Running head: BULIMIA NERVOSA 1

Bulimia Nervosa

Amanda Fox

Concordia University

October 19, 2012

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Bulimia-nervosa is a very serious disease in the United States. According to Marrow

(2010), “bulimia nervosa is a complex disorder and despite continuous efforts from mental health

specialists and doctors to understand its dynamics, researchers believe that a variety of factors

(biological, psychological, and environmental/sociocultural factors) work together in

determining if the disorder will occur”(pg. 1). A lot of progress has been made over the past few

years to determine the causes as well as treatment options. Multiple factors has been found to

impact this disease including; genetics, abuse history, social upbringing, etc. It is important to

know what influences this disease in order to prevent it as best as the community can.

In order to help figure out what causes the disease as well as the frequency levels

throughout the public, epidemiologists do numerous research studies to gain and much

information as they can. “Epidemiology is defined as ‘the study of the distribution and

determinants of disease frequency in human populations’” (Schneider, 2011, pg. 65). There

must be a clear understanding of a disease in order to study it to its full extent. Bulimia nervosa

is a complicated disease that affects many people throughout the world. Many people look at

this disease in only the psychological perspective but epidemiologists also study the disease in

the public health realm. There are many complications in studying this disease because of its

complexity but epidemiologists have been able to find risk factors and distribution of the disease

in the population.

The prevalence of eating disorders has increased over the years, especially in developed

countries. The disease is typically more prevalent in adolescent females than any other

age/gender group. Although people with eating disorders are secretive about their disease,

epidemiologists have done studies on the prevalence of the disease throughout the population.

According to Orlis (1998) there are 12.2 cases per 100,000 of the population. As stated above,

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the disease is a lot more prevalent in females than males. The disease affects 90% of women and

10% of males (Orlis, 1998). Another study was done on the prevalence of the disease in college

females. According to Ahira (2010) around 19% of college females are bulimic. The majority

of people with bulimia are known to have a college education. A lot of people who have the

disease do not disclose information that they have it so epidemiologists do the best they can in

figuring out numbers of cases.

There are many risk factors involved in bulimia nervosa, both environmentally and

genetically. According to the American Psychiatric Association (2006), some risk factors

include age, gender, ethnic factors, socioeconomic factors, personality disorders, accompanying

emotional disorders, being overweight, body image disorders, excessive physical activity,

vegetarianism, diabetes or other chronic diseases and early onset of puberty. As seen with these

risk factors, a lot deal with different psychological disorders but many are environmental as well.

Along with these risk factors comes the role of genetics. According to Brownell and Fairburn

(2002) bulimia nervosa is several times more common within biological relatives who have

bulimic tendencies than the general population. To go along with that information, they also did

studies with monozygotic twins and dizygotic twins. In the study, they found a strong

concordance rate between the monozygotic twins with bulimia than dizygotic implicating a

strong role for genetic factors (Brownell & Fairburn, 2002). As seen, there are many risk factors

involved with this disease. Some can be avoided, some cannot. More research is being done on

genetics and the relationship with bulimia.

Another area to look at for numbers of those affected by the disease is biostatistics.

Biostatistics plays a major role for the research aspect in public health. According to Schneider

(2011), “statistics are a vital part of public health’s assessment function, used to identify special

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risk groups, to detect new health threats, to plan public health programs and evaluate their

success, and to prepare government budgets” (pg. 117). When it comes to bulimia-nervosa,

statistics can be hard to come by. This is because it is a psychological problem so a lot of cases

go undetected. Researchers are trying really hard to get as much information and research on

this disease as possible. Many different studies and information has been collected on this

dangerous disorder.

There are many different ways to collect data for health problems. When it comes to

bulimia, researchers want to know the age, race, gender, etc. of who this disease is affecting.

