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Friday, 1 November 2013

Eating Disorders

Eating Disorders are defined as a group of abnormal eating habits associated to a person preoccupation weight, involving either insufficient or excessive food intake.

Types of eating disorder
1. Anorexia nervosa
Anorexia nervosa is a type of eating disorder usually develop in the teen years and effect over 90% of female, because of excessive food restriction and irrational fear to become fat due the wrongly influenced media as attractiveness is equated to thinness.

2. Bulimia nervosa
Bulimia nervosa is defined as a medical condition of  consuming a large amount of food in a short amount of time or one setting (binge eating), followed by self induced vomiting, taking a laxative or diuretic and/or excessive exercise, etc. to compensate for the binge. Bulimia vervosa also effects almost 90% of female.

3. Binge eating disorder
Binge eating disorder is defined as a condition of compulsive eating huge amounts of food while feeling out of control and powerless to stop. It is the common eating disorder in the United States affecting 3.5% of females and 2% of males.

Eating Disorders At Home - A Parent's Guide
An Invaluable Resource For Parents Of Sufferers Of 
Anorexia Or Bulimia, And Other Eating Disorders. Critical Information

I. Anorexia nervosa
Anorexia nervosa is a type of eating disorder usually develop in the teen years and effect over 90% of female, because of excessive food restriction and irrational fear to become fat due the wrongly influenced media as attractiveness is equated to thinness.

II. Symptoms and signs
A. Most common symptoms
1. Weight loss, sometime severe as a result of malnutrition.

2.  Refusal to maintain a normal or minimally above normal body mass index for their age and Dieting despite being thin or dangerously underweight
Dr. Evelyn Attia and B. Timothy Walsh, in the article of Anorexia Nervosa indicated that Anorexia nervosa is a serious mental illness characterized by the maintenance of an inappropriately low body weight, a relentless pursuit of thinness, and distorted cognition about body shape and weight(1).

3. Intense fear of gaining weight and primary or secondary amenorrhea
In the study Eating disorders. A review and update by Haller E. at the University of California indicated  Anorexia nervosa is diagnosed when a person refuses to maintain his or her body weight over a minimal normal weight for age and height, such as 15% below that expected, has an intense fear of gaining weight, has a disturbed body image, and, in women, has primary or secondary amenorrhea(2).

4. Obsession with calories and fat content of food and and try to avoid eating altogether. They deny hunger and will usually avoid eating around others as well as avoiding situations where food might be present(3).

5. Disturbance to body image the person hold of him/herself
In the study of  Eating disorders. A review and update, Dr E Haller indicated that , Anorexia nervosa is diagnosed when a person refuses to maintain his or her body weight over a minimal normal weight for age and height, such as 15% below that expected, has an intense fear of gaining weight, has a disturbed body image, and, in women, has primary or secondary amenorrhea(4).


8. Becomes intolerant to cold and frequently complains of being cold due to fat loss as a result of malnutrition(9)

9. Swelling cheek
Swelling cheek is considered Gradual onset of anorexia due to  enlargement of the salivary glands caused by excessive vomiting

10. Abdominal pain and distention
Anorexia nervosa is also associated abdominal and with  a sensation of elevated abdominal pressure and volume. There is a report of a 26-year-old female with anorexia nervosa binge/purge subtype, who presented with abdominal pain and nausea after a binge episode. Abdominal radiography and computed tomography showed a grossly dilated stomach measuring 32 cm × 17.9 cm consistent with acute gastric dilatation. She underwent exploratory laparotomy with gastrotomy and gastric decompression, and recovered uneventfully. Initially, the patient denied the binge episode, as many patients with eating disorders do, but later revealed an extensive history of anorexia nervosa binge/purge subtype. This case stresses the importance of obtaining a thorough history of eating disorders and maintaining a high index of suspicion for acute gastric dilatation in young women who present with abdominal pain and distention(5).

11. Bad breath
The associated of  bad breath and Anorexia nervosa are of the result of from vomiting or starvation-induced ketosis. In the study of Maintaining women's oral health, Dr. McCann AL and Dr. Bonci L. stated that adolescent women are more prone to gingivitis and aphthous ulcers when they begin their menstrual cycles and need advice about cessation of tobacco use, mouth protection during athletic activities, cleaning orthodontic appliances, developing good dietary habits, and avoiding eating disorders(6).

12. Swollen joints
There is a case of anorexia for the past 10 years have never experienced swollen joints, but now that too is becoming a problem and is explained as Electrolyte Imbalances(7)

13.  Lanugo hair

In the study of  Dr. Judith M. E. Walsh and the research team posted in the Journal of General Internal Medicine, indicated that detection requires awareness of risk factors for, and symptoms and signs of, anorexia nervosa (e.g., participation in activities valuing thinness, family history of an eating disorder, amenorrhea, lanugo hair)(8)

14. Etc.

B. Secondary symptoms
1. Leg pain, fatigue and general weakness
Anorexia nervosa is a disease with high prevalence in adolescents and carries the highest mortality of any psychiatric disorder, but there is a case of a 52-year old woman with longstanding anorexia nervosa was hospitalized due to progressive leg pain, weakness, and fatigue accompanied by marked weight loss. On physical examination she was cachectic but in no apparent distress. She had fine lanugo-type hair over her face and arms with an erythematous rash noted on her palms and left lower extremity.(9)

2. Depression and anxiety
Depression, anxiety and obsessive-compulsive disorder (OCD) frequently co-occur with Anorexia Nervosa (AN). In the review of all the studies done to investigate psychological factors in relation to malnutrition in AN using the keywords "Anorexia Nervosa", "depression", "anxiety", "obsessive-compulsive disorder" and "malnutrition". Only articles published between 1980 and 2010 in English or French were reviewed. From the articles on AN and depression, anxiety, and/or OCD, only the ones which investigated on the relation with malnutrition were kept(10).

3. Sleep disorder
Night eating is linked with a reduced consciousness and sleep disorders, mainly somnambulism. Patients never experience hunger, abdominal pain, nausea or hypoglycemia. Night-eating takes place invariant across weekdays, weekend and vacations. Patients consumed high caloric foods and fluids but never alcohol and purging does not occur. Diurnal bulimia is frequently associated with the sleep-related eating disorder(11)

5. Etc.

III. Cause and Risk factors
A. Causes
Some researchers suggested that The most commonly mentioned perceived causes were dysfunctional families, weight loss and dieting, and stressful experiences and perceived pressure(12). Others showed that Eating disorders (EDs) manifest as abnormal patterns of eating behavior and weight regulation driven by low self-esteem due to weight preoccupation and perceptions toward body weight and shape and Several lines of evidence indicate that brain-derived neurotrophic factor (BDNF) plays a critical role in regulating eating behaviors and cognitive impairments in the EDs(13).

B. Risk factors
1. Virtue of thin-ideal internalization, body dissatisfaction
Dr. Stice E, and the researchers team at the Oregon Research Institute, in the treatment of Anorexia nervosa showed that there is evidence that selective prevention programs that target young women at elevated risk for eating pathology by virtue of thin-ideal internalization, body dissatisfaction, and negative affect produce significant larger intervention effects than do universal programs offered to unselected populations(14)

2.  Gender
If you are girls and women, you are at higher risk to develop Anorexia nervosa, because of growing social pressures. In a community sample of young adults (n = 1,056) completed a questionnaire that contained the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorder Inventory, as well as probes for inappropriate compensatory behaviors, excessive exercise, and episodes of binge eating, showed that Women had substantially elevated scores on all of the factors except excessive exercise, for which men had significantly higher scores(15).

3. Gene mutation
Mutation of certain genes can cause increased risk of Anorexia nervosa, but certain gene change have been rule out such as , but some have been confirmed including Allele 13 of the marker D11S911 as it is significantly over represented in the anorexia nervosa population suggesting that a mutation in linkage disequilibrium with this locus may form part of the genetic component of AN. Further work is now required to try to reproduce these data in a second independent cohort and to further characterise this region of the human genome(15). Others found the linkage regions on chromosomes 1, 3, and 4 (anorexia nervosa) and 10p (bulimia nervosa)(16).

4. Family history
If you parent or siblings Anorexia nervosa, you are at increased risk to develop the disease. In the tduy to evaluate 420 first-degree relatives of 14 patients with anorexia nervosa, 55 patients with bulimia, and 20 patients with both disorders, Dr. Hudson JI, and the research team showed that the morbid risk for affective disorder in the families of the eating disorder probands was similar to that found in the families of patients with bipolar disorder; but was significantly greater than that found in the families of patients with schizophrenia or borderline personality disorder. These results add to the growing evidence that anorexia nervosa and bulimia are closely related to affective disorder(17).

5. Loss Weight intentionally
Dr. Müller MJ, and the team of scientists suggested that In regard to clinical practice, dietary approaches to both weight loss and weight gain have to be reconsidered. In underweight patients (e.g., patients with anorexia nervosa), weight gain is supported by biological mechanisms that may or may not be suppressed by hyperalimentation. To overcome weight loss-induced counter-regulation in the overweight, biological signals have to be taken into account. Computational modeling of weight changes based on metabolic flux and its regulation will provide future strategies for clinical nutrition(18).

6. Stress
People who are at stress and anxiety for what ever reason are at higher risk to anorexia nervosa. There is a case of report of athirty-five-year-old woman suffering from anorexia nervosa visited our hospital complaining of severe general weakness. She was diagnosed with stress-induced cardiomyopathy and mural thrombus using a transthoracic echocardiogram(19).

