Home

Cover Story

Current Issue

Daily Recipes

E-Newsletter

Podcast

Article Archive

Editorial Calendar

Datebook

Writers' Guidelines

Orgs/Links

Reprints

Search

We generally think of adolescents and young adult women as the at-risk population for eating disorders. The media usually focus on bulimic young models and self-starved teenage girls. However, for numerous reasons, eating disorders are appearing with increasing frequency among women in midlife and older.1

It is often difficult for professionals working with patients with eating disorders to keep in mind that restrictive eating, bulimic behavior, and compulsive overeating are all manifestations of underlying emotional issues. As nutrition professionals, we often focus on the concrete dietary and nutritional issues rather than exploring the psychological context.

Deep-seated emotional issues are usually the domain of the therapist, but we can serve as the bridge between specific food information and the more complicated emotional foundation of the eating disorder. We can also help our clients see the connection between food behaviors and other life issues.

Change Is Hard
Eating disorders often manifest during times of transition. In preadolescence, physical and associated social changes can lead to anxiety and feeling a loss of control. An eating disorder may (consciously or subconsciously) provide a way to slow or prevent the onset of puberty, provide a sense of control, and place a barrier against the intensity of teen life. During teen years, girls may be overwhelmed by unrealistic, but nonetheless real, expectations about appearance and attractiveness.

Transition from high school to a job or higher education often moves teens out of a familiar and safe childhood home, away from established friends, and removes them from direct parental support. An eating disorder offers a sense of control, a way to numb or distract, and a means to call for help and support.

Adulthood does not end internal conflict, especially for women. In midlife, there may be even more changes, more responsibility, less support, and a feeling of being invisible. Midlife is a time for a high level of change that often goes unappreciated and unnoticed, even by health professionals.1 Body image dissatisfaction in midlife women has increased dramatically over the last two decades.2 As the “baby boomers” grow older, the number of women with eating disorders will potentially increase. It will become even more important to screen this target group for possible eating disorders and find effective ways to respond.

“Mature” Issues
Some emotional issues affect women of all ages—body image/self-esteem, uncertainty about the future, and feeling overwhelmed or out of control. One major difference, however, is that women at midlife often must deal with loss or unresolved loss/transition. Often called the sandwich years—when the care needs of one’s aging parents and maturing children collide—midlife years speed by, leaving many women without time and resources to process the changes.

Consider the many issues at midlife—physical deterioration, loss of youthful vigor, menopause looms.3 For women who have raised a family, the pending loss of childbearing capability can be a mixed blessing. For women who have not had children, this can be a time of great loss and sadness.

Conversely, the “empty nest syndrome” robs many women of their primary adult role, raising children, especially if they have not had a career outside the home. Suddenly “I’m a mom” is replaced by “Who am I now?” Some women experience a sense of low self-value, which can be expressed as an apology for being “only a housewife and mother.” Society often sends a message that money and power equal value, so they feel less valuable than their career-oriented peers.

Besides menopausal symptoms, women experience changes in their skin, muscle tone, and body fat distribution. It becomes more difficult, if not impossible, to maintain the physical appearance they had a few short years ago. Joints and muscles do not work as well; pain and stiffness take longer to go away. Serious medical issues such as breast cancer, skin cancer, or arthritis may trigger thoughts of mortality.

Research tells us that women’s body dissatisfaction is sustained at a steady level throughout the lifespan. However, mid-life has the second-highest rate of divorce (after the late 20s). So the loss of a more youthful appearance comes at a time when women feel even more pressure to compete—for a mate or in the workplace.4 Age-peers may die, and one’s mortality becomes real, not abstract. Remarriage could mean sudden acquisition of a second or “blended” family.

A retired spouse means less private time, changed daily routines, possible home relocation or downsizing, changes in financial status, increased travel, and the need to begin a career or return to school. For careerists, there may be changes in work structure: Part-time work, home business, or telecommuting relationships can provoke a feeling of isolation.

A societal double standard admires men as they age but tends to make midlife women feel less revered. Since birth, women’s value has been associated with their physical body, not necessarily their inner qualities. As youthful appearance is lost, they believe they have also lost their value, sexual appeal, and personal power.

The work world offers little comfort. Again, they are competing—with men, with younger women, and with career women who have been in the field longer.

Mother Didn’t Tell Me...
Some women feel lost and alone because the issues and pressures they face at midlife are different from those their own mothers experienced. This means they are not able to get the support they need and may feel voiceless and isolated. Aging parents can be another stressor since caregiving can demand time and resources, or may even mean aged parents moving into the home. It also reverses the child-adult role, which can be a major emotional transition.

