Body Image, Eating Disorders, and Women at and Beyond Midlife:
The Nine Truths
By Margo Maine, PhD, FAED, CEDS
“Eating disorders.” Instantly, most of us just visualized a teenage or college-age girl. And let’s be honest—she was probably white.
True—not so long ago, age seemed to immunize adult women from the body image issues, weight issues, and eating disorders that plague the younger years. Although most cases still appear in adolescent girls and young women, an alarming shift has occurred—eating disorders are now on the rise among middle-age and older women. Between 1999 and 2009, inpatient admissions showed the greatest increase in this group, with women older than 45 accounting for a full 25 percent of those admitted in the U.S.1
The cultural pressures to be perfect—including having a flawless, slim body—have no expiration dates and no boundaries. Our fast-moving consumer culture has created unprecedented opportunities and unprecedented stress for women. Women have so much today—growing economic strength, political influence, and educational and career opportunities. Yet according to a Gallup Well-Being Index, women ages 45 to 64 have the lowest well-being and highest stress of any age group or gender in the U.S.
In response to these stressors, far too many women at and post-midlife find comfort in the rituals of compulsive eating and exercise, alternating between scrutinizing every morsel they ingest and shamefully bingeing or purging. Often, the eating disorder changes over time, starting with one category of symptoms and moving to another. The issue is less about the specific diagnosis and more about the frequency, intensity, and duration of the symptoms and other contributing factors—like comorbid substance abuse, severe mood and anxiety disorders, and trauma. In all life stages, anorexia is the least common of the eating disorders. Bulimia is more frequent, but binge eating disorder and the atypical eating disorders, now called other specified feeding and eating disorders (OSFED), are the most frequent, especially among adult patients.
Eating disorders are serious, life-threatening illnesses—not character flaws. It’s time to bring marginalized groups—like midlife-and-older women—who are often ignored in treatment and research out of the closet.
Inspired by the Academy for Eating Disorders Nine Truths About Eating Disorders,2 I propose The Nine Truths About Eating Disorders at and Beyond Midlife.
Truth #1. Eating disorders in women at and beyond midlife have rapidly emerged as a major public health problem. In the U.S., 13.3 percent of women 50 and older report eating disorder symptoms3, surpassing the 12.4 percent incidence of breast cancer.4 A recent lifetime prevalence in the U.K. indicates that as many as 15.3 percent of midlife women suffer from eating disorders. OSFED was the most prevalent diagnosis, mirroring my clinical experience. Only 27.4 percent in this study sought help or received any treatment for the eating disorder.5 I suspect that even fewer access services in the U.S. as a result of inadequate mental health insurance and stereotypical beliefs that eating disorders are a young woman’s problem.
Truth #2. Eating Disorders are multidetermined biopsychosocial disorders. DNA contributes risk but does not code for a specific condition or disease. In other words, genes create vulnerabilities to be tempered or intensified by other factors, including the environment, early development, physical conditions, and social experiences or expectations.6 The shared heritable environment is a key force contributing to disordered eating, including toxic intergenerational attitudes toward weight, food, and body image. As eating disorders still occur disproportionately in women, it is safe to say that gender is the greatest risk factor.7 Adult women experience countless repeated exposures to this toxic culture, but media literacy and prevention efforts focus much more on adolescents and young adults, rarely trying to raise consciousness about the risks of disordered eating and body image preoccupation in midlife and older women.
Truth #3. In contrast to the past, eating disorders are truly a global phenomenon. Eating disorders are found on all continents, including in Asia and in Arab countries, and in a broad range of cultural, racial, and ethnic populations.8 The world is in transition, so women are in transition.
In the words of holistic physician Christiane Northrup: “The state of a woman’s health is indeed completely tied up with the culture in which she lives and her position within it.”9 This new cultural environment includes: exposure to the “war on obesity,” weight bias, and the misinformation promulgated by the diet industry; an overpowering consumer culture with constant exposure to strict and unrealistic media images of beauty; shifting gender roles because of industrialization, urbanization, and modernization; and the trend toward highly palatable prepared and fast foods and the adoption of a more sedentary lifestyle, contributing to increased BMIs and eating issues. All of these factors create a global risk for body image issues and eating disorders.