7. Occupations 
Certain occupation such as Athletes, actors and television personalities, dancers, and models are at higher risk of anorexia. In a detailed interview (the Eating Disorder Examination), models reported significantly more symptoms of eating disorders than controls, and a higher prevalence of partial syndromes of eating disorders was found in models than in controls. A body mass index below 18 was found for 34 models (54.5%) as compared with 14 controls (12.7%). Three models (5%) and no controls reported an earlier clinical diagnosis of anorexia nervosa. Further studies will be necessary to establish whether the slight excess of partial syndromes of eating disorders among fashion models was a consequence of the requirement in the profession to maintain a slim figure or if the fashion modeling profession is preferably chosen by girls already oriented towards symptoms of eating disorders, since the pressure to be thin imposed by this profession can be more easily accepted by people predisposed to eating disorders(20).

8. Etc. 

IV. Complications and consequences
A. Complications
Anorexia nervosa may cause severe complications in every major organ system in the body  as a result of malnutrition due to self-imposed starvation.
A.1. Dermatologic signs of anorexia nervosa
Some researchers suggested that Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN. These manifestations include xerosis, lanugo-like body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrheic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, generalized pruritus, acquired striae distensae, slower wound healing, prurigo pigmentosa, edema, linear erythema craquele, acral coldness, pellagra, scurvy, and acrodermatitis enteropathica(21). Other suggested that the most frequent skin manifestations were xerosis (58.3%), hair effluvium (50%), nail changes (45.8%), cheilitis (41.6%), acne (41.6%), gingivitis (33.3%), acrocyanosis (29%), diffuse hypertrichosis (25%), carotenoderma (20.8%), generalized pruritus (16.6%), hyperpigmentation (12.5%), striae distensae (12.5%), factitial dermatitis, seborrheic dermatitis (8.3%), poor wound healing, melasma and Russell's sign (4.1%). In the patients with the bulimic type of AN, hair effluvium, acne, gingivitis, nail changes and generalized pruritus were more frequent than in the patients with the restrictive type(22).

A.2. Possible medical complications of anorexia nervosa
In the study of Eating disorders. A review and update, Dr. Haller E. at the University of California, indicated that Patients with eating disorders are usually secretive and often come to the attention of physicians only at the insistence of others. Practitioners also should be alert for medical complications including hypothermia, edema, hypotension, bradycardia, infertility, and osteoporosis in patients with anorexia nervosa and fluid or electrolyte imbalance, hyperamylasemia, gastritis, esophagitis, gastric dilation, edema, dental erosion, swollen parotid glands, and gingivitis in patients with bulimia nervosa. Treatment involves combining individual, behavioral, group, and family therapy with, possibly, psychopharmaceuticals. Primary care professionals are frequently the first to evaluate these patients, and their encouragement and support may help patients accept treatment. The treatment proceeds most smoothly if the primary care physician and psychiatrist work collaboratively with clear and frequent communication(23).

B. Consequences
In anorexia nervosa because of malnutrition as a result of self starvation, it can cause abnormal function of the body of that can lead to serious medical consequences:
1. Cardiovascular diseases
In the stidy of 181 women: 140 women with anorexia nervosa (AN) [85 not receiving oral contraceptive pills (OCPs) (AN-E) and 55 receiving oral contraceptive pills (OCPs)(AN+E)] and 41 healthy controls [28 not receiving OCPs (HC-E) and 13 receiving OCPs (HC+E)]. Dr. Lawson EA, and the research team at Harvard Medical School, showed that although hsCRP levels are lower in AN than healthy controls, OCP use puts such women at a greater than 20% chance of having high-sensitivity C-reactive protein (hsCRP), in the high-Cardiovascular (CV)-risk (>3 mg/liter) category. The elevated mean IL-6 in women with AN and high-risk hsCRP levels suggests that increased systemic inflammation may underlie the hsCRP elevation in these patients. Although OCP use in AN was associated with slightly lower mean LDL and higher mean HDL, means were within the normal range, and few patients in any group had high-risk LDL or HDL levels. IGF-I levels appear to be important determinants of hsCRP in healthy young women(24).
Other researchers suggested that anorexia nervosa can slow heart rate and low blood pressure, because of badly underweight.

2. Osteoporosis
Badly underweight can increase the risk of  Osteoporosis, researchers at the  Uniwersytet Medyczny suggested that the consequences of low energy fractures are the main causes of death in women with AN. Hormonal disturbances (e.g. hypoestrogenism, increased levels of ghrelin and Y peptide, changes in leptin and endocannabinoid levels), as well as the mechanisms involved in bone resorption (RANK/RANKL/OPG system), are considered to be of great importance for anorectic bone quality(25).


3. Muscle dysfunction
Protein-energy malnutrition in anorexia nervosa is an under-recognised cause of muscle dysfunction and weakness. In the study to characterise the skeletal myopathy that occurs in patients with severe anorexia nervosa, muscle function and structure. All of the patients showed impaired muscle function on strength and exercise measurement(26).

4. Severe dehydration
In the study to investigate the medical history, dental examination, and saliva tests of 39 patients aged 14 to 42 years, having suffered from AN for periods of 1 to 20 years, showed dental caries, due to excessive carbohydrate consumption, in all subjects, often in a rampant form. In patients with a history of intense vomiting (27 cases) severe lingual-occlusal erosion (perimylolysis) was nearly always present. Buccal erosion, mainly due to high consumption of acid fruits and drinks to relieve thirst caused by dehydration, was more frequent in vomiting than in non-vomiting patients(27). 
5. Fainting, fatigue, and overall weakness
Fainting, fatigue, and overall weakness are expected as patients  body required to conserve energy as protect the body organs due to malnutrition.

6. Lanugo
Lanugo is the growth of fine, downy hair on the face and body of anorexics. It's a sign that the body's natural defenses are at work. Hypertrichosis refers to the amount or length of extra hair that is grown -- to the point of excessive.
At a certain point during the starvation process, some anorexics may start to notice some fine, white hair on their body. People may even call it "fur".
It's usually visible on the face first, but it can appear anywhere on the body, including the back. Extra thick hair is normally found on the legs.
In women and girls with anorexia, the hair tends appear in areas where there is typically very little hair growth, such as the face, chest and back areas(28).

7. Psychiatric health problems
In a register study based on based on socio-economic and health data was conducted for a national cohort of female residents in Sweden born between 1968 and 1977, including 748 in-patients with anorexia nervosa. At follow-up 9-14 years after hospital admission, 8.7% of patients with anorexia nervosa had persistent psychiatric health problems demanding hospital care and 21.4% were dependent on society for their main income; the stratified relative risks were 5.8 (95% CI 4.7-7.6) and 2.6 (2.3-3.0) respectively, compared with the general female population(29).

8.   Psychoactive substance use and suicide
Anorexia nervosa is a mental disorder with high mortality. Dr. Papadopoulos FC, and the research team at the University Hospital, Uppsala, showed that the overall SMR for anorexia nervosa was 6.2 (95% CI 5.5-7.0). Anorexia nervosa, psychoactive substance use and suicide had the highest SMR. The SMR was significantly increased for almost all natural and unnatural causes of death. The SMR 20 years or more after the first hospitalisation remained significantly high. Lower mortality was found during the last two decades. Younger age and longer hospital stay at first hospitalisation was associated with better outcome, and psychiatric and somatic comorbidity worsened the outcome(30).
9. Reproductive issues  
The physical and psychological demands of pregnancy and motherhood can represent an immense challenge for women already struggling with the medical and psychological stress of an eating disorder. This article summarizes key issues related to reproduction in women with anorexia nervosa, highlighting the importance of preconception counseling, adequate gestational weight gain, and sufficient pre- and post-natal nutrition. Postpartum issues including eating disorder symptom relapse, weight loss, breastfeeding, and risk of perinatal depression and anxiety(31)
 
I would like summarize this section with research from Dt. Miller KK at Massachusetts General Hospital and Harvard Medical School, Boston "Despite significant progress in the field, further research is needed to elucidate the mechanisms underlying the development of anorexia nervosa and its endocrine complications. Such investigations promise to yield important advances in the therapeutic approach to this disease as well as to the understanding of the regulation of endocrine function, skeletal biology, and appetite regulation" (32).


V. Diagnosis and tests
The criteria of Anorexia nervosa diagnosed if a person refuses to maintain his or her body weight over a minimal normal weight for age and height, such as 15% below that expected, has an intense fear of gaining weight, has a disturbed body image, and, in women, has primary or secondary amenorrhea(33).
After taking the complex physical exam, including detail of absence of period and the examination the symptoms of Anorexia nervosa, such as skin and nails for dryness, hair, etc. If your doctor suspect that you have develop norexia nervosa, he/she may order
1. Hematological and blood coagulation tests
In a study of Red cell and haemoglobin values in 44 women with a typical picutre of anorexia nervosa showed that 20.5% presented a picture of true anaemia. Blood iron was low, sometimes very low, with a mean value of 66 mg 0/0. Clotting parameters: PTT, TT, PT, circulating platelets and TEG were normal. This finding serves to explain the low incidence of haemorrhage and the ready haemostasis noted in this disease, in spite of the considerable food deficit(33).
Other blood tests may be required to check electrolytes and protein as well as functioning of the liver, kidney and thyroid.

2. Urinary steroids
Urinalysis is to measure the levels of dehydroepiandrosterone. The increased level of the stress marker allo-tetrahydrocorticosterone refers to the involvement of stress in these diseases(34).

