- Bulimia Nervosa
- What are the different types of purging and non-purging in bulimia?
- What are the symptoms of bulimia?
- What are the causes and risk factors for bulimia?
- What are the complications of bulimia?
- How is bulimia diagnosed and treated?
- Recovering from bulimia
- Diabulimia - The rise of a new eating disorder associated with type 1 diabetes
Recovering from bulimia
When a person is undergoing treatment for bulimia and is entering recovery from the condition, one of the initial and often disheartening challenges is having to accept the inevitable changes that the body goes through.
While it is seen as a great accomplishment for someone to seek treatment for an eating disorder, it may be embarrassing or intimidating for them to speak to their doctor and/or loved ones about their eating struggles. It is recommended that loved ones be supportive and open to talking to the sufferer about the eating disorder and recovery at any time.
The journey to recovery from an eating disorder is often a long road for a person to travel and takes a lifetime of dedication and commitment to the process of healing and adjusting to healthy eating habits. Recovering from bulimia involves more than simply establishing a healthy relationship with food and eating. The process requires breaking away from old habits and learning new techniques in coping with the stresses of life. Dedication, strength and patience are required to face the inevitable challenges that may arise.
Patients, with the help of a mental healthcare professional will need to understand the triggers which may urge them to re-engage in binge-purge cycles. In knowing one’s triggers, a person can develop strategies in dealing with these in order to prevent any relapses.
Relapses should not be regarded as a failure or associated with feelings of guilt as these emotions may only provoke further relapses in the future. Relapses can be expected in recovery and individuals should not beat themselves up about them but rather tell a loved one or therapist about the binge-purge episode as soon as it occurs and talk about the emotions that triggered the relapse and how they may prevent this from happening again in the future.
Recovery is a daunting and often difficult process, however, it can be far less intimidating when people know what to expect so as to prevent future road blocks of disengaged loved ones and uncertainty in the course of treatment as these can lead to limited progress, feeling ambivalent and ultimately, dropping out of treatment.
Individuals will also need to bear in mind that each person’s body will react differently during the recovery process and the changes experienced will depend on the severity of the eating disorder and the effects it had on their body.
The below information describes what the majority of sufferers can expect when recovering from bulimia.
The stages of change for recovering from an eating disorder
There are five stages of change13 that have been established to help those deal with eating disorders, these are explained below:
1. Pre-contemplation stage
During this stage, the individual is not thinking about changing or receiving any form of help from loved ones or treatment from medical professionals. Those in this stage may defend their bad habits and not recognise their unhealthy ways of eating as an issue or an eating disorder. Friends and loved ones who are close to the person with the eating disorder are likely to pick up on some of the symptoms of bulimia such as bingeing and purging before the individual admits to struggling with the disorder. He or she may refuse to discuss the topic and deny any evidence of it. During this stage of an eating disorder, loved ones are advised to seek reliable information on bulimia and help in supporting a loved one dealing with it in order to inform the sufferer of the dangers of their condition and open their eyes to the potential health complications associated with bulimia.
2. Contemplation stage
This stage occurs when the affected person admits that they have an eating disorder and begin to open up to the idea of seeking medical and professional help, however, they may still be uncertain and play with the idea of whether they really have an eating disorder and if help is even necessary.
As this stage progresses, the sufferer may begin to become aware of the consequences of their condition and start to spend time thinking about the complications of their eating habits. He/she may weigh the pros and cons of modifying or even quitting their behaviour. They may also begin to doubt the long-term benefits of quitting due to the fear of weight gain.
The contemplation stage may take a number of weeks, months and even years to work through and move on from. However, loved ones should not lose hope as the sufferer is more likely to receive advice and information regarding their eating disorder during this phase and may be more willing to make use of educational interventions and reflect on their personal thoughts and feelings about their condition. All of this helps in moving them closer to the next step in their process of change.
3. Preparation / determination stage
When a sufferer transitions into this stage, this means that he or she is ready to seek treatment and have made some form of a commitment to change. The individual’s motivation to change is fuelled by knowing they have to do something about their eating disorder as a result of recognising the severity of their condition and the health consequences thereof. During this stage, the sufferer is likely to research their condition further and find what resources and strategies are available to help them to begin to take steps toward improving their health, eating habits and working toward the eventual cessation of bulimic behaviours.
