Anorexia and Bulimia

What’s the difference between anorexia nervosa and bulimia? And is it important?

There is a difference. And it is important.

Let’s start with bulimia nervosa. The word bulimia comes from the Greek word meaning “ravenous hunger,” and nervosa obviously refers to the emotional/nervous part of this condition.

Bulimia is an eating disorder characterized by binge eating followed by an abnormal emotional response resulting in purging. We need to understand “binge eating.” This happens to be an actual eating disorder and is the most common one in the United States, affecting somewhere between 2 and 3 percent of all Americans. This was initially known as “the night eating disorder,” probably because of those stealthy trips to the refrigerator for some ice cream. We know now that it occurs during all hours of the day, and is marked by consuming an amount of food that is definitely larger than what most people would eat in a similar period of time under the same circumstances. The individual experiences a sense of lack of control over eating during the episode (feeling that they cannot stop eating or control what or how much they are eating), eats more rapidly than normal, frequently eats alone, and will eat until uncomfortably full. To make the diagnosis, this needs to happen at least once a week for three months, and there is no purging following the episode, as with bulimia.

What do you mean by “purging”?

Most of us think this is an episode of self-induced vomiting. Frequently that’s the case, but other efforts to “purge” oneself of the excessive food and to lose weight might be taking laxatives, taking someone’s diuretics (fluid pills), fasting, over-the-counter-stimulants, and even excessive exercising. It’s this purging that causes the problems. Common findings are a low blood pressure, rapid heartbeat, dry skin, and problems with electrolytes, especially a low potassium or chloride. The blood chemistry changes stem from the excessive vomiting and can cause serious problems.

Another telltale physical marker of this disease is calluses or scars on the backs of fingers due to the repeated trauma from front teeth during attempts at self-inducing vomiting.

Frequent vomiting can also lead to inflammation and bleeding from the esophagus, bleeding from the stomach, menstrual irregularities and ultimately infertility in young women. From the nervosa component we see low self-esteem, depression, anxiety, an increased incidence of substance abuse, and a higher risk of suicide and self-harm. This is a serious problem, and a common one. The estimate is that 1 to 2 percent of us can be diagnosed with bulimia at any point in time, with the ratio of females to males as high as 9:1.

You might think this would be easy to diagnose, but it’s not. Most teenagers don’t want to talk about it and many parents don’t want to address it. Compounding all of that is the fact that most patients with bulimia are of normal weight. This is different from the binge eating we talked about earlier, and from what we will learn about anorexia nervosa.

It’s important to keep in mind that there is some overlap among all the eating disorders, so if you become a little confused and wonder how to keep them straight, don’t feel alone. It can be difficult to make the correct diagnosis, but with a good history from parents, and a focused and thorough exam, it can be done.

That “good history from parents” can sometimes be elusive. Family members and loved ones frequently have a sense that something’s going on, yet many times are reluctant to mention it. They shouldn’t be. Sometimes a life hangs in the balance.

So what are we looking for here? What are some of the things that should make our parental antennae stand on end? Here are some things to watch for:

• Frequent self-weighing
• Obsessive calorie counting
• Ritualistic eating behaviors, such as cutting food into extremely small pieces
• Binge eating behavior
• Frequent trips to the bathroom after a meal
• A preoccupation with body image and weight
• Misuse of over-the-counter laxatives and stimulants
• Characteristic physical changes, such as dental problems, dry skin, and calluses on the backs of fingers

And remember, individuals with bulimia nervosa are frequently of a normal size and weight. Even with that, this is still a serious and life-threatening eating disorder. Be aware and don’t be afraid to bring up the subject. There’s help out there, and this can be successfully treated and its health effects reversed.

While the findings of bulimia nervosa can be subtle, those of anorexia nervosa are far from it. Of all the eating disorders, this is the most deadly. It literally results in starvation and all the medical complications associated with it. We’ve all seen pictures of extreme cases, and maybe wondered how this could ever be missed and allowed to progress to such an emaciated condition. In fact, we may have friends or loved ones who have purposefully lost weight to an excessive degree and continue to do so. While it may appear obvious to an outside observer or even parents, the involved person usually has no insight into what’s happening to their body. There is a desire for thinness and an aversion to any body fat—sometimes to the point of death.