3. Psychological evaluation
Psychological self-assessment questionnaires are given to test  your thoughts, feelings and eating habits.
Dr. Gordon DP, and the research team in the study of A comparison of the psychological evaluation of adolescents with anorexia nervosa and of adolescents with conduct disorders indicated that Cognitive and projective psychological tests were administered to ten inpatient adolescents with anorexia nervosa and ten inpatient adolescents with conduct disorders. All subjects were selected on the basis of race, sex and overall intelligence. Results indicate that there are high numbers of neuropsychological deficits in both groups, but that neuropsychological deficits are especially numerous in the anorexia group. The two groups showed striking similarities in terms of some psychological functions, but results indicate that some aspects of personality style in the two groups are significantly different. A significant finding was that there were far more suicidal indicators on the Rorschach records of the anorectic group as compared with those found on the records of the conduct disorder group(35).


4. X-rays
X- ray may be taken to check for broken bones, pneumonia. In some cases, dual energy X-ray absorptiometry may be necessary to test for the presented osteopenia and  osteoporosis(36)

5. Electrocardiograms 
Electrocardiograms is necessary to look for heart irregularities. Anorexia nervosa caused demonstrable abnormalities of mitral valve motion and reduced left ventricular mass and filling associated with systolic dysfunction.

6. Etc.
 
VI. Preventions
A. The Do's and Do not's list
A.1. Primary prevention 
Dt. Michael Sidiropoulos in the article of Anorexia Nervosa: The physiological consequences of starvation and the need for primary prevention efforts indicated that there are numerous actions that the physician, along with the family, allied health care workers and/or through a broader public health initiative can accomplish in this particular case that will have longstanding implications on the patient's future development and growth and will increase the likelihood of healthy outcomes through primary
prevention(37).
1. Minimizing social pressures
In the study to evaluation the Sociological factors in the development of eating disorders, Dr Nagel KL, andand Dr. Jones KH. at the University of Georgia indicated that professionals in the educational and physical and mental health care fields need to be aware of the influence of social pressures on teenagers' perceptions of body image and appearance. This article reviews the sociocultural, socioeconomic, and sex-related factors which contribute to the development of eating disorders. It is recommended that professionals help adolescents resist societal pressure to conform to unrealistic standards of appearance, and provide guidance on nutrition, realistic body ideals, and achievement of self-esteem, self-efficacy, interpersonal relations and coping skills(38).

2. Minimizing family issues
Dr. Yager J. in the study of the family issues in the pathogenesis of anorexia nervosa, suggested that factors residing in family systems have been implicated in the pathogenesis of anorexia nervosa. In this paper I critically review literature that bears on this issue: the transmission of anorexia nervosa in families; family stress patterns, personality and psychopathological characteristics of parents, parent-child interactions, and whole family systems. Much additional research is needed to accurately determine the precise nature of such factors and the extent to which they actually contribute to the appearance of this syndrome(39).

3. Reducing individual factors
In the study to examine which unique factors (genetic and environmental) increase the risk for developing anorexia nervosa by using a case-control design of discordant sister pairs, Dr. Karwautz A, and the research team at University of London, suggested that he sisters with anorexia nervosa differed from their healthy sisters in terms of personal vulnerability traits and exposure to high parental expectations and sexual abuse. Factors within the dieting risk domain did not differ. However, there was evidence of poor feeding in childhood. No difference in the distribution of genotypes or alleles of the DRD4, COMT, the 5HT2A and 5HT2C receptor genes was detected. These results are preliminary because our calculations indicate that there is insufficient power to detect the expected effect on risk with this sample size(40).

A.2. Secondary prevention
Secondary prevention focuses early detection and intervention as  early detection is often difficult as individuals with eating problems often attempt to conceal their behavior. People such as Parents, peers and siblings, teacher and family doctor are in good position to detect changing attitudes around food,weight, and shape for detecting eating disorder early for effective treatment(41)

B. Diet and nutritional supplements to prevent anorexia nervosa
The aim of the diet and nutritional supplements is to provide enough nutrients as for people with anorexia nervosa are more likely to have vitamin and mineral deficiencies which can lead to certain symptoms of the diseases.
1. Caffeine
Caffeine intake increased over time between ages 9 and 19 years across all groups and this trend was not moderated by diagnostic status. For anorexia nervosa, relative to the non-eating disorder group, the proportional intake of caffeine from soda increased significantly before onset to onset to after onset and ingestion of chocolate-containing foods decreased sharply over time(42).

2. Alcohol
While the rate of anorexia was not elevated in alcoholics after controlling for other disorders, bulimia did occur at a greater than expected rate. However, both eating disorders were relatively rare, and much of the association with alcoholism occurred in the context of additional preexisting or secondary psychiatric disorders(43).

3. Tobacco
Although malnutrition may be expected to reduce DNA methylation through its effects on one-carbon metabolism, our negative results are in line with several in vitro and clinical studies that did not show a direct relation between gene-specific DNA methylation and folate levels. In contrast, smoking has been repeatedly reported to alter DNA methylation of specific genes and should be controlled for in future epigenetic studies(44)
.
4.  Drink 6 - 8 glasses of filtered water daily as water can decrease the risk of dehydration.
Caffeine, water, and aspartame consumption can be variable in patients with AN and the consumption of these substances seems to be only modestly related to purging behavior(45).

5. Promote healthy diet for maximum nutrients absorption.
6. The important of nutritional supplements
Some researchers suggested that conservation mechanisms resulting from starvation and/or self-prescribed nutrient supplements can result in laboratory values that appear within normal limits. These artificially inflated values drop to dangerous levels in some patients once rehydration and refeeding begin. Electrolyte status must be closely monitored during this time to prevent complications. Other micronutrient deficiencies can be corrected with adequate dietary intake, but patients with eating disorders are unlikely to consume such an adequate diet immediately upon entering treatment, so they may benefit from supplementation. Depleted nutrient stores require longer supplementation than acute inadequacies in nutrient intake. This review compiles the findings reported to date regarding micronutrient deficiencies and supplementation for patients with anorexia and bulimia. Because of the widely varying eating practices from patient to patient and the current lack of data controlling for nutrient self-supplementation, nutrition assessment performed by a nutrition professional via food intake history may be more practical than laboratory tests and more accurate than current food intake for determining potential micronutrient deficiencies(46).
 a.. In the study of  20 female patients with anorexia nervosa (AN) and in 10 lean and 10 normal weight, healthy, female control subjects. Patients with AN had higher activities of L-gamma-glutamyl transferase (gamma-GT) and glutamate pyruvate transaminase (SGPT) and a higher concentration of prealbumin in serum and lower leucocyte and lymphocyte counts in blood. For the other routine clinical chemical parameters no significant differences between the groups were observed. AN patients had higher serum vitamin B12 and retinol levels. No significant differences were found for the status parameters of thiamin, vitamin B6, vitamin C, folate, vitamin E and vitamin D. Contradictory results were obtained for the riboflavin status: AN patients had a lower level of flavin adenine dinucleotide (FAD) in blood and a lower stimulation ratio of the glutathione reductase activity in erythrocytes (alpha-EGR). Patients with AN had higher serum ferritin concentration and lower total iron binding capacity (TIBC). However, haemoglobin (Hb), haematocrit (Ht) and iron saturation were not significantly different. No significant difference was found in the concentration of zinc in plasma. In spite of the poor intake of nutrients and energy, the results obtained did not indicate an inadequate status of vitamins, iron and zinc in patients with AN(47).

b.  Other study of trace metals, vitamins, and other biochemical parameters in 30 female patients hospitalized for anorexia nervosa, showed that Anorexia nervosa patients showed hypogeusia, with the bitter and sour taste most severely affected, however plasma zinc levels did not correlate with taste recognition scores. Patients showed hypercarotenemia (214 +/- 129 microgram/100 ml; P < 0.01) with normal plasma vitamin A and retinol-binding protein levels. Total iron binding capacity was depressed (261 +/- 62 microgram/100 ml; P < 0.001) in contrast to plasma iron, ceruloplasmin and folic acid, which were normal. In nine patients, who were retested before discharge, taste function improved; plasma zinc, copper, and total iron binding capacity levels increased whereas plasma carotene and cholesterol decreased to normal levels. It is concluded that the observed zinc, copper, and iron binding protein deficiencies, and hypogeusia, reflect the self-imposed nutritional restriction of anorexia nervosa patients. Zinc and other micronutrients released from catabolized tissue along with vitamin intake may mitigate against more severe deficiency states in anorexia nervosa(48).
A daily multivitamin is an essential, as it contain numbers of vitamins and trace minerals such as vitamins A, C, E, the B-vitamins,  magnesium, calcium, zinc, phosphorus, copper, and selenium which are essential for the body needed. Other supplement include Omega-3 fatty acids, Coenzyme Q10, 5-hydroxytryptophan (5-HTP), Creatine, Probiotic supplement, etc.

C. Antioxidants to prevent anorexia nervosa
An antioxidant is a chemical that  protect cells against damage caused by free radicals and chain reaction of free radicals by inhibiting the oxidation of other molecules
 1. In the study of the antioxidant status in female adolescents (N = 82) with anorexia nervosa, by the measurement of erythrocyte tocopherol concentration, and the determination of activities of the main antioxidant enzymes: superoxide dismutase, catalase, glutathione peroxidase, and glutathione reductase.
showed that tocopherol was significantly decreased in the anorexic patients compared to reference values (p < .02). In 21% of patients, tocopherol levels were below the reference interval. Superoxide dismutase activity was significantly decreased (p < .0001), while catalase activity was increased (p < .0001). The activity of the glutathione system enzymes did not show significant differences between patients and controls.The deficient concentration of erythrocyte tocopherol together with the altered antioxidant enzyme activities suggest a certain degree of oxidative damage in anorexia nervosa owing to both factors deficient micronutrient intake and oxidative stress(49).

