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Adolescent Nutrition and Eating Disorders

Chapter 1  Eating Disorders During Adolescence

Chapter 2  Anorexia Nervosa In Adolescence

Chapter 3 Onset of Anorexia Nervosa during Adolescence

Chapter 4  Initial Stage of Anorexia Nervosa in Adolescence

Chapter 5  Crisis Stage Anorexia Nervosa in Adolescence

Chapter 6  Long-Term Recovery Stage Anorexia Nervosa in Adolescence

Chapter 7 Bulimia Nervosa in Adolescence

Nutritional Care Summarized - Table

Selected References & External Links

List of Reviewers

N.W. Regional Web Symposium
MPH Student Research 
Biographical Information

Eating Disorders during Adolescence:  Nutritional Problems and Interventions

Jane Mitchell Rees, PhD, RD, CD
Departments of Health Services and Pediatrics 
Maternal Child Health and Adolescent Medicine 
University of Washington, Seattle, WA 98195

Eating Disorders
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Useful Links



Risky Eating Behaviors

Weight Management

Chapter 7 Bulimia Nervosa in Adolescence

 [Table of Contents]

Bulimia Nervosa: Overview 

First called bulimarexia, bulimia nervosa is a more recently recognized eating disorder than anorexia nervosa. Bulimia nervosa is characterized by gorging on food followed by one of several extreme behaviors in attempts to rid the body of food and weight.  These symptoms may also be associated with starvation in anorexia nervosa but do not occur exclusively in that disorder.  [See APA web site].

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Bulimia Nervosa: Behavior and onset in adolescence

The adolescent suffering from bulimia nervosa often maintains close-to-normal weight-for-height-for-age, meanwhile eating abnormally large amounts of food, (known as binge eating) and regularly forcing her bowels to empty by taking laxatives (called purging) or voluntarily vomiting.  They may also resort to fasting or extreme forms of exercise rather than vomiting and/or purging.  These behaviors, designed to rid the body of food, weight and bulk, may be referred to collectively as purging.  Professionals must inquire carefully to determine what practices are described as "purging" in a specific situation.  Adolescents with bulimia nervosa may have somewhat less severely distorted perceptions of their body shape and size and less restrictive weight goals compared with those suffering from anorexia nervosa. Adolescents with bulimia nervosa are often older at age of onset.

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Bulimia Nervosa: Diagnostic criteria

American Psychiatric Association (APA) criteria may be found at their web site.  The diagnostic criteria established by the APA includes the following behaviors:
  • Recurrent episodes of binge eating, rapid consumption of abnormally large amounts of food in a discrete period
  • Sense of inability to control binges and eating
  • Regular self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting, or excessive exercise (inappropriate compensatory behaviors)
  • Occurrence of binge-eating episodes and compensatory behaviors on average at least twice a week for 3 months
  • Self evaluation inappropriately based on body shape and weight
Further two specific TYPES are described:

PURGING has regularly and is currently engaged in:

self induced vomiting, or misuse of laxatives, diuretics or enemas
NON-PURGING has regularly and is currently engaged in:
fasting or excessive exercise and nor other compensatory behaviors
Note that specific compensatory behaviors are listed in the criteria.  While some are categorized under PURGING TYPE and others NON-PURGING TYPE, each has specific detrimental effects and all should not be referred  to non-descriptively together as purging (as many adolescents will do) but specifically identified and treated.

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Bulimia Nervosa: Prevalence

The syndrome of bulimia nervosa should be differentiated from the recent behavior of many normal adolescent females who try to control their weight and shape by occasionally causing themselves to vomit.  These young women may also use laxatives or diuretics to rid themselves of body fluids and the products of digestion. By college age as many as 20% of females may engage in these inappropriate behaviors.  Only about 2-4% of college age women have serious disorders that meet the diagnostic criteria for bulimia nervosa.  The effected population is more diverse than with anorexia nervosa;  more are women of color, older at onset, male and from a broad economic spectrum. 

