KidsMD Health Topics

Bulimia Nervosa

  • Overview

    "It's important to note that eating disorders are illnesses of denial and secrecy; they're often very difficult to track down."

    Sara Forman, MD, Director of Children?s Hospital Boston?s Outpatient Eating Disorders Program

    It’s sad but true that a negative body image is not uncommon among today’s youth and teens, especially among girls. Sometimes, however, body image distortion and associated behaviors spiral out of control.

    Bulimia nervosa, usually referred to as “bulimia,” is defined as uncontrolled episodes of overeating (bingeing) and usually followed by:

    • purging (self-induced vomiting)
    • misuse of laxatives, enemas or medications that cause increased production of urine
    • fasting
    • excessive exercise to control weight

    Bingeing, in this situation, is defined as eating much larger amounts of food than would normally be consumed within a short period of time (usually less than two hours). Eating binges occur at least twice a week for three months and may occur as often as several times a day.

    • Studies suggest that there has been an increase in the number of cases of bulimia over the past 50 years in the United States.
       
    • It’s estimated that 1 to 5 percent of adolescents have bulimia. An estimated 1.1 percent to 4.2 percent of females in the United States are reported to have bulimia.

    Bulimia, and the medical problems that result, can damage nearly every organ system in the body, and may be fatal. Early diagnosis and treatment are extremely important.

    How Children’s Hospital Boston approaches bulimia nervosa

    The Eating Disorders Program at Children’s Hospital Boston provides comprehensive evaluation and treatment services every year to more than 200 adolescents with bulimia, anorexia nervosa, binge-eating disorder and related eating disorders. Staffed by expert specialists, the program addresses your child’s medical, nutritional and psychological needs in order to effectively treat her disorder.

    Our healthcare team also gives guidance to many providers in the northeastern United States and beyond.

    • Providers from the outpatient Eating Disorders Program and other members of Children’s Division of Adolescent Medicine have helped develop inpatient clinical guidelines for children who are admitted to the hospital for eating disorder-related medical needs.
    • Our providers also consulted on the National Eating Disorders Screening Project. They have advocated for insurance coverage for eating disorders at the Massachusetts State House, and give frequent presentations on eating disorders throughout New England.

    Get real, Barbie!

    In recognition of the National Eating Disorders Awareness Week, Children's Center for Young Women's Health created a replica of what the Barbie doll's proportions would be if translated to an actual woman.
    Barbie stands 5 feet 9 inches with a 39-inch bust, 18-inch waist and size 3 shoe — an imbalance that would probably require her to walk on all fours!

    Boys and their bodies: recognizing eating disorders in males

    When you read the terms “anorexia” and “bulimia,” what comes to mind? If you’re like most people, your brain probably conjures up images of smoky-eyed, waif-thin European models, or maybe the teenage girls who emulate them here in America. But according to a recent report from Pediatrics, eating disorders affect a far more diverse group of people than many realize.

    Bulimia nervosa: Reviewed by Sara F. Forman, MD
    © Children’s Hospital Boston; posted in 2011

    Boston Children's Hospital
    300 Longwood Avenue
    Boston MA 02115

    617-355-7178

    fax: 617-730-0185

  • In-Depth

    Our culture's obsession with achieving lower weight conveys an unavoidable message to maturing adolescents. According to the 2009 Youth Risk Behavior Survey, 33 percent of adolescent girls believed that they were overweight and 56 percent were attempting to lose weight 6 percent of girls and 2 percent of boys stated that they had taken laxatives or intentionally vomited to lose weight or keep from gaining weight.

    Adolescents with unrealistic expectations about weight may end up suffering from bulimia. Read on to learn more about the causes and signs of bulimia nervosa, as well as how Children’s Hospital Boston can help young adults struggling with an eating disorder.

    Causes

    What causes bulimia?