One of the ways data is collected for this illness is through surveys. An example of a certain

research project that was created for individuals, who described themselves as being recovered

from bulimia, was a survey made for those recovered individuals on the internet. The

description of this survey is “a mixed-method online survey that examined the types of treatment

accessed by those who had recovered from bulimia, their attitudes about recovery, and their

descriptions of what changed with their relationships to food, body, self, and others during

recovery” (Reynen, 2012). This survey produced both quantitative and qualitative data which

was made for professionals to help show what the best treatment methods were according to

people who experienced the illness.

Another big way researchers study eating disorders is in twins and families. It is found

that eating disorders are hereditary. A big study was done in 1996 by a foundation called the

Price Foundation. According to Shaw (2005), “an international group of scientists collected an

astounding amount of data: first, on some 600 families with two or more members who have

anorexia or bulimia, and later, on another group of 700 families with three members who have

anorexia or bulimia along with 700 "control" women for comparison studies”(pg. 1). Within this

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study, they found that certain genes may increase the person’s vulnerability to the disorder. This

was a huge finding because before the concept of genes came to play. Before this discovery,

researchers thought the reason for the disorder was due to overly-controlling parents. This was a

huge finding in research to see that genes and chromosomes have an influence on the disease

making them risk factors.

Seeing that studying families found genes playing a role-genetics then became a

biological factor of this disease. Another study that was done on genes found that half of the risk

of getting an eating disorder is inherited (Hirst, 1998). DNA samples have found similar genetic

characteristics in identical twins with eating disorders compared with those who did not. Seeing

that this disorder is partially due to genetics, explains why it is very difficult to treat the disease.

The study of genetics still has work to do to fully prove its significance but answers are starting

to be found, especially in identical twin studies.

Another biological characteristic that is involved with this disease is faulty

neurotransmitter links in the hypothalamus. The hypothalamus deals with hunger and satiety. In

humans, the ventromedial and lateral hypothalamus are what specifically deals with eating

behavior (Hirst, 1998). These two regions keep the body at the certain set point weight it is

supposed to be at. This study has been done in rats, which professionals know are not like

humans, but shows that damaging one of these areas actually can cause the rat to starve or

overeat. Researchers know rats are different than humans but have similar neurotransmission

functioning. With that being said, this could prove that damage done in humans alters their set

point and causes drastic weight loss or gain (Hirst, 1998).

Going along with neurotransmitter links is the study of hormones. People with eating

disorders have disturbances in serotonin. Serotonin is what helps regulate feeding, mood and

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neuroendocrine activity (Harris Center for Education, 2008). Bulimics binge on carbohydrate

rich food. The body uses the carbohydrates to convert to tryptophan which is then used to create

serotonin (Dombeck, Engel, & Reiss, 2007). Researchers are finding that the binge behavior in

bulimics may be a result of low serotonin levels because they are not getting a sense of satiety

while they eat. Going off of that, though, is that the abnormal eating behaviors could also knock

off serotonin levels causing the rest of the abnormalities within the brain.

More research was done concerning serotonin levels on individuals with bulimia and

found that the levels stay abnormal even after the bingeing and purging stop. “It is now believed

that serotonin imbalances contribute to the long-term mood disturbances, obsessionality and

perfectionism seen in individuals with bulimia” (Harris Center for Education, 2008, pg. 1). This

allows professionals to suggest that there have been serotonin abnormalities even before the

onset of the disease. This finding could explain the eating disturbances in these patients. Studies

are still being done to determine the exact ways the serotonin levels work in patients with eating

disorders.

Although a lot more research needs to be done on this disorder, one thing has been made

known within the biological aspect of the disease: Genetics is a main characteristic in knowing

if one is at risk for the disease. Some research has been done on neurotransmitters and hormones

in the brain to determine abnormalities in these areas can affect eating behaviors in those with

the disorder. More research needs to be done to show this is a 100% fact, but they are leaning in

the direction of those being biological factors of bulimia.

