Bulimia nervosa is an eating disorder in which a person binges and purges. The person may eat a lot of food at once and then try to get rid of the food by vomiting, using laxatives, or sometimes over-exercising. People with bulimia are preoccupied with their weight and body image. Bulimia is associated with depression and other psychiatric disorders. It shares some symptoms with anorexia nervosa, another major eating disorder. Because many people with bulimia can maintain a normal weight, they may be able to keep their condition a secret for years. If not treated, bulimia can lead to nutritional deficiencies and even fatal complications.
Signs and Symptoms
People with bulimia may have the following signs and symptoms:
- Binge eating of high-carbohydrate foods, usually in secret
- Exercising for hours
- Eating until painfully full
- Going to the bathroom during meals
- Loss of control over eating, with guilt and shame
- Body weight that goes up and down
- Constipation, diarrhea, nausea, gas, abdominal pain
- Missed periods or lack of menstrual periods
- Damaged tooth enamel
- Bad breath
- Sore throat or mouth sores
What Causes It?
No one knows what causes bulimia, although there are several theories. Genes may play a part -- there is some evidence that women who have a sister or mother with bulimia are at higher risk of developing the condition. Families may put an too much emphasis on achievement, or may be overly critical. Psychological factors may also play a part including having low self-esteem, not being able to control impulsive behaviors, and having trouble expressing anger. Some people with bulimia may have a history of sexual abuse. People with bulimia may also experience depression, self-mutilation, substance abuse, and obsessive-compulsive behavior. Cultural pressures to look thin can also play a part, particularly among dancers and athletes.
Who's Most At Risk?
People with the following conditions or characteristics are at higher risk for developing bulimia:
- White, middle-class women (mostly teenagers and college students)
- People with a family history of mood disorders and substance abuse
- People with low self-esteem
What to Expect at Your Provider's Office
Often, people with bulimia are ashamed of their condition and do not ask for help for many years. By then, their habits are harder to change. If you have symptoms of bulimia, you should talk to your doctor as soon as possible. The doctor should check for physical signs such as eroded tooth enamel and enlargement of the salivary glands, as well as signs of depression. Laboratory tests may show chemical changes caused by bingeing and purging. Your doctor or a mental health practitioner will do a psychological exam and ask about your feelings and your eating habits.
The most successful treatment combines psychotherapy, family therapy, and medication. It is important for the person with bulimia to be actively involved in their treatment.
Antidepressants are often prescribed for bulimia. The most common antidepressants prescribed are selective serotonin reuptake inhibitors (SSRIs). They include:
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Fluvoxamine (Luvox)
Prozac is the only antidepressant approved by the Food and Drug Administration to treat bulimia, although some studies suggest that other SSRIs, such as Luvox, may be even more effective.
Some studies indicate that Prozac and other antidepressants may cause some children and teenagers to have suicidal thoughts. Children who are taking these drugs should be monitored very carefully for signs of suicidal behavior.
People with bulimia may not be getting the nutrients their bodies need. Your health care provider may prescribe potassium or iron supplements, or other supplements to make up for any deficiency.
Complementary and Alternative Therapies
Psychotherapy is a cornerstone of bulimia treatment. Cognitive behavioral therapy, which teaches you to replace negative thoughts and behaviors with healthy ones, is a common treatment method.
Other mind-body and stress-reduction techniques, such as yoga, tai chi, and meditation, may help you become more aware of your body and have a more positive body image. A 6-week clinical trial showed that guided imagery helped people with bulimia reduce bingeing and vomiting, feel more able to comfort themselves, and improved feelings about their bodies and eating. More studies are needed to see if guided imagery has long-term benefits.
Always tell your health care provider about the herbs and supplements you are using or considering using.
Nutrition and Supplements
People with bulimia are more likely to have vitamin and mineral deficiencies, which can affect their health. Getting enough vitamins and minerals in your diet or through supplements can correct the problems.
Some natural therapies, including dietary supplements, may help general health and well-being.
