Bulimia Nervosa and Weight Loss: Understanding the Complex Relationship

Bulimia nervosa, often simply called bulimia, is a serious eating disorder characterized by a cycle of restrictive dieting, binge eating, and compensatory behaviors aimed at preventing weight gain. These behaviors, often referred to as purging, can include self-induced vomiting, misuse of laxatives or diuretics, excessive exercise, or fasting. Despite the intense efforts to counteract calorie consumption, bulimia typically does not lead to weight loss. In fact, it can even contribute to weight gain over time. People struggling with bulimia are often within a normal weight range, and some may even be overweight.

This article delves into the complex relationship between bulimia nervosa and weight loss, exploring why purging behaviors are ineffective for weight management, the underlying motivations behind these behaviors, the potential health consequences of bulimia, and available treatment options.

The Myth of Vomiting for Weight Loss

A common misconception is that vomiting can effectively eliminate calories and lead to weight loss. However, this is far from the truth. Vomiting, or throwing up, does not lead to weight loss. In reality, the body begins to digest food almost immediately upon consumption. Foods high in sugar and processed carbohydrates can be absorbed within minutes. Consequently, even when vomiting occurs immediately after a meal, the body retains more than 50% of the calories consumed.

Another common purging method involves the use of laxatives or diuretics. While these substances may lead to a temporary decrease in weight, this loss is primarily due to water depletion. Such practices can lead to dehydration and electrolyte imbalances, posing significant health risks without contributing to genuine weight loss.

Rita Faycurry, a Registered Dietitian (RD), emphasizes the importance of understanding that bulimia doesn't cause weight loss. She cautions against using this information as a catalyst for seeking other harmful weight loss methods. Instead, she advocates for building a healthy relationship with food and breaking free from all forms of disordered eating.

Read also: Understanding Bulimia's Effects

Why People with Bulimia Self-Induce Vomiting

Bulimia is characterized by cycles of binging and purging. During a binge, a person eats a large amount of food in a short time. To compensate, they may force themselves to vomit or use laxatives and diuretics. Some may also turn to excessive exercise to burn off calories.

The act of purging is often driven by intense feelings of guilt, shame, and anxiety associated with binge eating. Purging becomes a way to try to relieve this tension and "undo" the binge. It's a vicious cycle that starts with the urge to diet or severely restrict calories between binge eating episodes. The calorie restriction, stress, and overwhelming emotions, combined with a negative body image, can trigger the next binge eating episode.

While binge eating may bring temporary feelings of relief and a false sense of control, constant binging and purging can have long-term health consequences.

Bulimia Risks: Harmful Effects of Binge Eating and Purging

Bulimia nervosa is a life-threatening eating disorder that leads to health issues impacting the mind and body.

Physical Health

• Electrolyte imbalances: Frequent vomiting can lead to severe imbalances such as hyponatremia (low sodium) and hypokalemia (low potassium). This can lead to fatigue, dizziness, an irregular heartbeat, and seizures.
• Tooth erosion: Repeated purging brings stomach acid into contact with teeth, leading to enamel erosion, cavities, tooth decay, sensitivity to hot and cold foods, and gum disease. Additionally, vomiting stimulates saliva production, and repeated exposure to stomach acid causes the salivary glands to become inflamed and swollen, leading to puffy cheeks or "chipmunk cheeks."
• Throat issues: People with bulimia can develop a sore throat and mouth ulcers from stomach acid contact. In extreme conditions, cells in the esophagus may change their shape to resemble that of the stomach. This condition is known as Barrett's esophagus (BE). Throwing up frequently can lead to a tear in the food pipe called a Mallory-Weiss tear, resulting in blood in the vomit. If the tear is severe, it can lead to life-threatening bleeding.
• Cardiac issues: Bulimia can damage heart cells, leading to congestive heart failure, arrhythmias, and even sudden cardiac death.
• Hormonal imbalances: Females with bulimia often have low estrogen levels and experience skipped or missed periods, increasing the risk of infertility.
• Bulimia knuckles: calloused knuckles from using fingers to induce vomiting. In these situations, the knuckles of the hand scrape against the front teeth, causing scarring.

