During February each year the National Eating Disorders Association (NEDA) and other treatment and advocacy groups conduct awareness campaigns to educate the public on a cluster of disorders that can seriously impact the physical and mental health of affected individuals. Eating Disorders Awareness Week (EDAW) will occur in the United States from February 26 – March 3, 2024, and in keeping with its goals ESS will shine a light this month on the characteristics and risks associated with one specific eating disorder, Bulimia Nervosa (BN).

Eating disorders have the highest mortality rate of any mental illness and affect both males and females and individuals from all racial, ethnic, and socio-economic groups. Given the level of impairment that they cause, and the potential for severe health consequences, it is critical that educators, health professionals, and caregivers be aware of the signs of possible eating disorders in young people.

How Common are Eating Disorders?

According to the National Institute of Mental Health (NIMH) the lifetime prevalence of eating disorders in adolescents is 2.7% and is twice as prevalent among females (3.8%) compared with males (1.5%). Contrary to popular belief, Anorexia Nervosa (AN), characterized by the extreme restriction of food intake and low body weight, is not the most common eating disorder. Binge Eating Disorder (BED) and Other Specified Feeding and Eating Disorder (OSEFD, a catch-all category that is used when an individual has disordered eating behaviors that do not meet the criteria for a specific eating disorder) account for most of the eating disorder cases worldwide. NIMH reports that the overall prevalence of BN is 0.3% and that it affects twice as many females as males, with a prevalence of 0.5% in women and only 0.1% in men. The average age of onset for both BN and AN is 18 years-old although according to some recent studies the age of onset appears to be declining.

Although eating disorders can begin and/or recur later in life, data show that the initial onset of these conditions continues to be concentrated in adolescence and early adulthood. As such, early prevention and intervention efforts are critical as the longer disordered eating patterns are practiced the more resistant they are to change.

What is Bulimia Nervosa and What are Potential Signs?

BN is characterized by recurrent episodes of binge eating, that is, eating large quantities of food in a short period of time. Bingeing episodes are followed by behaviors meant to compensate for the calories consumed, including purging (self-induced vomiting), fasting, excessive exercise, and the use of laxatives, diuretics, or enemas to avoid gaining weight. Binge/purge cycles are typically accompanied by intense feelings of shame and the sense of being out of control.

Unlike AN, which is characterized by significant weight loss and extreme thinness, BN, as well as BED and OSEFD, can be harder to detect since individuals who struggle with these conditions often appear to be of average weight. These diagnoses might be overlooked even in those who are overweight since our society often judges overweight people as weak and lacking self-control rather than as suffering from a medical or mental health disorder.

Another factor that inhibits proper identification and treatment of these disorders is that affected individuals are often consumed with shame and go to great lengths to hide their unhealthy eating patterns. It is important, therefore, that parents, educators, and health professionals maintain an awareness of the warning signs of bulimia and monitor adolescents who:

• Frequently express concern about weight, body shape, or size and/or complain about “feeling” fat or express dissatisfaction with their bodies (body distortion or dysmorphia)
• Routinely visit the bathroom right after a meal (i.e., possibly to purge) or begin spending more time in the bathroom
• Exhibit frequent weight fluctuations
• Exhibit a change in eating patterns, including restricted or regimented eating habits
• Are uncomfortable with and avoid eating in public
• Have perfectionist tendencies
• Frequently deny hunger despite being preoccupied with food
• Link personal success and failure to weight loss and gain
• Suffer from anxiety or depression, and report feelings of shame, anger, or guilt
• Have ADHD – a recent study found that besides anxiety and depression, teens with ADHD are also at greater risk of developing an eating disorder
• Identify as transgender – a 2013 high school student survey revealed that eating disorder behaviors occur almost three times as often among transgender students

There are also some medical indicators that might signal bulimia:

• Chronic throat pain or inflammation
• Swollen salivary glands
• Dehydration because of purging fluids
• Acid reflux or other GI issues
• Dental issues such as tooth decay, worn enamel, or jaw pain
• Kidney problems from diuretic use
• An electrolyte imbalance that when severe can lead to heart attack or stroke
• Unexplained sores or scabs on the knuckles if hands are used to induce vomiting

What Causes Bulimia Nervosa?

As with all mental health conditions, there is no one cause of BN or any of the eating disorders: biological, genetic, psychological, and socio-cultural factors are all relevant. These disorders have a strong genetic component – it is reported that heritability is between 40 and 70%. A study recently reported by researchers at Yale has concluded that genetic and neurobiological factors appear to “shape the development of eating disorders much earlier than previously thought, with evidence emerging in children as young as 9 years old”. Two specific findings of this study were that that the genetic risk for high body mass index (BMI) was associated with eating disorder symptoms and that the specific risk of anorexia was associated with reduced volume of the brain structure known as the caudate. The researchers noted that “Patients with eating disorders struggle with intrusive thoughts about body image or food … so it might be that some underlying difference in the structure of these brain networks is contributing to those symptoms.”

Psychological factors related to both individual characteristics and family dynamics also play a role in the development of eating disorders. Individuals with unreasonable, perfectionist standards (self or other-imposed) and/or who grow up in highly disorganized, critical, or invalidating environments might seek to impact the one thing over which they have a significant amount of control: how much and when they eat. Likewise, individuals subjected to one or more traumas might seek to regain a sense of control in their lives through manipulating eating habits and weight.

And, clearly, societal pressures around thinness and appearance play a significant role, especially for young girls. Social media algorithms like those used by TikTok push harmful content toward teens and flood them with images and input that promote unhealthy behaviors and that can glorify and worsen symptoms.

