When Exercise Becomes An Eating Disorder: Exercise Bulimia Nervosa
There is a plethora of information and media exposure that exists around the type of bulimia that involves vomiting aka purging.
In fact, every show or documentary you’ve likely seen usually shows a woman (men and non-binary folks have bulimia too!) hiding her purging behaviors, having scars on her hands and trying to do her best to keep things secret. But what’s not talked about, and is often a missed part of eating disorder education, is bulimia nervosa that doesn’t involve purging.
Bulimia, one of the more commonly known eating disorders, is usually thought of as the ‘vomiting’ eating disorder, and while forceful vomiting, also known as purging, is one of the main behaviors of bulimia, it’s not the only defining trait of bulimia.
Just like all other eating disorders, bulimia is a complex psychiatric condition and can look differently in each case. You can in fact have bulimia and never use any purging behaviors, and instead you use exercise.
What is bulimia?
According to the DSM-5, bulimia nervosa is characterized by (1) :
Recurrent episodes of binge eating, which is defined as:
eating in a discrete period of time, typically a two hour period, an amount of food that is larger than most people would eat under similar circumstances
A sense of lost control over the eating episode
Recurrent behaviors used to prevent weight gain
Binge eating and compensatory behaviors that occur every at least one time a week for three months
Negative self evaluation determined by body appearance and weight
Without extensive knowledge of the types of bulimia, you might assume that “recurrent behaviors used to prevent weight gain” is referring to vomiting/purging. However, those with bulimia do many different things in an attempt to prevent gaining weight/ try to control their body shape and size.
Types of Bulimia: Purging vs. Non-purging.
Both purging and non-purging bulimia nervosa are attempts to “undo the damage done” following a binge eating episode. People with bulimia nervosa experience frequent episodes of binge eating that causes them to feel a loss of control with food. To make up for this, those with bulimia use compensatory behaviors in an attempt to prevent weight gain. mThe public’s “typical” perception of bulimia is purging-type bulimia. In these cases, individuals will experience episodes of bingeing and then purge in an attempt to prevent weight gain from the binge and rapidly rid the body of any food that has been consumed. Purging includes self-induced vomiting or the abuse of laxatives and emetics.
Those with a non-purging subtype of bulimia utilize other methods to prevent weight gain following a binge episode.
3 common behaviors seen in non-purging bulimia:
#1: Excessive or compulsive exercise.
Following a binge episode, many with non-purging type bulimia will use excessive exercise to prevent any weight gain. Any form of physical activity can be abused; however, it is most common with exercise bulimia to use forms of exercise that are high intensity. Examples of exercise used with exercise bulimia are:
Running
Weightlifting
Swimming
HIIT (high intensity interval training)
Cycling
Jumping rope
Discerning between helpful exercise and excessive/inappropriate exercise is difficult seeing that overexercise is glorified in our culture. This is yet another reason why eating disorders such as exercise bulimia are able to remain undiagnosed for long periods of time. Excessive, or inappropriate, exercise can be characterized by:
Feelings of anxiety, stress, or guilt if exercise is delayed or postponed
Exercise lasting more than three hours per day
Exercising at multiple points throughout the day
Exercise solely to influence weight or body appearance
Exercising despite the presence of an injury
Exercising during periods of sickness and medical ailment
Exercise that interferes with everyday activities, such as work or social gatherings
A note on Athletes and exercise bulimia
This risk for non-purging bulimia, especially exercise bulimia, is particularly high for athletes. In fact, one source states, “While about 1%-5% of the general population is at risk for developing an eating disorder such as anorexia or bulimia, that number can be as high as 30% for competitive athletes.” (5) For example, athletes may binge in secret and then use excessive exercise to prevent gaining weight. In this case, their exercise may be viewed as “honorable” or “dedication to the sport”. The compensatory behaviors to prevent weight gain are simply viewed as loyalty and discipline to the sport for many athletes.
Additionally, in order to keep their eating disorder unnoticed, those struggling with compulsive exercise may exercise at obscure times of day or in secret so their behaviors go unnoticed.
Exercise can become extremely complicated for those who are suffering from an eating disorder. Delving deeper into the motives and feelings underlying the drive to exercise can help you to understand your relationship to exercise and how it may be part of the eating disorder, as well as differentiate between appropriate exercise and compulsive exercise.
