Bulimia nervosa

What is bulimia nervosa?

Bulimia nervosa is an eating disorder where a person struggles with eating a larger amount of food than most people would eat over a short time, once a week or more for at least three months. A person with bulimia nervosa worries about gaining weight, feels shameful about the binge eating and will engage in unhealthy or dangerous purging behaviours (e.g., vomiting, taking pills, dieting to extremes or doing too much exercise) to prevent weight gain.

People with bulimia nervosa may be thin, average weight, or overweight. In addition to bingeing and purging, someone with bulimia nervosa feels unhappy about their appearance and wants to lose weight. People with bulimia nervosa may not seek help on their own because they may be embarrassed by or ashamed of their eating patterns. However, with treatment, they can often get better.

What are the signs and symptoms of bulimia nervosa?

Bulimia nervosa has a range of signs and symptoms.

Physical signs of bulimia nervosa

• can be of any body weight, shape or size
• puffiness of the face, especially around the cheeks
• callouses or marks on the knuckles
• broken blood vessels around the eyes and face
• bad breath because of vomiting
• dizziness
• vomiting blood
• digestive problems
• confusion, weakness or fatigue due changes in important electrolytes such as potassium or sodium
• thinning hair
• tooth decay
• potentially dangerous and sometimes fatal changes in heart rate

Behavioural signs of bulimia nervosa

• hide their binging and purging behaviors
• skipping meals
• weight fluctuations (increases and decreases) because of bingeing and purging
• eating large amounts in a short time
• eating quickly
• hiding food wrappers around the house
• eating in the middle of the night
• disappearing to the bathroom after eating
• not wanting to eat with others
• becoming more irritable or having mood swings and outbursts
• judge themselves based on their body weight

What if I think I may have bulimia nervosa?

Tell someone. Tell a trusted adult such as a parent, caregiver, teacher, coach or therapist. Explain your concerns and ask for their help.

Don’t feel alone. It can be hard to tell someone about your eating disorder thoughts and behaviors. You might be concerned about how they will react. However, it can help to have an open and honest conversation about your eating disorder with those you trust. It will help you feel less alone.

Get help early. It is important for you to see your health-care provider as soon as possible. Your health-care provider can help to determine whether you have an eating disorder and can also assess how serious the situation is. The sooner a diagnosis is made, the quicker you can start treatment, and the better chance for recovery.

It’s important to see your health-care provider if you:

• are worried you might have bulimia nervosa or another eating disorder
• have out-of-control eating episodes or binges
• are purging by making yourself throw up after you eat or taking pills to alter how food affects your body

It is especially important to see a health-care provider if you experience pain in your body, especially chest or stomach pain, or you begin to vomit blood.

What will a health-care provider do during an assessment for bulimia nervosa?

A health-care provider will do a complete history (medical, nutritional and psychosocial history) and a thorough physical examination including:

• measuring your weight and height (plotting measurement on a growth curve)
• taking your lying and standing blood pressure and heart rate
• taking your temperature
• assessing your pubertal growth development

They may also do some initial tests including blood and urine tests to check if there are abnormalities and an electrocardiogram to check how the heart is functioning.

How is bulimia nervosa treated?

If the health-care provider determines that a person has bulimia nervosa, they will arrange for appropriate care. Eating disorder care is usually done with multiple health-care professionals including pediatrician or adolescent medicine doctor or family doctor or nurse practitioner, nurses, dietitians, psychologists, psychiatrists, and social workers who specialize in treating children and teens with eating disorders.

The health-care provider will decide if the patient can be managed as an outpatient (outside the hospital), either in the health-care provider’s office, or in a specialized eating disorder program.

The first treatment recommended for young people is an outpatient treatment is called family-based treatment, which focuses on recovery of the eating disorder. Parents/caregivers play an essential role in the treatment and recovery of their child. Family-based treatment includes 3 treatment phases.

• Phase 1 focuses on weight restoration. Parents, supported by the therapist, take responsibility for making sure that the adolescent is eating sufficiently and also takes on all meal planning and preparation.
• Phase 2 is when substantial weight recovery has occurred and the adolescent gradually assumes responsibility for their own eating.
• Phase 3 is when weight is restored and the focus is on general issues of adolescent development.

If the health-care provider finds that the patient is too sick for outpatient treatment, they may refer the patient for urgent hospitalization.

The goals of treatment are to:

• ensure that the adolescent is medically safe
• achieve a weight that guarantees healthy growth and development
• stop the cycles of bingeing and purging
• work on having all types of food in moderation, including foods the adolescent may have binged on
• help manage any emotions about eating, including any worries about weight

If you are experiencing depression or anxiety in addition to bulimia nervosa, your health-care team may suggest other treatments for those mental health disorders once the eating disorder is under control.

Sometimes your health-care team may also suggest medication. Antidepressants can help with depression or anxiety and can sometimes also help with urges to binge or purge.

Full recovery from bulimia nervosa is possible. It is important to remember that an early diagnosis and treatment and an early response to treatment may be associated with better outcomes.

SickKids has an eating disorder program that treats children and teens who are struggling with symptoms of anorexia nervosa, bulimia nervosa and avoidant restrictive food intake disorder. For more information on our program visit: www.sickkids.ca/en/care-services/clinical-departments/adolescent-medicine/

NEDIC – National Eating Disorder Information Centre (Canada)

NEDA – National Eating Disorder Association (United States)

B-EAT – Beating Eating Disorders (United Kingdom)

Kelty Eating Disorders (Kelty Mental Health Resource Centre, BC Children's Hospital)

ANAD - National Association of Anorexia Nervosa and Associated Disorders (United States)