Financial Burden of Bulimia Nervosa: Cost of Food, Laxatives, Diuretics, and Diet Pills Adds Up

The financial burden of bulimia nervosa can be substantial, and yet little is known about the monetary costs associated with bulimic symptoms. At least little is known in academic circles – there is definitely a lot of anecdotal evidence floating around the internet. I found just one paper from 2009 by Scott J. Crow and colleagues. I stumbled upon it accidentally, actually. I was searching for articles on the economic burden of eating disorders (treatment cost, productivity loss, etc..) for a post I’m planning, but I thought I’d write about this in the mean time.

It is a short paper but I think it is important because it highlights an often overlooked issue.

The method Crow et al used to evaluate how much money individuals with bulimia nervosa spend on food, laxatives, diuretics and diet pills is simple (keep in mind, this hasn’t really been done before). Essentially, they asked 10 participants (with a clinical diagnosis of BN) to keep a food diary for a week. They then extrapolated these costs to determine the financial burden associated with bulimic symptoms over a year.

The average age of the participants was 26.6 (although the standard deviation was 6.2, meaning that there were people quite  a bit younger and quite a bit older, too). The mean duration of the illness was almost 13 years (standard deviation = 7.3). Importantly (because this may bias the results), these participants were seeking treatment, and were recruited to partake in this study during the time they were completing a clinical evaluation.

Besides recording their food intake and incidents of purging, participants also kept track of laxative, diet pull and diuretic use. They also classified binge eating episodes into “objective” and “subjective” categories, according to EDE (Eating Disorder Examination) guidelines.

In terms of calculating costs, the prices were based on food costs in a local grocery store ( Minneapolis/St. Paul region) or from restaurants and drug stores where the items were bought.

The results are shown in Table 1 below:

Over the one week period, the mean number of binge episodes was almost 5 (4.9), equally split between objective and subjective binges. The mean number of purges was less, at 3.6. Given that the sample size is only 10, the range of these values is also really interesting and important. With regard to binge eating, the range was 1 to 15, and for purging, the range was 0-9.

Commenting on whether those numbers are representative, high or low is irrelevant. They are just important in providing context for the monetary costs associated with bulimic symptoms in this study.

On average, cost for binge and purge food was around $30.5 a week (33% of total food cost), which adds up to almost $1,600 a year.While some individuals only spent roughly 7% of their total food costs on binge/purge food, others spent almost 10 times that amount: 68%. This equals to anywhere from $370 to $3,500 spent on binge/purge food, in this group.

Three out of ten participants reported the use of diet pills, diuretics or laxatives. Overall, the group average per week was $4.5, though the range was anywhere from $0 to $28 (or roughly $1,468 a year).

Of course, this is a tiny sample over a tiny period of time, but it does provide a hint of just how substantial the financials costs of bulimic symptoms can be. I think this arouses a lot of guilt on the part of the bulimic population. It does for me.

Particularly if you consider the accumulated cost over the duration of bulimia or bulimic symptoms:

The magnitude of these costs should be considered in the context of income levels. Median weekly earnings for women aged 25–34 in the United States in 2006 were $583; this yields annual earnings of $30,316. Mean annualized binge costs for participants in this study would thus represent 5.3% of pre-tax income. While these annual cost figures by themselves are substantial, they must be considered in relationship to the previously average duration from symptom onset to presentation for treatment. Previous reports suggest that this period is in the range of 4–7.5 years. If BN symptoms were of consistent severity from onset, this would correspond to an average accumulated cost of roughly $7,000–13,000 at the time of presentation.

Although the authors didn’t evaluate binge-purge type anorexics in this study, I don’t know if there’s reason to believe the numbers (especially if you sample a large enough population) would be any different.

Of course, these are just estimates: the sample is small, the duration of monitoring is short, the sample was treatment-seeking (and could possibly bias the findings), the very fact that their food intake was monitored could have led to reductions in binge eating/purging frequency, these estimates don’t take into account the short and long-term variation in BN symptoms within one individual and between individuals.

Additionally, the mean frequencies of binge eating and purging per week are somewhat less than those reported in
some recent treatment trials. For example, three recent BN trials have reported mean baseline binge eating frequencies of 23 and 25 binge episodes per 28 days. By comparison in this sample, weekly binge eating rates were equivalent to 19.6 binge episodes per week.

All this suggests that if anything, the numbers reported in this study are an underestimate.

So, what do you do with this information besides, if you are like me, feel really really guilty about all the money “wasted” on food?

(I’m usually a very, very thrifty person, but during periods of pretty symptomatic bulimia, this was thrown out of the window – though, if I would go shopping the next day for food that I didn’t think would be for bingeing/purging, I’d back to my super thrifty self, browsing through different flyers to find the cheapest tomatoes and lettuce around me. Point is: bulimic symptoms, the urgency of the act, the impulsiveness, the almost addictive features of bingeing and purging… well, they shouldn’t be underestimated, even for normally rational and money-conscious individuals.)

Crow suggests that this data can be useful for clinicians in “helping build a rationale for change when working with individuals presenting for treatment”, and while that’s certainly true, I do wonder what impact that would actually make.

This is a touchy topic –  I know many bulimics are blamed by their families and friends for wasting food, wasting money, and generally just being very inconsiderate. I recall people having to face those reactions when I used to go to group. That’s incredibly unfortunate, because it shifts the focus from the real issue here: you can be money-conscious, thrifty, non-materialistic individual but caught-up in the bulimic cycle, spend a significant proportion of your income on food.

This isn’t a weakness. It has nothing to do with being inconsiderate. Instead, it illustrates the intensity and power of bulimia. And I don’t mean that in any kind of external-force-that-can’t-be-conquered way. People can and do recover – a lot of people, actually. But, the difficulty of recovery shouldn’t be underestimated – it is rare that people can just stop “cold-turkey”.

Crow, S.J., Frisch, M.J., Peterson, C.B., Croll, J., Raatz, S.K., & Nyman, J.A. (2009). Monetary Costs Associated with Bulimia. The International Journal of Eating Disorders, 42 (1), 81-3 PMID: 18704919