Part 2 : The Consequences of Bulimia Nervosa

TW: The following article describes information about eating disorders that can be triggering for some people as it aims to describe some of the medical complications that can result from bulimia nervosa. Do not hesitate to contact us if you have any questions.

Do you or someone you know struggle with an eating disorder? In our last article, we explored some of the medical complications of anorexia nervosa. In this part 2, we will do the same for bulimia nervosa.

This article is the first in a 4-part series exploring some of the medical complications of EDs, and how recovery can reverse them or prevent them from worsening. 

What is Bulimia Nervosa? 

 

Bulimia Nervosa, or BN, is characterized by cycles of binge eating episode(s), followed by purging behaviours (1). This cycle tends to lead to feelings of guilt and shame, and some people go to great lengths to keep their actions a secret, which can make it difficult for loved ones to detect.

 

Binges are characterized by eating large amounts of food in a short amount of time and feeling out of control around food choices and portions. Purges are characterized by behaviours that intend to compensate for the amount of food eaten, to prevent weight gain. These behaviours can include:

  • Self-induced vomiting (SIV) – the most common behaviour
  • Misuse of laxatives, diuretics or enemas
  • Periods of fasting or extreme food restriction
  • Excessive exercise

Diagnostic criteria according to the DSM-5 includes that those suffering from BN tend to binge/purge at least once a week for at least 3 months, and tend to experience severe body image and weight preoccupations (1). Those with BN are often of “normal” weight, which is typically what distinguishes it from anorexia nervosa.

A Note on Purging

 

It is important to recognize that although it may seem logical to the ED mind to compensate for food eaten by finding ways to expel calories, no purging method is effective at eliminating calories consumed or preventing weight gain (3). When it comes to vomiting, research shows that the body will retain at least 40-75% of calories consumed, even when the purge is done immediately after eating (3,4). This is partly because digestion (and therefore absorption of calories) already begins before food reaches the stomach (4). 

It is also a myth that laxatives and diuretics can help control weight, as both of these substances create shifts in water weight, not body weight (3,4). Laxatives, for one, work on the large intestine, which is the last place in the digestive tract where calories can be absorbed. While laxatives can result in a ~10% loss of calories consumed, most calories and nutrients will be absorbed from the mouth to the small intestine before reaching the large intestine (3). When it comes to diuretics, they don’t play any role in influencing calorie absorption, which means that they will solely dehydrate the body by reducing fluid levels (3).

Some Medical Complications of BN

 

Complications of BN tend to stem from the different purging behaviours that are engaged in. For the sake of this article, we will explore the complications from SIV, and laxative and diuretic misuse, as the effects of restriction and excessive exercise are similar to those described in our previous article.

Mental and Emotional Health Considerations

 

Those with BN can become more impulsive, emotionally intense and sensitive, and have greater changes in mood (3). Over 70% of those with EDs also report a co-occurrence of other mental health conditions, for which the following are most commonly reported with BN (1,2):

  • Anxiety
  • Depression
  • Obsessive-compulsive disorder
  • Post-traumatic stress disorder (or a history of trauma)
  • Substance use disorders
  • Self-harm behaviours
  • Suicidal ideation

Oftentimes, those with BN use binges/purges to try to self-regulate distressing emotions, though they can also be used for self-punishment (3). An example of this can be engaging in a binge-restrict cycle, as shown in the graphic below. Note: the graphic shows a common flow through this cycle, though there are many other ways that one may experience it:

Consequences of self-induced vomiting

 

An obvious sign of SIV is the Russell Sign, where calluses develop on the top of the dominant hand – the teeth repeatedly scrape the hand when one is trying to provoke the gag reflex to vomit (2). This does not always occur, however, given some people are able to vomit “on command”, or may use other tools to hit their gag reflex (like spoons or other objects) (2).

Other signs of SIV include changes in the teeth and mouth, including tooth pain, decay, discolouring and/or erosion (2,3). Given the acidity of the purge, erosion to the inside and the corners of the mouth, as well as the throat can cause inflammation and tenderness to these areas (2). It can also make one’s voice sound hoarse, or lead to pain or difficulty when swallowing (called odynophagia and dysphagia, respectively) over time (2). More severely, there is an increased risk of aspiration pneumonia, meaning that an infection can develop in the lungs if saliva, food, vomit or other substances are inhaled (ie. “goes down the wrong way”) (2,3).

