Bulimia or bulimia nervosa is one of the eight defined eating disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). (1) It is defined by periods of binge eating and then purging at least once a week for 3 months. (3) Bulimia generally starts in adolescence and is 10 times more prevalent among females than males. (1) (3) As someone who has been diagnosed with bulimia and has spent the past 16 years as a naturopathic doctor helping patients with bulimia recovery and the side effects of bulimia, I understand the complexities of starting and completing bulimia treatment. For me, bulimia started out innocently in 9th grade with a friend suggesting that I might want to consider purging after eating junk food to help stay thin. That thought that was planted slowly developed over the next decade into an eating disorder, bulimia nervosa. Treatment has not always been simple, but I have learned to manage my condition and heal from it.
What is Bulimia?
Bulimia is an eating disorder which involves binge eating followed by purging. Binge eating is defined as eating a larger than average portion of food in an allocated time period and feeling a lack of control during this time. (3) In response to binge eating, a person with bulimia will use compensatory measures such as self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting or excessive exercise. (3) The reason behind these actions is most commonly to prevent weight gain or to help relieve stomach pains brought on by binge eating. (9)
Diagnosis of bulimia can be difficult. Often people with bulimia try to conceal their condition as there is a sense of shame and stigma associated with it. (1) Unlike those with anorexia or binge eating disorder, people with bulimia typically are average weight or overweight. Additionally, identifying if a person’s exercise is considered excessive can be difficult. Excessive exercise is considered if the exercise interferes with typical everyday life, if it occurs at inappropriate times or circumstances and if one continues to exercise despite injury. (1) Assessment by a healthcare professional can therefore be helpful.
Bulimia Health Risks
Bulimia affects millions of people and can lead to serious health consequences if not properly controlled. (3) (9) The consequences most commonly occur with the repeated purging aspect of bulimia. Effects include erosion of the enamel on teeth, gum disease, parotid gland enlargement and swelling in the body. (3) Bulimia is also linked to menstrual irregularities, a loss of menstrual cycle, infertility and osteoporosis. (1) A lot of people who have bulimia also suffer with gastrointestinal issues that may need to be addressed. (1) However, the most concerning consequence is electrolyte acid-base imbalance. (8) The result is low acid levels and low potassium levels. (8) In severe cases, this can lead to an irregular heartbeat and in some cases, death. (8) Therefore, it is important for those with bulimia to begin treatment.
Steps in Management
The first step to managing bulimia is to recognize and admit that there is an issue. This is often the hardest step to take. It is very difficult for a person to admit they have a problem and it is often a non-linear progression into recovery once they do start treatment. Often when dealing with management of a condition, it is good to identify the root cause. However, the root cause of bulimia is difficult to identify, as it is usually multi-faceted. (7) (3) Bulimia development can be influenced by the following:
- Media exposure about ideal body types and eating disorders
- Socialization about eating and eating disorders
- A history of trauma such as sexual abuse or bullying about appearance
- Family functioning, learned behaviour and stress
- Physiological imbalance with neurotransmitters such as GABA, dopamine, serotonin
- Hormonal imbalance such as leptin, ghrelin, cholecystokinin. (7)
How to Treat Bulimia
Due to the multi-faceted causes of bulimia, the treatment plan must also be multi-faceted. As such, it is important to work on the foundations of health: diet, sleep, exercise, stress management, thoughts and emotions.
Diet – In bulimia recovery, the emphasis is on eating nutrient dense foods, natural foods, and foods that manage blood sugar. Diets should not be restrictive and should not be focused on eliminating foods. Rather, a bulimia food plan should focus on increasing healthy foods and nutrients that a person’s body may be deficient in. As well, foods that support serotonin and dopamine neurotransmitter formation should be emphasized. I have created an eating plan called “The Essential Diet; Eating for Mental Health” which is the eating roadmap that I prescribe to my patients.
Sleep – In order for the brain and the body to work optimally, adequate rest and repair is critical. Sleep is imperative to anyone dealing with mental health concerns. It is important to assess sleep in bulimic patients, follow good sleep hygiene, and take supplements when needed.
Exercise – Exercise can be very helpful for people with mental illness. For those with bulimia, there needs to be a balance between exercising to improve overall health and exercising to compensate for a binging episode. (2) If exercise is prescribed to bulimic patients, they should start with low-intensity exercises such as yoga, stretching or walking. (2)
Stress Management – In many cases, stress plays a large role in initiating binge eating. (4) Addressing these stress levels can therefore help reduce the occurrences of episodes. Stress management should also be paired with learning to understand thoughts, emotions and reactions. There are several techniques that can be applied to help people become aware of their thoughts and emotions and decrease stress, such as, mindfulness, cognitive behavioural therapy, lifestyle counselling, Gestalt psychotherapy, and/or supplementation.
