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Manual of Articles Sections 15 - 28
Section 15
Bulimia Nervosa, Part I: Risk Factors

Question 15 |Test | Table of Contents

Bulimia Nervosa
Bulimia nervosa is more common than anorexia and it usually begins early in adolescence. It is characterized by cycles of bingeing and purging, and typically takes the following pattern:

• Bulimia is often triggered when young women attempt restrictive diets, fail, and react by binge eating. (Binge eating involves consuming amounts of food that are larger than average portions within a two-hour period.)
• In response to the binges, patients compensate, usually by purging, by vomiting, by using enemas, or by taking laxatives, diet pills, or drugs to reduce fluids.
• Patients then revert to severe dieting, excessive exercise, or both. (Some patients with bulimia follow bingeing only with fasting and exercise. They are then considered to have non-purging bulimia.)
• The cycle then swings back to bingeing and then to purging again.
• Some studies have reported that patients with bulimia average about 14 episodes of binge-purging per week. To be diagnosed with bulimia, however, a patient must binge and purge at least twice a week for three months. (Some experts believe that going through the cycle only once a week is sufficient for a diagnosis.)
• In some cases, the condition progresses to anorexia. Most people with bulimia, however, have a normal to high-normal body weight, although it may fluctuate by more than 10 pounds because of the binge-purge cycle.
It should be noted that young people who occasionally force vomiting after eating too much are not considered bulimic, and most of the time this occasional unhealthy behavior does not continue beyond youth.

Binge-Eating (Binge-Eating Disorder)
Binge-eating without purging is characterized as compulsively overeating (binge eating) without other bulimic behaviors, such as vomiting or laxative abuse, used to eliminate calories. Since binge-eating disorder is generally associated with weight gain, it will not be further discussed in this report.

Who Develops Eating Disorders?
The approach to food in Western Countries is extremely problematic. Enough food is produced in the US to supply 3,800 calories every day to each man, woman, and child, far more than any single person needs to sustain life. Obesity is a global epidemic, and few people living in this over-fed and sedentary culture eat a meal guiltlessly. One can nearly make the sweeping generalization that everyone who lives in a developed nation is at risk for either obesity or some eating disorder.

Age
In general, eating disorders occur in adolescents and young adults, although one study reported that 5% of cases occurred in children under 12 years old.

Age of Onset for Bulimia. A 1997 survey by the Centers for Disease Control of high school students reported that 4.5% induced vomiting after meals or used laxatives to lose weight. Estimates of the prevalence of bulimia nervosa among young women range from about 3% in adolescents to 10% in college women. Some experts claim that even these percentages grossly underestimate the problem because many people with bulimia are able to conceal their purging and do not become noticeably underweight. For example, a European study detected bulimic behavior in 14.4% of adolescents 14 to 16 years old, with full-blown bulimia observed in 1.8% of girls and 0.3% of boys.

Gender
Studies typically report that 90% of eating disorder cases are in females. However, the rate in males appears to be increasing. For example, a study of teenagers in Minnesota reported that 13% of girls and 7% of boys reported disordered eating behavior.

When eating disorders occur in young adults, men are more apt to conceal them, so the incidence among males may be underreported. One study of Navy men, for example, reported a prevalence of 2.5% for anorexia, 6.8% of bulimia, and 40% for binge eating. A recent study reported that the psychiatric and social profiles of men and women with eating disorders were very similar to each other, although profiles between men with eating disorders and men without were quite different. Sexual preference may affect the risk of specific eating disorders in men. One study reported that 42% of male civilians with bulimia reported that they were homosexual or bisexual while 58% of the men with anorexia were asexual.

Ethnic Factors
Most studies of individuals with eating disorders have been conducted using Caucasian middle-class females. Studies are now reporting, however, that minority populations, including Hispanic and African-American, are significantly affected. There is some indication that African-American girls and young women may be at particular risk for eating disorders because of poor body images caused by cultural attitudes that denigrate the physical characteristics of minorities. In one study, bulimia was equally common among both Caucasian and African American women, although the latter were more likely to binge recurrently, to fast, and to use laxatives and diuretics to control weight. Binge eating may be an even more severe a problem in Hispanic Americans. A study on Asian women also reported rates of dieting and body dissatisfaction that were similar to those in other cultures, but Asian women had much lower percentages of actual eating disorders.

Socioeconomic Factors
Living in any economically developed nation on any continent appears to pose more of a risk for eating disorders than belonging to a particular population group. Symptoms remain strikingly similar across high-risk countries.

Income Levels. Oddly enough, within developed countries there appears to be no difference in risk between the rich and the poor. Some studies suggest that those in lower economic groups may be at higher risk for bulimia.

Urban Life. City living is a risk factor for bulimia but it has no effect on risk for anorexia.

Intelligence. In one sample, people with eating disorders scored significantly higher than average on IQ tests. People with bulimia, but not anorexia, had higher nonverbal than verbal scores.