In up to 50% of those who SIV, swelling of the salivary and parotid glands can occur, usually after 3-6 days of purging (2,3). This can happen for a few reasons: the glands are being triggered to produce more saliva, the glands have enlarged to meet the demands of extra saliva production caused by vomiting, or because of a backup of saliva after vomiting has stopped (2).

Strain from vomiting can cause tenderness to the stomach and abdomen, as well as lead to Mallory-Weiss syndrome, which is characterized by tears in the esophagus that can cause blood to be thrown up (3). 

Other gastrointestinal symptoms that can commonly occur are bloating, flatulence, constipation, and stomach pain (3). With recurring SIV, the esophagus can become inflamed, and develop little cuts and ulcers, and the lower sphincter (like a band that opens and closes the connection between the esophagus and stomach) can become weakened leading to sudden bouts of reflux (3). Repeated exposure of the lining of the esophagus to stomach acids can also cause a condition called Barrett’s esophagus, which increases the risk of certain esophageal cancers (2,3). 

Consequences of laxative and diuretic misuse

 

Purging more than twice a week by laxatives and diuretics, but also SIV, can lead to dangerous cycles of dehydration that can lead to more purging (3). What happens is that since the body is dehydrated, it naturally adapts to retain extra water (to survive), which can lead to puffiness and body swelling, and thus temporary increases in water weight (3). Those with BN often perceive this as real weight gain, and feel compelled to purge, which will restart the cycle (3).

Although dehydration is also harmful, it’s the resulting shifts in electrolytes that add on to its danger. The biggest electrolyte of concern is potassium, which will decrease in the blood. Drops in potassium can cause muscle weakness, fatigue, dizziness, constipation, and more seriously, heart palpitations (which can lead to arrhythmias, and death from cardiac arrest) (3,4). 

When it comes to laxative misuse, gastrointestinal complaints are common. This can include IBS-like symptoms such as alternating diarrhea and constipation, though more serious consequences can occur such as nutrient malabsorption, muscle weakness, rectal bleeding, pancreatic damage, convulsions, and more (3). Frequent laxative use also builds one’s tolerance up, meaning they need larger doses to have the same effects and the risks of consequences increase (3).

Specifically around diuretic misuse, prescription or over-the-counter medications can be used, though the latter aren’t typically as effective at reducing water retention (3). Over-the-counter diuretics typically contain higher doses of caffeine, which can lead to symptoms such as sleep disturbances, nervousness, nausea and increased heart rate (3). Prescription diuretics can have more serious consequences, such as heart palpitations, blood in the urine, constipation, deterioration of kidney function (nephropathy), and more (3).

Conclusion

 

Bulimia nervosa is a complex eating disorder that can look different for many people. The commonality in BN is that it involves cycles of binge eating and purging, and it’s the consequences from purging that most significantly affects one’s physical health and quality of life. Regardless of the purging behaviour used, their ineffectiveness only adds to the harm that they can cause. Working toward recovery is vital for preventing long-standing complications, and finding more health-supporting tools for coping with life. 

Stay tuned for the final two articles in this series which will outline the consequences of Binge Eating Disorder, as well as the impacts of ED recovery on restoring one’s health. If you or someone you know are impacted by an eating disorder, do not hesitate to contact the Sööma team for support, at (514) 437-4260 or by email at info@sooma.ca. You can also book an appointment with one of our professionals directly by clicking this link.

Written by

Picture of Justine Chriqui

Justine Chriqui

Registered Dietitian

References

  1. Bulimia Nervosa. (n.d.). National Eating Disorder Information Centre. Retrieved from https://nedic.ca/eating-disorders-treatment/bulimia-nervosa/
  2. Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of Bulimia Nervosa. Cleveland Clinic Journal of Medicine, 88(6), 333–343. https://doi.org/10.3949/ccjm.88a.20168 
  3. Herrin, M., & Larkin, M. (2013). Nutrition counseling in the treatment of eating disorders (2nd ed.). Routledge/Taylor & Francis Group.
  4. Targowski, K., Bank, S., Carter, O., Campbell, B. & Raykos, B. (2022). Break Free from ED – Module 9: Purging. Perth, Western Australia: Centre for Clinical Interventions. Retrieved from https://www.cci.health.wa.gov.au/~/media/CCI/Consumer-Modules/Break-Free-From-ED/Break-Free-From-ED—09—Purging.pdf

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