Following these nutritional tips may help reduce symptoms:
- Avoid caffeine, alcohol, and tobacco.
- Drink 6 - 8 glasses of filtered water daily.
- Use quality protein sources -- such as lean meat and eggs, whey, and vegetable protein shakes -- as part of a balanced program to gain muscle mass and preventing wasting.
- Avoid refined sugars, such as candy and soft drinks.
If you aren’t getting enough of some nutrients, your doctor may suggest the following supplements:
- A daily multivitamin, containing the antioxidant vitamins A, C, E, the B-vitamins, and trace minerals, such as magnesium, calcium, zinc, phosphorus, copper, and selenium.
- Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil two to three times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources; eat two servings of fish per week. Fish oil can increase the risk of bleeding, so ask your doctor before taking it. Eating fish doesn’t cause the same problem.
- Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
- Creatine, 5 - 7 grams daily, when needed for muscle weakness and wasting. In high doses, creatine may harm the kidneys. People with kidney problems should not take creatine. People with bulimia should ask their doctor before taking creatine, and their doctor should check their kidney function.
- Probiotic supplement (containing Lactobacillus acidophilus among other strains), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Refrigerate probiotic supplements for best results.
Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.
These herbs are not used to treat bulimia specifically, but may be good for general overall health:
- Ashwagandha (Withania somniferum) standardized extract, 450 mg one to two times daily, for general health benefits and stress. Pregnant and breast-feeding women should not take ashwaganda. Ashwaganda can interact with some prescription medications, so ask your doctor before taking it.
- Holy basil (Ocimum sanctum) standardized extract, 400 mg daily, for stress. You can also prepare teas from the plant. Holy basil may make the effects of blood thinners, such as warfarin (Coumadin) and aspirin, stronger. Holy basil also interacts with pentobarbital (Nembutal), a sedative.
- Grape seed (Vitis vinifera) standardized extract, 100 - 200 mg three times daily, for antioxidant effects, and heart and blood vessel protection. Pregnant women should not take grape seed. Grape seed may increase the risk of bleeding, especially if you also take blood thinners such as warfarin (Coumadin). Ask your doctor before taking grape seed if you take blood thinning medication.
- Catnip (Nepeta spp.), as a tea two to three times per day, to calm the nerves and soothe the digestive system. Pregnant and breast-feeding women and women with pelvic inflammatory disease should ask their doctors before taking catnip. Stop taking catnip at least 2 weeks before surgery. Catnip may interact with lithium and sedative medications.
There are no scientific studies that support using homeopathy to treat bulimia. However, an experienced homeopath will consider your individual case and may recommend treatments to address both your underlying condition and any current symptoms.
There are no scientific studies that support using acupuncture to treat bulimia. However, a trained acupuncturist may be able to recommend acupuncture treatments to support your overall health. Many inpatient treatment centers for eating disorders include acupuncture in their overall treatment plan. Studies have found that acupuncture can be helpful in treating addictive behaviors and anxiety in general, which can help people with bulimia who are in recovery.
Therapeutic massage can be an effective part of a bulimia treatment plan. In one study, teen girls with bulimia got massage therapy for 5 weeks or were in a control group that didn’t get massage therapy. The 24 girls receiving massage improved, while the control group did not improve. Women in the massage group were less anxious and depressed right after their first massages. They also had better scores on the Eating Disorder Inventory, which helps health care providers assess psychological and behavioral traits in eating disorders.
Many people with bulimia relapse after treatment and need long-term care. Possible complications from repeated bingeing and purging include problems with the esophagus, stomach, heart, lungs, muscles, or pancreas. People with suicidal thoughts or severe symptoms may need to be hospitalized. Women with bulimia may find pregnancy emotionally difficult because of the changes in their body shape. The mother's poor nutritional health can affect the baby. Women who have stopped having periods because of bulimia will be unable to become pregnant.
Because bulimia is usually a long-term disease, a health care provider will need to check the person's weight, exercise habits, and physical and mental health from time to time.
