. These physical conditions include dental problems, gastrointestinal issues, and vitamin, nutrient, and electrolyte imbalances. These imbalances can be life threatening since they cause damage to the heart and other major systems of the body. The persistent purging behavior acts as the major catalyst to these issues due to the fact that the highly acidic stomach acid in vomit corrodes the lining of the esophagus as well as tooth enamel, leading to tooth decay and bad breath (National Eating Disorders Association [NEDA]). Purging also flushes out the major nutrients the body needs to be healthy, such as vitamins A, B, B12, C, D, E, K, and folic acid (Liberty, 2011). These deficiencies each trigger their own sets of issues. The misuse of medications to induce vomiting or to expedite waste movement causes damage to the muscles of the bowel system and can result in both constipation and diarrhea.

## Bulimia Nervosa vs. Anorexia Nervosa

Bulimia Nervosa is a dangerous eating disorder. One of the main diagnostic criterions for bulimia nervosa from the DSMV-IV is eating in large amounts then purging (Fairburn & Brownell, 2005). This binging then purging is mostly used to prevent weight gain after consuming large amounts of food. The initial red flag of bulimia is the binging. Another red flag is possible self-induced vomiting after meals. This can be evident if a person makes frequent trips to the restroom after meals. There is often a feeling of no control when a person is binging, as if they absolutely have to keep eating. This then leads to a feeling of shame or regret, and in order to not gain any weight or any other supposed effects of eating all the food, the affected purges.
Purging can come in many forms; although, a lot of the time it is associated only with self- induced vomiting. Purging by definition means to rid one self of something undesirable. In a bulimic’s case, what is undesired is the calories or fats associated with eating large amounts of food- or really any amount of food. However, within bulimia nervosa, there are two types defined by the Mayo Clinic (“Bulimia Nervosa,” 2015). Purging bulimia is when the affected regularly makes themselves throw up, or they overuse laxatives or diuretics in order to rid their body quickly of food they have just consumed. Non-purging bulimia is when they use other methods to get rid of the calories like strenuous exercise, dieting, or fasting. Purging itself is caused by the patient’s psychological need to rid the body of any amount food that could have been consumed.
Non-purging bulimia can be mistaken for anorexia nervosa because of the fasting or excessive exercise, but the main difference is that anorexia is associated with a fear of gaining weight, and often leads to weight loss that is extremely severe. Many people with bulimia could be around normal weight. A person can exhibit symptoms of both anorexia and bulimia, but when a person is underweight and begins to purge, the diagnosis of anorexia nervosa stands to be more important, and this would remain their primary diagnosis. The psychological need to compensate for consuming such large amounts of food stems from the person’s image of himself or herself. This cycle is the most telling sign of bulimia. Patients often diet, but break it and binge eat, and then the purging follows in order to make up for the lapse in the diet.
Both eating disorders are associated with an over valuing of skinniness, and dissatisfaction with a person’s own body. They are very much affected by the personality of the person and the environment they live in. If a person is very preoccupied with how they look to begin with, and someone in their surroundings begins to be a little hard on them, this could certainly make a person very susceptible to starting these behaviors and developing an eating disorder. To cure bulimia, intensive therapy and medication is needed. The University of Maryland Medical Center suggests that they must rebuild their physical and mental health in order to be truly cured of their eating disorder (Ehrlich, 2014). A patient must be able to break the cycle of binging and purging, and to do this, the patient must rid himself or herself of the need to be thin or lose weight. After this, they can then work on rebuilding the nutrients that they have been purging themselves of.

## Treatment

Nutrition plays a pivotal mark in the recovery of someone with bulimia. It provides the opportunity to become better educated about food, teaching the benefits of certain foods, or allows one to change they way they think about food (Lambert, 2015). Changing eating habits goes a long way in this process:
* Follow the Recommended Daily Allowances for foods along with the Acceptable Macronutrient Distribution Ranges for macronutrients
* Avoid fatty foods or saturated fats from processed foods because these foods contain large amounts of fat, sodium, and cholesterol and increase the risk of fat build-up, which moreover makes the person feel bad about their body
* Eat a fairly even amount of carbohydrates, the body’s main source of energy, fruits and vegetables, and dairy and protein.
* Encourage fiber-rich carbohydrates that cause immediate feelings of being full and foods that provide protein and fat for satiety
* Plan meals and snacks and record the plans prior to eating
* In addition, plan meals and snacks that require eating at the table and using utensils and avoid eating finger foods.
* Eat a well-balanced diet and regularly timed meals
* Consume adequate amounts of fluids but especially water
* Establishing a regular eating pattern is also important
* Seeking a nutritionist is essential in establishing goals for the patient to meet and allows them to work to a healthy weight
Instead of focusing on weight loss or weight gain, those seeking treatment should focus on weight maintenance. Major steps toward recover include discontinuing purging and restrictive dieting habits and learning to eat three meals a day plus snacks. (Rolfes, Whitney 2013)
In addition to focusing on changing the mindset about nutrition those affected by bulimia nervosa should also undergo psychiatric therapy. The largest controlled study supports that “Tailored cognitive behavioral therapy and, to some extent, interpersonal psychotherapy can help young women stop bingeing and purging, accept their appearance, and develop healthier ways of coping with stressful situations” (DeAngelis, 2002). Cognitive behavioral therapy is extremely useful is working through emotional crises. This can be used to overcome several obstacles that could be the root cause of Bulimia Nervosa. Therapists encourage the client to talk about the problems related to the eating disorder but in a non-directive manner. This type of therapy helps the person affected to become aware of inaccurate or negative thinking so that they can view challenging situations more clearly and respond to them in a more effective way. (Mayo Clinic. 2016). Individual therapy can also build awareness of one’s own feelings and help them gain independence from others. It is extremely important to the process to learn more adaptive ways to think about food and its relationship to the body. Those affected are taught how to monitor their food intake, introducing avoided foods into diet, and coping techniques for avoiding bingeing. They are taught to accurately read sensations of hunger and satiety. In-patient therapy can also be used in extreme cases. This allows the patient to be uninfluenced by their environment and really focus on achieving their health goals. Having support and being surrounded by those going through the same situation can help with the healing process. A nutritionist at the facility can lead groups, help establish meal plans, keep track of the calories consumed. A therapist there can hold individual and group sessions. Antidepressants can also be useful when treating bulimia. They can reduce bingeing and vomiting as well as enhance their sense of control.

## References

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