The hidden eating disorder: Bulimia nervosa

Bulimia nervosa can go undetected for years. So how can you tell if a loved one is suffering from it? And what can you do to help? Georgia Rickard and Paulette Crowley reveal the answers.

We hear a lot about the rising rates of overweight and obesity. But unfortunately, the number of Australians affected by bulimia nervosa is growing, too. According to the Eating Foundation of Australia, eating disorders such as bulimia nervosa are the third most common chronic health problem affecting young women today. And while once thought to be a condition suffered mainly by females, bulimia has now been found to affect a growing number of males.

Defining bulimia nervosa

People with bulimia nervosa follow a cycle of restricting, bingeing and purging of food. Their bodies react to food restriction as starvation, and then have to react to large amounts of food in a short time. The binges, usually shrouded in secrecy, cause sufferers to worry abut weight gain, causing them to ‘purge’ the food by vomiting, abusing laxatives or over-exercising. This results in feelings of guilt, shame and self-disgust, followed by a desire to keep their behaviour a secret from those closest to them – all of which contributes to feelings of despair, loneliness and depression. Sufferers also have an extreme fear of being overweight, an obsessive preoccupation with being slim, and regardless of their actual weight, think they are larger than what they are.

The hidden eating disorder

Unfortunately, this disease is often much more difficult to recognise than other health conditions, such as obesity or anorexia nervosa. “Bulimia nervosa often goes unnoticed because you don’t ‘see’ it as much,” explains Phillipa Hay, a professor of mental health at the University of Western Sydney who is currently studying the disease. “Sufferers can often be of a normal weight, and yet be very ill.” This explains why no one is exactly sure of how many suffer from bulimia, she says, but “studies have shown that up to 90 per cent of sufferers are not in treatment, not accessing treatment, or have not been identified.”

Yet left untreated, bulimia nervosa can result in long-term physical damage, such as reduced memory and thinking ability, bowel or stomach rupture, stunting of height or growth, cardiac irregularities, fertility problems or infertility, or impaired mental health. One study by the Mental Health Foundation also found that the suicide rate of women with an eating disorder to be 58 times greater than for women without an eating disorder. So it’s important to know which symptoms to look for – you could save someone’s life.

Why does bulimia nervosa develop?

According to Professor Hay, bulimia nervosa results from a number of factors. Among the most common, she says, are:

Dieting

“Usually, a bulimia sufferer is someone already vulnerable to certain pressures to be a certain weight, who is then exposed to an environment where there’s a lot of dieting,” says Professor Hay. “We know that dieting and restrictive eating drives overeating, and that’s the most common path into bulimia nervosa.” Parents who exhibit dieting behaviour can also be an influencing factor on a sufferer, as can suffering from diabetes, as this condition imitates the ‘restrictive’ eating patterns of dieting.

Family history

Having an unstable relationship with parents or a history of abuse can translate to low self-esteem, which can make someone particularly susceptible to the damaging ‘body beautiful’ ideals associated with bulimia nervosa. Those with a family history of mental illnesses such as eating disorders, alcoholism, depression and obsessive-compulsive disorder are also more likely to develop the disease.

Life transition

The associated ‘upheaval’ of any life change can precipitate “a greater need for a sense of control through restrictive eating,” says Professor Hay, which is a behaviour that can spiral in binge eating. This is especially pertinent during two life phases; puberty, and middle age. “Puberty is particularly pertinent for women, as the development of breasts, hips and a waist can lead a young woman to believe she’s becoming overweight when in fact she’s merely just changing into a post-pubertal body shape,” says Professor Hay. Middle age is also a potential risk factor: “a person’s body weight is naturally at its highest between the ages of 40–50, making it a time of increased sensitivity to body image and weight issues.”

Environment

Participation in a career or sport that requires thinness, such as dancing, modelling, horse-racing and body-building, can create unhealthy associations between having a low weight and personal worth. Living in cities is another known environmental risk factor for bulimia. “We’re not sure why this is exactly, but it seems to be because there’s a higher emphasis on body image in urbanised areas,” says Professor Hay.

Anorexia nervosa

According to the US Department of Health and Human Services’ Office on Women’s Health, half of all patients with an existing case of anorexia nervosa develop bulimia nervosa.

Signs to look for

It can be difficult to tell if someone you care about has bulimia nervosa, because people who have it are often obsessively secretive and extremely defensive about it, and may not look underweight. But there are signs you can look for, says Professor Hay.

Behavioural signs

• Food disappearing: especially high-kilojoule, high-carbohydrate foods (such as a whole loaf of bread, or block of chocolate).
• Frequent and/or prolonged bathroom trips: due to abuse of laxatives or regurgitation. Sufferers may also run a tap or shower, to mask sounds of vomiting.
• Financial difficulties: sufferers often spend a large percentage of resources on excess food. They may also shoplift food.
• Wanting to eat, or be alone: sufferers often prefer to live alone, so that they don’t have to account for missing food or eat meals with others.
• Children giving away lunch: usually at school.
• Unexplained disappearances: particularly after eating.
• Losing interest in activities: sufferers may begin to seem less interested in anything not related to food or exercise.
• Excessive teeth cleaning: or using strong perfumes to hide the smell of vomit.
• Anxiety when around food: particularly at events where food is an integral component, such as at family dinners.

Physical signs

• Poor quality teeth: or erosion of tooth enamel, due to frequent contact with regurgitated stomach acid.
• Signs of extreme tiredness: such as needing to sleep during the day.
• Fluctuations in weight: sufferers may at times be overweight, or underweight.
• Complaints of sore throat: caused by irritation from regurgitated stomach acid.
• Broken blood vessels: usually seen as tiny, red dots in the whites of the eyes.
• Swollen cheeks: this ‘chipmunk’ look is caused by a swollen parotid gland, due to vomiting.
• Callouses or abrasions: seen on the backs of fingers, created by forced vomiting.

What to do...

If you suspect that someone close to you is suffering from bulimia nervosa, Professor Hay recommends speaking with them.

“Most patients are reluctant to come forward and spontaneously talk about their issues, because the shame and the guilt associated with the behaviour inhibits them from talking about it, or seeking help. But mostly, they’ll find it a relief to be asked about it, and be ready to talk about their issues.”

Still, don’t take matters into your own hands, she rushes to add. “You’re much better off trying to get them help.” She recommends directing them to a GP and accompanying them if they request it.

There, they’ll most likely be referred to a psychologist, although a team of other health professionals may be involved in treatment. “It’s also really important to try and support them in eating normally as much as possible, too,” Professor Hay points out. “Part of the treatment is learning to eat in a normal, relaxed way, so continue to invite them to share meals with you.”

Finally, don’t stop trying to support them. The road back from an eating disorder can seem very long, but many do recover with the right treatment and support.

Does Medicare provide any support?

In Australia, people suffering from mental health issues such as eating disorders are eligible for government-subsidised treatment, once they have had their mental health assessed by a GP. This is known as the ‘Medicare Benefits Schedule’.

Once assessed, the doctor will place a sufferer under a GP Mental Health Care Plan. This identifies any action needing to be taken by the patient, selects appropriate treatment options including psychologists, arranges for ongoing management of the patient and documents progress. All psychology services are limited to a maximum of 12 individual sessions per person per calendar year, with the possibility of an additional six sessions in extreme cases (i.e. a significant change in condition). Clients may also be eligible for 12 group session services in a calendar year. For more information, see www.health.gov.au.