Melanie D'Andrea, Manager of Clinical Partnerships at Equip, experienced an eating disorder for the first time after going through a breakup at 18. D’Andrea began purging, a hallmark symptom of bulimia that involves “getting rid” of food after consuming a large quantity of it (a behavior known as binge eating). But while bulimia is often stereotyped as an illness that involves one very specific type of purging—vomiting—D’Andrea’s symptoms included a different, but equally dangerous behavior.

“My purging came in the form of compulsive exercise,” she says. What began as an interest in yoga and treadmill running eventually spiraled into an obsession that consumed D’Andrea day and night. “I started tracking calories in and calories out, using exercise as a form of punishment for eating ‘poorly,’ and making sure to ‘burn off’ every cookie or Frappuccino I consumed.”

Over time, D’Andrea discovered another way to achieve the “empty” feeling she craved: laxatives. “It began in small doses but quickly escalated to taking large volumes daily,” she says. “Laxatives, along with compulsive exercise, became my daily habits. Eventually, the laxative abuse meant I could no longer exercise due to lack of energy, inability to run without needing to use the restroom, and increasing depression.”

D’Andrea’s experience illustrates an important, but widely unknown fact about bulimia: it doesn’t always involve vomiting. So what exactly is the definition of purging? While it can commonly take the form of vomiting after meals, it can also appear as laxative or diuretic abuse, excessive exercise, restricting food to compensate for a binge, and more—and all these forms of purging can be just as serious and dangerous. Here’s what everyone should know about the realities of bulimia, the different types of purging, and why anyone struggling with any of these behaviors deserves care.

Purging definition: What “counts” as a purge?

Bulimia is characterized by uncontrollably eating large amounts of food (bingeing), followed by attempts to “get rid of” or “make up for” the food eaten, a behavior known as purging. Purging can manifest in a variety of different ways.

“Purging is the intentional act of compensating for calories,” says Equip Psychotherapist Hannah Bishop, LPC. “The stereotype for what is purging is recognized as vomiting, but that doesn’t mean other behaviors can’t fall into this definition."

According to Registered Dietitian, Nutrition Consultant, and Certified Personal Trainer Alix Turoff, purging refers to any intentional behavior used to try to “undo” or compensate for eating. While vomiting is the most commonly recognized form of purging, other versions she often sees in her clinical practice include:

• Compulsive or excessive exercise
• Laxative or diuretic misuse
• Insulin manipulation (a behavior known as diabulimia)
• Fasting or severe calorie restriction after eating
• Sauna abuse
• Using food rules and behaviors to “cancel out” intake

“These behaviors are often socially praised or normalized, which makes them harder to recognize and easier to dismiss,” Turoff says. “But if the behavior is being used to compensate for food or relieve distress or guilt about eating, it falls under purging.”

What are the different types of purging?

Oftentimes, people struggling with bulimia engage in a combination of multiple purging behaviors. Here’s what you should know about the types of purging and their dangers.

Self-induced vomiting

Vomiting in an effort to expel “excess” food is a very common behavior in people with bulimia. One study found that 56% of bulimia patients experienced self-induced vomiting at least once per day. Common signs of this behavior are frequent trips to the bathroom or disappearing after meals, and using gum or mouthwash frequently to mask the smell of vomit. Self-induced vomiting can also lead to a variety of medical complications including:

• Stomach rupture
• Heart and kidney problem
• Dental problems including stained teeth, tooth erosion, and cavities
• Irregular menstrual periods
• Inflamed esophagus
• Electrolyte imbalances, which can be fatal

Self-induced vomiting is a very serious purging behavior in itself, and can become even more serious when combined with other forms of purging.

Excessive exercise

As D’Andrea experienced, purging can often appear in the form of compulsive exercise (some people refer to this as “exercise bulimia” or “exercise addiction”). According to research, “problematic exercise”—which can be characterized by intense preoccupation and compulsivity around exercise and using exercise for weight regulation—occurs in about 55% of bulimia patients.

“The easiest form of purging to dismiss as ‘healthy’ is probably excessive exercise,” Turoff says. “Because exercise is so normalized and generally praised as a healthy behavior, it’s easy for compulsive or compensatory movement to fly under the radar. People are frequently praised for these behaviors for being disciplined, motivated, or ‘taking care of themselves,’ even when the exercise is being used to punish eating, relieve guilt, or earn food.”

But even though compulsive exercise is often viewed as a positive achievement, it can be extremely unsafe. “I struggled with compulsive exercise and would often receive many compliments on my ‘determination,’ which would fuel the eating disorder,” says Bishop, who is also in recovery from bulimia.

Overexercising can result in everything from fatigue and depression to overuse injuries and the loss of menstrual periods. Turoff adds that it also “reinforces the belief that food needs to be earned or erased, which keeps the eating disorder cycle going.” Compulsive exercise can also lead to a variety of medical complications, including:

• Hormone disruption
• Irregular or absent menstrual cycles
• Impaired bone health
• Strain on the cardiovascular system
• Fatigue
• Worsened mood and anxiety

“Exercising seems so normalized in today’s society, but the ‘why’ behind it is what matters,” Equip Peer Mentor Gabrielle Terzano says. “If you’re using exercise to compensate for what you ate, then it may be a sign that you’re using exercise to purge.”