Because women tend to care for others before themselves, they often do not take the time to process the transitions and losses occurring in their lives. Possible losses include loss of youth, childbearing, physical capabilities, health, relationships, children in the home, previous job, family home, parents, friends, support systems, spouse, or the dream of what they thought life would be like.

It is easy to see why midlife women may feel overwhelmed and out of control. Many women express guilt if they take the time and money to see a therapist or exercise. Many women cannot even think of the last time they did a “self-nurturing” activity.

Sometimes Food is All I’ve Got...
The incidence of eating disorders in midlife appears to follow three major paths. Some women presenting at midlife have had the eating disorder for a number of years, but it was never previously addressed. Others had treatment when they were younger but have relapsed. A third group, often because of accumulated stress or an acute episode (such as a divorce), now exhibit an eating disorder for the first time.

Many overweight women practice disordered eating, but it is important to note that many women who appear to have a weight problem may actually need intervention for an eating disorder. Compulsive overeating can follow a continuum of degree, similar to restrictive eating.

No matter what the path, working with an eating disorder team is crucial. In some cases, family or marital therapy may also be useful.

Problems With Eating Disorders at Midlife
An eating disorder at midlife creates profound health risk. As the body ages, there is loss of muscle mass, increased bone loss, and less vigorous immune response. With restrictive eating, these physical changes are exaggerated.

Women with a restrictive eating disorder for weight control are actually decreasing the control they could have over calories because of reduced muscle mass/metabolism. Sleep problems common at menopause can be worsened by restrictive eating. Because body fat can produce low levels of estrogen, having a healthy amount of body fat can reduce menopausal symptoms such as insomnia and hot flashes, so a youthfully slim menopausal woman may feel worse than a more rotund one.

Maintaining bone density is extremely important. At menopause, bone loss accelerates. Since bone is composed of a number of nutrients in addition to calcium, a restrictive diet can exacerbate bone loss.

Inadequate nutrients can also speed the rate of aging and increase the risk of disease by lowering protection against free radicals and reducing immune function. Compulsive overeating can be of concern depending on the choice of foods consumed. In some cases, the foods eaten are high in sugar and fat while low in fiber and nutrients. This can lead to heart health concerns, diabetes, intestinal issues, and some cancers.

Because of the possibility of increased weight with midlife and the increasing deposition of fat in the abdominal area, some midlife women turn to compulsive exercise. This may promote a sense of being more in control when their body and life start to feel out of control. Excessive exercise can increase the risk of injury and damage to body parts such as joints.

Depression is common among midlife women. Sometimes it is related to body changes, but it often goes well beyond. It can present as restrictive eating, purging, substance abuse, or compulsive overeating. Dealing with food issues and weight can be part of the solution, but there are still underlying issues that need to be addressed. Remember that the food response is only a symptom—not the cause.

Difficulties in Recovery
Women with a long history of an unresolved eating disorder are more entrenched in their thoughts and behaviors than younger women. They have spent more years denying their pain, emotional needs, and true feelings. There are fewer screening tools in place by healthcare professionals to flush out midlife eating disorders as compared with younger age groups. Because of busy lives and countless responsibilities, women with midlife eating disorders often use the excuse that it is difficult to commit the time and effort required for recovery.

Compared with younger women, this age group may get more easily discouraged. Few seek treatment because they feel that by midlife they “shouldn’t” have an eating disorder and “should” be able to recover on their own. They mistakenly believe their issues are less legitimate than those of younger women, despite having more complex lives. They may deny their pain; they may internalize shame and self-blame. They may fear disappointing others or revealing imperfections. Some surrender to the idea that they are doomed to be unhappy or don’t deserve to feel better. Compulsive overeaters often feel they have never succeeded with weight loss in the past, so why would it be any different now?

What We Can Do
Does any of the above sound familiar? The good news is that we can help. As dietitians, we need to address any food distortions, but we can also respond to emotional distortions and obstacles. Play detective and understand the underlying issues with clients. If we just touch the surface (concrete food issues), we will not be effective. We must ask: What are this woman’s emotional needs, fears, and hidden motivations?

Think of your clients’ lives as jigsaw puzzles. Eating and food are only one puzzle piece. To be effective, we must look at the whole picture. This may involve physical, emotional, spiritual, intellectual, and/or environmental factors.

Build trust by really listening rather than being too ready to lecture and solve their problem. They need to feel that someone truly understands. They may also be unaware of how their food issues relate to their emotional issues. Challenge them to look below the surface.

