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Cornerstones of treatment for women with bulimia include a trusting relationship with provider(s) and treatment based on a careful history of triggers for dysfunctional eating behaviors. Collaboration with the patient in assuming responsibility for healthy eating patterns is important along with support offered through therapy groups of patients with similar disorders. Education about healthy nutritional patterns may be useful for assisting women in interrupting their binge-purging patterns. Behavioral and psychological referral for insight and problem-solving is usually recommended.

Hospitalization Management of patients with bulimia rarely requires hospitalization. It is reserved for patients who have life-threatening complications, such as heart failure or renal compromise associated with electrolyte disturbances, severe concurrent substance abuse, or evidence of suicide risk. The nutritional goal for these patients is to maintain adequate weight by providing adequate intake, while medical problems are managed.

Nutritional Care For many women with bulimia, controlling the dysfunctional eating behaviors is often required before addressing weight management. Weight loss strategies, as discussed in the section on obesity, can then be used with obese women with bulimia. Goals and strategies of nutritional care for patients with managed bulimia nervasa are Dieting behavior is to be avoided. In a study of 75 patients with bulimia nervosa, subjective assessment of helpful components of treatment included encouragement to eat a balanced diet at regular intervals and to avoid binge foods. Less helpful components were recording food intake and bingeing and purging episodes and making meal plans.

Managing Dysfunctional Eating Behavior Because bingeing and purging are often viewed as behaviors initiated to gain control of one’s life, decisions about therapy should be shared, rather than mandated, and bulimic patients should be self-monitors of their progress. The only exception to this principle is if there is life-threatening risk to health from the bulimia, which is rare.

Cognitive-behavioral therapy (CBT) is the most well-established treatment for bulimia. It consists of time-limited therapy that systematically addresses both the cognitive aspects of the disorder, such as preoccupation with weight and food, perfectionism and low self-esteem, and the dysfunctional eating behaviors. Although CBT has been used effectively and appears to be more effective than medication, both interpersonal therapy and pharmacologic therapy are also effective in patients with bulimia nervosa and binge-eating disorder. Combination therapy with CBT and medication may be superior to either therapy alone.

Psychiuatric Treatment Sometimes, antidepressant medications are helpful, but these should be used when there is a psychological diagnosis to support such therapy. Antidepressants from either the selective serotonin reuptake inhibitor or the tricyclic category are the drugs preferred for control of either depressive or obsessive symptorns. Fluoxetine (60 mg/d) is the best studied and most easily tolerated medication effective in patients with bulimia nervosa. Women of normal or greater weight can usually be started on this dose at initiation of therapy or the medication can be increased from 20 to 60 mg over 1 to 2 weeks. Other medications effective for the treatment of bulimia nervosa are shown Desipramine (up to 300 mg/d) and imipramine (up to 300 mg/d) are other first-line agents.

Summary

The best treatment for obesity and disordered eating patterns is prevention. This is becoming more difficult each year in a culture bombarded with high-fat foods and sedentary lifestyles and media images of the idealized thin body. The time to start preventive efforts related to healthy eating and exercise is in childhood. This does not necessarily mean competitive sports, but it does mean regular physical activity that continues throughout life. It does not mean rigid and restrictive diet plans, but emphasis on healthy eating patterns with food selections weighted toward the base of the food pyramid. In addition, children should be taught to eat only when hungry and to stop eating when full.
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