By Donna Feldman, MS, RD

Thanks to the recent publicity about starving fashion models, there has been plenty of media coverage on the dangers of eating disorders. Most people could recognize the skeletal look of anorexia. However, the equally serious eating disorder, bulimia nervosa, is notoriously hard to spot. Friends and parents may be suspicious, but without clear symptoms, may be unable to recognize bulimia.

Bulimia Basics

A bulimic tries to control food intake and body weight by establishing all manner of rigid rules on types and amounts of food to eat or avoid. She could spend all day thinking about this. When any of these rules are broken, an out-of-control binge-eating episode can result. After bingeing, the feelings of self-loathing lead to vomiting or laxative abuse, or compensatory exercise. The vicious cycle starts over, as the bulimic returns to the rigid food rules, and inevitably spirals into another binge.

The binge eating and purging are secretive behaviors. There are few outward signs of bulimia. Unlike with anorexia, the bulimic person is probably normal weight, or even slightly overweight. What is similar is the obsession with weight and body image, and the extreme desire to restrict eating. Bulimia is not simply an alternative method of dieting. It is considered a mental illness. It is related to depression and is worsened by chaotic family or social circumstances.

Diagnostic Criteria

The diagnostic criteria used by health professionals who work with suspected bulimia nervosa patients include:
- Recurrent episodes of binge eating, or eating an amount in a short period of time that is clearly larger than what a normal person would eat and being embarrassed by the amount.
- Recurrent compensatory behaviors after bingeing to prevent weight gain, such as vomiting, laxative abuse, enemas, fasting, or excessive exercise.
- These episodes occur at least twice a week for 3 months.
- Fixation with body weight and shape, with sense of self-worth based on weight or shape. 1,2

The one health care professional who can see unmistakable signs of bulimia is the dentist.  Frequent vomiting erodes tooth enamel, especially on the back of the upper teeth. There may be other signs of irritation in the mouth as well. While many dentists will discuss these issues with the patient, or with parents, many do not. Dentists are not obligated to report suspected bulimia to parents. Some bulimics avoid visiting the dentist in order to hide their condition. A concerned parent should be proactive and request the dentist’s opinion.

Other Signs of Bulimia

Friends and family members may suspect someone is bulimic based on other signs and behaviors:

• Hiding in the bathroom after meals, with water running to mask sounds.
• Fixation on weight, shape, and appearance in conversation.
• Rigid food rules and/or periodic fasting.
• Entire life structured around eating and exercise.
• Compulsive or excessive exercise.
• Empty laxative packages.
• The smell of vomiting.

Some of these signs could be due to the temporary food fetishes of a typical teenager, or could be misinterpreted by worried parents. An athletic teenager in training for a sport may seem to be compulsively exercising, but is not. Some signs, like the smell of vomit or empty laxative packages, clearly are significant.  

What to Do?

Uncontrolled bulimia is not a benign problem. Severe electrolyte imbalances caused by vomiting can lead to dangerous medical conditions. Do not fail to act because you are embarrassed by what other people might think about the behaviors. Some therapists recommend opening a non-judgmental discussion with the bulimic person, expressing your own worry about what you have noticed.

Meanwhile, investigate local resources for psychological and medical intervention, including local treatment centers or referral lists. Sometimes school systems have resources for parents. All eating disorders should be treated by a team of health professionals, led by a mental health expert who specializes in eating disorders. The team should also include a physician and registered dietitian.

Conclusion

Bulimia nervosa is just as serious as anorexia. The stigma associated with purging and binge eating makes it more embarrassing. The bulimic may deny there is a problem. Friends and family have to be persistent and diplomatic, while encouraging appropriate and necessary professional intervention.

1http://clevelandclinicmeded.com/diseasemanagement/psychiatry/eating/table2.htm
2http://www.edreferral.com/bulimia_nervosa.htm
*This article is intended for general information purposes only, is not individual-specific, nor is it intended to replace the advice of your healthcare team.