Many individuals struggling with bulimia nervosa hide behind their symptoms and will do everything in their power to mask their disorder. Hiding food, sneaking into the bathroom at odd hours, avoiding confrontational discussions, blunting their emotions, turning a blind eye to any news or media coverage associated with eating disorders and isolating themselves from others who may be skeptical of their conduct are common behavioral patterns used to mask the telltale symptoms and signs of bulimia nervosa. Individuals who are struggling with this binging and purging eating disorder are usually very successful in concealing their behaviors, and as a result, even their closest friends and family members will often be unaware of the gravity of their disorder. Eating Disorder Awareness Week is held in the last week of February and is a nationwide campaign to lower the stigma, increase the awareness and spread education in regards to eating disorders and how these lethal conditions can affect anyone and everyone in society. So how can you tell if your loved one is battling with bulimia nervosa?

1. A decline in oral health

Bulimia nervosa is characterized by binging episodes followed by self-induced purging. The most common form of purging is vomiting which involves not only the upchuck of unwanted calories in the form of partially digested food but also stomach acid that can have harmful effects on the esophagus and oral cavity including teeth and gums. The majority of individuals with bulimia nervosa will show signs and symptoms of tooth decay and cavities over time. Bringing acidic contents from your stomach into your mouth through self-induced vomiting can cause erosion of the enamel surface of your teeth. This damage usually appears primarily on the inside and biting surfaces of the teeth, and over time as the enamel is eroded by repeated exposure to gastric acid. For example, teeth may lose their shine, break, turn yellow, wear down, and chip. Stomach acid also potentiates the risk for cavities, and when combined with a high intake of sugary food, commonly seen in those who engage in binging, the risk for dental caries increases at a higher rate.

2. Consuming huge portions of food

Individuals with bulimia consume larger portions of food than what is considered normal over short periods. This behavior is often done in secrecy as many individuals cycle through feelings of loss of control followed by guilt and shame, which eventually results in compensatory behaviors, aimed at “undoing” calories consumed.

3. Unusual behaviors around meals

Consistently disappearing following a meal, especially to the bathroom, can be a sign indicative of bulimia. The same can be said for finding open wrappers or stashes of food in unusual places; for instance, opened packs of candy bars underneath one’s bed or in their closet. Excessive fluid intake after eating, especially water or diet soda, can be a precursor to certain purging behaviors. Regularly eating alone in private, avoiding social gatherings around food or showering immediately following meals are also possible causes for concern.

4. Excoriations and scars on the back of the knuckles and hands (Russell’s Sign)

Individuals who engage in self-induced vomiting as a compensatory behavior will often have excoriations on the back of the knuckles. Repeated contact of the fingers with teeth during self-induced vomiting episodes can lead to characteristic abrasions, small lacerations, and calluses on the back of the hand overlying the knuckles; formally known as Russell’s Sign.

5. Treatment for bulimia nervosa

Similar to anorexia nervosa and other eating disorders, bulimia nervosa is best treated by a professional eating disorder treatment center. Depending on the severity of the illness, levels of care range from inpatient treatment and residential treatment to partial hospitalization, intensive outpatient therapy, and outpatient treatment. A treatment plan is initiated immediately upon treatment admission, and this plan includes the components of the treatment team, psychotherapy approaches, nutritional and dietary counseling, and discharge and aftercare planning.