You’re an adult with multiple decades to your credit, and you’ve got it all together — or look like you do. You never have a kind word for yourself when you look in the mirror, but who does? Your eating and exercise obsessions, secret binges, and occasional purges can’t possibly be signs of an eating disorder. After all, your friends, family and even your doctor praise you when you lose a few more pounds. Besides, you’re too “old” for an eating disorder — right?
The truth is that eating disorders in midlife — and beyond — are all too common among women. “The belief that we all have is that eating disorders are a white girl’s disease, in high school and college, when really it is across all ages,” said Margo Maine, a Connecticut-based clinical psychologist and co-author of “Pursuing Perfection.” “We have every color, every class, every ethnicity, and eating disorders are now in every country around the globe.”
A 2012 study estimated that 13 percent of American woman age 50 and older have eating disorder symptoms. A 2017 study found that about 3.5 percent of women older than 40 have a diagnosable eating disorder, yet most are not receiving treatment. Another study found that though rates of anorexia plateau around age 26, rates of bulimia don’t plateau until around age 47, and rates of binge-eating disorder don’t plateau until the 70s.
Awareness of eating disorders in midlife has been increasing slowly. Maine’s 2005 book “The Body Myth” has helped spotlight the issue. Many of her adult eating disorder patients were mothers of former patients who finally realized they had problems, too. “One of them had bulimia for 30 years and had had two marriages,” she said. “Neither of her husbands knew, her children didn’t know, her doctors didn’t have a clue.”
Jennifer Gaudiani, medical director of Denver’s Gaudiani Clinic and author of “Sick Enough,” said the data suggests that most older women with eating disorders have experienced at least some disordered eating — if not a diagnosable eating disorder — earlier in life. “It’s more common for those seeds to have been planted earlier on,” she said. “Major life transitions — divorce, a child’s death, illness, or even departure for college, menopause, an older parents’ health struggles — are a common trigger for an older woman’s surge in eating disorder symptoms.”
Research suggests the hormonal changes of perimenopause may open a “window of vulnerability” to developing eating disorders. Couple that with the do-it-all, have-it-all mind-set of modern women, and that’s a potent mix. “Who can take a break and think about ‘What do I need to do for myself today?’ let alone ‘What do I need to do to stop dieting and have a better relationship with my body?’ ” Maine said. “Instead of thinking about ‘What am I doing?’ they’re just going on to the next diet or aerobics class. The body becomes the answer.”
Cynthia Bulik, founding director of the University of North Carolina Center of Excellence for Eating Disorders, said ageism is overlooked as a midlife trigger, in part because of its subtlety. “When people are worried about job security and see younger people taking over in the workplace, they can be propelled to engage in unhealthy eating and exercise practices to try to preserve an air of youth,” she said, even though looking younger may not translate to feeling younger. “That discrepancy — between how we look and how we feel — can also be distressing and be a trigger to engage in yet more disordered eating behaviors.”
Bulik said eating disorders don’t look much different in midlife than during the teen years, but the effects and consequences can be. “The bottom line is that older bodies are older, and eating disorders at any age take a toll on just about every bodily system,” she said, adding that aging bodies may be more vulnerable to the medical complications of eating disorders.
The nutritional deficiencies caused by eating disorders can lead to digestive issues such as gastroesophageal reflux disease, or GERD, and slow stomach emptying, as well as brittle bones, strain on the heart, hormonal imbalances that affect the reproductive cycle, tooth decay or breakage, and gum disease. Some of these complications can cause sudden death, as with cardiac arrest or suicide, or take a slower path, as with bone loss that results in a hip fracture that leads to a downward health spiral. Eating disorders also often accompany other mental-health disorders, such as depression and anxiety.
Though eating disorders are underdiagnosed across the board, they’re missed more frequently in midlife. Women 40 or older admitted for treatment at an eating disorder facility tend to have had their eating disorders longer than younger women who are admitted for treatment.
“Doctors still have trouble seeing eating disorders in anyone other than young patients,” Maine said. “Everyone who’s losing weight, they’re the star — they don’t ask you how you lost the weight. The emphasis on weight as a standard of health is absurd and it just encourages eating disorders.”
Shame and weight stigma are significant barriers to treatment, Gaudiani said. “The vast majority of patients with eating disorders do not live in visually emaciated bodies, which means, unfortunately, that many of those with eating disorders who are in larger bodies are actually advised by their physician to restrict calories and lose weight,” she said. “This puts a serious chilling effect on appropriate diagnosis and referral to specialists.”
Maine recalls one patient in her early 40s who had been dieting since puberty. She struggled with — and overcame — anorexia in college, but when she couldn’t lose weight after her second pregnancy, she started purging and excessively exercising. Eventually, she realized her behavior was out of control, even though her weight wasn’t low enough to raise alarms. She finally went to her OB/GYN because she trusted him. “What she was not ready for was when her doctor walked into the room and said, ‘How does your husband like your new body?’ ” Maine said. “That vignette, and what that woman said to me, was why I wrote ‘The Body Myth.’ ”
Dennett is a registered dietitian nutritionist and owner of Nutrition by Carrie.