In order to find all the information professionals have on this disease, a lot of research

has been gathered. There are different methods researchers use to get information on this disease

such as surveys, gathering information from psychological professionals, and gathering

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information from people who have overcome this disease. It is a little more difficult gathering

information on this disease because people are not open about having it but with the different

research and findings coming in, more is becoming known about it. The new known finding is

the genetic relationship between family members. This finding taught researchers a lot about the

illness. There is also research being done on trying to prevent the disease as well as figuring out

the best methods of treatment.

When it comes to bulimia-nervosa, professionals are trying to understand how different

factors affect certain individuals and are coming up with different ways to promote these

individuals to live healthier lives (Schneider, 2011). There are now many different models

professionals use to explain how these psychosocial factors influence these bulimic behaviors. It

is very important for professionals to fully understand this disease to help people who have it

want to change their behaviors. It is a terrible disease that needs better understanding to help

people in need. Recently, professionals have used the transtheoretical model of behavioral

change to study the readiness of change for people with bulimia. Schneider (2011) states that the

transtheoretical model involves five stages of change; precontemplation, contemplation,

preparation, action, and maintenance. Professionals try to figure out which stage someone is in

with this disease to help them move to the next stage, until finally reaching the end and

overcoming the disease.

There are many behavioral and social factors involved with bulimia-nervosa. There is a

lot of information found relating genetics to the onset of bulimia but family factors and

sociocultural causes also play a big role. Researchers have found that interpersonal relationships

within the family impact the risk of the onset of bulimia. A study was done to show that there is

a significant relationship between children being sexually abused and later developing bulimia

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because of that (Encyclopedia of Mental Disorders, 2012). They have also found that if there are

food struggles in the family, such as parents being restrictive or overly obsessed with food, as

well as parents being overly obsessed with their weight, shows correlation to the child

developing an eating disorder. Certain sports also play a role in determining if a child is at

higher risk for developing bulimia. Kids who are in certain sports such as gymnastics, dance,

figure skating, modeling and wrestling also have a higher susceptibility to having an eating

disorder because these sports require strict weight control (Encyclopedia of Mental Disorders,

2012).

Along with behavioral factors comes the impact of sociocultural causes and eating

disorders. The media plays a huge role in promoting unhealthy eating habits. The emphasis on

being extremely skinny and relating that to beauty and being desirable creates distorted thinking

in certain individuals. Professionals say that this "ideal" female figure the media has created is

unattainable by most women, and is lighter than most standards correlated with good health by

insurance companies (Encyclopedia of Mental Disorders, 2012). They also have found that

models in 1965 weighed about 8% less than the average American woman and they presently

weigh about 25% less (Encyclopedia of Mental Disorders, 2012). Women are shown that

looking like this is ideal and in order to be somebody in this world, they must look and act this

way. They will not be successful if they do not meet this standard that has been set by media.

Professionals who work with people with eating disorders look at the transtheoretical

model to determine the roles of readiness to change and which treatment methods are best in

determining engagement and outcome of treatment. Different treatment methods such as

cognitive behavioral therapy and motivational enhancement therapy were used in a study to see

which one would help patients more in their recovery process. They found that treatment

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methods made no different, rather which stage of change the patients were in made the biggest

different. Of course, they found patients in the action stage had better outcomes than patients in

the contemplation stage (Treasure et al. 1999). Overall, they found that patients who were more

ready to change as well as those who formed a good alliance with their therapy workers were

more likely to diminish bulimic behaviors.

Another approach used when looking at the behavioral factors of eating disorders is the

ecological model of health behavior. According to Schneider (2011), "the ecological model

describes five levels of influence that determine health-related behaviors" (pg. 233). The first

aspect looked at on the ecological model is the individual level. When an individual goes in to

see a health professional, this professional is trying to help them with their knowledge, attitudes

and beliefs on the disorder (Brown, 2011). When it comes to the interpersonal intervention, the

family is one of the biggest support groups for the person dealing with the disorder. The family

must help and encourage healthy living for this person. When it comes to the organizational

level for eating disorders, support groups and even in and outpatient facilities can help encourage

individuals and give them tools they need to help them deal with their disease (Brown, 2011).