    It’s hard to pinpoint the cause of bulimia nervosa. The condition usually begins with dieting, but gradually progresses to extreme and unhealthy weight control methods. There are several factors thought to be associated:

    • Social attitudes toward body appearance — often unrealistic — are believed to play a large role.
    • Adolescents who develop bulimia are more likely to come from families with a history of weight problems, physical illness and mental health problems, such as depression or substance abuse. Genetics may also play a role.
    • Often teens with bulimia come from families with high levels of stress, poor patterns of communication, unrealistically high expectations and underdeveloped problem-solving skills.
    • Sports or activities in which leanness is emphasized (e.g., ballet, running or wrestling) and sports in which scoring is partly subjective (e.g., skating or gymnastics) are associated with a higher incidence of eating disorders.
    • Teens with bulimia often have other mental health problems, such as anxiety disorders, obsessive-compulsive disorder (OCD), affective (or mood) disorders and problems with substance abuse. They may also be dependent, immature in their emotional development and likely to isolate themselves from others.

    How can I tell if my child is “bingeing”?
    Bingeing is defined as eating much larger amounts of food than would normally be consumed within a short period of time (usually less than two hours). In bulimia eating binges occur at least twice a week for three months and may occur as often as several times a day.

    Signs and symptoms

    If your child has bulimia, some of the symptoms you may notice include:

    • normal, high or low body weight (but sees self as overweight)
    • recurrent episodes of binge eating (rapid consumption of excessive amounts of food in a relatively short period of time; often secretive), coupled with fearful feelings of not being able to stop eating during the bingeing episodes
    • self-induced vomiting (usually secretive)
    • excessive exercise or fasting after eating
    • peculiar eating habits or rituals
    • inappropriate use of laxatives, diuretics or other cathartics
    • irregular or absence of menstruation
    • anxiety
    • discouraged feelings related to dissatisfaction with themselves and their bodily appearance
    • depression
    • preoccupation with food, weight and body shape
    • scarring on the back of the fingers from the process of self-induced vomiting

    Other signs you may notice include:

    • dehydration
    • swollen face
    • sore throat
    • tooth decay or cavities
    • dry, flaky skin
    • constant upset stomach
    • heartburn
    • constipation
    • weight fluctuations

    What are the warning signs

    Eating disorders are illnesses of denial and secrecy; they're often very difficult to track down. So family members and friends shouldn't feel badly about not figuring out right away if their loved one has a problem.

    That being said, there are some signs you can look for:

    • unexplained weight fluctuations
    • dizziness
    • fainting
    • fatigue
    • irritability or moodiness
    • going to the bathroom often, especially after meals
    • food disappearance from the kitchen

    Also be on the lookout for major change in eating or exercise behavior.

    What are the possible complications of bulimia?

    Bulimia is a serious disease. Here are some of the complications a young adult with bulimia may develop:

    In addition, electrolyte abnormalities such as low potassium levels, from the body losing potassium after vomiting, can lead to serious heart problems and even death.

    Prevention

    Researchers are actively exploring the question of whether bulimia nervosa can be prevented.

    Awareness increases the chance of early detection and intervention — which in turn can reduce the severity of symptoms, enhance your child's normal growth and development and improve her quality of life.

    Encouraging healthy eating habits and realistic attitudes toward weight and diet may also be helpful.

    To some extent, parents can help prevent eating disorders in their children:

    • Here at Children’s Hospital Boston, our doctors encourage parents to avoid using food as a behavioral reward and to provide variety in appropriate portion sizes.
    • Parents should carefully monitor growth and development, helping their children avoid obesity through sensible eating and physical activity.
    • Parents should stress health and fitness—not “thinness.”

    Long-term outlook

    Treatment for bulimia nervosa is a slow process that may last years.

    The vast majority of adolescents suffering from bulimia will enter a recovery phase, but there may be a life-long struggle with food and consequent weight loss or gain.

    Questions to ask your doctor

    You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider, and that you understand your provider’s recommendations.

    If you’ve made an appointment to talk to a doctor about your child’s eating and/or exercise habits, you probably already have some ideas and questions on your mind. But at the appointment, it can be easy to forget the questions you wanted to ask. It’s often helpful to jot them down ahead of time so that you can leave the appointment feeling that you have the information you need.

    You may want to suggest that your child write down what she wants to ask her health care provider, too.

    Some of the questions you may want to ask include:

    • How much experience do you have treating bulimia?
    • What are the treatment options?
    • How will we know whether the treatment is working?
    • Will my child need to be hospitalized?
    • What’s therapy and how does it work?
    • How will the treatment for bulimia affect my child’s day-to-day life?
    • What is the long-term outlook for my child?
    • What can I do to help support my child’s health and help her cope with her condition?