Excessively Physically Active People
Highly competitive athletes are often perfectionists, a trait common among people with eating disorders.

Women Athletes and Dancers. Women in "appearance" sports, including gymnastics and figure skating, and in endurance sports, such as track and cross-country, are at particular risk for anorexia. Success in ballet also depends on the development of a wiry and extremely slim body. Estimates for episodes of eating disorders among such athletes and performers range from 15% to over 60%.

Male Athletes. Male wrestlers and light-weight rowers are also at risk for excessive dieting. One-third of high school wrestlers use a method called weight-cutting for rapid weight loss. This process involves food restriction and fluid depletion using steam rooms, saunas, laxatives, and diuretics. Although male athletes are more apt to resume normal eating patterns once competition ends, studies are showing that the body fat levels of many wrestlers are still well below their peers during off-season and are often as low as 3% during wrestling season. Of concern is a recently recognized body-image disorder, referred to as muscle dysmorphia, that occurs mostly in men who are preoccupied with weight lifting and perceive themselves as puny.

Men and Women in the Military. Studies are also showing a higher-than-average risk for eating disorders in men and women in the military. A study of eating behavior on one Army base reported that 8% of the women had an eating disorder, compared to 1% to 3% in the civilian female population.

Vegetarians
Studies report that vegetarianism in adolescence is a risk factor for eating disorder in both males and females. In one study, while these teens appear to eat more fruits and vegetables, they are also twice as likely to diet frequently, four times as likely to intensively diet, and eight times as likely to use laxatives as their non-vegetarian peers. This study does not mean that being a vegetarian equals having an eating disorder. It does suggest, however, that parents with children who suddenly become vegetarian, should be sure their children are eating a balanced meal with sufficient calories. Anorexic behavior in vegetarians should be suspected under certain conditions:

• If the person has stopped eating meat only to avoid fat rather than from other motives, such as love of animals.
• If vegetarian diet coincides with rapid weight loss.
• If the person is avoiding certain foods, such as tofu, nuts, and dairy products, that contain oils or fats.

Young People with Diabetes or Other Chronic Diseases
According to one survey, 10.3% of teenage girls and 6.9% of boys with chronic illness, such as diabetes or asthma, had an eating disorder.

Diabetes. Eating disorders are particularly serious problems in people with either type 1 or type 2 diabetes.
• Binge eating (without purging) is most common in type 2 diabetes and, in fact, the obesity it causes may even trigger this diabetes in some people.

• Both bulimia and anorexia are common in type 1 diabetes. Some experts report that one-third of insulin-dependent patients have an eating disorder, most often because diabetic women omit or under-use insulin in order to control weight. If such patients develop anorexia, their extremely low weight may appear to control the diabetes for a while. Eventually, however, if they fail to take insulin and continue to lose weight, these patients develop life-threatening complications. [See also How Serious Are Eating Disorders?]

Early Puberty
There is a greater risk for eating disorders and other emotional problems in girls who undergo early puberty, when the pressures experienced by all adolescents are intensified by experiencing, possibly alone, these early physical changes, including normal increased body fat. One interesting study reported the following:

• Before puberty, girls ate quantities of food appropriate to their body weight, were satisfied with their bodies, and noted their depression increased with lower food intake.
• After puberty, girls ate about three-quarters of the recommended calorie intake, had a worse body self-image, and noted their depression increased with higher food intake.

This study was reporting on girls without eating disorders, but it certainly suggests patterns that can lead to eating problems, particularly in girls who go through puberty early.
- Eating Disorders; Eating Disorders: Anorexia and Bulimia; (A.D.A.M.); 2002.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about risk factors for bulimia nervosa.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Cognitive Behavioral Therapy
for Eating Disorders: A Map
of the Systematic Review Evidence Base

Kaidesoja, M., Cooper, Z., & Fordham, B. (2023). Cognitive behavioral therapy for eating disorders: A map of the systematic review evidence base. The International journal of eating disorders, 56(2), 295–313.

Peer-Reviewed Journal Article References:
Fitzpatrick, S., MacDonald, D. E., McFarlane, T., & Trottier, K. (2019). An experimental comparison of emotion regulation strategies for reducing acute distress in individuals with eating disorders. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 51(2), 90–99.

Lowe, M. R., Marmorstein, N., Iacono, W., Rosenbaum, D., Espel-Huynh, H., Muratore, A. F., Lantz, E. L., & Zhang, F. (2019). Body concerns and BMI as predictors of disordered eating and body mass in girls: An 18-year longitudinal investigation. Journal of Abnormal Psychology, 128(1), 32–43.

Luo, X., Nuttall, A. K., Locke, K. D., & Hopwood, C. J. (2018). Dynamic longitudinal relations between binge eating symptoms and severity and style of interpersonal problems. Journal of Abnormal Psychology, 127(1), 30–42.

QUESTION 15
What are the four socioeconomic factors related to bulimia nervosa? To select and enter your answer go to Test.

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