The deadly binge and purge cycle of bulimia – why women are resorting to desperate measures to get the ‘perfect’ body.
The exact moment I realised being thin wasn’t in any way glamorous was when I found myself on my knees at the side of a road late one night with a bloated face and bloodshot eyes, in a puddle of vomit. The remains of my Dh500 dinner,” confesses 32-year-old Dubai resident Megan*. “My throat ached, my knees were bleeding, my designer dress was ripped and I looked and felt anything but beautiful. I was, quite literally, in the gutter.”
This was Megan’s shocking weight-loss strategy. She calls it her dirty little secret, one she kept from family and friends for years. Triggered by a chance remark about her ‘thunder thighs’ while at school, Megan’s bulimia took hold at 14, the age at which she first forced herself to be sick.
“I have always used food to comfort myself emotionally, but I just didn’t want to get fat,” confides Megan. “I used to weigh myself six times a day, make myself sick at least five times daily and planmy life around when I could binge and purge without being found out,” she says.
Megan’s life sounds miserable, and it is. Bulimia, the most common of the six eating disorders and an official mental illness, involves a food binge, the frenzied consumption of 1,500 to 3,000 calories in typically a two-hour sitting, followed by feelings of disgust, guilt and selfloathing, leading sufferers to rid their bodies of the just-eaten food. Most commonly, this involves purging – either through self-induced vomiting or laxatives, while some bulimics are non-purging, using excessive exercise and starvation to compensate for the calories.
As well as the obvious physical strain, bulimia also involves secrecy and subterfuge. “In retrospect, I guess I was no different from an addict,” confesses Megan. “I not only distanced myself from people, missing out on many productive relationships, but I lied constantly to the people I loved, even my husband, for years.”
Motivated by a fear of weight gain, a growing number of women are resorting to bulimic behaviour to keep their weight in check. According to the National Eating Disorders Association, almost half of all adult Americans are on a diet on any given day, with 20 to 25 per cent of them progressing to an eating disorder. And while there is no hard data on eating disorders in the UAE, it is, say regional experts, an illness they’re seeing more and more.
A 2010 study at Zayed University revealed that nearly a quarter of students have abnormal eating attitudes, putting them at risk of developing an eating disorder. And the latest local study backed up these rather disturbing findings: three quarters – 78 per cent – of female UAE students are unhappy with their bodies, with one in four at risk of developing an eating disorder. “Prevalence of eating disorders in the UAE seems to be comparable toWestern countries and further seems to be increasing here,” says Clare Smart of LifeWorks personal development training centre in Dubai.
An invisible illness
In theWest, a staggering one in 50 women between the ages of 15 and 24 is bulimic and these numbers are on the rise. According to the BritishMedical Journal, the number of people diagnosed with an eating disorder each year has risen 15 per cent in the past nine years.
What’s even more worrying is that many experts believe bulimia to be more common than such numbers reveal. But its invisibility as an illness makes it so much more difficult to detect, and therefore treat.
“Bulimics are more difficult to diagnose than anorexics because they do not have the extreme weight loss and are not emaciated,” explains Dr Veena Luthra, chief of the obesity and eating disorders unit, American Center for Psychiatry and Neurology, Abu Dhabi.
LifeWork’s Clare agrees. “There is not always a weight change that’s noticeable and people can suffer for many years without getting help.”
And they do. A decade of bulimic behaviour is not unusual in the eating disorders landscape. Clare explains that bulimia commonly begins as a young person enters adolescence, with the average age of bulimia onset at just nine to 12 years of age.
Megan’s troubling relationship with food began at boarding school at 14. And while many women will abandon their teenage missions to look like supermodel Kate Moss, many will continue their feast-or-famine eating patterns into adulthood. “I remember the first time I purged, thinking, ‘I’ll just do it this once and
never again,’” says Megan. But one time turned into 18 years, eventually becoming an obsession that was out of control.
“The cycle of bingeing and purging, alongside unhelpful thinking, can become very difficult to break especially without help,” says Clare. For some, it can lie dormant for many years, resurfacing years later when a trauma – a divorce or a death – occurs, or at times of despair, stress, loneliness or depression. Frequently, feeling stressed or anxious triggers the binge, which is then followed by feelings of depression and guilt, explains Dr Veena.