It is often the case that sufferers will skip this stage entirely, moving directly from contemplation to action and their efforts of change, as a result, will face failure due to the fact that they have not adequately researched and accepted the challenges they may face in making a major lifestyle change, not only mentally but physically.
4. Action / willpower stage
During this stage, the person will believe that they have the power and ability to change their unhealthy eating habits and will be actively involved in taking the steps needed to change, using a number of different techniques and options available to them, moving from preparing for change to putting these changes into action.
This stage mostly depends on the willpower of the individual as they begin to make significant efforts in changing their behaviour and quitting their eating disorder. This stage also has the biggest risk of relapse13 as these changes can be daunting.
It is essential that the sufferer trusts the process of treatment and the team and support network available and is also open to new ways of thinking and dealing with stressors in their lives, both past and present.
5. Maintenance stage
In reaching the maintenance stage, the bulimia sufferer will have sustained their action stage for roughly six months or more. The maintenance stage will involve the affected person actively practicing new behaviours and ways of thinking in order to ensure the success of their treatment. A vital part of this phase will involve revisiting potential stressors which have been identified as triggers of bingeing and purging episodes, so as to prevent a relapse.
**My Med Memo – It is important to individuals going through the stages of change to accept that regression is natural and normal. A person may reach one stage, only to regress to the previous one later on. This is to be expected as part of making changes in one’s behaviour. The stages of change should be viewed as cyclical rather than linear in their progression. An individual may go through this cycle of change more than once and revisit a specific stage multiple times before moving to the next. This makes the recovery for someone with bulimia nervosa complex, challenging and completely individualised.
Dealing with the stages of change in a loved one or child
The information below explains how to deal with a loved one or child who may be going through the stages of change in bulimia:
- It is important to not be in denial of your loved one or child’s eating disorder
- Educate yourself on the symptoms and signs of bulimia and know what to be aware of
- Do not rationalise his or her eating behaviours
- Try to share your concerns and thoughts openly with the person
- If you are the parent of a child who is younger than 18 years of age, then you can insist that he or she receive the help they need from a mental health care professional, it is advised that you do not force your child into anything but rather show your support for the matter in a firm yet loving way.
- Listen to your child and allow them to openly express what they are going through, be prepared to accept blame even though it may not always be accurately attributed.
- Do not attempt to fix the issue yourself, rather seek professional help.
- As a parent and loved one, you will also need support as an eating disorder in someone close to you will take a personal toll, try to find encouragement from friends, family or local support groups for loved ones dealing with eating disorders in children, friends or other family members.
- Meet with a mental healthcare professional and identify your role in the process of recovery.
- Explore what your personal thoughts on food, body shape, weight and appearance are to assess what influence you may have on the person dealing with bulimia.
- Speak to your child or loved one about their condition, their treatment and how they would like you to be involved.
- Ensure that your child or loved one follows their treatment plan.
- Try to remove any triggers from the sufferer’s environment, such as stress (as far as possible) and scales.
- Offer support and encouragement, be caring and warm yet determined and in enforcing the appropriate guidelines and rules, particularly as a parent.
- Try to reinforce positive ideologies on body shape, weight or appearance.
- Applaud your child or loved one’s success and milestones in their path to recovery
- Be aware of possible relapses and allow for the sufferer to discuss these with you
The symptoms and signs of bulimia recovery
There are a few notable signs and symptoms that sufferers and loved ones may notice. Some of which are often discouraging to the person in recovery as they may bring about emotions of body image and trigger feelings of doubt and guilt associated with eating. However, these changes are temporary, and the severity thereof will depend on the individual.
The initial phase of recovery – the bulimia bloat
The bulimia bloat, also known as ‘recovery bloat’ occurs as a result of the body adjusting to normal eating times and adequate quantities of food during recovery. Eating healthy quantities of food rather than bingeing can result in constipation and gas as the bowels have to deal with processing more food due to the cessation of self-induced vomiting and/or attempt to work without the aid of laxatives. The digestive system attempts to regulate itself and normalise according to new eating patterns and food intake.
A number of people will experience this during recovery from an eating disorder and one should not let this symptom discourage their progress as bloating tends to only last for the initial phase of recovery. The bloating will typically occur within the first few days of recovery and last only for a few weeks. The vital thing for sufferers to remember is that this is a sign of healing within the body and is not permanent.
There are a few tips that may help those experiencing this type of bloating:
- Speak to a doctor about taking probiotics to help digestion get back on track. Some doctors may also suggest the use of digestive enzymes.