2. Antioxidant vitamins in Anorexia Nervosa by V. MATZKIN¹, C. GEISSLER¹ and M. BELLO, indicated that antioxidant vitamins (tocopherol, retinol and carotene) protect against lipid peroxidation caused by free radicals and active oxygen species. Patients with Anorexia Nervosa (AN) are at a greater risk of oxidative damage due to undernutrition and stress (Moyano, et. al., 1999). There is contradictory evidence concerning concentrations of tocopherol (Mira et. al. 1987, Phillip et. al., 1998 and Moyano et. al., 1999), retinol (Robboy et. al., 1974, Lagan and Farrell, 1985 and Vaisman, et. al., 1992) and carotene (Van Binsbergen et. al., 1988, Rock et. al., 1996) in AN(50).

3. Etc.

VI. Treatments 
A. In conventional medicine perspective
A.1. Non medical therapy
1. Cognitive behavior therapy (CBT) 
In the examining psychological factors that influence the level of weight gain across the first 20 sessions of cognitive behavioral therapy (CBT) for anorexia nervosa, found that during CBT for anorexia nervosa, weight gain might be enhanced by addressing a range of aspects of axis 1 pathology (e.g., depression, hostility, and features of anxiety). However, the approach is likely to be less important at first than directly addressing eating pathology and overvalued ideas about eating, shape, and weight(51).

2. Psychodynamic therapy
In the reviews of the results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi-experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research(52).

3. Interpersonal therapy 
The goals of the therapy are to improve interpersonal functioning and thereby decrease symptomatology. Factors identified as important in the development of anorexia nervosa are readily conceptualized within the interpersonal psychotherapy problem areas of grief, interpersonal disputes, interpersonal deficits, and role transitions(53).

4. Family therapy 
In six randomised controlled trials investigating the use of family therapy in the treatment of adolescents with anorexia nervosa, and these all had small sample sizes. Some, but not all, of these trials suggest that family therapy may be advantageous over individual psychotherapy in terms of physical improvement (weight gain and resumption of menstruation) and reduction of cognitive distortions, particularly in younger patients(54).
A.2. Medication
The aim of medical intervention is to treat physical problems associated with anorexia, but rarely changes behavior. There are no medications specifically approved to treat anorexia, but medical conditions caused by anorexia can be treated with certain medication depending to the condition.

B. In herbal medicine perspective
Herbs can be used to strengthen and tone the body's systems.
1. Ashwagandha also known as Withania somnifera is a nightshape plant in the genus of Withania, belonging to the family Solanaceae, native to the dry parts of India, North Africa, Middle East, and the Mediterranean. It has been considered as Indian ginseng and used in Ayurvedic medicine over 3000 years to treat tumors and tubercular glands, carbuncles, memory loss and ulcers and considered as anti-stress, cognition-facilitating, anti-inflammatory and anti-aging herbal medicine. According to the article of "Steroidal lactones from Withania somnifera, an ancient plant for novel medicine" by Mirjalili MH, Moyano E, Bonfill M, Cusido RM, Palazón J.(55). Ashwagandha root may be used to treat the stress and antioxidants causes of anorexia nervosa(56)


2. Fenugreek 
Fenugreek may be used to treat free redical cause of anorexia nervosa, In the study of total phenolics and antioxidant activities of fenugreek, green tea, black tea, grape seed, ginger, rosemary, gotu kola, and ginkgo extracts found that The total phenolics of the plant extracts, determined by the Folin-Ciocalteu method, ranged from 24.8 to 92.5 mg of chlorogenic acid equivalent/g dry material. The antioxidant activities of methanolic extracts determined by conjugated diene measurement of methyl linoleate were 3.4-86.3%. The antioxidant activity of the extracts using chicken fat by an oxidative stability instrument (4.6-10.2 h of induction time), according to "Total phenolics and antioxidant activities of fenugreek, green tea, black tea, grape seed, ginger, rosemary, gotu kola, and ginkgo extracts, vitamin E, and tert-butylhydroquinone" by Rababah TM, Hettiarachchy NS, Horax R.(57)

3. Milk thistle  
In the observation of the active extract of milk thistle, silymarin, is a mixture of flavonolignans and its antioxidant effect found that Exposure to light significantly reduced sprout growth and significantly increased the polyphenol content and antioxidative capacity. The polyphenol content was 30% higher in seeds originating from purple inflorescences than in those from white ones. We thus found milk thistle to be a good candidate source of healthy edible sprouts, according to "The potential of milk thistle (Silybum marianum L.), an Israeli native, as a source of edible sprouts rich in antioxidants" by Vaknin Y, Hadas R, Schafferman D, Murkhovsky L, Bashan N.(58)

4. Catnip 
Catnip is to calm the nerves and soothe the digestive system. The alcohol extract of catnip has a biphasic effect on the behavior of young chicks. Low and moderate dose levels (25--1800 mg/kg) cause increasing numbers of chicks to sleep, while high dose levels (i.e. above 2 g/kg) cause a decreasing number of chicks to sleep, according to the study of `The effect of an ethanol extract of catnip (Nepeta cataria) on the behavior of the young chick`by Sherry CJ, Hunter PS.(59)

5. Etc.
C. In traditional Chinese medicine  
According to Perspectives on Eating Disorders and Traditional Chinese Medicine Norman Kraft, LST, DCH, MTOM, Dipl.Ac., L.Ac(60) 
1. Kidney deficiency 
a. Kidney deficiency (primarily of Yin and Essence) leads to Empty Fire (pathological Will) and poor control of the Heart’s Fire.
b. Chinese herbal formula: Liu Wei Di Huang Wan, ingredients include
b.1. Sheng Di Huang (Rhemannia) 15-20 gm
b.2. Shan Zhu Yu (Cornus) 12-15 gm
b.3. Shan Yao (Dioscorea) 10-15 gm
b.4. Ze Xie (Alisma) 9-12 gm
b.5. Mu Dan Pi (Moutan) 6-9 gm
b.6. Fu Ling/Fu Shen (Poria/Poria Spirit) 9-12 gm
Fu Shen is preferred over Fu Ling in this formula

2.   Kidney Yang Deficiency 
a. But One must be careful in using Yang tonics and warming herbs with bulimia in particular, for while the overall picture may be Yang Deficiency the constant abuse of the stomach tends to quickly lead to Stomach Yin Deficiency with Heat.
b. Chinese herbal formula: Jin Gui Shen Qi Wan, ingredients include
b.1. Fu Zi (Aconite) 6 gm
b.2. Rou Gui (Cinnamomum)  6 gm
b.3. Shu Di Huang (Rehmannia) 20-30 gm
b.4. Shan Zhu Yu (Cornus)  10-15 gm
b.4. Mu Dan Pi (Moutan) 10-12 gm
b.4. Fu Ling/Fu Shen (Poria/Poria Spirit) 10-15 gm
b.5. Shan Yao (Dioscorea) 10-15 gm
b.6. Ze Xie (Alisma) 10-15 gm

3. Fire/Heart deficiencies
a. Fire/Heart deficiencies than Water/Kidney issues,
b. Chinese Modification of Gui Pi Tang, ingredients
b.1. Ren Shen (Ginseng) 6-9gm
b.2. Huang Qi (Astragalus) 9-12gm
b.3. Bai Zhu (Atractylodes)  9-12gm
b.4. Dang Gui (Angelica) 6-9gm
b.5. Fu Shen (Poria) 6-9gm
b.6. Suan Zao Ren (Zizyphus) 9-12gm
b.7. Long Yan Rou (Euphoria) 9-12gm
b.8. Yuan Zhi (Polygala) 3-6gm
b.8. Mu Xiang (Saussurea) 3-6gm
b.9. Zhi Gan Cao (Glycyrrhiza)  3-6gm
b.10. Hong Zao (Jujuba) 3-5 pc
b.11. Bai Zi Ren (Biota) 6-9gm
b.12. He Huan Pi (Albizzia) 6-9gm
b.13. Shi Chang Pu (Acori) 6-9gm
b.14. Bai He (Lilii) 6-9gm

4. The author also notes that with care in formulation taking into account the cold temperature of the herb, Bai He could be added to the other two formulas above as well. In Liu Wei Di Huang Wan I usually combine Bai He with Zhi Mu (Anemarrhena) as these two herbs work very well together to calm Shen disturbed by interior Heat due to Deficiency of Yin.