Barabasz M. Efficacy of hypnotherapy in the treatment of eating disorders. Int J Clin Exp Hypn. 2007 Jul;55(3):318-35. Review.
Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Current concepts: eating disorders. N Engl J Med. 1999;340:1092-1098.
Carei TR, Fyfe-Johnson AL, Breuner CC, Brown MA. Randomized controlled clinical trial of yoga in the treatment of eating disorders. J Adolesc Health. 2010 Apr;46(4):346-51.
Esplen MJ, Garfinkel PE, Olmsted M, Gallop RM, Kennedy S. A randomized controlled trial of guided imagery in bulimia nervosa. Psychol Med. 1998;28(6):1347-1357.
Field T, Schanberg S, Kuhn C, et al. Bulimic adolescents benefit from massage therapy. Adolescence. 1998;33(131):555-563.
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill; 2008.
Holman RT, Adams CE, Nelson RA, et al. Patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids. J Nutr 1995;125:901-907.
Humphries L, Vivian B, Stuart M, McClain CJ. Zinc deficiency and eating disorders. J Clin Psychiatry. 1989;50:456-459.
Kronenberg, HM ed. Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa: W.B. Saunders; 2008.
Krysanski VL, Ferraro FR. Review of controlled psychotherapy treatment trials for binge eating disorder. Psychol Rep. 2008 Apr;102(2):339-68. Review.
Laessle RG, Beumont PJV, Butow P, et al. A comparison of nutritional management with stress management in the treatment of bulimia nervosa. Br J Psychiatry. 1991;159:250-261.
LaValle JB, Krinsky DL, Hawkins EB, et al. Natural Therapeutics Pocket Guide. Hudson, OH: LexiComp; 2000: 387-388.
McClain CJ, Humphries LL, Hill KK, Nickl NJ. Gastrointestinal and nutritional aspects of eating disorders. J Am Coll Nutr. 1993;12(4):466-474.
Mooney J. Management of eating disorders. J Naturopathic Med. 1997;7(1):114-118.
Moyano D, Sierra C, Brandi N, et al. Antioxidant status in anorexia nervosa. Int J Eating Disord. 1999;25:99-103.
Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Pediatr Int. 2000;42:76-81.
Rock CL, Vasantharajan S. Vitamin status of eating disorder patients: Relationship to clinical indices and effect of treatment. Int J Eating Disord. 1995;18:257-262.
Rotsein OD. Oxidants and antioxidant therapy. Crit Care Clin. 2001;17(1):239-47.
Schauss A, Costin C. Zinc as a nutrient in the treatment of eating disorders. Am J Nat Med. 1997;4(10):8-13.
Setnick J. Micronutrient deficiencies and supplementation in anorexia and bulimia nervosa: a review of literature. Nutr Clin Pract. 2010 Apr;25(2):137-42. Review.
Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21(6):495-505.
Smith KA, Fairburn CG, Cowen PJ. Symptomatic relapse in bulimia nervosa following acute tryptophan depletion. Arch Gen Psychiatry. 1999;56:171-176.
Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Tarcher/Putnam; 1995.
Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs. 2000;9(9):2103-19.
Wheatland R. Alternative treatment considerations in anorexia nervosa. Med Hypotheses. 2002;59(6):710-5.
Williams PM, Goodie J, Motsinger CD. Treating eating disorders in primary care. Am Fam Physician. 2008 Jan 15;77(2):187-95. Review.
Wiseman CV, Harris WA, Halmi KA. Eating disorders. Medical Clin N Am. 1998;82:145-159.
Wolfe BE, Metzger ED, Jimerson DC. Research update on serotonin function in bulimia nervosa and anorexia nervosa. Psychopharmacol Bull. 1997;33:345-354.
Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J. 2005;46(5):585-96.
Young D. The use of hypnotherapy in the treatment of eating disorders. Contemporary Hypnosis. 1995;12:148-153.
Eating disorders - bulimia