- It may help to partake in some gentle exercise, with a doctor’s permission of course. Keep in mind that the body may be weak as a result of healing.
- Avoid any diuretics and laxatives or teas referred as ‘fat-burning’, ‘cleansing’ or ‘weight-loss’ as these will only aggravate the digestive system further and may increase any constipation and bloating, interfering with the goals of the treatment program.
During recovery from bulimia many sufferers will fear gaining weight as a result of no longer purging, partaking in rigorous and compulsive exercise, or using fat burners and laxatives.
It is common for one to experience weight fluctuations during recovery as the body adjusts to regulated food intake and the processing of food naturally, however, it is vital to be aware of the fact that bulimia in itself is not effective in attempting to manage weight anyway. Once a person’s chaotic patterns of eating have settled, their weight will stabilise.
Changing one’s eating habits is bound to have an impact on body weight and appearance. As structured eating is put into practice, the individual will begin to notice changes in their weight, however, this does not happen to everyone. Bingeing and purging during recovery is seen as one of the main causes of weight gain as this interferes with healthy eating habits and healing.
The quicker someone is able to implement and adjust to normal eating routines, the quicker their weight will stabilise. A number of people may actually notice some weight loss as their episodes of bingeing typically involved junk food, some of which would have been absorbed by the body. When the person starts eating healthier foods in smaller portions, their body may react by inducing fat loss.
The below are a few tips for dealing with fluctuations in weight during recovery
Someone who experiences weight gain in recovery will need to learn how to practice patience. Treatment and recovery are both long-term with weight gain being a temporary effect of a return to normal eating. It is best to avoid the scale as weighing oneself may evoke feelings of anxiety and guilt and cause a relapse. It is advised that the person allows their body to heal and learns to consider their symptoms, although disheartening, as a sign of healing and health.
Water retention tends to be episodic throughout recovery from bulimia. Water retention may be a cause of increased sodium intake in food, higher carbohydrate intake, changes in hormones and adjusting to a normalised intake of food. This is a perfectly natural response of the body and should be expected. Again, this is usually temporary.
Here are a few tips for dealing with water retention during bulimia recovery:
- Keep up a steady intake of fluids as fluid loss may result in water retention as the body attempts to hold on to liquid
- Avoid alcohol and caffeine as these liquids lead to water retention
Positive changes in recovery
Recovery is not all bad, it is best not to let the challenges associated with the phases of recovery to be off-putting. There are some positive changes of recovery that can be expected as a result of a healthy intake of food, constructive mental health sessions and the use of the appropriate medications. These include:
- Increased quality of sleep due to a balance of hormones and lack of hunger which may have once caused one to wake up at night
- Clearer skin (this is often experienced once the body has adjusted to hormonal and dietary changes as skin issues may be experienced during the initial stages of recovery)
- A decrease in anxiety and stress
- Stabilised emotions and mood
- Improvement in self-esteem
- Overall improvement of symptoms associated with bulimia
Bulimia recovery – Refeeding during remission
Although bulimia does not usually result in unhealthy and significant weight loss, refeeding is still sometimes a necessary part of patient recovery. Bear in mind, refeeding is typically used in those recovering from anorexia nervosa as this condition often causes severe weight loss and malnutrition.
Refeeding refers to a form of treatment that attempts to restore a healthy body weight. This form of treatment attempts to rectify the effects of unhealthy eating habits and malnutrition and the impact this has on cognitive functioning and overall health.
The process involves strategically increasing one’s intake of food (calories), ensuring that the body is receiving the right amount of nutrients. For example, the patient may begin with an intake of 1400 to 1800 calories per day, or less, depending on their current state, with this advancing by roughly 300 calories every three days or so, some experts may view this as an aggressive form of refeeding and recommend that calorie increase is more gradual. If this is done in hospital or in a care facility, the attending doctor will monitor the patient’s electrolytes and cardiac health during a refeed, otherwise, the individual will need to stick to their refeeding program at home, with the help of loved ones or parents.
Refeeding should only be done under medical supervision (i.e. through a specialist such as a dietician) and can be conducted via meals or nasogastric (i.e. reaching the stomach via the nose) feeding tubes. In the case of bulimia, a meal-based approach is often favoured as it is associated with fewer health risks and the patient may not struggle with the concept of eating as much as someone with anorexia nervosa. Some patients may require both a meal and a tube-based method. Those with severe malnutrition may eat normally, or as much as they are capable of, during the day, and have a tube at night.