Emotional Health

Bulimia nervosa is associated with several mental health conditions and can significantly worsen emotional well-being.

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• Co-existing psychological disorders: The constant binging and purging and the secrecy surrounding eating disorders like bulimia can increase stress levels.
• People with bulimia may also battle severe depression, obsessive-compulsive disorder (OCD), anxiety, impulsiveness, low self-esteem, and poor body image. Often, they may also have issues with addiction or substance use disorder.

Potential to Lead to Other Eating Disorders

Faycurry RD, "There is a risk that bulimia may morph into a different eating disorder. An example is when it becomes harder for someone with bulimia to purge in secret after meals. In this case, they may begin to restrict food intake to lose weight without purging, leading to anorexia nervosa. This is dangerous and can be a toxic disordered eating cycle of binge eating disorder, bulimia, and anorexia."

What Causes Bulimia Nervosa?

The exact causes of bulimia nervosa are unknown, but several factors increase the risk of developing the disorder.

Genetics

According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD), there is a 28%-83% risk of developing eating disorders if there is a family history.

Chemical Imbalances

Eating disorders may also be linked to a chemical imbalance in the brain involving serotonin, the "happy hormone" primarily produced in the gut.

Some research indicates that females with diabetes may be at a higher risk of developing eating disorders. This may be due to fluctuating blood sugar levels. These shifts can affect appetite and mood, which might trigger the urge to binge.

Read also: Beef jerky: A high-protein option for shedding pounds?

Coping with Trauma and Negative Emotions

Many who binge and purge use food as a way to cope with negative emotions, trauma, childhood neglect, and challenging transitions such as changing jobs or schools, going through puberty, or heartbreak.

Studies show that more than 50% of people with eating disorders also have post-traumatic stress disorder (PTSD). Research also suggests a strong link between bulimia and childhood sexual assault.

Social Pressure Related to Weight

The social pressure to be "skinny" can trigger eating disorders. Kids bullied or shamed for their weight are especially vulnerable. Even indirect messages, like hearing loved ones praise others for being "thin," can have a lasting impact. Add constant ads promoting the "perfect" body, and the influence grows stronger.

At the same time, the food industry floods us with messages to "treat" ourselves with ultraprocessed foods. Packed with empty calories and lacking fiber, these foods are engineered to hijack brain chemicals and fuel binge eating.

Bulimia Diagnosis

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) outlines the criteria for diagnosing bulimia as:

• Binge eating: eating large amounts of food in a short period of time (less than two hours) compared to what people usually eat in the same timeframe. During a binge, the person will report feeling a lack of control over their feeding habits.
• Compensatory behaviors: A binge followed by purging, laxative misuse, fasting, or excessive exercise to negate the effects of the binge.

Faycurry RD notes, "Binging and purging must take place at least once a week for 3 months to be considered bulimia nervosa."

If you suspect you or a loved one has bulimia, please visit a licensed healthcare provider who has experience with eating disorders. They are the only professionals authorized to diagnose bulimia.

Bulimia Treatment and Recovery

Like all eating disorders, bulimia can be overwhelming and wreak havoc on a person's mental and physical health. Many feel trapped in the restrict-binge-purge cycle and cannot imagine a life free from thoughts of food.

However, recovery is possible, and individuals can build a better relationship with food. Bulimia treatment involves psychological counseling by a mental health professional, nutritional counseling by a dietitian, and physical conditions treated by a doctor. Additionally, bulimia medication may play role.

The first step is to seek treatment from experts who specialize in eating disorders.