Eating Disorders At Home - A Parent's Guide
An Invaluable Resource For Parents Of Sufferers Of 
Anorexia Or Bulimia, And Other Eating Disorders. Critical Information 

Sources
(1) http://ajp.psychiatryonline.org/article.aspx?articleID=99258
(2) http://www.ncbi.nlm.nih.gov/pubmed/1475950
(3) http://drsandie.com/Eating.html
(4) http://www.ncbi.nlm.nih.gov/pubmed/1475950
(5) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966577/
(6) http://www.ncbi.nlm.nih.gov/pubmed/11486666
(7) http://answers.yahoo.com/question/index?qid=20100712185150AAciPvv
(8) http://www.springerlink.com/content/f7m6m410h608g046/
(9) http://www.ncbi.nlm.nih.gov/pubmed/15257758
(10) http://www.ncbi.nlm.nih.gov/pubmed/20920829 
(11) http://www.ncbi.nlm.nih.gov/pubmed/11760692
(12) http://www.ncbi.nlm.nih.gov/pubmed/12616580
(13) http://www.ncbi.nlm.nih.gov/pubmed/22473707
(14) http://www.ncbi.nlm.nih.gov/pubmed/20074299
(15) http://www.ncbi.nlm.nih.gov/pubmed/12386907
(16) http://www.ncbi.nlm.nih.gov/pubmed/15287815
(17) http://www.ncbi.nlm.nih.gov/pubmed/6573224
(18) http://www.ncbi.nlm.nih.gov/pubmed/21173874
(19) http://www.ncbi.nlm.nih.gov/pubmed/22125562
(20) http://www.ncbi.nlm.nih.gov/pubmed/18355925
(21) http://www.ncbi.nlm.nih.gov/pubmed/15943493
(22) http://www.ncbi.nlm.nih.gov/pubmed/20808514
(23) http://www.ncbi.nlm.nih.gov/pubmed/1475950
(24) http://www.ncbi.nlm.nih.gov/pubmed/17519306
(25) http://www.ncbi.nlm.nih.gov/pubmed/22161979
(26) http://www.ncbi.nlm.nih.gov/pubmed/9650756
(27) http://www.ncbi.nlm.nih.gov/pubmed/14394
(28) http://www.anorexia-reflections.com/lanugo.html#axzz1wVB7hbqL
(29) http://www.ncbi.nlm.nih.gov/pubmed/17077433
(30) http://www.ncbi.nlm.nih.gov/pubmed/19118319
(31) http://www.ncbi.nlm.nih.gov/pubmed/22003362
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(33) http://www.ncbi.nlm.nih.gov/pubmed/869704
(34) http://www.ncbi.nlm.nih.gov/pubmed/15560936
(35) http://www.ncbi.nlm.nih.gov/pubmed/6501640
(36) http://www.ncbi.nlm.nih.gov/pubmed/22137016
(37) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC483668/
(38) http://www.medicine.mcgill.ca/MJM/issues/v09n01/case_rep/Anorexia%20Nervosa.pdf
(39) http://www.ncbi.nlm.nih.gov/pubmed/1539487
(40) http://www.ncbi.nlm.nih.gov/pubmed/11232918
(41) http://www.nedic.ca/knowthefacts/documents/Preventionofeatingdisorders.pdf 
(42) http://www.ncbi.nlm.nih.gov/pubmed/8540597
(43) http://www.ncbi.nlm.nih.gov/pubmed/19189405 
(44) http://www.ncbi.nlm.nih.gov/pubmed/22398003
(45) http://www.ncbi.nlm.nih.gov/pubmed/19189405
(46) http://www.ncbi.nlm.nih.gov/pubmed/20413694
(47) http://www.ncbi.nlm.nih.gov/pubmed/3074921
(48) http://www.ncbi.nlm.nih.gov/pubmed/7405882
(49) http://www.ncbi.nlm.nih.gov/pubmed/9924658
(50) http://www.fac.org.ar/fec/foros/cardtran/gral/antioxidant.htm
(51) http://www.ncbi.nlm.nih.gov/pubmed/22422613
(52) http://www.ncbi.nlm.nih.gov/pubmed/16096078
(53) http://www.ncbi.nlm.nih.gov/pubmed/10657886
(54) http://www.ncbi.nlm.nih.gov/pubmed/21894130
(55) http://www.ncbi.nlm.nih.gov/pubmed/19633611
(56) http://www.ncbi.nlm.nih.gov/pubmed/9582008
(57) http://www.ncbi.nlm.nih.gov/pubmed/15291494
(58) http://www.ncbi.nlm.nih.gov/pubmed/20709593
(59) http://www.ncbi.nlm.nih.gov/pubmed/421844 
(60) http://www.myacudoc.com/images/ED.article.pdf 


 
  
I. Bulimia nervosa
Bulimia nervosa is defined as a medical condition of  consuming a large amount of food in a short amount of time or one setting (binge eating), followed by self induced vomiting, taking a laxative or diuretic and/or excessive exercise, etc. to compensate for the binge. Bulimia nervosa also effects almost 90% of female. Unlike anorexia nervosa, people suffering from bulimia nervosa are usually normal or slightly over weight.

II. Symptoms and Signs
A. Symptoms
A.1. Binge Eating Symptoms
1. Eating and impulsive behavioral symptoms
In the study of the implications of impulsivity in its relationship with binge-eating or purging behaviors, with all participants (n=180) asked to complete a series of self-reported inventories of impulsive behaviors and other psychological measures. Dr. Tseng MC and  Hu FC. at National Taiwan University Hospital and National Taiwan University College of Medicine showed that three latent classes of bulimic women were identified. These were women who exhibited relatively higher rates of purging, symptoms of impulsive behavior, and multiple purging methods (17.8%), women who used no more than one purging method with a low occurrence of impulsive behavior (41.7%), and women who showed higher rates of purging behaviors and the use of multiple purging methods with a low rate of impulsive behavior (41.7%). The impulsive sub-group had comparable severity of eating-related measures, frequency of binge-eating, and higher levels of general psychopathology than that of the other two sub-groups(1).

2. Greater fat consumption
In the study to investigate the association of fruit, vegetable, and fat consumption to binge eating symptoms in African American (AA) and Hispanic or Latina (HL) women. AA and HL women in the Health Is Power (HIP) study (N=283) reported fruit and vegetable intake, fat intake, and binge eating symptoms. Women were middle aged (M=45.8 years, SD=9.2) and obese (M BMI=34.5 kg/m(2), SD=7.5). Greater fat consumption was correlated with lower fruit and vegetable consumption (r(s)=-0.159, p<0.01). Higher BMI (r(s)=0.209, p<0.01), and greater fat consumption (r(s)=0.227, p<0.05) were correlated with increased binge eating symptoms. Multiple regression analysis demonstrated that for HL women (β=0.130, p=0.024), higher BMI (β=0.148, p=0.012), and greater fat consumption (β=0.196, p=0.001) were associated with increased binge eating symptoms (R(2)=0.086, F(3,278)=8.715, p<0.001). Findings suggest there may be a relationship between fat consumption and binge eating symptoms, warranting further study to determine whether improving dietary habits may serve as a treatment for BED in AA and HL women(2).

3.  Depression and/ or anxiety and eating preocuoation
Binge eating is often triggered by stress, depression, or other negative emotions. Compared with the normal-eater group, the BS(either BN or normal weight Eating Disorder NOS with regular binge eating or purging) women demonstrated significantly less dexamethasone suppression test (DST) suppression. Among BS women, DST non-suppression was associated with more severe depression, anxiety and eating preoccupations. BS women to show less DST suppression compared to normal eater women, and results link extent of non-suppression, in BS individuals, to severity of depression, anxiety and eating preoccupations(3).

4. Other symptoms include
In the study of among the 3,714 women and 1,808 men who responded, men were more likely to report overeating, whereas women were more likely to endorse loss of control while eating. Although statistically significant gender differences were observed, with women significantly more likely than men to report body checking and avoidance, binge eating, fasting, and vomiting, effect sizes ("Number Needed to Treat") were small to moderate(4). Other studies indicated that increasing evidence shows that the combination of ubiquitous ads for foods and emphasis on female beauty and thinness in both advertising and programming leads to confusion and dissatisfaction for many young people and have revealed a link between media exposure and the likelihood of having symptoms of disordered eating or a frank eating disorder(5).

5. Etc.

A.2. Purging Symptoms
Women who develop the Bulimia vervosa may consider purging as a method of regaining control of themselves after binge eating of that can lead to
1. Damage to teeth and gum as a result of self induced vomitting causes of acid exposure
2. Dehydration due to self induced vomiting
3. Fatigue due to nutrients deficiency
4. Irregular heart beat as a result of dehydration cause of low levels of potassium due to self induced vomiting.
5. Colon damage as a result of laxative abuse
6. Gastrointestinal symptoms
In bulimic patients, the most commonly reported gastrointestinal symptoms were bloating (74.4%), flatulence (74.4%), constipation (62.8%), decreased appetite (51.2%), abdominal pain (48.8%), borborygmi (48.8%), and nausea (46.5%). The average symptom score (sum of severity ratings) on the gastrointestinal symptoms questionnaire decreased from 20.6 +/- 10.8 (mean +/- SD) on admission to 13.46 +/- 10.5 (t(27) = 3.31, p < 0.01) on discharge but remained significantly higher than that of the control group (4.4 +/- 6.2, t(43) = 4.02, p < 0.001). However, the severity of reported gastrointestinal symptoms was correlated with the severity of depression (r = 0.43, p < 0.05), and when the possible mediating effects of depression on gastrointestinal symptoms were controlled statistically (analysis of covariance), the effects of treatment on gastrointestinal symptoms were not statistically significant. Dr. Chami TN, and the research team at Florida Medical Clinic indicated(6).

A.3. Psychological  symptoms 
In the review of symptoms of Bulimia vervosa, most of reviews have focused on reductions of binge eating and purging; however, the cognitive model of BN that underlies the CBT approach identifies three additional symptoms as central to the disorder: restrictive eating, concerns with shape and weight, and self-esteem(7).
Other suggested that Binge eating is often triggered by stress, depression, or other negative emotions. Compared with the normal-eater group, the BS(either BN or normal weight Eating Disorder NOS with regular binge eating or purging) women demonstrated significantly less dexamethasone suppression test (DST) suppression. Among BS women, DST non-suppression was associated with more severe depression, anxiety and eating preoccupations. BS women to show less DST suppression compared to normal eater women, and results link extent of non-suppression, in BS individuals, to severity of depression, anxiety and eating preoccupations(8).