A serious condition is one that is uncontrollable, and includes psychological features that impair normal functioning.  Bulimia nervosa sometimes develops in obese adolescents or following episodes of anorexia nervosa. The disorder may also arise in adolescents with less fashionable hereditary shapes, e.g. large or unusually shaped leg muscles.  The adolescent with bulimia is more likely to be fertile than the individual with anorexia nervosa.  Therefore, certain young women will have bulimia during pregnancy (See section on Bulimia Nervosa in Pregnancy).

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Bulimia Nervosa: Common psychosocial characteristics

Bulimia nervosa, a serious eating disorder, indicates important psychological disturbances in the adolescent.  Her self-esteem is often extremely low and tied to her feelings about certain characteristics of her body that are genetically controlled. She usually thinks of herself as physically unattractive, although others may observe that she is well groomed and has normal, even attractive, physical features.  Normal weight adolescents with bulimia obviously will not have the seriously compromised nutritional status of those starving with anorexia nervosa.  Thus, unlike adolescents with anorexia nervosa, they will not experience the mental dysfunction and distorted perception resulting from starvation neurosis (described by Keys et al in The Biology of Human Starvation, U of Minn. Press, 1950, vol. II). See section on Crisis Stage: Psychological effects of starvation

Superficially, the adolescent with bulimia nervosa may keep a heavy social schedule, but in reality she may have few close friends. In contrast to the more rigid adolescent with anorexia nervosa, young women with bulimia nervosa often demonstrate poor impulse control. By all accounts, gorging, vomiting, and purging serve to release tension for the sufferers.  They often describe feeling “numbed out” during a binge.  However, the residual guilt and feelings of inadequacy bring renewed tension that helps perpetuate an uncontrolled cycle.  Social isolation is also perpetuated because they fear their secret will be found out. 

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Bulimia Nervosa: Food related behavior

The teenager with bulimia nervosa periodically eats large amounts of food and then voluntarily vomits, purges or exercises excessively.  Each person with bulimia nervosa defines a binge for herself.  Because of distortions in thinking about food, as little as one doughnut may be thought of as a binge by one person while as much as an entire package of doughnuts may constitute a binge for another. As the habits continue, it becomes easier for adolescents to vomit.  Eventually, the vomiting is a nearly automatic response.  In addition, an adolescent may abuse laxatives to purge herself of the food she has ingested or use diuretics to remove body fluid.

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Bulimia Nervosa: Common physical symptoms

Physical symptoms of the adolescent with bulimia nervosa will include:
  • Cracked, damaged lips 
  • Tooth damage
  • Throat irritation
  • Esophageal inflammation (all of the above symptoms are caused by exposure of unprotected tissues to acidic vomitus)
  • Callused hands (from contact with teeth when used to stimulate vomiting)
  • Swollen salivary glands (caused by acidic reflux or constant stimulation)
  • Broken blood vessels in face (from force of vomiting)
  • Rectal bleeding (caused by overuse of laxatives)
  • Fluctuations in body weight
Life-threatening situations are rarer in adolescents with bulimia nervosa than with anorexia nervosa. They are:
  • Dehydration and electrolyte imbalance 
  • Ruptures in the upper gastrointestinal tract 
  • Kidney disorders
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Bulimia Nervosa: Dental destruction

Adolescents who regularly vomit due to an eating disorder will sustain severe damage to dental enamel, most prominently on the lingual surface of the teeth.  A specific pattern of erosion of enamel, and even of dentin, has been identified in frequent vomiters and described in detail.  Previously applied fillings will be left standing above the surface of teeth that have been eroded.  Dentists, may be the first health care professionals in position to recognize an eating disorder if an adolescent seeks improved dental esthetics.  Dental specialists have developed a protocol for prevention of further erosion, meanwhile referring adolescents for eating disorder treatment.  The strategy includes neutralizing oral fluids following vomiting episodes and avoiding abrasion of the teeth.  Thus, adolescents are taught to use bicarbonate of soda washes and to refrain from brushing after vomiting.  Dentists supply fluoride as a preventive.  Meanwhile, to insure the restoration will be effective, restorative procedures are delayed until adolescents are in treatment and have ceased vomiting. 

