Page 88 Complete Your CE Test Online - Click Here A factor that differentiates bulimia nervosa from anorexia nervosa is the fact that clients who have bulimia nervosa usually maintain a normal weight, while some affected persons are slightly overweight. However, like people with anorexia nervosa, bulimic clients are desperate to lose weight and are very unhappy with their body size and shape[1,16] . Incidence and prevalence of bulimia nervosa The onset of bulimia nervosa usually begins in late adolescence or early 20s and can occur simultaneously with anorexia nervosa[2,9] . Onset before puberty or after the age of 40 is uncommon. Binge eating often starts during or after a period of dieting to lose weight. Experiencing multiple stressful life events can also trigger the onset of bulimia nervosa[1] . Binging and purging behaviors are done in secret since clients are often shamed and disgusted by their own actions. Because of the secrecy surrounding these actions, as well as the fact that clients with bulimia nervosa usually have a normal or slightly above normal weight, exact statistics pertaining to incidence and prevalence may not be completely accurate[2,9,16] . The disease is diagnosed more often in females compared to males. For every man affected by bulimia nervosa, there are nine women with the disease[9] . However, the number of males with bulimia is increasing significantly[6] . Nursing consideration: Binge eating, purging, or overeating are reported by 31% of male teenagers[6] . As the numbers of males with eating disorders increases, so must the ability of nurses and other healthcare professionals to recognize such disorders and intervene appropriately. It is estimated that nearly 2% of adult women meet the diagnostic criteria for the disease, and five to 15% of adult women have some symptoms of the problem[9] . It is also estimated that by their first year of college, 4.5 to 18% of women and 0.4% of men will have a history of bulimia[5] . Evidence-based practice alert! Bulimia has a significant mortality rate. About 3.9% of clients will die from complications associated with the disease[2,5,9] . This makes it imperative that nurses and other healthcare professionals facilitate prompt diagnosis and treatment for all persons affected by bulimia and other eating disorders. Eating disorders such as bulimia nervosa are found most often in higher socioeconomic groups and affluent cultures. Such disorders are almost non-existent in cultures and geographic areas where poverty and malnutrition are common. They are also extremely uncommon in developing countries. Cultural norms that influence body image are a major factor in the development of eating disorder development[9] . In the United States, being thin is seen as being attractive. Being overweight is viewed with contempt. Television, movies, and print and social media showcase women who are ultra-thin. What many impressionable young women (and young men) do not realize is that many of the print and social media images are altered to make women appear thinner (and men more muscular) than they really are[6] . Possible causes and risk factors of bulimia nervosa As with anorexia nervosa, the exact cause of bulimia nervosa is not known[9] . Research indicates that many clients with the disease participate in disturbed, inappropriate eating behaviors for at least several years prior to diagnosis[1] . The course of bulimia nervosa may be chronic or intermittent. There may be periods of remission alternating with a recurrence of binging and purging behaviors. Interestingly enough, long-term follow-up shows that signs and symptoms seem to diminish with or without treatment. However, treatment has a significant impact on positive outcomes[1] . Evidence-based practice alert! Better long-term outcomes are associated with periods of remission that last for more than one year[1] . Nurses must monitor, and help clients and families to monitor, periods of remission and reinforce how length of remissions are associated with long-term outcomes. There are a number of risk factors associated with an increased risk for the development of bulimia nervosa. These include the following factors: ● ● Being a female: Females are more likely to develop the disease than males. As previously noted, for every man affected by bulimia nervosa, there are nine women with the disease[9] . However, the numbers of males affected by the disease are rapidly increasing[6] . ● ● Genetic factors: Family history of eating disorders increases the risk for developing bulimia nervosa and other eating disorders. People who have a first-degree relative (meaning siblings or parents) with an eating disorder are at particular risk[16] . ● ● Physiological factors: Childhood obesity and early puberty increases risk for the disease[1] . ● ● Psychological issues: Low self-esteem, depression, social anxiety disorder, obsessive-compulsive disorder, and over-anxious disorder of childhood are associated with increased risk for bulimia nervosa. Impulsiveness and problems managing anger are also linked to a greater risk for disease development. Experiencing traumatic events may also contribute to its occurrence[1,16] . ● ● Experiencing abuse: People who experienced childhood sexual or physical abuse are at greater risk for developing bulimia nervosa[1] . ● ● Social and cultural pressures: Societal and peer pressure to be thin makes some persons more vulnerable to the disease. The appearance of people in the media (i.e. models, actors, and actresses) adds to these pressures[1,9,16] . ● ● Career factors: People whose size and appearance affect their livelihood are at higher risk for bulimia nervosa and other eating disorders. Examples of such people are dancers, actresses, and models[1,9,16] . ● ● Sports-related expectations: Athletes are often under pressure to lose weight and restrict caloric intake. Coaches and parents who want to see young athletes succeed may encourage weight loss and maintenance of a low weight because they believe that this will enhance their ability as athletes. This is especially true of female athletes such as gymnasts, runners, and skaters[16] . Clinical presentation Gerald and Jeanne have always been proud of their daughter Diane’s accomplishments, especially her performance as a high-school gymnast. Diane is now a freshman at a large university where she is a member of the gymnastic team. Gerald and Jeanne frequently travel long distances to attend Diane’s competitive events and often visit her at school. Lately they have noticed that Diane’s hands and