A.4. Non Purging technique
Although many bulimics use purging technique, others may engage in excessive exercise and fasting  to prevent weight gain.

B. Signs
People with Bulimia vervosa are very good in hiding the health problems and related symptoms, but some possible signs of a person may have bulimia vervosa include:
1. Eats in isolation
2. Frequent sore throats from vomiting
4. Gastrointestinal symptoms
5. Feelings of withdrawal
6. Frequently spending time alone and wanting privacy
7. Obsession with food, dieting and exercise
9. Mood swings and irritability
10. Perfectionism
11. Etc.

III. Causes and risk factors
A. Causes
The causes of bulimia vervosa is unknown but in  the study to examine the beliefs of women concerning causes and risk factors for eating-disordered behaviour, showed that having low self-esteem' was considered very likely to be a cause of BN by 75.0% of respondents, and the most likely cause by 40.5% of respondents. Other factors perceived as significant were 'problems from childhood', 'portrayal of women in the media', 'being overweight as a child or adolescent' and 'day-to-day problems', while genetic factors and pre-existing psychological problems were perceived to be of minor significance. Most respondents believed that women aged under 25 years were at greatest risk of having or developing BN(9).

B. Risk factors
1. Gender
It you are female, you are at 90% higher risk to develop bulimia nervosa.
2. Age 
In both anorexia nervosa and bulimia nervosa, age at onset showed a significant decrease according to year of birth(10)
3.  Social pressure
The fear of become fat due to wrongly influent in the western society where attractiveness is equal to thinness
4. Family history
If one the member of your direct family has bulimia nervosa, you are at increased risk to have that disease as well.
5. Migraine
Dr. D'Andrea G, and the research team at the Biochemistry Laboratory for the Study of Primary Headaches and Neurological Diseases, Research and Innovation S.p.A suggest that migraine may constitute a risk factor for the occurrence of ED in young females. This hypothesis is supported by the onset of migraine attacks that initiated, in the majority of the patients, before the occurrence of ED symptoms, in the study of Is migraine a risk factor for the occurrence of eating disorders? Prevalence and biochemical evidences(11).

6. Obstetric complications
Researchers found that several complications, such as maternal anemia (P = .03), diabetes mellitus (P = .04), preeclampsia (P = .02), placental infarction (P = .001), neonatal cardiac problems (P = .007), and hyporeactivity (P = .03), were significant independent predictors of the development of anorexia nervosa. The risk of developing anorexia nervosa increased with the total number of obstetric complications, the obstetric complications significantly associated with bulimia nervosa were the following: placental infarction (P = .10), neonatal hyporeactivity (P = .005), early eating difficulties (P = .02), and a low birth weight for gestational age (P = .009). Being shorter for gestational age significantly differentiated subjects with bulimia nervosa from both those with anorexia nervosa (P = .04) and control subjects (P = .05)(12).

7. DRD4 gene
Although there is no evidence of the direct association between DRD4 gene and bulimia nervosa, researchers suggested that its variants are associated with a history of childhood ADHD in BN probands. This may have relevance for the understanding, prevention, and treatment of BN that evolves in the context of childhood ADHD(12a).

8. Other risk factors includes
Low self-esteem', 'problems from childhood', 'portrayal of women in the media', 'being overweight as a child or adolescent' and 'day-to-day problems', while genetic factors and pre-existing psychological problems(13) 

9. Etc.

IV. Effects of bulimia nervosa (BN)
A. Psychological effects
1. Mood disorders and suicidality
Onset of bulimia nervosa (BN) typically occurs in adolescence and is frequently accompanied by medical and psychiatric sequelae that may have detrimental effects on adolescent development. Potentially serious medical consequences and high comorbid rates of mood disorders and suicidality underscore the need for early recognition and effective treatments(14)

2. Substance abuse
In the study to examine the significance of a past history of substance abuse on treatment outcome for bulimia nervosa, showed that Although patients with a history of substance abuse reported higher levels of anxiety and depression at presentation for treatment than patients without such histories, the two groups reported a similar age of onset of their bulimia nervosa and similar severity of eating pathology with regards to binge and vomit frequencies and measures of concern about body shape and weight. On all outcome measures, the improvement of the substance abuse group was equal to or greater than that in the group without a history of substance abuse(15).

3. Etc.

A.2. Physical consquences
1. Acute gastric dilation
There are a report of a  case of a young woman with bulimia nervosa who developed acute gastric dilation that was diagnosed by computerized tomography. The patient had no history of factors associated with delayed gastric emptying. The treatment course is reviewed, as is the pathophysiology of acute gastric dilation(16).


2. Electrolyte imbalances
Dr. Olson AF., in the study of Outpatient management of electrolyte imbalances associated with anorexia nervosa and bulimia nervosa, said "Bulimia nervosa and anorexia nervosa are eating disorders with significant morbidity that often go undetected. Nurses and primary care providers are encouraged to recognize the early signs and symptoms of these disorders and to intervene appropriately. Several case reports in this article describe patients with these disorders and various related electrolyte abnormalities. Understanding electrolyte imbalances associated with both disorders may lead to earlier effective intervention and overall improved health outcomes"(17).

2. Arrhythmias
In the examination of signal-averaged electrocardiography (SAECG). on 48 female ED patients [21 with anorexia nervosa (AN) and 27 with bulimia nervosa (BN)] and on 20 healthy women. An LP was judged positive if two or more of the following criteria were fulfilled: QRS duration >120 ms, root-mean-square voltage <20 microV, and a high-frequency, low-amplitude duration >38 ms. that indicated BN patients with a history of AN had significantly more SAECG abnormalities(18).


3. Oesophageal and gastric motor activity
In the study of esophageal and gastric motor activity in patients with bulimia nervosa, found that (i) bulimic behaviour can obscure symptoms of oesophageal motor disorders and (ii) gastric emptying is frequently delayed in bulimia nervosa(19).

4.  Pancreatitis
There is a report of a 19-year-old woman with bulimia nervosa who died of acute hemorrhagic pancreatitis. The symptoms of both conditions are very similar, the pre-existence of an eating disorder should not distract physicians from the possibility that potentially lethal acute pancreatitis may coexist(20).

5. Absence of period
Some researchers suggested that amenorrhea is one of diagnostic criteria of bulimia nervosa(21)

6. Visceral fat and increased adrenal gland volumes (AGV)
BN patients had significantly more visceral adipose tissue (VAT) (HC, 1589.3 +/- 967.6 ml versus 927.2 +/- 428.4 ml, p < .05) and an increased relative AGV (0.068% of body volume versus 0.048% of body volume, p < .05) compared with HC, although waist circumference and BMI did not differ. Although the VAT part in the upper abdomen was increased, especially the VAT of lower abdomen along with the pelvis or any subcutaneous fat compartment was not increased(22).

7. Sleep disturbance
Sleep disturbances are highly associated with anorexia nervosa (AN), buLimia nervosa (BN) and non-specified eating disorders (ED-NOS)(23)

8. Other physical effects 
Dt, Mitchell JE and Crow S. at the University of North Dakota School of Medicine and the Neuropsychiatric Research Institute, in the study of Medical complications of anorexia nervosa and bulimia nervosa, showed that the frequently cited risk of premature death in those with anorexia nervosa. A plethora of dermatologic changes have been described, some signaling serious underlying pathophysiology, such as purpura, which indicates a bleeding diathesis. Much of the literature continues to delineate the fact that diabetic patients with eating disorders are at high risk of developing diabetic complications. Gastrointestinal complications can be serious, including gastric dilatation and severe liver dysfunction. Acrocyanosis is common, and patients with anorexia nervosa are at risk of various arrhythmias. Low-weight patients are at high risk for osteopenia/osteoporosis. Nutritional abnormalities are also common, including sodium depletion and hypovolemia, hypophosphatemia and hypomagnesemia. Resting energy expenditure, although very low in low-weight patients, increases dramatically early in refeeding(24).

V. Diagnosis and tests
Diagnosis of bulimia nervosa is difficult, as people with Bulimia vervosa are very good in hiding the health problems and related symptoms, but certain signs of a person can be helpful.
A. Criteria
Based on the results of the clinical follow-up study of 41 female patients, diagnostic criteria of bulimia nervosa that should be used in clinical studies are suggested as follows:
(1) presence of anorexia nervosa or transitory amenorrhea in the premorbid period;
(2) eating attacks with losing of the control over food consumption not less than twice a week during 3 months;
(3) compensatory behavior in the form of spontaneous vomiting, abuse of purgative and diuretic medications etc;
(4) fear of obesity;
(5) cycloid affective changes with higher impulsivity, reduction of the control over primitive drives and/or expressed anxiety disorders; inclination to alcohol and drug abuse and nicotine dependence;
(6) changes of the body mass index;
(7) absence of amenorrhea. The disease dynamics is characterized by formation of the pathological cycle "diet--overeating--compensatory behavior" on the background of cyclothymic affective disorders. Two types of bulimia nervosa--with and without other drive disorders--have been singled out(25).