    When to seek medical advice

    If you notice changing eating or exercising habits in your child, it might mean that she has an eating disorder such as bulimia. You should make an appointment with your child’s pediatrician right away.

    If your child has already been diagnosed with bulimia, you should call her doctor if you see any further change in your child’s behavior relating to food or exercise.

    Useful medical terms

    Anorexia Nervosa (Anorexia) is an eating disorder characterized by self-starvation with or without over-exercise or purging. Anorexia is a complex disease involving psychological, sociological, and physiological elements.

    Anxiety disorder is a generalized term used to describe mental health disorders relating to excess worrying, phobias and nervousness. A person suffering from an anxiety disorder may have panic attacks and may be unable to pursue normal daily routines.

    Behavioral problem or disorder is a generalized term used when a child or teenager behaves—over a long period of time—in ways that are not socially acceptable for his or her age and situation or in ways that are destructive or self-destructive.

    Bipolar disorder is a mood disorder characterized by severe mood swings. A person with this disorder may go from being manic, extremely elated and energetic to being depressed, sad, and sluggish. People with this disorder are sometimes known as “manic depressives.”

    Bulimia Nervosa (commonly known as Bulimia) is an eating disorder characterized by extreme overeating or “binge” eating followed by self-induced vomiting, excessive exercising, inappropriate use of laxatives or enemas, or fasting.

    Clinician is an individual who is trained to practice medicine or psychological counseling and who works directly with people instead of in a laboratory.

    Depression (clinical) is a mental health disorder characterized by a sad mood that is both prolonged and severe. Clinical depression can be treated with medication, therapy, and hospitalization if necessary.

    Diagnostic evaluation refers to a clinician assessing the symptoms presented by your child in order to come to an informed opinion about what condition is causing those symptoms.

    Dietician/Nutritionist refers to professionals with specialized training in nutrition. They, along with nurses and doctors, help families design healthy eating plans and provide long-term follow-up.

    Mood disorder is a generalized term referring to mental health disorders where a person’s general mood is distorted or inappropriate given the circumstances. Clinical depression and bipolar disorder are both mood disorders.

    Nurse Practitioner refers to a person with an Advanced Practice Nurse (APN) degree who manages patient care and provides primary care services as well as specialty services. Unlike most nurses, nurse practitioners can diagnose patients and prescribe medications.

    Psychiatrist refers to a medical doctor who has specialized training in behavioral and mental health disorders. Psychiatrists can prescribe medication to their patients.

    Psychologist refers to a mental health professional who is not a medical doctor and who does not prescribe medication. Clinical psychologists have extensive training in therapy and psychological testing.

    Social Worker refers to a professional who patients and their families deal with the broad range of psychosocial issues and stresses related to coping with illness and maintaining health.

    Center for Young Women's Health

    Explore the Center's website for in-depth information on issues affecting teen girls today, including healthy eating, nutrition and eating disorders.

     

    Talking about eating disorders

    Read our Q & A with Sara Forman, MD, Director of Children's Outpatient Eating Disorders Program.

  • Tests

    How is bulimia nervosa diagnosed?

    It can be hard to diagnose bulimia nervosa, since many adolescents with the disorder try to keep their illness very private and hidden. Parents, teachers, coaches or instructors may be able to identify a child or adolescent with bulimia, but the diagnosis is usually made by a qualified mental health professional or medical provider.

    Since early treatment can often prevent future problems, if you note symptoms of bulimia in your child, it’s a good idea to seek evaluation and treatment sooner rather than later.

    If an eating disorder is suspected, some components of the evaluation may include:

    • a careful patient and family history
    • physical examination
    • laboratory tests, including a complete blood count and a urinalysis
    • mental health and nutritional assessments

    To help diagnose bulimia, your child’s doctor will:

    • assess weight changes
    • inquire about self-perceptions of weight and desired weight
    • ask your child about bingeing and out-of-control eating and purging
    • ask your child about use of laxatives and diet pills
    • ask your child about:
      •  abdominal pain
      •  bloating
      • constipation
      • hair loss or change in hair texture
      • cold intolerance
      • fatigue
      • weakness
      • fainting
      • substance use
      • sexuality
      • depression
      • amount of physical exercise
      •  stress fractures

    Your child’s doctor will likely also conduct the following studies:

    • a social history — a review of risk factors focusing on the home, education and activities
    • a family history — information about conditions and disorders within the family, including eating disorders, obesity, alcoholism, depression or other mental illness
    • a physical exam —a clinician will assess and examine your child’s blood pressure, pulse, temperature, weight and height, skin and hair changes, heart function and abdomen.