Truth #4. Age does not immunize women from body image preoccupation and eating disorders. In the past, women tended to become more accepting and less critical of their bodies as they aged, but in the 21st century, the opposite seems to be true. In fact, in one study, women ages 61 to 92 ranked weight as the greatest bodily concern.10 Today, disordered eating and a fear of aging go hand in hand for many women.11 This issue crosses cultural, racial, and ethnic lines with equal frequency of disordered eating occurring in African American, Hispanic, and Caucasian women ages 42 to 55 in the U.S.12 Other countries reflect similar patterns. For example, while 4.6 percent of Austrian women ages 40 to 60 met the full criteria for a clinical eating disorder, another 4.8 percent met the subthreshold standards. However, full-spectrum and subclinical groups reported the same degree of psychopathology, distress, and impairment. We must take subclinical eating disorders as seriously as full-spectrum ones,13 especially in our adult patients who have suffered for decades.
Truth #5. When comparing eating disorders in adult women with the younger population, we find some significant differences.14 Older women tend to experience significant shame for having a “teenager’s problem.” With more years spent speaking the language of fat, this self-hatred feels normal, and admitting the need for help is a foreign concept. They often have a painful awareness of what they have lost in their relationships and in general well-being. Motivation for treatment is also different, as they may be concerned about the impact of their eating disorder on their children and hope to not pass it down to them. Because of their many other responsibilities (families, jobs, and their role in their extended families and communities), adult women experience significant obstacles to accessing care.
As with younger women, developmental transitions place midlife and older women at risk for disordered eating and body image issues. For most, adult development ushers in heightened anxiety about appearance and health owing to the natural aging process, the loss of power and status as women age, and multiple stressors and losses that accompany adult development. Eating disorder behaviors are powerful distractions from these new challenges and emotions.
Truth # 6. Relational Cultural Theory (RCT) is an effective therapeutic framework for the treatment of eating disorders.15 Decades into my experience treating women with eating disorders, I see RCT as the most inclusive and most sensitive approach. According to RCT, eating disorders are disorders of disconnection that begin as self-protection when relationships are challenged. Women use eating disorder symptoms to maintain emotional safety and distance despite wanting a relationship. Gradually, the relationship with the eating disorder replaces and competes with true relational possibilities.16 In contrast, RCT offers growth-fostering relationships based on connection and mutuality. The more traditional medical model of treatment provides a top-down “power over” framework, within which the treaters direct the care. RCT, however, is a feminist framework promoting a “power with” collaboration as the client and clinician move through the treatment experience, with mutual empathy as the primary therapeutic tool.17 Fluid expertise, a core concept of RCT, refers to the shared resources and insight that both the client and clinician bring to the treatment experience.
Truth #7. The most current findings in neuroscience uphold the basic tenets of the relational model.18 RCT challenges the paradigm of the separate self in traditional psychological theories and views isolation as the major source of suffering for people. Similarly, neuroscience has found that the human brain is “hardwired to connect” and that isolation actually causes the human brain to deteriorate and waste away. Both RCT and interpersonal neurobiology propose that recovery can only happen in the context of healthy relationships that provide mutual growth.
Truth #8. Adult patients suffer the same medical sequelae as younger patients, in that every system is affected by malnutrition.19 Our adult patients often feel immune to the severe medical consequences of eating disorders, but sooner or later, that immunity runs out. Despite long-term stability, medical complications can emerge quickly in older patients. Adult women also experience some unique issues medically. For example, depleted fat stores will likely increase menopausal symptoms, and muscle-wasting can reduce metabolic rate and hasten neuromuscular decline. In the elderly, dieting is especially risky.20 Cognitive impairment secondary to dieting may also be greater,11 and the mortality risk associated with low weight is greater as people age.21
Truth #9. Psychoeducation is a powerful tool for the treatment of eating disorders at and beyond midlife. Women at and beyond midlife deserve to be treated as adults and empowered in treatment – not simply told what to do. Psychoeducation works for them because it is a “power with” modality. A psychoeducational approach is essentially relational in that it levels the power differential, increases the mutuality of the clinical relationship, and makes women more effective collaborators in their care. When I share information about the incredible natural resources of the female body, women slowly begin to appreciate its natural wisdom and are more likely to make changes in their attitudes and behaviors.
Reflections: Psychoeducation in Action
Watching so many women suffer and then recover from eating disorders, I recognize firsthand that the female body is designed with extraordinary strength, wonder, and resilience. My work over the past 35 years with women of all ages suffering from eating disorders has taught me to never give up and to keep providing support, validation, and education no matter how long or deep their suffering has been.