Understanding Disordered Eating

Eating is disordered when it interferes with daily functioning, causes psychological distress, and results in fluctuating weight, such as what is experienced in people with bulimia nervosa (BN). Signs of disordered eating may include:

• Frequent dieting, starving, binge eating, purging, or using laxatives or diuretics to lose weight. Engaging in these behaviors long-term damages the body and results in emotional distress.
• Social isolation, anxiety, and depression. As disordered eating behaviors increase, individuals tend to isolate themselves from friends and family, avoiding social activities and even work or school obligations. This, in turn, can lead to increased anxiety and depression.
• Weight fluctuation. In one longitudinal study, those who used unhealthy weight-control methods were three times more likely to have higher body weights after five years, six times more likely to develop binge eating disorder, and five times more likely to become addicted to diet pills, laxatives, or diuretics.

Motivations Behind Disordered Eating

The biggest motivating factors driving disordered eating include:

• Media use
• Rebound from failed dieting attempt
• Body dissatisfaction
• Weight-related teasing or shaming

If someone feels compelled to lose weight due to these factors, which is very common in our society, discussing them in counseling, learning about how diet culture influences our views of food, eating, and exercise, acknowledging distressing feelings, and practicing mindfulness and intuitive eating can help prevent falling into disordered eating.

Body Acceptance and Mindful Eating

A truly healthy approach to body weight entails unlearning our society’s harmful messaging that fat is bad, weight is an indicator of health and is to blame for many health problems, and losing weight will solve those problems. This approach entails learning about all the factors that can actually lead to weight gain and how weight is not a viable indicator of health. Educating yourself about concepts that include Health at Every Size® (HAES®), weight stigma, fatphobia, body positivity, and weight neutrality will help you understand how skewed our perception of health is and how biased we are against fat.

Body acceptance comes from a place of self-love, respect, and compassion. That’s hard to achieve in a culture that idealizes certain body types over others, teaches us to hate our bodies, and tells us we need to change our bodies to fit in–which leads to eating disorders. But there are things you can do to redirect your efforts to pay attention to what your body needs to function effectively and for you to feel good about yourself.

While disordered eating stems from negative emotions and feeling badly about yourself and your body, maintaining weight mindfully is a positive paradigm and honors the body’s innate cues for hunger, satiety–or feeling satisfied, and fullness.

Applying the principles of mindful eating can help you improve your relationship with food, eating, and your body and give your body what it needs to function properly. They include:

• Awareness of physical sensations. Notice how it feels to be hungry, satiated, full, and uncomfortably full. If nausea arises before, during, or after eating, pause and reflect on the psychological drive behind the nausea. The body needs food to survive, so nausea (rejecting the food), stems from viewing food as negative, the enemy, or the cause of unpleasant feelings.
• Awareness of thoughts and feelings related to eating. If anxiety or uncomfortable feelings arise, note where they sit in the body. For some, it may start in the chest or reside in the belly. Some describe it as pressure or burning. Simply note what arises.
• Acceptance and non-judgement of sensations, thoughts, feelings, and the body. Allow the feelings of nausea, anxiety, etc., to be present in the body and mind. Thank the body and mind for trying to protect itself.
• Awareness and step-by-step change of daily patterns and eating habits. Explore other ways of self-soothing. This process takes time and is best done with a trained therapist or physician. Relapse is entirely normal and to be expected. If this happens, avoid self-deprecating thoughts or behaviors, and continue to repeat steps 1-4.

Studies also show that group therapy, body scan-guided imagery, journaling, and art therapy can be highly beneficial and supportive to walking through the steps outlined above.

Unhealthy vs. Mindful Exercise

People who have bulimia and other eating disorders often exercise excessively to compensate for food eaten. Exercise is considered extreme if you:

• Feel preoccupied with exercise (think about it when not exercising)
• Feel a need to exercise in increasing amounts of time in order to achieve satisfaction
• Have an inability to control exercise
• Feel restless or irritable when attempting to cut down or stop exercising
• Use exercise as a way of escaping from problems or of relieving a poor mood (feelings of helplessness, guilt, anxiety, or depression)
• Lie to family members or friends to conceal the extent of involvement with exercise
• Jeopardize or risk the loss of a significant relationship, job, educational, or career opportunity because of exercise
• Keep returning to exercise after spending an excessive amount of money on exercise-related expenses
• Go through withdrawal when not exercising (increased depression, anxiety)
• Exercise longer than originally intended

When an unhealthy relationship with exercise develops, someone will feel emotionally distraught and guilty when they do not exercise. They may restrict eating to only on days when they can exercise or purge when they miss a workout. Injuries often occur due to nutritional deficiencies or overexertion. At the end of working out, instead of feeling accomplished, someone will feel relieved or that they have permission to eat. They may compulsively track caloric intake and compare this with how many calories they’ve burned while exercising.

