Women with eating disorders at midlife and beyond continue to fly under the radar, and the effects can be devastating. With potentially severe medical complications such as organ failure and an elevated risk of mortality (Smink, van Hoeken, & Hoek, 2012), untreated eating disorders can be dire. Although clinical studies suggest that an increasing number of women at midlife are presenting for the treatment of eating disorders (e.g., Ackard, Richter, Frisch, Mangham, & Cronemeyer, 2013), the number of women aged forty and over with disordered eating in the community is substantially higher (Mangweth-Matzek, Hoek, & Pope Jr, 2014). Even women who receive treatment often have a wide gap in time between their eating disorder onset and care (Ackard et al., 2013). Many women over age fifty report not feeling heard or having their needs taken seriously by their health care providers (Hofmeier et al., in press), suggesting missed opportunities for prevention and early intervention. Misdiagnosis, under treatment, and misunderstanding of midlife eating disorders pose a major concern for both patients and providers.
To help ensure that providers are meeting midlife and older adult women’s concerns around disordered eating effectively, we carried out the gender and body image (GABI) study (Gagne et al., 2012), which collected detailed information online about eating, weight, and shape concerns in 1,849 women over age fifty in the US. These data, along with other research, have provided us with greater knowledge about the unique challenges facing aging women today and how to detect and intervene better with those women at risk or affected by eating disorders. Below is a brief review of this literature, focusing on strategies for screening and intervening with women at mid- and late-life—a population that is growing and yet remains underserved.
How Midlife Eating Disorders Present
The DSM-5 (APA, 2013) includes four main eating disorder diagnoses, all of which can be diagnosed in women during midlife: anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and the catchall category, other specified feeding and eating disorder (OSFED; previously “eating disorder not otherwise specified,” or EDNOS), which includes atypical or subthreshold—but no less clinically severe—variants of the former disorders. According to a community-based study of Australian women from forty to sixty years of age (Mangweth-Matzek, Hoek, Rupp et al., 2014), BED and BN based on DSM-IV criteria appear most common, with a prevalence of about 1.5 percent and 1.4 percent, respectively. AN appears least common, with about 0.8 percent of women in the community meeting current (DSM-5) criteria. A much higher prevalence (13.3 percent) of US women aged fifty and older struggle with core eating disorder symptoms (Gagne et al., 2012), including binge eating, purging, and low body mass index. Regardless of diagnosis, midlife eating disorders typically present in one of three ways.
Early-Onset Chronic Disorder
These are women who developed their eating disorder early in life, perhaps in adolescence or young adulthood, but who continue to struggle with the disorder throughout adulthood. They may have been in prior treatment, but failed to achieve much relief from their symptoms, which are often fairly entrenched by the time they present in mid- or late-life.
Early-Onset Relapsed Disorder
These are women who experienced a relapse of a remitted disorder that occurred earlier in life. They may have achieved full recovery for years prior to relapsing later in life.
These are women who first developed eating disorder symptoms in their forties or later. Late-onset disorders encompass about 69 percent of midlife eating disorder cases (Lapid et al., 2010).
Eating disorder symptoms in midlife women are similar to those observed in adolescents and young adults (Ackard et al., 2013). Weight change is often observed in the context of AN (i.e., weight loss) and BED (i.e., weight gain), which can be a sign to providers that something may be awry. However, like younger counterparts, weight is not a great marker of clinical severity in these women, and thinking patterns (e.g., obsessive thoughts around food; undue influence of shape/weight on self-worth), feelings (e.g., extreme guilt following eating; distress about weight) and behaviors are more telling. Dietary restriction, purging, laxative use, and compulsive exercise are common weight control techniques observed in women with eating disorders across the age- and weight- spectrum. Binge eating, body dissatisfaction, and preoccupation with food or appearance—including body checking—can be present as well and cause much distress.
Women over age fifty grapple not only with typical body image concerns such as disliking the size or shape of their stomach, hips, and/or thighs, but also contend with aging-related changes like sagging skin and loss of muscle mass (Gagne et al., 2012). Both “fat talk” (i.e., speech that reinforces the thin-ideal standard of female beauty, e.g., “I am disgustingly fat”) and “old talk” (i.e., speech that reinforces the young-ideal standard of beauty, e.g., “Ugh, I’m getting wrinkles”) may be present, and can exacerbate body dissatisfaction. Importantly, satisfaction with one aspect of the body does not render one immune to dissatisfaction with others—the body image of older women can be quite complex.