“It became my crutch for getting through the bad times. It was like an old friend who would come back to visit at moments of crisis… a way of coping when things were uncertain or stressful,” explains Megan.
Its hidden nature is not the only concern, however. One of the biggest dangers of the disease, unlike anorexia, is the lack of awareness as to its seriousness. Many bulimics do not think that what they’re doing is harming them. But it is. Hair loss, tooth decay, infertility issues and even heart attacks are some of the scary effects, not to mention loss of relationships, jobs and interests.
Laura* is a case in point. What started as a weight-loss strategy for this 28-year-old Abu Dhabi resident soon became an addiction that she still cannot escape. Despite not successfully losing weight. Laura has binged for the past 12 years, using a combination of purging, laxatives, over-exercise and starvation, with her weight constantly fluctuating by 3 to 4kg from one week to the next. Her signature binge is a large loaf of bread and a jar of Nutella, which she can eat in less than an hour.
“I realised I could raid the fridge, scoff a couple of fast food fried meals or a 5,000 calorie brunch and simply make up for all the food I’d consumed by making myself ill,” she says. “I don’t think I have an eating disorder. This is normal. I have a highly paid job, a busy social life and a healthy relationship. I’m even studying part-time. How could I hold all that together if I was ill?” she insists.
Like Laura, many bulimic sufferers are highly functioning – educated, intelligent, affluent women leading what look on the surface like very successful lives. So, what is making such smart women in public so stupid in private?
Western culture and its representation of the female ideal body type is to blame, states a recent Dubai government-backed study, explaining how “thin body ideals and widespread body dissatisfaction” was limited toWestern Europe and North America until the early 1990s, but has now spread to the Middle East. And certainly theWestern societal pressure to be thin has an impact, and on young girls especially.
Research by the National Association of Anorexia Nervosa and Associated Disorders US (ANAD) reveals that some 69 per cent of girls in grade 5 to 12 in the US reported that magazine pictures influenced their idea of a perfect body shape. And considering that the average model – viewed by many as the perfect body shape – weighs 23 per cent less than a typical woman, it’s little surprise body dissatisfaction, leading to eating disorders, is so prevalent in theWest. Add to this the UAE’s beach-based lifestyle, which for expats, in particular, says Clare, can put them under pressure to achieve ‘the beach body’ and you have a recipe for an eating disorders disaster.
Of course, we’re all bombarded with ridiculous messages of what is ‘ideal’ and we’re not all making ourselves ill. So, what makes a person more vulnerable?
The battle within
Underneath the desire to be thin, say experts, issues of insecurity and problems of perfectionism are prolific, with women feeling they’re simply not living up to expectations.
Many bulimics, and those suffering from eating disorders generally, struggle with this similar fear of not being ‘good enough’ – also known as atelophobia – with low self-esteem and disappointment at their own perceived failings, taking centre stage. “A voice in the back of my mind was always saying, ‘Just one more purge and you’ll be good enough, pretty enough, thin enough’,” explains Megan, who admits to never really fulfilling the academic expectations of her parents or being as successful as her sister.
It’s a battle with themselves bulimics are unlikely to win, however, because contrary to popular belief, laxatives and vomiting do not a skinny girl make. “There’s a misconception that by vomiting or using laxatives, the calories and fat consumed are then removed,” says Clare. “But this does not happen. What is eliminated is mainly waste product along with fluids,” she explains. And it’s this loss of fluids that not only means we’re more likely to hold
on to the initial fat and calories, but is also a danger to our bodies. So, not only are purging bulimics wasting their time and energy, they are also putting their health – and in rare cases lives – in jeopardy. “Bulimics frequently have severe medical complications due to electrolyte imbalance from vomiting and laxatives, while forced vomiting can cause stomach bleeding and even rupture,” explains Dr Veena. She cites a patient of hers who used a toothbrush to induce vomiting and needed surgery after accidentally swallowing it.
