Hidden in plain sight: The invisible battle faced by middle-aged and older women with eating disorders

Written by Jessica Page-Campbell

Our understanding so far

Eating disorders are mental health conditions which lead to unhealthy and life-threatening behaviours such as eating too little, too much, or experiencing anxiety about weight and body shape. (1,2,3) The most common types of eating disorders include anorexia nervosa, which is characterised by not eating enough food, exercising too much, or both to suppress weight gain. (1,2) Another is bulimia, which is defined by losing control over eating and then taking extreme measures to suppress weight gain. (1,2) The third is binge eating disorder, which involves a compulsion to over eat on a regular basis. (1,2) Although eating disorders affect both men and women, these conditions are more than twice as prevalent among females than males. (3,4) For example, in 2021 and 2022 there were over 5100 women diagnosed with anorexia nervosa in England, compared to fewer than 300 men. (3)

A problem reserved for young girls?

Little is known about the prevalence of eating disorders in middle-aged women since most research into the field has been based on younger women. (2) However, the cliché assumption that eating disorders are a problem for young girls is inaccurate, no one is too old for an eating disorders, as we now know that all age groups can experience these conditions. (2,5)

In reality, eating disorders are all too common among middle-aged and older women. (5) In recent years, the admission rate for women over the age of 45 to inpatient eating disorder facilities has increased considerably, now accounting for 25% of admissions. (5) Partial, residential, and outpatient treatment programs have also found that 35% of their patients are over the age of 45. (5) Despite these findings, so far there are no specific eating disorder treatment programs available for women with eating disorders in later life. (5)

Clinicians and researchers tend to describe eating disorders in women at midlife and beyond using these three distinct categories: (5)

1. Lifelong disordered eating: Those living with symptoms of disordered eating from adolescence into later life.
2. Early life disordered eating with a relapse: Recovery from an eating disorder has taken place, partially or fully, with recurrence or relapse in later life.
3. Onset disordered eating in mid or later life: Women experience their initial eating disorder onset in mid or later life, without a history of recognised symptoms.

Potential causes and contributors

Current understandings surrounding eating disorders are limited and are especially sparse when considering older individuals. (2,5) Presently, eating disorders in middle-aged and older women are thought to be caused by a combination of factors which differ from case to case. (1,2)

The menopause and its associated bodily changes

During menopause, women typically experience bodily changes such as increased weight gain. (5) Resultantly, women who have been struggling with disordered eating and practising weight suppression throughout their lives may find their eating disorders heightened during this time. (5) One study found that over 50% of women of “normal weight” (Body Mass Index [BMI] <25) report increased body dissatisfaction and greater discontent with their bodies at the age of 50 and above, compared to their younger years. (6)

Interestingly, the change in oestrogen levels during perimenopause has also been implicated in increasing the risk of eating disorder development. (7) Research has suggested that the oestrogen change during perimenopause may present a window of vulnerability to eating disorder development or redevelopment for midlife women. (7) However, further research into this area is required to determine its true implication in eating disorder development.

Socio-cultural pressures

The ever-present sociocultural pressures, which have increased in recent years, promoting a thin and youthful beauty ideal, can cause many women to engage in extreme behaviours to counteract weight gain in later life. (5) Both young women and adolescent girls may be subject to sociocultural pressures to be thin, which can be compounded later in life by concerns about age?related bodily changes. (7) Consequently, the relentless pressure to sustain the idealised images of a thin and youthful obsessed media culture has caused a rise in disordered eating and weight preoccupation amongst middle-aged to older women. (8,9)

Cultural beliefs and attitudes: Limited data from ethnic minority populations

It is also important to point out the very limited data for eating disorders amongst ethnic minority populations, and the different risk factors which may affect these groups.(10) Although Westernised beauty standards and pressures are the most commonly associated with eating disorders, disordered eating behaviours are found on all continents and within a broad range of cultural, racial, and ethnic populations. (11) Research has found that cultural beliefs and attitudes could be significant contributing factors in the development of eating disorders, since rates of these disorders vary across different racial/ethnic and national groups, also changing over time as cultures evolve. (11) Additionally, historical, and cross-cultural experiences suggest that cultural change may be linked to increased susceptibility to eating disorders, particularly when values about physical aesthetics are involved. (11) Such a change may occur over time within a given society, or on an individual level, like embracing a new culture when moving to a new country. (11) However, there is very limited research in this field, and further studies are urgently needed in order to uncover the true extent of cultural influence in the development of eating disorders. (11)

Why has this issue been overlooked in middle-aged and older women?

