One of the hallmark features of eating disorders is placing a high value on body weight and shape in determining one’s self-worth. In addition, people with eating disorders often believe that diet, exercise, or–in the case of bulimia nervosa–purging, can control body shape and weight. Individuals with bulimia nervosa purge in an attempt to eliminate calories consumed (which is actually ineffective), empty or flatten the stomach, modulate mood, or as a self-imposed negative consequence for binging. Bulimia carries serious mental and medical health risks. The road to recovery from bulimia usually involves (at least) outpatient therapy with a qualified mental health professional such as a psychologist or other eating disorder therapist.
Cognitive behavioral therapy (CBT) is the most well-researched and effective treatment for bulimia. Therapy begins with an initial goal to immediately stop purging. Other immediate goals include monitoring food intake and implementing regular eating, which usually looks like three meals and two to three snacks spread out over the course of the day. Over the course of therapy, the patient and therapist address the various factors that maintain the eating disorder. These include the over-evaluation of weight, shape, and one’s ability to control these factors. Other factors include dietary restraint and restricting food intake, as well as mood and anxiety-related factors associated with the eating problem.
A majority of patients with bulimia nervosa present to treatment at a weight that is in the middle range for their height. This is in contrast to those with anorexia nervosa, who by definition are at a lower weight. Despite being at a perceived “normal” weight, the characteristic weight and body dissatisfaction associated with bulimia are strong at the beginning of treatment. Patients believe that they are controlling their weight via their purging behaviors. People with bulimia often restrict food intake in various ways. But this control breaks down and leads to an eventual binge and purge. Treatment involves eating meals at regular intervals without purging. Thus, a common fear at the outset of treatment is whether changing eating patterns will result in weight gain. The answer is…maybe.
Weight Changes During Bulimia Treatment
For most patients with bulimia nervosa, treatment will not cause significant weight changes. However, some patients may gain weight. A small percentage of patients may lose weight as a result of eliminating binge eating. We do not advise patients in recovery from an eating disorder (or anyone, for that matter) to have a specific goal weight in mind. Focusing on weight loss is incompatible with CBT strategies to eat balanced and sustaining meals at regular intervals. Weight may naturally fluctuate over the course of treatment. Furthermore, when a person is eating normally, the body naturally gravitates toward a setpoint–a biologically determined weight that is largely out of our control. Indeed, learning to focus less on body weight as a determinant of achievement or self-worth is a valuable treatment goal.
Some patients with bulimia may start treatment at a weight that is in the normal range for their height or even on the high side but low in the context of their adult weight history. Weight suppression is maintaining a body weight that is lower than an individual’s highest adult weight. Recent research has begun to shed light on the effects of weight suppression on eating disorders, especially bulimia. Bulimia is often kick-started with a desire to lose weight and attempt at weight loss through dieting.
Research has demonstrated that living at a suppressed weight has a significant impact on bulimic behaviors. It increases the likelihood of binge eating–potentially through a brain-based biobehavioral self-preservation mechanism–and subsequently purging. Relatedly, and counterintuitive to what people with bulimia believe about their ability to control their weight, weight suppression is associated with weight gain over time. This further promotes dieting and purging given the strong fear of weight gain that most patients experience.
Will I Gain Weight?
So, what does this mean for treatment and recovery? For patients seeking treatment, this means that yes, you may gain weight. This is especially likely if your weight is lower than a previous higher adult weight. This may feel scary, especially at first. Clinicians may even feel uncomfortable having this discussion. They may even be tempted to reassure you that you will not gain weight. However, this message is inconsistent with what we now know about weight suppression. In addition, it merely reinforces the idea that gaining weight is to be feared and avoided at all costs. Gaining some weight may actually be the key to breaking the cycle of binging and purging, which is much more valuable than maintaining a lower weight.
Greater weight suppression is associated with continued bulimia symptoms and relapse, so gaining some weight may actually increase the likelihood of recovery from bulimia and also serve as protection against future eating disorder relapse. Weight gain may not just be a side effect of treatment, but it may be an appropriate treatment goal if you have bulimia and are living at a suppressed weight, just as it is an important goal for someone recovering from anorexia.
If you have had previous treatment, but are still binging and/or purging, it is important to explore whether weight suppression might be a contributing factor. You can discuss whether gaining some weight might be appropriate with your clinician. Understanding the role of weight suppression in the maintenance of the eating disorder should serve as motivation to continue treatment and work toward managing negative feelings related to weight gain. Indeed, it is helpful to explore the motivation behind the importance of thinness or maintaining a certain weight and challenging fears associated with gaining weight. You may find that living at a slightly higher weight, once acceptance is achieved, can be much less stressful and time-consuming than forcing your body to weigh less than it is biologically programmed to.
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Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York, NY: Guilford.
Juarascio, A., Lantz, E. L., Muratore, A. F., & Lowe, M. R. (2018). Addressing weight suppression to improve treatment outcome for bulimia nervosa. Cognitive and behavioral practice, 25(3), 391-401.
Lowe, M. R., Piers, A. D., & Benson, L. (2018). Weight suppression in eating disorders: a research and conceptual update. Current psychiatry reports, 20(10), 80.