The deadly binge and purge cy­cle of bu­limia – why women are re­sort­ing to des­per­ate mea­sures to get the ‘per­fect’ body.

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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

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