Bulimia can be fatal. Eating disorders have, according to Beat UK, a mortality rate of 20 per cent, the highest of any mental health issue, with the risk of premature death from eating disorders 6 to 12 times higher than the general population. It has always been assumed anorexia is the most fatal of the eating disorders, but a study published in 1998 in the Journal of Child and Adolescent Psychiatric
Nursing revealed the estimated mortality rate for bulimia nervosa to be up to 19 per cent.
Often viewed as a ‘less severe’ eating disorder, the fatal risks of bulimia are not taken as seriously as anorexia. However, the most recent study (published in American Journal
of Psychiatry, 2009) revealed for the first time reliable mortality rates for bulimia that showed it as having elevated mortality risks, similar to those found in anorexia. Studies, and therefore mortality rates vary widely, partly because those who suffer may ultimately die of heart failure, organ failure, or malnutrition, so the bulimia is not given blame.
The late singer Amy Winehouse is a case in point. Though it was declared she’d died of her addictions (drink and drugs), her family, who said she had battled with bulimia since the age
of 17, believe bulimia killed her, weakening her body so much, her heart failed. Heart failure, due to extreme electrolyte imbalance, caused by severe dehydration from vomiting/laxatives, is the most common cause of sudden death in bulimia and in reality, a bulimic could die from purging just once, if you experience such a fatal rupture of the heart. But bulimics can develop any number of fatal conditions, including stomach rupture, life-threatening kidney problems, oesophageal cancer and choking.
The short and long-term damage
Even though she hasn’t suffered anything this serious, Megan has had her fair share of accidents, a scar on her forehead revealing the most recent. “Not long before I got treatment, I knocked myself out and needed 14 stitches after blacking out. It was at the end of a particularly frenzied binge-purge session,” she says.
Accidents aside, common, ongoing symptoms of bulimia include dizziness, headaches, fatigue, heartburn, abdominal pain, broken blood vessels in the eyes, bloating, bladder infections, menstrual irregularity, muscle cramps and fainting. It also causes short-term and long-term damage, from dental erosion (89 per cent of bulimics suffer tooth decay and erosion as early as six months after behaviour begins), to serious bowel tumours, irreversible reproductive problems, and even heart attacks.
Laura admits to having chest pains and bladder infections, as well as being constantly lethargic. She’s also recently been diagnosed with kidney stones. While Megan did eventually leave her bulimia behind, she discovered that not only is she at risk of osteoporosis, she is unlikely to ever conceive. But while bulimia can be tough to tackle, people can, as Megan has proved, recover by re-establishing a healthy relationship with food. “I finally received treatment – an intensive programme of therapy and nutrition advice back in the UK, after a close friend became suspicious and confronted me,” explains Megan, who is now back in Dubai having left the binge-purge cycle behind her.
“The UK National Institute for Health and Care Excellence (NICE) guidelines recommend treatment as one or a combination of selfhelp, cognitive behavioural therapy (CBT) and sometimes medication,” says Clare, who uses CBT at her own practice in Dubai. Proven to be of most benefit in treating eating disorders, CBT challenges unrealistic thoughts about food and appearance and helps sufferers develop healthy eating patterns. Hypnotherapy, however, can also work wonders. It’s effective at identifying the psychological origins, before breaking down negative behaviour patterns and replacing them with positive ones.
In addition, the first holistic programme for eating disorders debuted in the UAE just last year at The American Center for Psychiatry and Neurology in Abu Dhabi. A team-based approach sees 10 experts take care of everything. “We offer multidisciplinary services, including medical assessment, psychiatrist, psychotherapy and nutrition,” says Dr Luthra.
After hitting rock bottom, Megan is back on track after tackling bulimia’s biggest hurdle – herself. Despite sometimes still having ‘fat days’, Megan has started to be OK with the way she looks. “I can now look in the mirror without being revolted and I go to bed without weighing myself… that’s a big step for me. And far from being in the gutter, I feel happy, healthy and really rather beautiful.”
Underneath the drive to lose weight or stay slim is a feeling of never quite measuring up, never being good enough
The invisible nature of bulimia means it is more difficult to detect and therefore diagnose. People can suffer for years without getting help