Disordered eating in midlife and beyond

Aging can be a challenge to body image. For some women, it may bring on — or rekindle — an eating disorder.

Many baby boomers are experiencing a disconnect between how old they feel and the birth date on their driver's licenses. In a 2009 Pew Research Center survey, half of people in their late 60s and early 70s said they felt at least 10 to 20 years younger than their actual age.

Feeling youthful inside is great, but a glance in the mirror may bring you up short. No matter how young you feel, you're likely to see some wrinkles, sags, tummy fat, and less-firm muscles. At the same time, we're surrounded by many unrealistic images aimed squarely at older women. Of course, you know that when you see a model or celebrity touted as looking "good for her age," it's the work of plastic surgeons, colorists, stylists, and airbrushers — but your unretouched body can't help but suffer by comparison.

"As our society values youth and as baby boomers reinvent what it means to be middle-aged, there are growing social forces that can undermine older women's self-esteem and potentially lead to body dissatisfaction — for example, if you think the surface of your skin or the contours of your body aren't supposed to match your chronological age. That, combined with health concerns about obesity, can make people feel bad about their bodies and, in turn, could result in eating strategies that undermine well-being," says psychiatrist Anne E. Becker, director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital and president of the Academy for Eating Disorders.

A growing problem

Eating disorders are usually regarded as a problem of adolescents and young women; their prevalence among older women is less clear. Secrecy and shame often accompany these disorders, and women may not seek help — particularly if they fear being forced to gain unwanted weight or stigmatized as having a "teenager's disease."

"You have a neighbor in her 50s who's slim and running all the time, and you don't know she's purging and exercising four to five hours a day. She falls over dead, and it gets charted as sudden cardiac death when the real problem was an eating disorder," says Kathryn Zerbe, professor of psychiatry at Oregon Health & Science University.

Despite the underdiagnosis of eating disorders in older people, treatment professionals are now reporting an upswing in requests for help from older women. For some of these women, the problem is new, and others have struggled with disordered eating for decades.

In surveys conducted in 1995 and 2005, Australian researchers found that while younger people reported eating disorder behaviors more often than older people did, the proportion of those with eating disorders who were older increased dramatically between the two surveys. The percentage of people ages 65 and over tripled among those engaged in strict dieting or fasting, nearly tripled among binge eaters, and quadrupled among purgers. In a 2010 study at the Oregon Health & Science University, women ages 65 to 80 were just as likely as young adult women to feel fat or concerned about their body shape.

This dissatisfaction matters. People with eating disorders are usually intensely unhappy about their body shape and size. A negative body image can suggest or prefigure a full-blown eating disorder — or a "sub-clinical" problem in which a woman never becomes alarmingly thin but organizes her life around food and weight control.

Types of eating disorders

Eating disorders include the following:

Bulimia nervosa. Women with bulimia regularly binge, consuming large amounts of food in a short period of time. Afterward, they compensate by purging — forcing themselves to vomit, taking laxatives or diuretics, eating little or nothing, or exercising excessively. They may or may not be underweight.

Anorexia nervosa. Women with anorexia nervosa are extremely thin and preoccupied with weight. They are unwilling to maintain a healthy weight and unable to see themselves as underweight. They severely restrict or regiment their eating, limiting the amounts or types of foods they consume. They may also occasionally binge or use the purging techniques of bulimics (whether or not they've binged). Some take diuretics, laxatives, diet pills, or other stimulants.

Binge-eating disorder. Binge eaters regularly eat a large amount in a short period of time, usually in secret and feeling guilty or ashamed. Unlike bulimics, they don't follow a binge with a purge, so they may be overweight or obese, and their eating disorder may not be recognized. In the diagnostic manual for psychiatric diagnoses, binge-eating disorder is categorized as an "eating disorder not otherwise specified," or EDNOS. This label, which is used for patterns of disordered eating that don't fit the strict definitions of anorexia or bulimia, describes the largest category of eating disorders.

Tipping the scales

Disordered eating at midlife and beyond has various causes, including these:

Grief. With age, you're increasingly likely to lose people you care about. Mourning can take away your appetite, and restricting food or purging can be a way to deal with distressing feelings. For example, Joan Rivers, in her autobiography Bouncing Back: I've Survived Everything…and I Mean Everything…and You Can Too!, tells how she suddenly developed bulimia in her 50s after her husband's suicide.

Divorce. Besides causing grief and a sense of loss, the breakup of a marriage can spur a woman to view her body unfavorably.

Heightened awareness of an aging body. This can be particularly acute when women return to school or work or need to keep working past the traditional retirement age, especially in fields where looks may be important.