Pandemic Related Changes in Prevalence and Access to Treatment

As reported by NBC News “Eating disorder-related health visits — which include hospital stays, pediatrician visits, telehealth talk therapy, and everything in between — more than doubled among people younger than 17 in the past five years … From 2018 through mid-2022, visits among this age group jumped 107.4% across all eating disorders, from around 50,000 visits at the beginning of 2018 to more than 100,000 in 2022. Visits related to anorexia nervosa, which has the highest death rate of any mental illness, jumped 129.26%.”

Similarly, the National Eating Disorder Association (NEDA) reported a more than 53% percent increase in call volume to its helpline during the pandemic, with slightly over 33% of patients in the 13 to 17 age range, and about 36% between 18 to 24 years old.

As mentioned above, teen anxiety and depression are both risk factors for the development of eating disorders, and the pandemic increased both of these conditions. The pandemic also interfered with two factors that can protect young people from eating disorders: strong social connections and consistent exposure to strong messages about a healthy body and self-image. Students were isolated, with significant disruptions in daily routines – including eating patterns – and frequently felt out of control. Students had more time to be on social media, and more time to be “in their heads” to ruminate about both food and self-image. They were disconnected from things that might boost confidence and self-esteem, e.g., sports teams, theater groups, etc. And, along with the adults in their lives, they became highly vulnerable to the boredom/stress-increased eating-weight gain-dieting cycle.

Since the pandemic, students are presenting for treatment with more severe symptoms, and to make matters worse, the mental health system is under significant strain. Because of the mental health crisis with our nation’s youth, the demand for services has greatly outpaced the capacity of mental health practitioners and programs.

Some Thoughts on Intervention and Recovery

Eating disorders typically start in adolescence or early adulthood, and evidence strongly suggests that early intervention leads to better outcomes and a better chance for a full recovery. Given the current difficulties in accessing treatment resources, it seems clear that the earlier we can identify a potential eating disorder problem, the better. Teachers, coaches, and other school personnel as well as parents should understand the basic signs of disordered eating patterns and have clear directives about who to contact to initiate a referral. School-based mental health professionals should be trained on how to conduct a basic eating disorder screening and have contact information for specialized community professionals and programs at their fingertips. As with treatment for other mental health concerns, there are various levels of care available, from outpatient to intensive outpatient to partial hospital to inpatient services, as well as long term residential programs for the most severe cases.

Most eating disorder treatment regimens utilize a combination of individual, group, and family therapy, nutritional counseling, and medications such as Prozac if appropriate to manage co-existing conditions such as anxiety, depression, and ADHD. One study reported by researchers at Stanford University affirmed that teens’ families play a critical role in their recovery from bulimia. Those adolescents who received family-based therapy were more likely to have stopped their abnormal eating patterns than those who received a more individually based, cognitive behavior therapy (CBT) approach. In the family-based approach, teens and parents worked together to interrupt dysfunctional eating behaviors and to re-direct to healthier options. While CBT alone was less effective, it still has a role, however, in helping individuals to identify and shift unhelpful thoughts and beliefs about food and eating.

What Schools and Parents Can Do to Help

There are various actions that schools and parents can consider when trying to help specific youngsters showing signs of disordered eating and the entire school community:

1. Create a non-judgmental environment that fosters open communication about positive body image, self-esteem, and healthy eating habits.
2. Actively call out body-shaming and other comments that emphasize appearance over other personal characteristics.
3. Intervene quickly and decisively to put a stop to bullying behaviors, and make sure that body-shaming is listed on any bullying policy materials offered to the school community.
4. Examine health curricula to assess/update how nutrition, one’s relationship to food, body positivity, and self-acceptance are addressed.

• Provide training and ongoing information to teachers, coaches, and parents about recognizing bulimia warning signs.
• Provide school personnel with clear guidelines about who to contact to share concerns and to initiate a student mental health referral as soon as concerns are noted; inform parents immediately about concerns and suggest a pediatrician visit.
• Consider bringing in a speaker and educational materials for awareness sessions during Eating Disorder Awareness Week.
• Approach a child suspected of having bulimia (or other eating disorder) with empathy, active listening, and a non-judgmental stance. “I notice you’ve been spending a lot more time in the bathroom recently (or, not eating your lunch at school, etc.). Is there anything you’re dealing with that you’d like to talk about?”
• Encourage parents to maintain regular family mealtimes and to engage children in the preparation of healthy meals. Suggest that adults look at their own eating patterns (e.g. frequent dieting) that model for children how to relate to food, weight, and body image.
• Re-assess vending machine and cafeteria offerings on a regular basis to prioritize healthy food choices while not endorsing a “good food – bad food” mindset. No foods are off-limits (barring allergy considerations), but some foods are better used as infrequent “treats” rather than for daily consumption.

Some Final Thoughts

Bulimia Nervosa and other eating disorders are complex and serious conditions that require specialized assessment and treatment. School professionals should not be expected to intervene with students beyond the scope of their usual roles. As daily observers of youngsters under their guidance, however, they can facilitate early identification and intervention and help shepherd struggling students and their families toward better outcomes.

Resources

2023 Eating Disorder Statistics: 79 Unthinkable Facts (breakbingeeating.com)
Eating Disorders in Children and Teens: Symptom Test (additudemag.com)
Biological factors modulate eating disorder risk in early adolescents | YaleNews
Eating disorders like anorexia, bulimia are more severe than ever (nbcnews.com)
Eating disorders among teens have more than doubled during the COVID-19 pandemic – here’s what to watch for (theconversation.com)
For teens with bulimia, family-based therapy works best | News Center | Stanford Medicine
About Eating Disorders – MEDA – Multi-Service Eating Disorders Association (medainc.org)
Bulimia Nervosa | Psychology Today
Eating disorders like anorexia, bulimia are more severe than ever (nbcnews.com)