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Anorexia and bulimia are diseases that involve alterations in brain chemistry. The choices women make for the direction of their lives, however, can help them overcome brain chemistry.
We usually think of anorexia and bulimia as heartbreaking conditions that usually strike women in their teens and twenties. But the reality is that anorexia and bulimia are heartbreaking conditions that can strike women at any stage of life.
Case in point is Cassandra W. who lives in a small town near Austin, Texas. Casandra was a devoted but frustrated wife and mother of two. Married at the age of 18 to the first man she ever dated, Cassandra felt she had closed off her options for life early. And when computer company executive her husband divorced her to marry her best friend (whom he also abandoned a few years later), Cassandra was stuck raising two children on a minimum wage salary and no means to pay the legal fees to get regular payment of child support.

Cassandra not only managed to survive motherhood, her son and daughter seemed to thrive. They graduated from college. Cassandra did, too. Cassandra and her kids all found good jobs and Cassandra soon found herself in the role of grandmother.

At the age of 45, Cassandra fulfilled two lifelong dreams. She earned her doctorate in theology and became an ordained senior minister of a thriving small church. She also became regular participant in "iron woman" triathlons all over the world. At the age of 58, however, Cassandra had to be hospitalized for an illness no one in her life even guessed she had. Cassandra was bulimic.

Bulimia and the Mid-Life Woman

Bulimia is a term that is derived from two Greek words, bous, meaning ox, and limos, meaning hunger. People who have bulimia have regular needs to eat until their stomachs are beyond full. Many people who suffer bulimia purge their excessive meals with laxatives or self-induced vomiting. Others avoid purging but engage in intensive physical exercise to burn off thousands of extra calories. Cassandra was in the latter category.

Cassandra channeled her need to exercise into a hobby she enjoyed a great deal. Her participation in triathlons took her all over the world, gave her opportunities to meet fascinating people, and garnered the admiration of friends, family, and parishioners. In that regard, Cassandra was an atypical non-purging bulimic. Most bulimics do joyless exercise compulsively out of the fear they will become unmanageably fat. And some bulimics who do not purge, exercise, take stimulants, or, if diabetic, omit insulin injections, do attain enormous size. But why would anyone become bulimic?

The Epidemiology of Bulimia

It turns out that the people most likely to develop bulimia are those who survived anorexia. Most people with anorexia are women, about 10 times as many women as men. Most people who develop bulimia are also women, also about 10 times as many women as men. Anorexia and bulimia occur in all races and ethnic groups.

The average episode of either anorexia or bulimia goes on for about eight years. Athletes of both sexes are at special risk of eating disorders, especially runners, gymnasts, and participants in any activity that requires "making weight" for a special competitive category, such as wrestlers and boxers. Actors, dancers, and models are subject to eating disorders—as are about 20% of active duty military. Soldiers, sailors, Marines, and members of the Air Force, especially in the United States, must maintain desirable weight to be considered for promotion.

Anorexia is more common earlier in life and bulimia is more common later in life. But neither is a purely psychological problem.

The Brain and Bulimia

Anorexia and bulimia are psychiatric disorders, and there is a strong psychological component in both conditions. It's a not weakness of willpower or a quirk of character, however, that makes someone anorexic or bulimic.
Both anorexia and bulimia seem to involve alterations in the production of a hormone known as brain-derived neurotrophic factor. This complex protein has a number of functions in the brain. Among those functions is to stimulate the growth of neurons that produce and respond to the reward chemical dopamine. If you don't have enough dopamine in your brain, you don't feel the "joy" that most people feel after everyday activities, especially eating. More and more eating is needed for the brain to register "enough." People who have either anorexia or bulimia may also have problems with hyper-sexuality, hoarding, gambling, shopping, or "punding," which is a prolonged feeling of purposelessness.

On the other hand, exercise and starvation seem to increase the production of brain-derived neurotrophic factor. The lack of the factor causes the need to eat (with or without purging). But people also learn that they feel better when they work out extremely hard or starve themselves. Moreover, the effects of brain-derived neurotrophic factor, or not having enough of it, are mediated through another protein called neuropeptide Y. People who have anorexia or bulimia experience literal, physical pain when they don't eat. But they also experience freedom from compulsion to eat when they don't eat. That's why binging is following purging and people who develop anorexia also tend to develop bulimia. But can be done about it?

Cassandra seems to have been on the right track. Participating in iron woman triathlons gave her a lasting sense of satisfaction that made her feel better even when she was not running, biking, or swimming on a course on Hawaii or Crete. She felt better about herself all the time because of exercise choices—far more than if she had tried to work off the calories she felt compelled to consume on by spending hours on an elliptical trainer or an exercise bike.

Cassandra's symptoms emerged about the time she was completing off the major items on her personal "bucket list," getting the kids through school, earning a doctor's degree, owning a house, achieving a position of respect. These activities no longer provided the dopamine boost her brain was looking for, so she developed an unmanageable attraction to food.
Some women in midlife, of course, develop the opposite problem, anorexia. Both bulimics and anorexics of either sex need medical care. However, the choices people can make to keep their condition under control center on finding goals and activities that are even more meaningful than eating  (if they are bulimic) or worth looking fat (if they are anorexic).

Human will is a powerful force. Love is a powerful force, too. Women in midlife usually have had experiences that have led them to make sacrifices for others. The key to overcoming eating disorders may be the willingness to make sacrifices for themselves, finding goals in life that are even more important than self-image or the sensation of food. It's still important to get all the help that can be found, but understanding the nature of the disease can lead to the choices that overcome it.
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