Others suggested that A diagnosis of bulimia nervosa is made when a person has recurrent episodes of binge eating, a feeling of lack of control over behavior during binges, regular use of self-induced vomiting, laxatives, diuretics, strict dieting, or vigorous exercise to prevent weight gain, a minimum of 2 binge episodes a week for at least 3 months, and persistent overconcern with body shape and weight. Patients with eating disorders are usually secretive and often come to the attention of physicians only at the insistence of others(25a).

B. Blood, urine tests and X ray
After taking the complex physical exam, including detail of absence of period and the examination the symptoms of Bulimia nervosa, Blood and urine tests may be ordered
a. Blood tests 
The aim of the Blood tests are to check for signs of malnutrition, including levels of  potassium levels and electrolyte imbalances.
b. Urine steriods
 The increased level of the stress marker allo-tetrahydrocorticosterone refers to the involvement of stress in these diseases, but the relevance of hormone alteration to the pathophysiology of eating disorders remains to be elucidated(26)
c. X ray
The aim of the X ray to check for broken bones, pneumonia. In some cases, dual energy X-ray absorptiometry may be necessary to test for the presented osteopenia and osteoporosis(27) 
 d. Etc. 

VI. Preventions
There is no sure way to prevent bulimia nervosa, but the following may be helpful
A. The Do's and Do not's list
A.1. Primary prevention
1. Increasing self-esteem and and less concern with body shape and weight
Increasing self-esteem and less concern with body shape and weight are associated to the reduce risk of bulimia nervosa, Dr.Meijboom A, and the research team at the Universiteit Maastricht, showed that Apparently, the automatic, nonconscious processing of body shape and weight words was influenced in high restrained eaters with a low state self-esteem, whereas the strategic, conscious processing was not. As soon as the body shape and weight stimuli were processed consciously, the initial increased accessibility was countered and the effect disappeared(28).

2. Improving media awareness
Louise Armstrong in the article of From Awareness to Prevention - Developing Solutions Through Media Literacy suggested the prevention and awareness of eating disorder, include
a. Consciousness-raising - promoting discussion and increasing awareness of the issues
b. Competence - cultivating the skills necessary to address the issues
c. Connection - understanding the world and the roles these issues play in it 

d. Change - creating(29)

3. Strengthening the family
 Dr. Cybele Ribeiro Espíndola and Dr.  Sérgio Luís Blay, in the study of Family perception of anorexia and bulimia: a systematic review said "Besides parents, family members showed similar views about the disease affecting another member of the family. Care provided to patients should include the opportunity of examining and consulting family members at diagnosis and interventions. These interventions can meet demands for clarifications and general information about patient care (advice of psychoeducational nature is recommended) and situations involving pathological functioning of patients and their family (complex interventions for restructuring of personality and family dynamics are recommended). Support networks with staff trained to diagnose and provide interventions should be strongly considered and low-cost procedures may have positive effects on patient management such as meeting with families experiencing similar situations or self-help networks"(30).

4. Etc..


A.2. Secondary prevention
Secondary prevention focuses early detection and intervention as  early detection is often difficult as individuals with eating problems often attempt to conceal their behavior. People such as Parents, peers and siblings, teacher and family doctor are in good position to detect changing attitudes around food,weight, and shape for detecting eating disorder early for effective treatment(31)

B.  Diet and nutritional supplements to prevent bulimia nervosa 
The aim of the diet and nutritional supplements is to provide enough nutrients as for people with bulimia nervosa a are more likely to have vitamin and mineral deficiencies which can lead to certain symptoms of the diseases. Dr. Siega-Riz AM and the research team at the University of North Carolina at Chapel Hill, suggested that Women with binge-eating disorder before and during pregnancy had higher intakes of total energy, total fat, monounsaturated fat, and saturated fat, and lower intakes of folate, potassium, and vitamin C than the referent (P < 0.02). Women with incident binge-eating disorder during pregnancy had higher intakes of total energy and saturated fat than the referent (P = 0.01). Several differences emerged in food group consumption between women with and without eating disorders, including intakes of artificial sweeteners, sweets, juice, fruit, and fats(31a).
1. Caffeine
Caffeine intake increased over time between ages 9 and 19 years across all groups and this trend was not moderated by diagnostic status. For anorexia nervosa, relative to the non-eating disorder group, the proportional intake of caffeine from soda increased significantly before onset to onset to after onset and ingestion of chocolate-containing foods decreased sharply over time(32).

2. Alcohol
While the rate of anorexia was not elevated in alcoholics after controlling for other disorders, bulimia did occur at a greater than expected rate. However, both eating disorders were relatively rare, and much of the association with alcoholism occurred in the context of additional preexisting or secondary psychiatric disorders(33).

3. Tobacco
Although malnutrition may be expected to reduce DNA methylation through its effects on one-carbon metabolism, our negative results are in line with several in vitro and clinical studies that did not show a direct relation between gene-specific DNA methylation and folate levels. In contrast, smoking has been repeatedly reported to alter DNA methylation of specific genes and should be controlled for in future epigenetic studies(34)
.
4.  Drink 6 - 8 glasses of filtered water daily as water can decrease the risk of dehydration.
Caffeine, water, and aspartame consumption can be variable in patients with AN and the consumption of these substances seems to be only modestly related to purging behavior(35).

5. Promote healthy diet for maximum nutrients absorption.
6. The important of nutritional supplements
Some researchers suggested that conservation mechanisms resulting from starvation and/or self-prescribed nutrient supplements can result in laboratory values that appear within normal limits. These artificially inflated values drop to dangerous levels in some patients once rehydration and refeeding begin. Electrolyte status must be closely monitored during this time to prevent complications. Other micronutrient deficiencies can be corrected with adequate dietary intake, but patients with eating disorders are unlikely to consume such an adequate diet immediately upon entering treatment, so they may benefit from supplementation. Depleted nutrient stores require longer supplementation than acute inadequacies in nutrient intake. This review compiles the findings reported to date regarding micronutrient deficiencies and supplementation for patients with anorexia and bulimia. Because of the widely varying eating practices from patient to patient and the current lack of data controlling for nutrient self-supplementation, nutrition assessment performed by a nutrition professional via food intake history may be more practical than laboratory tests and more accurate than current food intake for determining potential micronutrient deficiencies(36).

7. Etc.

C. Antioxidant to prevent bulimia nervosa 
Please read Antioxidant to prevent anorexia nervosa

 
VII. Treatments
A. In Conventional Medicine Perspective 
A.1. Non medication Therapies
1. Group therapy
In the study to evaluate the Guided self-help versus cognitive-behavioral group therapy in the treatment of bulimia nervosa, showed that A mixed-effects linear regression analysis indicated that subjects in both treatment conditions showed a significant decrease over time in binge eating and vomiting frequencies, in the scores of the EDI subscales, and in the BDI. Both treatment modalities led to a sustained improvement at follow-up. A separate analysis of the completer sample showed significantly higher remission rates in the self-help condition (74%) compared with the CBT condition (44%) at follow-up(45).
.
2. Cognitive behavioral guided self-help
In the study of 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data, showed that Cognitive behavioral guided self-help is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa(46).

3. Psychoeducational therapy
In the assessment of 241 seeking-treatment females with bulimia nervosa completed an exhaustive assessment and were referred to a six-session psychoeducational group, Regression analyses of treatment response were performed. Childhood obesity, lower frequency of eating symptomatology, lower body mass index, older age, and lower family's and patient's concern about the disorder were predictors of poor abstinence. Suicidal ideation, alcohol abuse, higher maximum BMI, higher novelty seeking and lower baseline purging frequency predicted dropouts. Predictors of early symptom changes and dropouts were similar to those identified in longer CBT interventions(47).

4. Psychodynamic therapy
In the examined 14 bulimic clients' experiences of individual psychodynamic psychotherapy through semistructured interviews, which were analyzed using qualitative methods. The results showed that the psychodynamic approach was a challenge to most of the clients. Yet, most clients profited from therapy both symptomatically and with regard to interpersonal relations and affect regulation. There were, however, marked differences in the clients' experiences. One subgroup rather quickly felt that the therapy met their needs, another initially felt challenged by the approach and the therapeutic attitude but ultimately succeeded in using this particular kind of therapy. A third group remained predominantly critical of their therapies. The clinical implications and possible explanations of the results are discussed(48).


5. Relational theory
In the article to explain how the psychology of women can inform group treatment by translating relational theory (RT) into practice within a short-term outpatient bulimia group. First, the article provides a brief overview of a relational understanding of women's psychological development, the etiology and maintenance of bulimia nervosa, and group psychotherapy. Then, clinical vignettes illustrate the application of RT in practice through discussion of four main healing factors at work in the different stages of the group. Through promoting validation, self-empathy, mutuality, and empowerment, the leader helps group members identify and change relational patterns that have kept them connected with food and disconnected from themselves and others. The goal of treatment is to help members move toward mutually empathic and empowering relationships inside and outside the group(49).

6. Cognitive-Behavioral therapy(CBT)
In the study to examine the potential efficacy of CBT for eating disorder individuals with bulimic symptoms who do not meet full criteria for bulimia nervosa. Twelve participants with subthreshold bulimia nervosa were treated in a case series with 20 sessions of CBT. Ten of the 12 participants (83.3%) completed treatment. Intent-to-treat abstinent percentages were 75.0% for objectively large episodes of binge eating (OBEs), 33.3% for subjectively large episodes of binge eating (SBEs), and 50% for purging at end of treatment. At one year follow-up, 66.7% were abstinent for OBEs, 41.7% for SBEs, and 50.0% for purging(50).


