What We Need to Know about Eating Disorders in Midlife
By Carolyn Karoll, LCSW-C, CEDS-S
Why are mid-life women often invisible suffers?
There is no age limit to disordered eating nor does aging naturally eradicate negative body image; in fact, eating disorders span the life cycle. Women in mid-life and older may suffer from a broad spectrum of eating disorders as defined by The 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These include: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Other Specified Feeding and Eating Disorders (OSFED). While the symptoms within each diagnostic category may not differ much, regardless of the sufferer’s age, the context in which they are experienced is often different and unique.
Women who experience eating disorders in mid-life typically present with symptoms that have changed over time. Therefore, the most common diagnosis for this population is OSFED. (1) For instance, a woman who has suffered from anorexia and considers herself improved, stabilized, or even recovered, might later find herself engaging in other symptoms such as bingeing or purging, although not meeting the full criteria for bulimia. Even in cases where symptoms might be considered subclinical, these can lead to the same and sometimes greater physical and psychological consequences as the recognized diagnoses. (2)
Women in mid-life with eating disorders typically fall into three categories: those who developed eating disorders earlier in life, remitted to some extent, and reemerged in midlife; those who experience their eating disorder as a chronic condition (although it may change in type and severity over time); and those who are first time suffers, whose symptoms occurred later in life.
The majority of mid-life sufferers have actually dealt with some sort of eating disorder from a much younger age. They have had some type of food and weight issue most of their life which was not formally diagnosed, or it may not have risen to the point of a diagnosable eating disorder. This may have looked like a history of picky eating or chronic dieting. In fact, they may never have recognized their behaviors as disordered as these issues tend to be normalized in American culture.
In my private practice as an Eating Disorder Specialist, I often encounter women who would not self-identify with an eating disorder diagnosis despite reporting behaviors that may include preoccupation with food and weight, restrictive eating habits, compulsive exercise routines, habitual laxative use, bingeing, and self-induced vomiting. These behaviors are often couched as diets, wellness plans, “cheat days,” a reaction to “food sensitivities,” and lifestyle choices in the pursuit of health. Their rigidity is referred to as “discipline” and the compensatory behaviors are simply seen as a response to “falling off the wagon.” Because these women are often resistant to acknowledging their thoughts and behaviors as a problem to themselves or others, their struggles remain shrouded in secrecy and shame, and thus, women in mid-life often remain invisible sufferers of eating disorders.
Barriers to Receiving Treatment
Some of the stereotypes that prevent suffers from getting help include the stereotypes related to age and weight. These stereotypes are reinforced as family, friends, and even medical and mental health practitioners overlook symptoms and attitudes that, in a younger and/or thinner person, would be recognized as an eating disorder. This allows eating disorders to remain subversive and unabated as older adults fear they will be labeled as being “too old,” “too large,” and/or not “sick enough” to have an eating disorder. Sadly, older women may also be invested in the idea their eating disorder is actually a medical problem as opposed to a psychological/mental health problem due to the stigma. (3)
Another barrier to receiving treatment may be the egosyntonic nature of eating disorders, particularly symptoms such as excessive exercise and restrictive eating patterns. These symptoms are often lauded by others, such as friends, family, and medical and mental health professionals who are advising mid-life women to diet and exercise. Fueled by the cultural fear of obesity, these women are frequently praised for their low heart rates and body mass indices despite no evidence to support the belief that diet and exercise will mitigate morbidity or mortality outcomes. (4)
What makes mid-life women susceptible to eating disorders?
As women age, the challenges of adulthood and its unique life stressorsbecome risk factors in the development or recurrence of an eating disorder. (5) Living in a culture with a standard of beauty that includes concepts such as “the thin ideal” and “ageless skin,” it is not a surprise women in midlife fear the loss of status. These women areleft feeling inadequatedue changes in their body that occur as a part of the natural aging process and might feel compelled to control their body via diet, exercise, and cosmetic procedures. (6)
Women in mid-life also may undergo major life transitions involving changing roles and changes in their health status that can serve as triggers for eating disorders. (7) This may include adjustment in roles and in family structure due to marriage, pregnancy, parenting, divorce, re-marriage, and even death. Other changes include children getting older, leaving home, marrying, and having children themselves. These may leave a woman feeling overwhelmed and isolated, at times even feeling a loss of identity and purpose.