Natural Supplements for Bulimia – While it is often best to try to increase nutrients and correct deficiencies through diet, most patients need support through. Supplementation, if needed, can include zinc, essential fatty acids, 5HTP and B vitamins.
- Zinc – Zinc deficiency is very common in people with bulimia. (5) Studies have shown that supplementing with 34 mg of zinc everyday reduced the amount of episodes of binge eating per week. (5) The role zinc plays in bulimia management is possibly due to the dampening effect on the glutamate receptors, as well as antioxidant and anti-inflammatory properties. (5) Correcting deficiencies, such as zinc deficiencies can be important for bulimia recovery.
- Essential fatty acids – Essential fatty acids, such as Omega 3 oils have anti-inflammatory benefits. Essential fatty acids have not been studied in bulimia, however, there has been some promising research in other eating disorders. One theory as to why essential fatty acids help people with eating disorders, is that people with anorexia nervosa and bulimia nervosa, experience inflammation related to the foods they are eating. (6) This inflammation can cause anxiety and thus contribute to the eating disorder – a vicious cycle. Because essential fatty acids lower the amount of inflammation and anxiety, it may be beneficial in bulimia. (6)
- 5HT – Tryptophan is an essential amino acid, meaning that our bodies do not produce it and we must get it from the diet. If someone has adequate stores of Vitamin B3 and is not under severe stress, tryptophan gets converted to 5HTP which is the precursor to forming the neurotransmitter serotonin. Because bulimia is related to low serotonin levels, supplementing with 5HTP may be helpful.
- B vitamins –B vitamins play a variety of different roles in the body. Several B vitamins help to control blood sugars, thus reducing the urge to binge eat. Some B vitamins help to support neurotransmitter pathways. Supplementing with a good B vitamin complex can be helpful in patients with bulimia.
The Bottom Line
Bulimia is a multi-faceted condition which requires a multi-faceted treatment approach. The best treatment will explore diet, lifestyle, sleep, stress management and lifestyle counselling to help the patient manager their thoughts, emotions and reactions. Treatment for bulimia is possible and taking the first step of admitting the need for help is always the most important. Recovery takes time, patience, understanding, commitment and dedication to one’s health. It’s okay if your recovery journey is ‘wavey’ with ups and downs and remember to learn to love yourself throughout the process. It is best to garner the support of friends, family and healthcare professionals committed to guiding you in the process.
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596
- Cook, B., Wonderlich, S. A., Mitchell, J., Thompson, R., Sherman, R., & McCallum, K. (2016). Exercise in Eating Disorders Treatment: Systematic Review and Proposal of Guidelines. Medicine and Science in Sports and Exercise, 48(7), 1408–1414. https://doi.org/10.1249/MSS.0000000000000912
- Harrington, B. C., Jimerson, M., Haxton, C., & Jimerson, D. C. (2015). Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa. American Family Physician, 91(1), 46–52.
- Kaye, W. (2008). Neurobiology of Anorexia and Bulimia Nervosa Purdue Ingestive Behavior Research Center Symposium Influences on Eating and Body Weight over the Lifespan: Children and Adolescents. Physiology & Behavior, 94(1), 121–135. https://doi.org/10.1016/j.physbeh.2007.11.037
- Sakae, K., Suka, M., & Yanagisawa, H. (2020). Polaprezinc (Zinc–l-Carnosine Complex) as an Add-on Therapy for Binge Eating Disorder and Bulimia Nervosa, and the Possible Involvement of Zinc Deficiency in These Conditions. Journal of Clinical Psychopharmacology, 40(6), 599–606. https://doi.org/10.1097/JCP.0000000000001284
- Shih, P. B., Morisseau, C., Le, T., Woodside, B., & German, J. B. (2017). Personalized polyunsaturated fatty acids as a potential adjunctive treatment for anorexia nervosa. Prostaglandins & Other Lipid Mediators, 133, 11–19. https://doi.org/10.1016/j.prostaglandins.2017.08.010
- Waller, G., & Sheffield, A. (2008). Causes of bulimic disorders. Psychiatry, 7(4), 152–155. https://doi.org/10.1016/j.mppsy.2008.02.002
- Westmoreland, P., Krantz, M. J., & Mehler, P. S. (2016). Medical Complications of Anorexia Nervosa and Bulimia. The American Journal of Medicine, 129(1), 30–37. https://doi.org/10.1016/j.amjmed.2015.06.031
- What Are Eating Disorders? (2017). https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders