Bulimia Nervosa: Care Staff Guide to Recognition and Support

Bulimia is often hidden. A person may maintain a typical weight, eat normally in front of others and appear to be coping well, while privately struggling with cycles of bingeing, shame and purging. For that reason, it is frequently missed, and people can live with it for years without help. Care staff may notice signs such as long periods in the bathroom after meals, secrecy around food, dental problems or exhaustion. This guide, based on NHS information and NICE guideline NG69, explains bulimia nervosa and how to support someone with it kindly and safely.

What is bulimia?

The NHS describes bulimia (bulimia nervosa) as an eating disorder and a serious mental health condition. Its message is hopeful: it can affect anyone, treatment may take time, but people can recover. NICE guideline NG69 on eating disorders covers anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorders. NICE states that eating disorders most often start in adolescence but can begin in childhood or adulthood, are linked to poor quality of life and social isolation, and have a substantial impact on family members and carers.

NICE cites estimates from the eating disorders charity Beat of more than 725,000 people in the UK with an eating disorder, based on hospital admission figures from 2012 to 2013. It notes that although about 90% of the people in that estimate were female, more recent community studies suggest that as many as 25% of people with an eating disorder are male. Bulimia is not a condition of one group, and staff should not assume that someone does not have an eating disorder because of their age, gender or weight.

Signs and symptoms

The NHS groups the signs of bulimia into three areas.

• Emotional: feeling tense, irritable, anxious or depressed; a fear of putting on weight; guilt and shame; and a sense of having no control over eating
• Behavioural: binge eating; purging, including self-induced vomiting, using laxatives or diuretics, or going long periods without eating; excessive exercise; an obsession with weight and body shape; secrecy about eating; and avoiding social situations involving food
• Physical: tiredness and sleep problems, weakness or dizziness, a sore throat from vomiting, bloating or stomach pain, swollen glands causing puffy cheeks and jaw, and irregular or stopped periods

The NHS adds that it is important to get help even if someone has only some of these signs. In care settings, staff may also notice food going missing, disappearing to the toilet soon after eating, the smell of vomit, a worn or damaged dental appearance, low mood and withdrawal.

Physical risks

The NHS lists complications of bulimia including damage to tooth enamel and the lining of the throat from stomach acid, irregular or absent periods, seizures, heart or kidney problems, bowel problems such as constipation, and weakened bones. It warns that without support, bulimia can be life-threatening. Some risks can build quietly: for example, repeated vomiting or laxative use can disturb the body's salts and fluids, which can affect the heart. Because of this, any person with an eating disorder who has palpitations, fainting, severe weakness, muscle cramps, chest pain, seizures or confusion needs urgent medical attention. Call 999 in an emergency.

Eating disorders and physical health monitoring also matter for people at risk of malnutrition or serious complications. Our guide to MEED guidance on eating disorder physical health monitoring explains how physical risk is assessed and monitored.

Mental health and risk

Bulimia often co-occurs with anxiety, depression, self-harm and, in some people, suicidal thoughts. NICE notes that anorexia nervosa is the most common cause of death from eating disorders, mainly through malnutrition, suicide and physical problems, which is a reminder that eating disorders carry serious risk to life across the spectrum. The NHS says hospital admission may be needed for serious health problems or if there is a risk of self-harm or suicide. Staff should take expressions of hopelessness seriously and follow the guidance in our article on suicide and self-harm awareness.

Getting help

The NHS advises seeing a GP if you think you might have bulimia, or if treatment is not helping. If you are worried about someone else, encourage them to see their GP. Care staff can support this by creating a private, unhurried moment to raise their concern, saying what they have noticed without blame, and offering to help arrange an appointment or go along.

Treatment

According to the NHS, treatment for bulimia usually includes talking therapies, often involving a self-help booklet or online programme used alone or with a therapist, with family involvement for people under 18. Other parts of care may include:

• Medicines, such as antidepressants, where another condition like anxiety or depression is also present
• Support from a dietitian
• Hospital admission for serious physical problems, being severely underweight, or risk of self-harm or suicide

The NHS also advises anyone who is pregnant, or who has had an eating disorder, to tell their midwife and GP. NICE guideline NG69 sets out recommendations on identifying eating disorders early, keeping people safe, supporting family members and carers, and ensuring access to evidence-based physical and psychological care.

How to talk to someone you are worried about

• Choose a private moment and start with care, for example "I've noticed you seem tired and I'm worried about you".
• Focus on feelings and health, not food, weight or appearance.
• Avoid blame, bargaining or ultimatums, and avoid comments about body size, even if well meant.
• Listen without trying to fix. Shame is central to bulimia, and a calm, non-judgemental response makes it more likely the person will seek help.
• Do not make them eat or monitor them in a controlling way unless this is part of an agreed care plan.
• Know where to signpost, including the GP, NHS 111 in urgent situations and Beat, the eating disorders charity, which offers information, helplines and carer support.

Supporting recovery

The NHS suggests helpful steps for the person in recovery, such as avoiding weighing themselves, limiting mirror-checking, avoiding weight-loss content online, rinsing the mouth with water after vomiting, and talking to someone they trust. Staff can reinforce these gently, keep mealtimes relaxed and non-judgemental, avoid diet talk in the setting and make sure that any agreed meal plan is followed consistently by the whole team. Relapse can happen, and it is not a failure. If it does, encourage re-engagement with the clinical team.

Anxiety and low mood are common alongside bulimia, and our guide to generalised anxiety and panic disorder may help staff recognise and respond to these.

Supporting families and carers

The NHS notes that carers can get advice from Beat, YoungMinds and other charities. Families often feel guilt, fear and exhaustion. Offer information, listen and signpost to carer support.

Frequently asked questions

Can someone with bulimia be a healthy weight?

Yes. People with bulimia often maintain a typical weight, which is one reason it can go unnoticed. The NHS stresses that getting help matters even if someone has only some of the signs.

Can people recover from bulimia?

The NHS says treatment may take time but people can recover.

Is bulimia only a problem for young women?

No. NICE notes that although it most often starts in adolescence, eating disorders can begin in childhood or adulthood and as many as 25% of people with an eating disorder may be male, according to recent community studies.

Keep building your knowledge

Kind, informed responses help people take the first step towards help. Explore the health and social care learning available through Learnsignal CPD to keep your knowledge up to date.

This article is general information for care staff, based on NHS information and NICE guidance, and does not replace the advice of a person's own clinicians. If you are worried about someone's health right now, contact their GP, NHS 111 or, in an emergency, call 999.