#2: Fasting, restriction, or other forms of dieting.
Another common characteristic of non-purging bulimia is dieting following a binge eating episode to “make up for” the calories consumed. Dieting can take many forms, and can look like the following:
Skipping meals or snacks
Fasting for hours or days at a time
Reducing portion sizes
Only consuming conventionally “healthy” foods
Eating a limited variety of foods or unbalanced meals
For many struggling with non-purging bulimia, restriction often precedes and follows episodes of binge eating. This is known as the restrict-binge-shame cycle, and looks like this:
You attempt to diet and restrict the types of foods and portion sizes that you normally eat. Because you feel unsatisfied, unfulfilled, and are undernourished, your body develops an intense craving for food, leading you to binge eat. Following the binge, you feel guilty, stressed, and ashamed as if you have failed; you feel like theres something wrong with you. In order to compensate for this perceived failure and curb the fear of gaining weight from the binge, you resort back to restriction and dieting.
This creates an endless cycle of bingeing and dieting that leaves you unsatisfied and feeling out of control in your relationship with food.
#3: Use of medications that influence appetite.
Individuals with non-purging bulimia can abuse medication stimulants such as “caffeine, prescription drugs, and illicit drugs” (2).
Caffeine can temporarily alter connection hunger cues and it has long-since been abused among many people with different types of eating disorders. Additionally, caffeine has a diuretic effect so the caffeine can increase the amount of urine that is produced by the body. People struggling with eating disorders like non-purging bulimia sometimes use caffeine as a means to urinate more frequently. Because urinating causes a temporary reduction in weight and displacement of liquid, this gives an illusion of weight loss. Caffeine abuse is typically reported in those struggling with non-purging bulimia.
Non-purging bulimia sometimes also involves the use of prescription medications to reduce or curb appetite too. This is commonly seen with medications that are normally intended to treat those with attention-deficit hyperactivity disorder (ADHD). Medications like Ritalin, Adderall, Vyvanse, and Concerta are known to cause many people who take them to “forget to eat”. While these medications are important for treating ADHD, these medications can become extremely dangerous for those with eating disorders. These medications can quickly become abusive and exacerbate disordered eating behaviors and patterns.
While a large portion of those with non-purging bulimia resort to medication stimulants to reduce appetite, some people use illicit drugs in an attempt to prevent weight gain and suppress appetite. Illicit drugs, including but not limited to, methamphetamines, bariturates, marijuana, and cocaine, have been documented in those with non-purging bulimia as a means to temporarily suppress appetite cues. In fact, it has been proven that those with bulimia have stronger associations with substance abuse than any other eating disorder (3).
What are the health risks of non-purging bulimia?
Just as purging bulimia can present serious medical risks, nonpurging bulimia also has very serious negative impacts on the body. Ongoing nonpurging bulimia can lead to many health risks, including (4):
Metabolic disorders
Substance abuse disorders
Low self-esteem
Depression
Nutrient deficiencies
Dehydration
Weakened immune system
Heart health issues
Increased risk of exercise-related injuries
Death
In summary, purging is not the only criteria used to diagnose those with bulimia and this misconception causes many who are struggling to be overlooked. Non-purging bulimia can be difficult to diagnose, as most people and health clinicians are unaware that a non-purging subtype even exists. For people that have been engaging with these compensatory behaviors for a long time, they may not even know that these behaviors are problematic and/or that they meet criteria for an eating disorder. Overlooking these critical symptoms of non-purging type bulimia can prolong the eating disorder and put the individual at an even greater risk for dangerous health issues.
If you believe that you or someone you know may be struggling with nonpurging or purging bulimia, reach out to an eating disorder registered dietitian to get help! At Bravespace Nutrition in Seattle, WA we have specialized eating disorder dietitians that have the tools and resources to help you heal from bulimia and mend your relationship with food, exercise, and more.
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Struggling with bulimia (purging or non-purging type) is incredibly difficult and you don’t have to navigate healing from the eating disorder on your own! Our dietitians specialize in eating disorders, disordered eating, intuitive eating and body-image concerns. Reach out to us to schedule a discovery call today so that bulimia doesn’t rule your life.