Medical illness. If a woman loses weight because of illness, she may receive compliments on her slender appearance and therefore continue to restrict food after recovering.

Some older women decide to get professional help after years of disordered eating. The reasons vary but may include these:

Accumulated medical problems. Eating disorders take a toll on the body that becomes more apparent with age. A woman may seek treatment because of dental problems, arrhythmias (irregular heartbeats or cardiac rhythms), or osteoporosis (a common complication of anorexia nervosa). In an older body, forceful vomiting may result in a medical emergency, such as a stomach rupture or tear in the esophagus.

Shifting priorities. Disordered eating and attempts to hide it take a great deal of time and energy. Sometimes, after an unrelated health scare, the death of a loved one, or some other crisis, a woman just decides that enough is enough. "Why am I 55 years old and still hung up on the fact that my father used to pinch me and say, ‘You have baby fat'?" one patient told Dr. Zerbe. "It's ridiculous; my father's been dead for 20 years."

Getting help for disordered eating

First, you need a thorough medical examination. Certain medical conditions that cause rapid weight loss, interfere with appetite, or make eating difficult can be confused with an eating disorder.

Tell your clinician about any experiences with weight loss or gain, eating disorder behaviors, or use of drugs to control weight (e.g., diuretics, laxatives, enemas, ipecac, insulin, thyroid medication, stimulants, street drugs, or supplements such as cleanses or "skinny pills"). Your clinician also needs to know about any emotional problems you're confronting, including depression and anxiety. After taking a history and performing a physical, she or he may order certain tests, such as an electrocardiogram to check for arrhythmia, laboratory tests for metabolic imbalances, or a bone density scan.

To help physicians without special training in the treatment of eating disorders, the Academy for Eating Disorders has published a basic guide for early recognition and treatment. "Download it, and ask your clinician to take a look. It can help start the conversation," suggests Dr. Becker. (To download the guide, go to www.aedweb.org and click on Eating Disorders Guide to Medical Management.) If your clinician shows little interest in your eating concerns, ask to see a specialist.

Treating eating disorders

The goal of treatment is to achieve a healthy weight, exercise level, and eating pattern; to eliminate binge eating and purging; and to address any contributing emotional problems or distorted thinking. This usually requires the help of one or more physicians, a mental health professional, and a nutrition professional. "From the standpoint of psychiatric symptoms, the best person for treatment is a psychologist, psychiatrist, or other therapist. Because of the many medical complications, it's also very important to work closely with an internist and, if there is bone loss, with an endocrinologist as well," says Pouneh Fazeli, instructor in medicine at Harvard Medical School.

Treatment approaches include the following:

Psychotherapy. This is the cornerstone of treatment for eating disorders. Cognitive behavioral therapy (CBT) challenges unrealistic thoughts about food and appearance and helps you develop more productive thought patterns. Other types of psychotherapy, such as interpersonal and psychodynamic therapy, can help you gain insight into issues such as role transitions, loss, and unresolved relationships that may underlie disordered eating and an excessive focus on body image.

CBT is the best-studied approach and seems to be the most effective treatment for bulimia. For anorexia nervosa and binge eating, other approaches may also be effective. According to Dr. Zerbe, "CBT can be very helpful, but women in midlife often benefit from therapy that gets under the surface and also looks at the spiritual-existential dimensions of life. You look back to make sense of why you did what you did up until now, and you prepare for the next phase of your life."

Nutritional rehabilitation. A dietitian or nutritional counselor can help a woman recovering from an eating disorder to learn (or relearn) the components of a healthy diet and motivate her to make the needed changes. A nutrition professional will help her plan how to eat in a way that keeps the digestive system working well during recovery while avoiding the dangerous electrolyte and fluid imbalances that can arise when normal eating begins again after a period of semi-starvation.

Medication. Fluoxetine (Prozac) is the only medication approved for the treatment of an eating disorder. When taken at certain doses and combined with psychotherapy, it can reduce bingeing and vomiting up to 70% in the first eight weeks; without psychotherapy, results are much poorer. Other antidepressants and the seizure medication topiramate (Topamax) are sometimes prescribed for bulimia or binge-eating disorder, but their effectiveness hasn't been proved in controlled trials.

No medications are approved specifically for treating anorexia nervosa. Although antidepressants, seizure medications, and certain antipsychotic medications are sometimes prescribed, no drug works well until some weight is restored. The primary "medication" is simply food. Drugs may be helpful for associated depression or anxiety.

Hospitalization. Hospitalization may be recommended if a woman is dangerously underweight, unable to eat or stop vomiting, or seriously depressed or suicidal. It may also be necessary if she is medically unstable or has other medical complications that require inpatient treatment.