7.  Etc.
 
A.2. Medical treatments
Fluoxetine (Prozac), a type of selective serotonin reuptake inhibitor (SSRI, the only antidepressant approved by the Food and Drug Administration may help to ease the symptoms of bulimia.

B. In herbal medicine perspective
Herbs can be used to strengthen and tone the body's systems
 1. Ashwagandha also known as Withania somnifera is a nightshape plant in the genus of Withania, belonging to the family Solanaceae, native to the dry parts of India, North Africa, Middle East, and the Mediterranean. It has been considered as Indian ginseng and used in Ayurvedic medicine over 3000 years to treat tumors and tubercular glands, carbuncles, memory loss and ulcers and considered as anti-stress, cognition-facilitating, anti-inflammatory and anti-aging herbal medicine. According to the article of "Steroidal lactones from Withania somnifera, an ancient plant for novel medicine" by Mirjalili MH, Moyano E, Bonfill M, Cusido RM, Palazón J.(37). Ashwagandha root may be used to treat the stress and antioxidants causes of anorexia nervosa(38)

2. Milk thistle  
In the observation of the active extract of milk thistle, silymarin, is a mixture of flavonolignans and its antioxidant effect found that Exposure to light significantly reduced sprout growth and significantly increased the polyphenol content and antioxidative capacity. The polyphenol content was 30% higher in seeds originating from purple inflorescences than in those from white ones. We thus found milk thistle to be a good candidate source of healthy edible sprouts, according to "The potential of milk thistle (Silybum marianum L.), an Israeli native, as a source of edible sprouts rich in antioxidants" by Vaknin Y, Hadas R, Schafferman D, Murkhovsky L, Bashan N.(39)

3. Catnip 
Catnip is to calm the nerves and soothe the digestive system. The alcohol extract of catnip has a biphasic effect on the behavior of young chicks. Low and moderate dose levels (25--1800 mg/kg) cause increasing numbers of chicks to sleep, while high dose levels (i.e. above 2 g/kg) cause a decreasing number of chicks to sleep, according to the study of `The effect of an ethanol extract of catnip (Nepeta cataria) on the behavior of the young chick`by Sherry CJ, Hunter PS.(40)

4. Grape Seed Extract is the commercial extracts from whole grape seeds that contains many concentrations, including vitamin E, flavonoids, linoleic acid, oligomeric proanthocyanidins(OPCs), etc..The herb has been used in traditional medicine as antioxidant, anti-inflammatory agents and to treat skin wounds with less scarring, allergies, macular degeneration, arthritis, enhance circulation of blood vessels, lower cholesterol, etc.
a. Ulcer
in the comparison of effects of Grape Seed Extract (GSE) and vitamins C and E on aspirin- and ethanol-induced gastric ulcer and associated increases of lipid peroxidation in rats, found that GSE protected against ethanol-induced gastric ulcers more effectively than VC or VE, while its protection against aspirin ulcers was comparable for all treatments. GSE produced the greatest reductions of gastric MDA in both models, according to" Effects of grape seed extract, vitamin C, and vitamin e on ethanol- and aspirin-induced ulcers" by Cuevas VM, Calzado YR, Guerra YP, Yera AO, Despaigne SJ, Ferreiro RM, Quintana DC.(41)

b. Antioxidant Activity
in the assessment of phenolic content, antioxidant activity of White and red wines spiked with green tea extract and grape seed extract found that the green tea extract and grape seed extract increased antioxidant activity dose-dependently and the CRTs varied considerably between the Korean and Australian groups, with Koreans preferring wines spiked with green tea extract and Australians showing a preference for wines spiked with grape seed extract, according to "Total Phenolic Content, Antioxidant Activity and Cross-Cultural Consumer Rejection Threshold in White and Red Wines Functionally Enhanced with Catechin-Rich" by Yoo YJ, Saliba A, Prenzler PD, Ryan DM.(42)

5. Lavender is a flower plant of the genus Lavandula, belonging to the family Lamiaceae, native to Asia. The herb has been used in traditional medicine to treat painful bruises and aches, to relieve various neuralgic pains, sprains, rheumatism, etc.
a. 'Subsyndromal' anxiety disorder
In the investigation of orally administered Lavandula oil preparation and its effect on'subsyndromal' anxiety disorder, found that Lavandula oil preparation had a significant beneficial influence on quality and duration of sleep and improved general mental and physical health without causing any unwanted sedative or other drug specific effects. Lavandula oil preparation silexan is both efficacious and safe for the relief of anxiety disorder not otherwise specified. It has a clinically meaningful anxiolytic effect and alleviates anxiety related disturbed sleep, according to "Silexan, an orally administered Lavandula oil preparation, is effective in the treatment of 'subsyndromal' anxiety disorder: a randomized, double-blind, placebo controlled trial"by Kasper S, Gastpar M, Müller WE, Volz HP,
Möller HJ, Dienel A, Schläfke S.(43)
b.  Antidepressant-like effect
In the classification of the antidepressant effects of essential oils of Anthemis nobilis (chamomile), Salvia sclarea (clary sage; clary), Rosmarinus officinalis (rosemary), and Lavandula angustifolia (lavender)found that clary oil could be developed as a therapeutic agent for patients with depression and that the antidepressant-like effect of clary oil is closely associated with modulation of the DAnergic pathway, according to "Antidepressant-like effect of Salvia sclarea is explained by modulation of dopamine activities in rats" by Seol GH, Shim HS, Kim PJ, Moon HK, Lee KH, Shim I, Suh SH, Min SS.(44)
6. Etc.

C. In Traditional Chinese medicine perspective
According to Perspectives on Eating Disorders (bulimia nervosa and anorexia nervosa) and Traditional Chinese Medicine Norman Kraft, LST, DCH, MTOM, Dipl.Ac., L.Ac(51) 
1. Kidney deficiency 
a. Kidney deficiency (primarily of Yin and Essence) leads to Empty Fire (pathological Will) and poor control of the Heart’s Fire.
b. Chinese herbal formula: Liu Wei Di Huang Wan, ingredients include
b.1. Sheng Di Huang (Rhemannia) 15-20 gm
b.2. Shan Zhu Yu (Cornus) 12-15 gm
b.3. Shan Yao (Dioscorea) 10-15 gm
b.4. Ze Xie (Alisma) 9-12 gm
b.5. Mu Dan Pi (Moutan) 6-9 gm
b.6. Fu Ling/Fu Shen (Poria/Poria Spirit) 9-12 gm
Fu Shen is preferred over Fu Ling in this formula

2.   Kidney Yang Deficiency 
a. But One must be careful in using Yang tonics and warming herbs with bulimia in particular, for while the overall picture may be Yang Deficiency the constant abuse of the stomach tends to quickly lead to Stomach Yin Deficiency with Heat.
b. Chinese herbal formula: Jin Gui Shen Qi Wan, ingredients include
b.1. Fu Zi (Aconite) 6 gm
b.2. Rou Gui (Cinnamomum)  6 gm
b.3. Shu Di Huang (Rehmannia) 20-30 gm
b.4. Shan Zhu Yu (Cornus)  10-15 gm
b.4. Mu Dan Pi (Moutan) 10-12 gm
b.4. Fu Ling/Fu Shen (Poria/Poria Spirit) 10-15 gm
b.5. Shan Yao (Dioscorea) 10-15 gm
b.6. Ze Xie (Alisma) 10-15 gm

3. Fire/Heart deficiencies
a. Fire/Heart deficiencies than Water/Kidney issues,
b. Chinese Modification of Gui Pi Tang, ingredients
b.1. Ren Shen (Ginseng) 6-9gm
b.2. Huang Qi (Astragalus) 9-12gm
b.3. Bai Zhu (Atractylodes)  9-12gm
b.4. Dang Gui (Angelica) 6-9gm
b.5. Fu Shen (Poria) 6-9gm
b.6. Suan Zao Ren (Zizyphus) 9-12gm
b.7. Long Yan Rou (Euphoria) 9-12gm
b.8. Yuan Zhi (Polygala) 3-6gm
b.8. Mu Xiang (Saussurea) 3-6gm
b.9. Zhi Gan Cao (Glycyrrhiza)  3-6gm
b.10. Hong Zao (Jujuba) 3-5 pc
b.11. Bai Zi Ren (Biota) 6-9gm
b.12. He Huan Pi (Albizzia) 6-9gm
b.13. Shi Chang Pu (Acori) 6-9gm
b.14. Bai He (Lilii) 6-9gm

4. The author also notes that with care in formulation taking into account the cold temperature of the herb, Bai He could be added to the other two formulas above as well. In Liu Wei Di Huang Wan I usually combine Bai He with Zhi Mu (Anemarrhena) as these two herbs work very well together to calm Shen disturbed by interior Heat due to Deficiency of Yin.

Eating Disorders At Home - A Parent's Guide
An Invaluable Resource For Parents Of Sufferers Of 
Anorexia Or Bulimia, And Other Eating Disorders. Critical Information 

Chinese Secrets To Fatty Liver And Obesity Reversal
Use The Revolutionary Findings To Achieve 
Optimal Health And Loose Weight

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I. Binge eating disorder
Binge eating disorder is defined as a condition of compulsive eating huge amounts of food while feeling out of control and powerless to stop. It is the common eating disorder in the United States affecting 3.5% of females and 2% of males. Binge eating disorder is different from bulimia, as binge eating disorder do not involve self induced vomit regularly or use other ways to get rid of calories. Please see Bulimia vervosa for more information.