    After we complete all necessary tests, Children’s experts will meet to review and discuss what they have learned. Then we will meet with you and your family to discuss the results and outline the best treatment options for your child.

    Get more information about eating disorders

    Boston Children’s Eating Disorders Program has put together a list of links with additional information about eating disorders, including their causes, prevention and treatment.

  • Bulimia nervosa is usually treated with a combination of:

    • individual therapy (usually including both cognitive and behavioral techniques)
    • family therapy
    • nutritional rehabilitation
    • behavior modification
    • psychopharmacologic treatment

    It's important to remember that family members play a vital supportive role in any treatment process.

    Children's Eating Disorders Program is committed to helping you, your child and your family at every step of the treatment process. The program uses a multidisciplinary approach for evaluation and treatment to help formulate an individualized treatment plan and make preliminary recommendations that will work best for your child's individual needs and circumstances.

    Providers in our Eating Disorders Program see both inpatients and outpatients —about 200 new cases annually. As outpatients, adolescents are seen by a physician from Children's Division of Adolescent Medicine, as well as a dietician. Your child will also see a psychologist or social worker with whom you can meet separately. Your doctor will recommend follow-up visits if necessary.

    If your child becomes really sick—her condition gets worse, causing unstable vital signs, for example—he or she will be admitted to the hospital. Inpatients are placed on the hospital's "Restrictive Eating" clinical practice guideline. This means they meet with the same types of caregivers as an outpatient would, while participating in a special meal plan with customized weight gain goals.

    What to expect at your appointment

    While no patient's experience is exactly like another, below is a general idea of what you will experience when your child has an appointment in the Children's Eating Disorders Program.

    What to bring

    Please bring contact information for any providers your child is seeing (therapist, nutritionist, pediatricians).

    Your first appointment

    Your initial consultation will include:

    • A medical evaluation by a doctor skilled in adolescent medicine and eating disorder treatment. The doctor will assess your child's health by checking her height, weight, blood pressure, pulse and temperature, and will determine the severity of any existing medical complications he or she may have. Our doctor will contact your child's primary care provider to help coordinate care.
       
    • A mental health consultation with a counselor experienced in treating adolescent eating disorders. Fighting back against these disorders requires improving your child's body image and self-esteem and addressing other emotional issues.
      • During treatment, some adolescents discover they have other problems such as depression or substance abuse. The therapist can assist in diagnosing these difficulties.

    Therapy can also be an important part of getting well if family tensions, relationships with friends or poor communication skills are disrupting your child's life.

    • A nutrition evaluation with a dietician. This can help you and your child create a safe eating plan and answer questions about food. Teens receive many mixed messages in a culture obsessed with fast food, dieting and body image. The dietician can discuss some of these harmful myths, and help your child design an individualized guide to achieving healthy eating and healthy living.

    Your additional appointments

    After the initial evaluation, the Eating Disorders Program will help you set up appropriate treatment. The program works with primary care providers to ensure a comprehensive treatment program. Referrals to local health care providers, as well as to providers At Boston Children's Hospital, are available.

    Treatment may involve:

    • Ongoing individual and family therapy
    • Medical monitoring
    • Nutritional support

    Coping and support

    It's essential to remember that while learning that your child is struggling with bulimia nervosa can feel very isolating, many children and their families have been down this path before. We've helped them, and we can help you, too.

    There are lots of resources available for your family—within Children's, in the outside community and online. These include:

    Patient education:From the very first visit, our staff will be on hand to walk you through your child's treatment and help answer any questions you may have. And they'll also reach out to you by phone, continuing the care and support you received while at Children's.

    Parent to parent: Want to talk with someone else whose teen has been treated for bulimia? We can put you in touch with other families who have been through similar experiences and can share their stories.