We’ve known about this disorder for hundreds of years, but the name anorexia, which means “no appetite,” is a misnomer. Individuals with this have not lost their appetite. They suppress it in order to lose weight and attain what they believe is the desirable body image. Here are some of the things we need to be looking for:

• A persistent restriction of energy intake (food) that leads to an abnormally low body weight
• An intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain
• A distorted perception of body weight and shape

But what constitutes an abnormally low body weight?

Most experts utilize the BMI (body mass index), a simple calculation that can be found at www.cdc.gov/healthyweight/assessing/bmi/index.html. You only need to know your child’s height and weight. Here are some general categories of low body weight:

• Mild : a BMI of 17 to 18.5
• Moderate: a BMI pf 16 to 16.99
• Severe: a BMI of 15 to 15.99
• Extreme: a BMI less than 15

An example would be that of a teenage girl who is five feet six inches tall and weighs 102 pound. She would be in the “moderate” category. The same girl weighing less than 90 pounds would be in the “extreme” group. But why is this important? Remember, this is about starvation, so let’s consider what starving does to our bodies.

When a human is starved, we start to breakdown protein and fat, all in an effort to maintain critical energy levels and cellular activities. As a result, cells start to shrink, and we see atrophy of the heart, brain, liver, intestines, and muscle. The severity of this depends upon the length and magnitude of the starvation. (In Auschwitz, where prisoners were intentionally starved, receiving only 3-400 calories a day, the life expectancy was about three months.)

With the starvation of anorexia nervosa, it’s not uncommon to see cardiovascular complications, such as a reduced cardiac muscle mass, scarring, and heart valve problems. Absence of menstrual periods and infertility are well-documented, as is the early development of osteoporosis. As with bulimia, if self-induced vomiting is part of the picture, we’ll see the same GI complications. And importantly, starvation will ultimately affect our bone marrow, resulting in dangerous anemias, low white-cell counts that can lead to overwhelming infections, and low platelet counts, causing easy bruising and uncontrolled bleeding.

This is all bad stuff, but do they go away with treatment? Sometimes, but not always. Changes in both the gray and white matter in the brain as well as those cardiac changes can last a lifetime. That’s why we need to pay attention to this and intervene as quickly as we can.

So what are we looking for? Here are some tips.

Some skin changes should raise a few red flags. Yellowing of the skin is commonly seen, as is dryness and scaling. Hair loss occurs, as well as evidence of the easy bruising noted above. Darkening of the skin can also be seen, as well as persistent itching. Slowly healing wounds can be a problem, due to poor nutrition and an impairment of the immune/healing process. Something called lanugo should always raise the suspicion of this disorder. This is the development of fine, dark, downy hair on the trunk and face. We’re not sure why or how this happens, but in the setting of unexplained weight loss, this is an important warning sign.

In addition to these physical findings, there are many behavioral and psychological warnings we need to be aware of.

• Restlessness or hyperactivity
• A relentless and unfounded pursuit of thinness
• Concerns about eating in public
• A fear of certain foods
• Inhibited expression of emotions
• Poor sleep
• A need to control one’s environment
• Inflexible thinking
• A lack of insight into the existence of a potential eating problem
• Anxiety or depression
• An intentional resistance to treatment and weight gain
• An obsessive preoccupation with food manifested in unusual ways, such as hoarding or collecting recipes
• Constantly counting calories
• Consistently overestimating the number of calories in food
• Overusing condiments and artificial sweeteners
• Food-related rituals, including cutting food into small pieces, avoiding certain colors of food, and keeping food separated on the dinner plate

We all could check off some of these behaviors, and occurring by themselves, they’re not necessarily pathologic. But if consistent, worsening, and combined with the kind of weight loss we’ve considered, they point to a more significant problem. Keep in mind, this is the most dangerous of the eating disorders, and if you think your child could possibly be affected, get some help.

But where do we turn? Your pediatrician or family physician is a good place to start. Another good source of accurate and helpful information is NEDA, the National Eating Disorders Association (www.nationaleatingdisorders.org). If you have any suspicion about this, the most important thing to do is act. It won’t go away on its own, and at some point, it can become too late.