While both teenagers and mid-life women experience transitions in their lifetime, the developmental milestones of younger women (i.e. Bat Mitzvah, graduations, weddings etc..) are often celebrated with rituals and the support of others. In contrast, older women may be left alone during these transitional periods and ashamed at the changes that occur with the passing of time.
While not everyone in midlife who struggles with impaired body image develops an eating disorder, we do know that body image dissatisfaction can be a precursor for the development of an eating disorder. It is important to be aware that interventions to either change the body or maintain a body that is by its very nature changing can led to an eating disorder and certainly feelings of inadequacy and depression. (8)
Making self-deprecating remarks about one’s aging body is normalized in our society to the extent that body bashing and diet talk become a way that women begin to bond with one another. Women’s dissatisfaction with their aging bodies is illustrated in a 2012 qualitative study of 1,849 women over age 50. This study found that 70% of the women in the sample were trying to lose weight, 62% claimed that their weight or shape negatively impacted their life, 79% said that their weight or shape affected their self-perception, 64% reported that they thought about their weight or shape daily, and 66% were unhappy with their overall appearance; this dissatisfaction was highest when it came to their stomach. (9)
Physical changes resulting from the natural aging process include postpartum changes. Women are having babies at older ages and the pressure to “get my body back”
can be strong. (10) Other women may have a desire to have a baby but cannot conceive due to complications of an eating disorder; this challenge may lead her to question her womanhood, the shame of which might lead her to become even more entrenched in symptoms.
Menopause and associated hormonal changes may result in skin losing its elasticity, wrinkles, tooth discoloration, graying hair, decreased muscle mass, and weight gain. Women gain, on average, 5-10 pounds per decade of life as body fat increases with each developmental milestone (puberty, pregnancy, menopause). As the thin ideal and a youthful appearance become less attainable, mid-life women may be left feeling self-conscious. A study by Mangweth-Matzek et al. suggests that menopause, like puberty, may represent a vulnerable window for eating disorder behaviors and negative body image because of hormonal changes, body composition, and conceptions of womanhood. (11)
What can you do if you or a loved one may be suffering from an eating disorder?
Regardless of age, all eating disorders are about food and weight and yet not about food and weight. The behaviors have served you or your loved one in some way that will need to be honored and addressed in the recovery process. These functions may range from providing a sense of control, competence, purpose, and certainty, as well provide a release of tension, a distraction, pleasure, and identity. Giving up an eating disorder is scary and ambivalence should be expected as a natural part of any change process.
Due to this ambivalence, it is also important to remember the process is typically not a linear one. Keep in mind that the compulsion to hold onto symptoms is driven by fear of losing their function that may be seen as vital to survival. An eating disorder in mid-life and beyond more often than not becomes an ingrained coping mechanism reinforced by a relatively functional life. It may even become an identity, i.e. “not what I do, but who I am.” Addressing this problem requires creating a space of compassion for yourself or your loved one. It also requires persistence, as, like a weed, if the roots are not fully unearthed and destroyed, it will continue to grow.
Medical problems are more likely to be serious and even life threatening due to the chronicity of eating disorders in mid-life. That being said, it is important to remember that many doctors receive little to no training in treating or diagnosing eating disorders during medical school. Therefore, it is important to advocate for yourself or your loved one, seek specialists whenever possible, and remember that medical professionals are also subject to the allure of diet culture.
Other recommendations I would make based on my expertise with eating disorders in mid-life include:
- Seek out a therapist who has experience in the treatment of eating disorders and working with women in mid-life. Consider a full treatment team that includes: a dietitian, primary care doctor, and psychiatrist, if needed, that all have this expertise and experience.
- Get support from your therapist to educate family/friends. They will likely have questions about the diagnosis and treatment course. There is also a great deal of learning to be had regarding which behaviors unknowingly maintain the eating disorder, perpetuate shame among sufferers, and those which support recovery.
- Identify and adopt realistic role models. Look at media images with a critical eye. Make a conscious choice to look for women in your age cohort and beyond who have attributes such as strength, wisdom, and courage to be your role models. Think about the attributes you admire in women in your life; it is amazing how rare it is to then identify attributes such as body shape or size or what they eat for dinner.
- Stop the fat talk and reject the diet culture. This can feel very alienating as women often bond by comparing their diets and hating their bodies. It means setting boundaries with friends and family when possible and redirecting them to talk about things that are more interesting, entertaining, or important.