    Faith-based support:If you are in need of spiritual support, we'll help connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions who will listen to you, pray with you and help you observe your own faith practices during the time you and your child are in the hospital.

    Social work and mental health professionals: Our social workers and mental health clinicians have helped many other families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial difficulties.

    On our For Patients and Families site, you can read all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    Children's Behavioral Medicine Clinic helps children who are being treated on an outpatient basis at the hospital—as well as their families—understand and cope with their feelings about:

    • being sick
    • handling pain
    • taking medication
    • changes in friendships and family relationships
    • managing school while dealing with an illness
    • grief and loss

    Children's Psychiatry Consultation Service is comprised of expert and compassionate pediatric psychologists, psychiatrists, social workers and other mental health professionals who understand the unique circumstances of hospitalized children and their families. The team provides several services, including:

    • short-term therapy for children admitted to one of our inpatient units
    • parent and sibling consultations
    • teaching healthy coping skills for the whole family
    • educating members of the medical treatment team about the relationship between physical illness and psychological distress

    Children's Department of Psychiatry offers a free booklet, “Helping Your Child with Medical Experiences: A Practical Parent Guide”. (Please note that Adobe Acrobat is required to view and download the guide.) Topics in the booklet include:

    • talking to your child about his or her condition
    • preparing for surgery and hospitalization
    • supporting siblings
    • taking care of yourself during your child's illness
    • adjusting to life after treatment
      Multidisciplinary care

      One frequently used treatment for eating disorders involves an interdisciplinary team approach, involving a medical provider, dietician (with experience in treating eating disorders) and a mental health professional.

  • Research & Innovation

    In addition to our clinical practice, Children’s researchers are actively involved in finding new ways to understand, treat and prevent anorexia nervosa:

    Understanding

    A study led by Children’s researchers has shown an interesting paradox: People with anorexia have high levels of fat within their bone marrow. If the body isn’t getting enough nutrients, stem cells (the special cells that can change into other types of cells, like fat cells or blood cells) found in the bone marrow develop into fat cells, rather than bone-forming cells. This may help explain one serious consequence of anorexia — early and severe osteoporosis, or bone weakening.

    Treating

    Another Children’s research initiative aims to find a way to prevent bone loss in teens and in healthy adults. Estrogen helps to maintain bone density in young adults with eating disorders. DHEA is a natural hormone that is also associated with preventing bone loss and strengthening bones. Through a combination of a low-dose estrogen therapy and DHEA, it may be possible to increase bone density.

    Preventing

    We all know that good nutritional habits and adequate exercise are key to staying healthy, but

    less clearly understood is the way social and physical environments play into these goals. Children’s researchers are investigating how school and community settings affect adolescent nutrition, physical activity and risk of eating disorders — and are working to design and evaluate school- and community-based interventions and preventive measures that encourage healthy nutritional habits.

    The Eating Disorders Program at Children's is actively involved in many other research projects aimed at providing a better understanding of adolescent eating disorders and developing new interventions. Our current projects include:

Request an Appointment

If this is a medical emergency, please dial 9-1-1. This form should not be used in an emergency.

Patient Information
Date of Birth:
Contact Information
Appointment Details
Send RequestIf you do not see the specialty you are looking for, please call us at: 617-355-6000.International visitors should call International Health Services at +1-617-355-5209.
Please complete all required fields

This department is currently not accepting appointment requests online. Please call us at: 617-355-6000. International +1-617-355-6000.

This department is currently not accepting appointment requests online. Please call us at: 617-355-6000. International +1-617-355-6000.

Thank you.

Your request has been successfully submitted

You will be contacted within 1 business day.

If you have questions or would like more information, please call:

617-355-6000 +1-617-355-6000
close
Find a Doctor
Search by Clinician's Last Name or Specialty:
Select by Location:
Search by First Letter of Clinician's Last Name: *ABCDEFGHIJKLMNOPQRSTUVWXYZ
BrowseSearch
Condition & Treatments
Search for a Condition or Treatment:
Show Items Starting With: *ABCDEFGHIJKLMNOPQRSTUVWXYZ
View allSearch
Locations

Related Services

The future of pediatrics will be forged by thinking differently, breaking paradigms and joining together in a shared vision of tackling the toughest challenges before us.”
- Sandra L. Fenwick, President and CEO
Close