Many midlife women believe they should be able to counter the changes happening to their physical body and continue to compare themselves with younger women. Dietitians must educate them about normal body changes with aging and help them accept the inevitable process.5 Helping women discover other ways to express power and value besides their physical bodies is difficult but always worthwhile.

Have clients make a list of emotional issues. Identify any relationship problems or individuals preventing their recovery. Facilitate their thinking about solutions to these issues.

If there are stressors over which they have some control, encourage them to take action. If there is no solution (such as inevitable aging), discuss how can they learn to accept the situation and move on.

If there are stressors over which they have no control, explore their current coping mechanisms and brainstorm healthier ones. If they have a history of other abusive behaviors, such as substance abuse, it is even more crucial to practice appropriate responses.

Society sends the message that women should be able to “do it all.” Women may not even question the role of “superwoman” they try to fill. Some believe they are not living up to expectations if they do not constantly feel overwhelmed. It may also be a way to avoid working on emotional issues.

Have your clients consider the positives and negatives of life choices. Is the benefit worth the stress? Have them practice asking for help from others—family members, friends, professionals, etc—and setting boundaries. Taking time for rest is not loafing.

What do they currently do for self-nurturing? What self-nurturing activities could they do if they were not constantly helping others? Have them make a list with the goal of doing at least one self-nurturing activity each day. What perceived obstacles prevent self-nurturing? How can these be overcome? Remind them of the message we get on a plane—“put on your oxygen mask before you assist others.” We are only able to help others if we have taken care of ourselves first.

Help clients see the “red flags” that lead to disordered thinking—usually a series of escalating events. What situations start the snowball rolling toward eating disorder behaviors? When they see these coming, such as an emotional event that could trigger negative thoughts, what can they do to prevent an eating disorder response?

Three Ds
Distancing, delaying, or distracting can be developed as self-protective tools.

Distancing can mean either removing oneself from a situation or physically distancing oneself from foods one tends to binge on or overeat. Delaying means providing some time between the emotional event and the usual coping mechanism to allow for emotional decompression. A healthier coping mechanism can then be inserted to replace the old. Distracting means finding something totally different from the emotional issue, food environment, and normal coping response.

• Lists. Since emotions are spontaneous, you may want to help the client make and keep handy a list of ways to distance, delay, and distract. When the emotional event occurs, they can practice suggestions on the list.

• Journaling. A food/mood/coping mechanism journal can provide additional information for the dietitian. The client can also use this written evidence to identify areas of progress and areas that need further work. Encourage communication of feelings to appropriate others and discourage isolation.

• Support. If they have not processed or grieved past losses or unachievable dreams or have had a relapse from a previous eating disorder intervention from younger days, suggest discussing these topics with a therapist.

• Positivity. Many midlife women are so caught up in their regrets that they fail to see the many good years ahead. Encourage them to consider what they want to do with the rest of their life. Everyone needs “a light at the end of the tunnel”—something encouraging them to move ahead. What are their unrealized dreams they can now pursue? What is their current sense of self-value? What criteria do they have for judging themselves?

• Paradigm shift. If they have been involved in a role change, encourage them to consider what new role they would like to fill. What else can give them a feeling of self-worth besides the old paradigm? Can they expand their interests? Volunteer? Go back to school? Change jobs?

• Exercise. If they do not currently exercise regularly, explore what physical movement may be pleasurable. This can help with mood, weight goals, body appreciation, sexuality, and stress reduction.6 A gym workout may not appeal to some women, so have them think outside the box. What did they find pleasurable when they were younger? Many midlife women start ballroom dancing or taking yoga or tai chi classes. These are not only pleasurable but will remind women what their body can do, not what it cannot do.

• Inner growth. In addition to the physical benefits, yoga and tai chi also involve spirituality. More women are finding that some of their emotional hungers are actually a lack of spirituality. This does not necessarily mean religion—it can be related to inner reflection and meditation. It places more focus on the inner self rather than the outer self. Midlife women must learn to value themselves because of their inner beauty and nonphysical life accomplishments. These are the true reasons for self-value.

• Communication. Have clients consider the messages they are sending to other women. Are their eating disordered behaviors and attitudes about food and body image affecting their children, grandchildren, or other women in a negative way? Might they be able to make changes to become a better role model for others? Have them seek positive role models close to their age or older to serve as mentors.

Support groups, if done well, can be very successful for this age group. They allow women to realize that they are not alone with their problems and concerns. They can share ideas about what has helped them move in positive ways toward recovery. This age group may be more motivated to take action because they see the problems will only worsen with inaction and the time clock is ticking. The sense of urgency can assist recovery.