To change their minds about their bodies, I often share these compelling facts: women’s bodies are hardwired to respond to starvation. In a famine, only 10 percent of women die, but as many as 50 percent of men will. Women’s bodies are simply designed for survival.22
Fat is an essential part of that survival strategy. Before puberty, a girl’s body is composed of approximately 12 percent body fat. During puberty, fat cells multiply to about 17 percent of our body composition—enough for ovulation and menstruation. A mature woman’s body will have about 22 percent body fat, providing the energy necessary for an ovulating female to survive famine for nine months.23 In other words, women’s bodies have the capacity to maintain the human race—even when threatened by starvation.
Quite simply, that troubling weight gain in puberty and at menopause is not only about staying alive, but also keeping the human race alive. Women gain fat first in the breasts, buttocks, hips, and thighs to protect our fertility, reproductive, and feeding organs. During the transition through menopause, women experience an average weight gain of 12 to 15 pounds, while metabolism slows 15 percent to 20 percent.24 This weight gain is not due to a lack of willpower, laziness, or “giving up” on themselves. Midlife weight gain is biologically programmed for good reason. During menopause, hormonal shifts increase the size of fat cells surrounding our reproductive organs as these cells produce estrogen, offsetting the shutdown of the ovaries. This natural process allows women to maintain bone density, decrease the risk for osteoporosis, and manage symptoms of menopause.
Moderate weight gain at midlife is actually associated with longer life expectancy for women!25,26
Most women—even well-informed, resourceful women—don’t know these facts. The truth is that the female body simply knows how to take care of itself.
After I shared this information with a 73-year-old woman who had battled her body for decades, she came back the following week and announced: “I used to see this roll around my middle as my spare tire, and I hated it. Now I see it as my life preserver!”
It’s about time to respect the wisdom of the female body—if we did, perhaps we would make some progress in our fight against eating disorders.
Not long ago, breast cancer also was hidden in the closet. Women tended to feel isolated. Alone. Hopeless. But then, brave patients, medical providers, women’s health experts, researchers, and others began talking openly about it. Gradually, the shame faded. Research trials, treatment innovations, early detection through mammograms and self-examination, and support services grew. Today, women with breast cancer don’t feel so alone. New knowledge and care options are cause for optimism.
As with breast cancer, age doesn’t lessen the risk for developing an eating disorder. Eating disorders at and beyond midlife must rank as a high priority on our health care agenda. Medical providers, insurers, and government agencies must learn about the unique female physical and psychosocial experiences that create risk for eating disorders at and beyond midlife. Screening should be routine, with simple questions about weight fluctuations, dieting, nutrition, body image, anxiety, and life stressors. This is not just the job for pediatricians. Obstetricians and gynecologists, family practitioners, internists, and even geriatricians all have a vital role in the fight against eating disorders.
Mental health clinicians and dietitians need to collaborate with medical providers to develop resources for these women. Given the competing demands of their families, jobs, and financial resources, adult women face multiple barriers to treatment. We must make it easier for them to access care.
Women also need to feel safe telling the stories of their bodies. Just like breast cancer, eating disorders are a life-threatening and treatable disease, not a character flaw. As a society, we all have a role in addressing this critical public health issue. It’s time to approach eating disorders affecting women in midlife and beyond just as openly, seriously, and compassionately as we approach breast cancer and other public health problems.
About the author:
Margo Maine, PhD, FAED, CEDS, is a clinical psychologist who has specialized in eating disorders and related issues for over 35 years. A Founder and Adviser of the National Eating Disorders Association and Founding Fellow of the Academy for Eating Disorders, Dr. Maine is author of: Pursuing Perfection: Eating Disorders, Body Myths, and Women at Midlife and Beyond; Treatment of Eating Disorders: Bridging the Research-Practice Gap; Effective Clinical Practice in the Treatment of Eating Disorders; The Body Myth; Father Hunger; and Body Wars. The 2007 recipient of The Lori Irving Award for Excellence in Eating Disorders Awareness and Prevention, 2014 recipient of the Don and Melissa Nielsen Lifetime Achievement Award and 2015 NEDA Lifetime Achievement Award, she served as senior editor of Eating Disorders: The Journal of Treatment and Prevention for 25 years. A former board member and vice president of the Eating Disorders Coalition for Research, Policy and Action, a member of the Renfrew Foundation Conference Committee, and their Clinical Advisory Board, and of the Walden Clinical Advisory Board, Maine is a 2016 Honoree of the Connecticut Women’s Hall of Fame. She lectures nationally and internationally on eating disorders and maintains a private practice, Maine & Weinstein Specialty Group, in West Hartford, CT. She loves the earth and gets up early every day to celebrate it.
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