Studies have shown that the stigma of experiencing an eating disorder at an ‘untypical’ age, and the glorification of sports activity often hinder the recognition and diagnosis of eating disorders in middle-aged and older individuals. (12) Eating disorders are already hugely stigmatised, with research highlighting vast stereotypes, prejudices, and discriminations against people living with eating disorders. (13) Due to these factors, eating disorders, which are under reported anyway, are scarcely reported by older people to healthcare professionals. (12–15) Additionally, studies of eating disorder prevalence are often performed in high-risk populations like younger women in schools and at universities, with incidence studies usually focused on detected cases in hospital records of inpatients and outpatients in mental healthcare facilities. (12,15) Therefore, the data for eating disorders are limited in representing the general population. (12)

To add to the problem, healthcare professionals have been accused of missing clinical presentations of eating disorders or overlooking opportunities for eating disorder diagnosis. (16) An Australian study demonstrated that most clinicians have low perceived confidence when dealing with eating disorders. (16) Also, a UK study found a wide variation in referral patterns of GPs, with more referrals being seen from practices with female GPs. (16) This variation in eating disorder detection and low confidence may be due to the absence of curriculum attention to eating disorders. (16) A 2018 study reported that UK undergraduate medical education spends less than 2 hours on the subject of eating disorders (a finding that rang mass alarm bells and was the catalyst for an urgent review). (16,17) More recently, a study of US eating disorder physicians and residents echoed this lack of training and awareness for appropriate supporting resources, where nearly all voted for improved education in eating disorders. (18)

The screen for disordered eating in midlife to older women

Since 15.3% of women struggle with occurrences of eating disorders at midlife, healthcare professionals must be educated and prepared to assess for eating disorders. (5,19) It is also essential that older women are routinely screened for these conditions, to hasten diagnosis and intervention. (5) The screen for disordered eating (SDE) was developed as a more accurate measure of anorexia nervosa, bulimia nervosa, and binge eating disorder, and includes questions such as ‘Do you often feel the desire to eat when you are emotionally upset or stressed?’. (5) The SDE captures the full range of ?Diagnostic and Statistical Manual of Mental Disorder (DSM-5) eating disorders, has been noted to increase accuracy, and is particularly efficacious when screening an ageing population. (5) Therefore, the SDE holds promise and has been thoroughly recommended to midlife and older women, as it can help to bring an individual’s eating disorder to light and aid healthcare professionals in making a diagnosis. (5)

Conclusion

Mounting evidence has shown that ageing does not lessen the risk of developing an eating disorder, yet this population of women remain invisible. To date, there are no specifically dedicated treatment programs available for women with eating disorders in later life. (5) Eating disorders at midlife and beyond should be a high priority on our healthcare agenda. Healthcare professionals, insurers, and government agencies must learn and be made aware of the unique female physical and psycho-social experiences that create risk for eating disorders at midlife and beyond. (16,18) Moreover, older women need to feel safe telling the stories of their bodies without shame and judgement. As a society, we all have a role in addressing this critical public health issue and working to recognise eating disorders as the life-threatening diseases they are. It is well past the time to approach eating disorders affecting middle-aged and older women just as openly, seriously, and compassionately as we approach other public health problems.

References

1.?NHS. Eating disorders. Accessed 2nd June 2023. Available at: https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/eating-disorders/overview/

2.?Mangweth‐Matzek B, et al. Prevalence of eating disorders in middle‐aged women. International Journal of Eating Disorders. 2014;47(3):320–324.

3.?Statista. Hospital episodes involving a primary diagnosis of an eating disorder in England in 2021/22, by type and gender. Accessed 20th June 2023. Available at: https://www.statista.com/statistics/987218/england-eating-disorders-by-type-and-gender/.

4.?Bramon‐Bosch E, Troop NA, Treasure JL. Eating disorders in males: a comparison with female patients. European Eating Disorders Review. 2000;8(4):321–328.

5.?Samuels KL, et al. Disordered eating, eating disorders, and body image in midlife and older women. Current Psychiatry Reports. 2019;21:1–9.

6.?McLaren L, Kuh D. Body dissatisfaction in midlife women. J Women Aging. 2004;16(1-2):35–54.

7.?Baker JH, Runfola CD. Eating disorders in midlife women: A perimenopausal eating disorder? Maturitas. 2016;85:112–116.

8.?Pruis T, Janowsky J. Assessment of body image in younger and older women. Journal of General Psychology. 2010;137:225–238.

9.?Bulik C. Midlife eating disorders: your journey to recovery. New York: Walker; 2013.

10. Striegel-Moore RH, Cachelin FM. Etiology of eating disorders in women. The Counselling Psychologist. 2001;29(5):635–661.

11. Miller MN, Pumariega AJ. Culture and eating disorders: A historical and cross-cultural review. Psychiatry: Interpersonal and biological processes. 2001;64(2):93–110.

12.?Mangweth-Matzek B, Hoek HW. Epidemiology and treatment of eating disorders in men and women of middle and older age. Current Opinion in Psychiatry. 2017;30(6):446.

13.?Brelet L, et al. Stigmatization toward People with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder: A Scoping Review. Nutrients. 2021;13(8):2834.

14.?Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Current Opinion in Psychiatry 2006; 19:389–394.

15.?Hoek HW. Epidemiology of eating disorders. Eating disorders and obesity: a comprehensive handbook, New York: Guilford Press; 2017:237–242.

16.?Jafar AJ, et al. Recognising and managing eating disorders in the emergency department. Postgraduate Medical Journal. 2023;99(1169):101–111.

17.?Ayton A, Ibrahim A. Does UK medical education provide doctors with sufficient skills and knowledge to manage patients with eating disorders safely? Postgraduate Medical Journal. 2018;94:374–380.

18.?Ma C, et al. Emergency medicine physicians’ knowledge and perceptions of training, education, and resources in eating disorders. Journal of Eating Disorders. 2021;9:4.

19.?Micali N, et al. Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors. BMC Medicine. 2017;15:1.