Pain and discomfort in the oral cavity may interfere with normal eating patterns adolescents need to adopt in order to recover from bulimia or anorexia nervosa.  Thus, the permanent teeth of adolescents need to be protected by attentive clinicians of all disciplines who can refer them to dentists familiar with the complexities of serving adolescents with eating disorder syndromes.

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Bulimia Nervosa: Intervention strategies

The techniques most frequently reported in treating adolescents with bulimia nervosa are similar to those employed to promote recovery of anorexia nervosa adolescents, including psychotherapy, nutritional therapy, medical monitoring and health education.  Pharmicotherapy may be included with other modalities when providers determine it will improve overall treatment.  An experienced, well trained treatment team will be needed for greatest success.

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Bulimia Nervosa: Psychotherapy

The emphasis of this component of psychotherapy is freeing the person from guilt, facilitating gains in self-esteem, and helping her deal with anxiety.  Distorted goal setting linked to perfection or changing inherent body characteristics is challenged. Ideally the adolescent’s family or partner will be included in certain aspects of psychotherapy, though not as routinely as for anorexia nervosa since adolescents are generally older.

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Bulimia Nervosa: Nutritional therapy

While she deals with the psychological problem, the adolescent with bulimia nervosa will need reeducation to nourish herself properly.  Physical and nutritional education can fill gaps in the knowledge of these teenagers about their body functions. Over time, myths about weight management can be dispelled and more normal eating habits developed. Because of distorted feelings about food, the adolescent with bulimia may feel guilty every time she eats, despite the fact that food is necessary to sustain life.  The family often reinforces her guilt with a misguided overfocus on food, thinness and physical appearance.  An adolescent with bulimia usually attempts to restrict her food intake to match the “ideal” (generally restrictive) plan she conceives for herself.  Binges may thus arise from the natural physical and psychological urge to end hunger, with an over compensation for the deprivation earlier in the day.

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Bulimia Nervosa: Role of the clinical nutritionist

The clinical nutritionist on the interdisciplinary treatment team will help a young person with bulimia nervosa understand the role of food in life and accept a more realistic weight. Helping her understand energy balance and nutrient functions as well as the effects or gorging, vomiting, and purging is especially useful.  Education must be done in a counseling mode, allowing for gradual alteration of the adolescent's rigid set of beliefs.  Psycho-therapists will provide concurrent family and individual psychotherapy, dealing with underlying causes of obsessional food behavior.  They may determine group therapy will be most effective at some stages of recovery.  Physicians will manage the physical care, monitoring symptoms and progress.

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Bulimia Nervosa: Coincident with pregnancy

If pregnant, the teenager with bulimia may be committed to protecting her unborn child but retain ideas that inhibit normal nourishment of herself, her fetus, and the child after birth. Physical concerns during pregnancy are the adverse bio-chemical- chemical environment for the mother and fetus, the mother’s abnormal weight gain pattern and the mother’s unrealistic ideas about infant feeding.  Weight loss, lack of weight gain or inordinate gain during gestation, indicate adverse nutritional status.  During recovery, care of any pregnancy that may occur must be included.

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Bulimia Nervosa: Pregnancy care 

The teenager with bulimia nervosa who is pregnant can be helped to accept the idea that the baby she wants must be adequately nourished. She is then supported in retaining foods that the fetus needs. If she cannot give up bingeing and vomiting, or purging, totally, she must be taught to delay it until nourishing foods have been digested.  Delaying detrimental bulimic behavior is analogous to making sure an oral contraceptive is not vomited out of the system, which sexually active adolescents who wish to avoid pregnancy learn to do.  All aspects of gestational progress should be carefully monitored.  The pregnant adolescent with bulimia should also be helped to learn to recognize natural hunger signals from her baby after it is born.  Intensive therapy for an eating disorder, building on skills the young woman developed to maintain health during gestation, can begin post partum.

[ Nutritional Care Summarized - Table ]

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This Web Site is a reference for health care professionals, students and educators; it is not intended to provide advice or treatment to people with eating disorders.  If you have an eating disorder or disturbed eating patterns, consult a qualified physician who specializes in eating disorders.

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