Genetic, biological, and environmental factors all play a role in causing an eating disorder. Body dissatisfaction is a key risk factor for an eating disorder, but other common psychosocial stressors include divorce, conflict with a partner, trauma, health problems, and aging-related anxiety (Slevec & Tiggemann, 2011). In older age groups, grief and loss are the most common of these stressors (Forman & Davis, 2005). From losing a loved one to experiencing “empty nest syndrome” to grieving the loss of one’s youthfulness, loss can bring about emotional experiences that can activate problematic eating disorder behaviors.
Regardless of age, negative emotions such as anxiety, feelings of inadequacy, or depression have been described as trigging eating disorder symptoms . Although perhaps an unconscious decision, some women report controlling their food as a way to feel more control of their life or to cope with negative emotional states. For example, binge eating can be an effective, albeit harmful way to numb painful emotions temporarily.
Also dieting is a common precipitant to an eating disorder, and may have been a conscious behavior undertaken either for “health purposes” or because of a desire to lose weight. Not surprisingly, women in midlife often report pressure from the media to attain a slender or fit appearance, and this pressure can cause women to engage in drastic measures to change their weight or shape. Some women who developed an eating disorder report that their doctor advised them to diet and lose weight for “health purposes,” with the diet quickly spinning out of control. Of course, not everyone who goes on a diet develops and eating disorder, highlighting role of genetics and biology in eating disorder onset.
Biology plays an important role in the onset and exacerbation of eating disorders. For example, risk for eating disorders increases during times of hormonal change, including pregnancy (Hawkins & Gottlieb, 2013) and the menopausal transition (Mangweth-Matzek et al., 2013). Biological changes can affect eating, mood, and thinking but can also result in physical changes that may impact body image. Metabolism slows, weight increases, and fat redistributes from legs to trunk during these times and naturally with age or subsequent to medications or physical illness. Women often report feeling blindsided by such changes (Hofmeier et al., in press), and may desperately turn to unhealthy eating and exercise behaviors to gain back control.
Thus, the combination of novel psychosocial stressors together with potent and sometimes chaotic hormonal fluctuations and aging-related body change may contribute to the development of eating disorders in women at midlife or later. Providers should be attuned to the signs and symptoms and events triggering eating disorders in this age group, especially among women with a family or personal history.
Barriers to Recognition
Unique challenges to seeking help and receiving treatment exist for older women with eating disorders. Although a substantial body of literature has debunked the myth that eating disorders only affect adolescent girls, many people (including providers) remain unaware of this fact—and stigma lingers today. As a result, providers may fail to assess and detect eating disorder symptoms in older-age patients and miss crucial windows of opportunity for referral and intervention. When screening is done, assessments developed for youth or single-question body image screenings lacking necessary complexity may be inadvertently administered. False-negative findings could send women home with the belief that they are “just fine” or that their eating disorder is not serious enough.
On the flip side, older patients may be hesitant to disclose eating disorder symptoms due to embarrassment, shame or fear of judgment. Some may minimize or rationalize their struggles away or fail to recognize their symptoms as problematic due to the nature of the eating disorder. Others may have experienced negative encounters with providers when discussing weight and shape concerns. Consequently, until in severe form, eating disorder symptoms may go underreported, largely ignored, and untreated.
Screening and Intervention
Eating disorders show up in nearly every health care setting—from primary care to physical therapy to emergency room and substance abuse programs—providing many opportunities for prevention and intervention. Health care providers are encouraged to assess and discuss weight, shape, and eating-related concerns sensitively with all women walking into their clinics.
As the waiting room is the first space seen, providers may first wish to ask themselves, “Is my clinic inviting to women of all ages, shapes, and sizes?” Do visible brochures, pictures, and magazines feature only young women or advertise weight loss or antiaging products? If yes, consider replacing them with ones that are representative of “real women” of all ages that include messages promoting a focus on health, not appearance. Also, clinic chairs should be large enough to accommodate women on the higher end of the weight spectrum and clinic gowns should come in varying sizes. Women report being discouraged by the lack of products and services tailored for older women (Hofmeier et al., in press), and these small changes to our clinics may not go unnoticed. In fact, such changes could promote thinking and behavioral patterns that enhance body satisfaction (Runfola et al., 2013). They may also result in a comforting and inviting environment conducive to open, honest discussion about any challenges related to eating, body image or aging.