Mindful exercise in bulimia recovery integrates mind and body and includes profound inward mental focus. Examples include yoga or tai chi, which focus on non-judgemental inward focus, instead of compulsively targeting heart rate. Mind-body exercise incorporates these criteria:

• Meditative/contemplative in nature. This means performing exercise in a non-competitive way. Focus on being present instead of goal oriented.
• Proprioceptive and kinesthetic body awareness. This means honing mental focus with muscular movement.
• Breathwork. Focusing on the breath and controlling how you breathe regulates your nervous system and alleviates distress.
• Anatomic alignment or proper choreographic form. Focusing on this will prevent overuse injuries, sprains, and strains. If pain develops while exercising, instead of pushing through it, mindfully acknowledge the pain and tailor back.
• Energy centric. This means noticing the flow of the body’s intrinsic energy. If someone is feeling sluggish, weak, or tired while exercising, then positively, compassionately note this and respect how the body is feeling.

The Role of Weight Suppression

Weight suppression, which is the discrepancy between a patient’s highest weight and current weight, may be an important factor in the course and outcome of bulimia nervosa (BN). Individuals who are weight suppressed weigh less than they once did. Because patients with BN usually present for treatment at a normal weight, the fact that many were once overweight or obese is often overlooked. The perpetual dieting and/or compensatory behaviors that are needed to maintain a suppressed weight could maintain binge eating and purging. This large reduction in weight also could make patients with BN more susceptible to weight gain (possibly due to reduced metabolic rate, increased overeating, or both), leading to even greater dietary restriction, which maintains the binge/purge cycle.

Two studies have found that weight suppression predicted weight gain in patients with BN. This weight gain could cause increased body image dissatisfaction and lead to higher rates of disordered eating in an effort to avoid future weight gain or to lose the undesired weight. Additionally, since many individuals with BN were previously overweight, they may have an even greater fear of weight gain because they have previously seen those fears realized. This fear of weight gain could also contribute to greater levels of dieting and compensatory behaviors.

Weight suppression is calculated by two factors: current weight and highest weight. Research has examined whether either factor is predictive above and beyond weight suppression. To date, highest weight has not been predictive of BN symptoms or treatment outcome.

Individuals who have high weight suppression and low current weight might have the greatest motivation to stay thin and may engage most in unhealthy eating behaviors. Individuals who are high in weight suppression and have a relatively high weight or those who are thin but not weight suppressed may have less severe symptoms, possibly because these individuals are not as afraid of weight gain or experience less biological pressures toward weight gain. In addition, the combination of high weight suppression and low weight could engage defensive biological mechanisms that could induce more binge eating and metabolic efficiency and therefore predispose these individuals towards weight gain.

Studies have shown that weight suppression was related to the frequency of binge eating and purging and interacted with BMI such that those who were high in weight suppression and low in BMI exhibited more than twice as much binge eating than groups representing other combinations of weight suppression and BMI status. Those higher in weight suppression also exhibited more purging, but neither BMI nor the interaction of BMI and weight suppression were related to purging.

Low BMI and high weight suppression could have biological and behavioral effects that increase food intake, feelings of loss of control over eating, or both. Previous research has shown that large weight losses in normal weight individuals can result in binge eating-like behavior. Substantial weight loss also produces decreases in anorexigenic hormones such as leptin and orexigenic hormones like ghrelin. These hormonal changes could fuel overeating or binge.

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