Invisible Women: Eating Disorders at Midlife
By Margo Maine, PhD, FAED, CEDS
The aging process does not immunize women from the body image issues, weight concerns, and eating disorders that plague the younger years. It never has. Today, more than 15 percent of women at midlife and beyond suffer from eating disorders,1 surpassing the number affected by breast cancer!2 In fact, inpatient admissions between 1999 and 2009 showed the greatest increase in this age group, with women older than 45 accounting for a full 25 percent of admissions.3
Despite these hard facts, eating disorders in midlife and older women continue to hide in plain sight in our health care delivery system. These are the Invisible Women, long neglected, whose needs are ignored and/or discounted by modern medicine, simply because we stubbornly cling to the stereotype that these recalcitrant, life-threatening problems belong to young women and no one else.
To this day, so many of my adult patients burst with shame for having an eating disorder at their age, apologizing for needing help. It breaks my heart to hear their stories: decades of pain, suffering, and isolation, as the negative feelings about their bodies and their basic needs for food create an eating disorder that never wants to let go of them. Their eating disorders have flourished, yet medical and mental health professionals have never asked a question about their eating habits, weight control issues, exercise, or body image.
I have been passionate about moving adult eating disorders out of the darkness and into the light of the mainstream approach to women’s health and mental health for far too long. My first book about midlife eating disorders, The Body Myth: Adult Women and the Pressure to Be Perfect, was published in 2005.4 My second book, Pursuing Perfection: Eating Disorders, Body Myths, and Women at Midlife and Beyond, came out in 2016.5 Both alone and with my colleagues Karen Samuelson and Mary Tantillo, I have led countless webinars and conference presentations, written journal articles, and collaborated with the media on articles and interviews about this topic. Over the years, we have made some progress, with a bit more research, more publications and presentations, and some mention of this issue in the popular press. But we still have so far to go.
Many years later, we unfortunately have not succeeded in getting adult eating disorders out of the closet. We still devote far too little attention to these Invisible Women; thus, I welcome the publication of Betsy Brenner’s beautifully written memoir, The Longest Match: Rallying to Defeat an Eating Disorder in Midlife. 6 Brenner’s story illustrates how the stressors of midlife can knock a high-functioning woman off her feet and into a full-blown eating disorder with little warning. She includes journal entries from her adolescent and earlier adult years revealing occasional negative thoughts about her weight or food, but it was decades later that body shame and despair and fear of food gradually and unexpectedly took over her life.
The Longest Match is a desperately needed teaching tool for clinicians and a guide for women struggling with body image and disordered eating in midlife and later years. Her story shows how an adult woman’s eating disorder can hide in plain sight and progress without recognition, reaching a dangerous precipice. With this book shedding light on them, Invisible Women may be identified and supported into recovery.
Eating disorders can affect people of any age and any race or color, with research showing equal incidence across African American, Hispanic, and Caucasian women at midlife.7 Research also tells us that middle-aged women report the same degree of psychopathology, distress, and impairment, whether their issues meet the full diagnostic criteria for anorexia nervosa, bulimia nervosa, or binge eating disorder, or are subclinical—suggesting that we must take subclinical eating disorders as seriously as we do those that are full spectrum.8 The majority of the midlife and older women that I see fall into that category. Perhaps their symptoms are “subclinical,” but the ensuing pain and suffering are far from that descriptor.
Over and over, my patients of all ages tell me stories about the Invisible Women they have known. These include their mothers, grandmothers, great-grandmothers, and other role models whose lives are full of diet pills, laxatives, pathogenic weight control, anxiety, depression, and despair about their bodies. These intergenerational issues simply continue to “hide in plain sight” because we never ask about them.
Screening for mental health issues, including domestic violence, has become standard in medical settings. Yet we have no routine screening for disordered eating. Sadly, the only attention paid to the subject of weight in routine medical visits is recording body mass index, as misleading as the measure is.
It’s time to start talking.
What if medical and mental health professionals included a few standard questions at intake that could pick up the themes related to eating disorders, like these:
- Has your weight fluctuated during your adult years?
- Are you trying to “manage” your weight? If so, how?
- What did you eat yesterday?
- How much do you think or worry about weight, shape, and food?9
These questions would move the problem of eating disorders in midlife and older women out of the darkness and into the light. Invisible Women might begin to believe that someone would see them and acknowledge their pain. They might take a chance and start to talk, no longer feeling ignored and discounted.
Eating disorders are serious, life-threatening, and heartbreaking illnesses at any age. Brenner’s book proves that point. It is time that they 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 throughout adult development. Screening should be routine, with simple questions about weight fluctuations, dieting, nutrition, body image, anxiety, and life stressors. This is not just a job for pediatricians. Obstetricians and gynecologists, family practitioners, internists, and even geriatricians all can play 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.10 Similar to breast cancer, eating disorders are a life-threatening and treatable disease, not a character flaw. We have extensive education and outreach about breast cancer, with pink ribbons everywhere—even on NFL players’ uniforms on the gridiron. We need the same for eating disorders.
As a society, we all can play a role in addressing this critical public health issue. It is 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 Founder and 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; and Senior Editor Emeritus of Eating Disorders: The Journal of Treatment and Prevention. She is currently writing a book about women’s relationship with their hair, a neglected aspect of body image. The 2007 recipient of The Lori Irving Award for Excellence in Eating Disorders Awareness and Prevention, the 2014 recipient of the Don and Melissa Nielsen Lifetime Achievement Award and the 2015 NEDA Lifetime Achievement Award, Maine is a member of the Renfrew Foundation Conference Committee, and their 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.
1. Micali, N., Martini, M. G., Thomas, J. J., Eddy, K. T., Kothari, R., Russell, E., Bulik, C. M., & Treasure, J. (2017). Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: A population-based study of diagnoses and risk factors. BMC Medicine, 15(1), 12.
2. American Cancer Society (2017). Breast cancer facts & figures 2017-2018. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf
3. Zhao, Y., & Encinosa, W. (2011). An update on hospitalizations for eating disorders, 1999 to 2009: Statistical brief #120. In Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality (US).
4. Maine, M., & Kelly, J. (2005). The body myth: Adult women and the pressure to be perfect. Wiley.
5. Maine, M., & Kelly, J. (2016). Pursuing perfection: Eating disorders, body myths, and women at midlife and beyond. Routledge.
6. Brenner, B. (2021). The longest match: Rallying to defeat an eating disorder in midlife. Stillwater River Publications.
7. Marcus, M. D., Bromberger, J. T., Wei, H. L., Brown, C., & Kravitz, H. M. (2007). Prevalence and selected correlates of eating disorder symptoms among a multiethnic community sample of midlife women. Annals of Behavioral Medicine, 33(3), 269-277.
8. Mangweth-Matzek, B., Hoek, H. W., Rupp, C. I., Lackner-Seifert, K., Frey, N., Whitworth, A., Pope, H. G., & Kinzl, J. (2014). Prevalence of eating disorders in middle-aged women. International Journal of Eating Disorders, 47(3), 320-324.
9. Maine, M. (2010). The weight-bearing years: Eating disorders and body image despair in adult women. In M. Maine, B. McGilley, & D. Bunnell (Eds.), Treatment of eating disorders: Bridging the research-practice gap (pp. 285–300). Elsevier.
10. Zerbe, K. J. (2013). Late life eating disorders. Eating Disorders Review, 24(6), 3-5.