Screening for eating disorders should occur early and often, but especially around high-risk times such as pregnancy, menopause or weight gain. Administration of the SCOFF (Hill, Reid, Morgan, & Lacey, 2010; Morgan, Reid, & Lacey, 1999), a five-question eating disorders screening measure devised for use by nonprofessionals, is recommended. If less pressed for time, longer measures like the Eating Disorder Examination-Questionnaire (Cooper, Cooper, & Fairburn, 1989) can be administered. Clinical experience suggests that a few simple questions can also engage women in open discussion around any challenges related to eating and weight. For example, “What concerns do you have about your weight, shape or appearance?” “How do you feel about your current eating patterns?” and “Has anyone expressed concern to you about your eating?” If an eating disorder symptom is disclosed or a sign is observed in a presenting patient (see Table 1), further probing and a referral to an eating disorder specialist for a comprehensive evaluation of eating disorder symptoms and severity is recommended.
As there is often reluctance around seeking treatment, especially in individuals with AN, validating patients by expressing understanding of the two opposing positions of seeking treatment may help to promote open dialogue around their concerns for undergoing further assessment. Listening to these concerns, expressing empathy, and addressing them appropriately can make or break a disclosure experience and a patient’s follow-up with referrals for care. Exploring the pros and cons of treatment may also help to enhance motivation to seek care. Providers should be forthright with patients regarding the seriousness of their presenting symptoms, including medical risk (see AED, 2012) and necessity of receiving care. If a patient remains hesitant to follow-up with referrals, providers can reassure patients that they need only commit to an initial assessment with the eating disorder specialist, with decisions regarding subsequent care made from there. The primary goal for providers is to get the patient “in the door” to the specialist clinic.
Think Prevention at Every Encounter
Health care providers may be able to help prevent midlife eating disorders by better preparing women for impending aging-related changes. Educate patients about the physical changes commonly associated with aging and provide relevant resources in advance. Offering visible resources about eating disorders in waiting and exam rooms is also beneficial (Sim et al., 2010). Discussion around changes such as increase in abdominal fat, greater elasticity of skin, and hormonal fluctuations during menopause may assist in the prevention of negative psychological and behavioral consequences related to poor coping with the aging process.
Brief interventions aimed at enhancing media literacy may also help to prevent body dissatisfaction in these women. Within this discussion, providers may benefit from encouraging women to shift focus away from physical appearance towards functionality, while encouraging physical activity as a means of self-care and way to attain both physical and mental health. Such factors are associated with body satisfaction in midlife women (Runfola et al., 2013).
When discussing weight, a weight-inclusive approach to health promotion is encouraged (see Tylka et al., 2014). This approach endorses development of healthy behavioral and thinking patterns for the purpose of achieving physical and mental health, as opposed to weight change. Helping patients to recognize that there are a number of behavioral and modifiable health indices that indicate health status rather than weight alone (e.g., blood pressure) can reduce unhealthy pressure to lose weight or diet—which can ultimately backfire, and increase risk for weight gain down the line. Although weight extremes (BMI < 18.5 or > 35 kg/m2) can have major health consequences, discussing health-related behaviors with patients (rather than weight) is most effective for aiding them in attaining a healthy state. Getting patients to appreciate that healthy bodies naturally come in a variety of shapes and sizes—and are influenced by a variety of factors including genetic, biological, behavioral, and environmental ones—may also help to prevent body image and weight concerns in this population.
Taking patient’s body image concerns and eating disorder symptoms seriously is critical. It is best to err on the side of caution and refer patients to providers specializing in eating disorders for a full assessment of symptoms after initial disclosure. These providers can be licensed therapists, psychiatrists, physicians, or dietitians who have expertise in assessing and treating eating disorders. Engaging significant others (e.g., family) in the referral process may help to bridge the gap between diagnosis and care. Depending on type of eating disorder, psychological treatments, including individual or group cognitive-behavioral therapy, interpersonal therapy, and couple-based therapy approaches, may be appropriate and effective for treating the eating disorder. These therapy approaches are typically part of a multidisciplinary treatment approach that includes nutritional counseling, medication management, and ongoing medical monitoring. When receiving proper treatment, women suffering from midlife eating disorders can and do recover.
Assessing for eating disorder symptoms in adult patients can be life changing. Universal screening of eating, weight, and shape concerns in midlife and older women may help to capture those displaying eating disorder symptoms. Such identification may help to improve early intervention efforts, prevent development of serious eating disorders, and facilitate the treatment referral process.
Acknowledgments: Dr. Runfola was financially supported by the Global Foundation of Eating Disorders (GFED) and would like to thank Susan Kleiman for her edits to the initial manuscript draft.
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