Misuse of laxatives, diuretics, or diet pills

Many people with bulimia misuse various medications and pills in an effort to purge. Not only is this practice ineffective for weight loss, it’s also highly dangerous. Laxatives artificially stimulate the large intestine to empty—but most calories are actually absorbed before food reaches this part of the digestive system. The "weight" that's lost from laxatives, diuretics (water pills), or diet pills is most often a combination of water, electrolytes, minerals, indigestible fiber, and colon waste.

Studies suggest that anywhere from 10-60% of people in the U.S. with eating disorders have misused laxatives at some point in their life. The list of medical problems associated with laxative abuse is long, and it includes electrolyte imbalances and changes to the body’s pH levels, which can result in potentially lethal kidney and cardiovascular complications.

Fasting or compensatory restriction

While food restriction is often exclusively associated with anorexia, it’s a symptom that’s common to all eating disorders—including bulimia. And eating very little (or not at all) is a somewhat common form of purging.

Here’s why:

• In most cases, the binges that are characteristic of bulimia are preceded by periods of restriction.
• The resulting biological hunger from that restriction can trigger a binge, and make the person feel they’ve lost control.
• This combination often leads people to restrict after binges in an attempt to “make up” for the episode, but the restriction only perpetuates the harmful cycle.

You can learn more about the differences between anorexia vs bulimia here.

Insulin misuse/mismanagement

Insulin misuse or mismanagement, sometimes called “diabulimia,” is a form of purging specific to people with diabetes. “Diabulimia is probably the least well known because it impacts a smaller subset of individuals with eating disorders,” Turoff says.

Research on diabulimia has indicated:

• People with type 1 diabetes (T1D1) may restrict or use extra insulin as a form of purging.
• Insulin by itself doesn’t affect weight: when someone with T1D1 correctly manages their condition with insulin, their weight isn't affected.
• But according to the Cleveland Clinic, up to 40% of young people assigned female at birth and 10% of young people assigned male at birth with T1D take less insulin than they need in an effort to lose weight.

The negative effects of insulin mismanagement include (among many others):

• Severe dehydration
• Serious infections
• Eye damage
• Cardiovascular, kidney, and liver disease

How to help yourself or someone you know who struggles with purging

Everyone who struggles with any type of purging deserves immediate, effective support—period. It’s important that you or your loved one seek out specialized treatment from providers who are educated on the complexities of bulimia and the variety of ways it can show up in patients.

“The most important step in treating purging is early, specialized intervention with professionals who specialize in eating disorders,” Turoff says. “If purging isn't addressed, it can escalate quickly. Getting help as early as possible is critical, because purging behaviors can become more ingrained and medically risky the longer they continue.”

Because many of the physical consequences of purging—particularly electrolyte imbalances, cardiovascular strain, and hormonal disruption–can develop quickly and may not be obvious at first, Turoff says immediate care is critical. “Early treatment improves outcomes, reduces medical complications, and makes recovery more achievable,” she says. However, no matter how long you or a loved one have been struggling, recovery is possible.

It’s also important to note that if someone is exhibiting purging behaviors but not episodes of bingeing, they may fit the criteria for purging disorder, a sub-type of other specified feeding and eating disorder (OSFED.) It’s important to seek out a provider who will listen carefully to your symptoms and give you a proper diagnosis. Talk to your medical provider, or schedule a free, no-commitment consultation with an Equip team member.

Treatment for purging

No matter where you seek care for yourself or your loved one, it’s important to work with a multidisciplinary team of specialists who can address the different aspects of the eating disorder. This will usually include a therapist, dietitian, and medical provider, at a minimum. At Equip, patients work with a 5-person care team specialized in using evidence-based treatment modalities to treat bulimia. These providers work together to help the patient understand and combat their unique purging behaviors. Care is 100% virtual and built to fit into patients’ lives.

Effective treatment should be personalized to each patient’s unique needs, but care for purging behaviors often involves some similar, evidence-based approaches. These include:

Urge surfing: In bulimia treatment, patients learn various coping skills that can help replace or resist the urge to engage in purging behaviors. One example Terzano encourages patients to explore is called “urge surfing,” and describes a technique used to avoid acting on harmful behaviors. “If you feel the urge to purge, set a timer for 10 minutes before you act on it,” she says. “Even if you do end up going through with the behavior, it’s still progress if you’re able to delay it! And then do this over and over again because repetition is key.”

Therapy: Therapy can also be a key to recovering from purging behaviors. Using modalities like CBT-E and DBT, a therapist can help a patient unpack the underlying issues that may have caused them to begin the binge and purge cycle in the first place, and create a plan on how to break it. In fact, CBT-E is proven to be most effective when treating bulimia.

Relapse prevention: Like other eating disorders, relapse can be a common part of the recovery journey. Terzano wants all patients and their loved ones to know that relapse isn't equivalent to failure. “It can take time to completely stop the behavior and even more time for the urges to stop completely,” she says. “Oftentimes when we feel stressed, we want to turn to a behavior that will make us feel better in the moment. Purging may give you instant satisfaction and gratification, but it won’t help in the long-term.” At Equip, patients work with their team to develop a relapse-prevention plan that provides concrete, actionable guidance to address slip-ups and protect recovery.

No matter what type of purging behaviors you or your loved one are struggling with, know that recovery is possible with the right support. Talk to a trusted medical provider, or schedule a call with Equip today.