The next level is the community and this can be a little tricky with eating disorders but some

communities put together eating disorder awareness events to get the community aware and give

education tips to help prevent the disease. The last level to this model is public policy. This

needs the most help when it comes to eating disorders. Diminishing media influences on "ideal"

weight is something that can definitely help in prevention of the disease.

As seen, a lot more research needs to be done on bulimia to get a better understanding of

the disease. Numerous groups are involved in the study of the disease including;

epidemiologists, biostatisticians, mental health professionals, researchers, doctors and

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community health workers. A lot has been done to find biological, environmental, sociocultural

and other factors that influence the occurrence of this disease. Progress has been made to find

different ways to try and prevent this disease through talking with patients who have recovered

from it, internet surveys, and lab studies on genetics of those who have been diagnosed with the

disease. So much progress has been made in the past few decades to get a much better

understanding on the disease but because it is so complex, a lot more research needs to happen to

fully understand the extent of the illness.

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References

Ahira, A. (2010). The epidemiological studies of bulimia nervosa. Retrieved on September 15,

2012, from http://www.methedoctor.com/bulimia-epidemiology.htm.

American Psychiatric Association. Treatment of patients with eating disorders, third edition.

American Psychiatric Association. Am J Psychiatry. 2006 Jul;163(7):4-54.

Brown, S. (2011). Using a social-ecological model to examine weight interventions for

children and adolescents. Retrieved on October 7, 2012, from

http://lib.dr.iastate.edu/cgi/viewcontent.cgi?article=1484&context=etd.

Brownell, K. & Fairburn, C. (2002). Eating disorders and obesity (2nd ed.). New York, NY:

The Guilford Press.

Bulimia. (2012). In Encyclopedia of Mental Disorders online. Retrieved from

http://www.minddisorders.com/Br-Del/Bulimia-nervosa.html.

Dombeck, M., Engel, B., & Reiss, N. (2008). Causes of eating disorders-biological

factors. Retrieved on September 27, 2012, from

http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=11749&cn=46.

Harris Center for Education. (2008). The biological basis of bulimia nervosa. Retrieved

on September 27, 2012, from

http://www2.massgeneral.org/harriscenter/about_bn.asp.

Hirst, J. (1998). Biological causes of anorexia nervosa and bulimia nervosa. Retrieved

on September 27, 2012, from

http://serendip.brynmawr.edu/bb/neuro/neuro98/202s98-paper3/Hirst3.html.

Morrow, A. (2010). Bulimia nervosa causes and risk factors. Retrieved on October 19, 2012,

from http://www.omnimedicalsearch.com/conditions-diseases/bulimia-causes-risk-

factors.html.

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Orlis, M. (1998). Bulimia nervosa. Retrieved on September 15, 2012, from

http://www.education.ucsb.edu/jimerson/bulimia.html.

Reynen, E. (2012). Recovery from bulimia: what helps with healing. Retrieved September 22,

2012, from http://sophia.stkate.edu/cgi/viewcontent.cgi?

article=1077&context=msw_papers.

Schneider, M. J.( 2011).  Introduction to public health ( 3rd ed.).  Mississauga, Ontario: Jones

and Bartlett Publishers Canada.

Shaw, G. (2005). Anorexia and bulimia: cracking the genetic code. Retrieved September 22,

2012, from http://www.webmd.com/mental-health/anorexia-nervosa/features/anorexia-

bulimia-genetic-code.

Treasure, J., Katzman, M., Schmidt, U., Troop, N., Todd, G., & De Salva, P. (1999).

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential

design comparing motivation enhancement therapy and cognitive behavioural therapy.

PubMed, 37(5), 405-418. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/10228313.