The overall idea and goal of refeeding is to help individuals to normalise their eating behaviour.
What is refeeding syndrome?
Refeeding syndrome may develop when a severely malnourished person begins to up their intake of nutrition (i.e. refeed). It is defined as a shift in electrolytes and fluids that may occur in those who are significantly malnourished and are receiving artificial refeeding (whether this is done enterally through the digestive system or parenterally through infusions or injections into a vein or muscle). These shifts in the body are potentially fatal14.
The symptoms of refeeding syndrome include:
- Mental confusion
- Difficulty breathing
- Heart failure
According to the National Institute for Clinical Excellence (NICE)15, the risk factors associated with refeeding syndrome include one or more of the below:
- A weight loss of more than 15 percent of one’s body weight in the last three to six months
- A BMI (body mass index) of less than BMI of less than 16 kg/m2
- Very little nutritional intake for more than ten days
- Low magnesium, potassium and magnesium levels before the refeed
Alternatively, the risk factors include having two or more of the below conditions:
- A weight loss of more than 10 percent of one’s body weight in the last three to six months
- A BMI that is less than 18kg/m2
- Very little or no nutritional intake for longer than five days
- A history of alcohol or drug abuse (this includes using laxatives, insulin and diuretics)
Not all patients who have one or more of the aforementioned risk factors will develop refeeding syndrome. However, should a patient be at risk, it is vital that they are medically monitored by a team of experienced health care professionals in order to prevent any fatal complications.
Who is at risk of refeeding syndrome?
Patients who have a high risk of developing refeeding syndrome are chronically undernourished patients, as well as those who have had little to no food (energy) intake in the previous ten days14. Patients with bulimia who fast, or abstain from food after bingeing may be at risk of this.
The development of refeeding syndrome
We have briefly touched on the aim of refeeding and why it is conducted. To further understand the process of refeeding, it is beneficial to be aware of the effect that this form of treatment has on the body. Refeeding syndrome is more commonly seen in those with anorexia nervosa, as these patients are more commonly in a state of malnourishment than to those with bulimia (who often have a normal weight). The below information briefly describes the processes involved in the development of refeeding syndrome.
The shift in fluids and electrolytes that occurs during refeeding are a result of metabolic and hormonal changes that may cause severe clinical complications.
The symptoms of refeeding syndrome are a result of the imbalance of electrolytes which alter function of potassium, magnesium and phosphorus:
- Potassium helps to control cardiac functions in the body, facilitates nerve impulses and regulates blood pressure.
- Phosphorus is a vital electrolyte for the formation of teeth and bone and the activations of a number of vitamin B enzymes and complexes.
- Magnesium aids in increasing the body’s bone mineral density and stimulates brain activity.
Refeeding syndrome is a complex condition that may also lead to abnormal balances of sodium and fluids in the body, changes in fat metabolism and glucose, hypokalaemia (potassium deficiency), hypophosphatemia (low levels of phosphorus), thiamine deficiency (vitamin B1 deficiency), and hypomagnesaemia14 (low levels of magnesium).
When the body is starved for a long period of time it will be in a state of catabolism, this refers to the breakdown of nutrients for energy. When refeeding begins, the body will shift from catabolism to anabolism, also known as an anabolic state wherein it begins to rebuild and repair tissue. The body will get the energy it needs to function from reserved fat and protein. When refeeding occurs, carbohydrates will be introduced to the system again, the tissues will begin to resume their natural process of producing energy from the breakdown of glucose.
When glucose is suddenly increased through refeeding, insulin levels will increase to aid in the transport of glucose to the cells for energy. This surge of insulin and the changes of the body in shifting from a catabolic state to an anabolic state, may result in a chain reaction that causes a largely increased uptake and use of potassium, magnesium and phosphorus in the cells. This results in a number of complications and symptoms in patients, such as confusion, seizures, heart problems and fluid retention, some of these (i.e. cardiac heart failure as a result of low levels of phosphorus) may be fatal. However, through accurate diagnosis, treatment and management, severe complications can be prevented.
14. NCBI. 2008. Refeeding syndrome: what it is, and how to prevent and treat it. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/ [Accessed 13.11.2017]
15. NICE. 2006. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Available: https://www.nice.org.uk/guidance/cg32/chapter/1-guidance [Accessed 08.03.2018]