- Engage in self-care practices. Role demands can lead to neglect of healthcare practices and reduce body-directed self-care. Use practices that can teach you to value your body, reconnect with it, and respond to your physical needs. This can range from putting lotion on your body and going to doctor appointments to practicing meditation and yoga.
- Get accurate information about aging and the impact eating disorder behaviors have or may have on your health. Ask yourself,how does it serve you not to accept your body?
- Focus on the exploration of existential issues, examples include engaging in a life review or thinking about what you want your legacy to be. This may enable some midlife women to shift focus on fundamental values and personal transcendence rather than on appearance. Exploring these larger issues interrupts the preoccupation in “staying youthful” or having the “perfect body” and brings attention to the natural aging process and the value one has apart from appearance.
If you are suffering or even think you may be suffering from an eating disorder and are outside the demographic often associated with eating disorders (adolescents, teens, 20’s, and early 30’s), it is important to know you are not alone. Not only are there other women just like you struggling with eating disorder symptoms in all stages of recovery, there are also providers, like myself, who are passionate about helping midlife women make peace with food and their bodies.
About the author:
Carolyn Karoll, LCSW-C, CEDS-S is a board certified Licensed Clinical Social Worker (LCSW-C), a Certified Eating Disorder Specialist (CEDS-S), and has earned the Approved Supervisor designation from the International Association of Eating Disorders Professionals (iaedp) Foundation. Carolyn started a private practice in Towson, Maryland, where she is specializing in the treatment of eating disorders. She provides her clients with both empathy and education as she works with them to explore the various influences that impact their body image and self-esteem. She is committed to supporting her clients get underneath their struggles with food and weight and identify new mindsets and skills to allow them to find a place of self-compassion, self-acceptance, and self-love. Her eating disorder experience includes her work as therapist at The Center for Eating Disorders at Sheppard Pratt Health System and as The Clinical Supervisor at The Renfrew Center, Baltimore. Carolyn has presented on the topics of eating disorder prevention, diagnosis and treatment, and body image concerns in the community. She has also been featured in print media. Since 2015 Carolyn, has co-facilitated an eating disorder recovery group (Thrive) with her co-presenter, Adina Silverman. This group supports women in recovery from eating disorders to make peace with their relationship with food and their bodies.
1.Mangweth-Matzek, B. & Hoek, H. (2017). Epidemiology and treatment of eating disorders in men and women of middle and older age. Current Opinion in Psychiatry. doi: 10.1097/YCO.0000000000000356
- Bulik, C. M. (2013). Midlife eating disorders: Your journey to recovery. New York: Walker & Company, 43.
- Bulik, C. M. (2013). Midlife eating disorders: Your journey to recovery. New York: Walker & Company, 36-37.
- Bacon, L., & Aphramor, L. (2011). Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal, 10, 9. http://doi.org/10.1186/1475-2891-10-9
- Maine, M., & Kelly, J. (2016). Pursuing perfection: Eating disorders, body myths and women at midlife and beyond. New York: Routledge, Taylor & Francis Group, 80-82.
- Maine, M. (2000). Body Wars: Making Peace with Women’s Bodies. Carlsbad, CA: Gürze Books, 161-164
- Maine, M., & Kelly, J. (2016). Pursuing perfection: Eating disorders, body myths and women at midlife and beyond. New York: Routledge, Taylor & Francis Group, 10.
- Maine, M., & Kelly, J. (2016). Pursuing perfection: Eating disorders, body myths and women at midlife and beyond. New York: Routledge, Taylor & Francis Group,17-18, 36-37.
- Gagne, D.A., Von Holle, A., Brownley, K.A., Runfola, C.D., Hofmeier, S., Branch, K.E., Bulik, C.M. (2012) Eating disorder symptoms and weight and shape concerns in a large web-based convenience sample of women ages 50 and above: Results of the gender and body image (GABI) study. International Journal of Eating Disorders. 45, 832-44.
- Bulik, C. M. (2013). Midlife eating disorders: Your journey to recovery. New York: Walker & Company, 185-188.
- Mangweth-Matzek, Barbara & Hoek, Hans & Rupp, Claudia & Kemmler, Georg & G Pope, Harrison & Kinzl, Johann. (2013). The menopausal transition-A possible window of vulnerability for eating pathology. The International Journal of Eating Disorders. 46. 10.1002/eat.22157.