Self-Sabotaging
In some cases, a woman may, consciously or subconsciously, not want to give up her eating disorder because it is serving a purpose. For some, it provides a sense of control. For others, it creates an identity or role. Giving up the eating disorder would mean establishing a whole new role or identity. Reassure them that change can often be difficult but is not impossible. Work together to develop a plan of small steps and congratulate the accomplishment of each step as progress.

Many women with eating disorders use the huge amount of time spent thinking about food and their body as a distraction from emotional issues or losses they do not want to address. Compulsive exercisers often rationalize the need for a high level of exercise to purge their stress and counter the health concerns of growing older.

Depending on personal history, an eating disorder may serve as a source of punishment women feel they deserve. Women with anorexia may use restrictive eating and a shrinking body size to feel invisible, matching the message from our culture. For many, it is the only coping mechanism or vehicle for communication.

By trying to take away the symptom of the eating disorder—the eating response—it leaves women feeling even more empty and out of control. Think of a sliding door. Consider small actions steps to increase self-esteem, a sense of value, a forward-thinking sense of purpose, and other ways to feel in control. Then, encourage a gradual change in eating behaviors. Genuine cheerleading is important. Support, praise, and encouragement are crucial. Let them know that short lapses are normal and talk about how to use them as a learning tool. Help them work toward a goal of shorter, less frequent lapses.

Although many of these topics do not directly involve food, until they are brought to the surface and action begins to change the root causes of the eating disorder, dietitians will not make much of an impact with dietary changes. We are not trained to deal with deep-seated psychological issues, such as a sexual abuse history or major depression, but we can at least work with the client in a more comprehensive approach to increase our chances of helping them move forward.

— Pamela Stuppy, MS, RD, LD, has a nutrition consulting business with offices in York, Me., and Newington, N.H. She has written a course on osteoporosis for Nutrition Dimension, Inc., is the dietitian for Phillips Exeter Academy, and is the consulting dietitian for Oakhurst Dairy. She is also the weekly columnist for three southern New Hampshire newspapers.

References
1. Zerbe KJ. Eating disorders in middle and late life: A neglected problem. Primary Psychiatry. 2003;10(6):80-82.

2. Serdula MK, Mokdad AH, Williamson DF, et al. Prevalence of attempting weight loss strategies for controlling weight. JAMA. 1999;282:1353-1358.

3. Bulik CM, Taylor N. Runaway Eating: The 8-Point Plan to Conquer Adult Food and Weight Obsessions. Emmaus, Pa.: Rodale, 2005.

4. Tiggemann M. Body image across the adult lifespan: Stability and change. Body Image. 2004;1:29-41.

5. Zerbe KJ, Domnitei D. Eating disorders at middle age. Eat Disord Rev. 2004;15(3):1-8.

6. Kearney-Cooke A, Isaacs F. Change Your Mind, Change Your Body: Feeling Good About Your Body and Self After 40. New York: Simon & Schuster/Atria Books, 2004.

2. When does body dissatisfaction end for women?
a. Adolescence
b. Mid-20s
c. Right before menopause
d. It remains stable across the life span.
e. After approximately the age of 70

3. Which of the following may contribute to a midlife eating disorder?
a. Body changes due to aging
b. Stress of dealing with aging parents
c. Increasing medical issues
d. Changing roles
e. All the above

4. Why does an eating disorder appear at midlife?
a. Never addressed at a younger age
b. Treated previously and relapsed
c. The body responds more easily to food restriction at this age.
d. Culmination of numerous emotional issues/responsibilities
e. a, b, and c

5. What health concern is most likely to be aggravated by a midlife eating disorder?
a. Kidney stones
b. Bone density
c. Breast cancer
d. Diverticulitis
e. Rheumatoid arthritis

6. What can get in the way of recovery?
a. Fear of role change
b. Learning the truth about aging
c. Wanting to use food issues as a distraction
d. Distaste for exercise
e. a and c

7. How can the dietitian improve outcomes in midlife eating disorders?
a. Clarify food distortions.
b. Discover and help the client realize underlying emotional issues.
c. Encourage other ways to define self-value besides physical body.
d. Encourage self-nurturing activities.
e. All the above

8. What rationalization may a compulsive overexerciser use when self-sabotaging?
a. She is building muscle mass.
b. Practicing competition.
c. Reducing stress.
d. Showing the dietitian she is ready to work towards recovery.
e. None of the above

9. Within ethical boundaries, how can the dietitian serve as a “bridge” for eating disorders?
a. Explore emotional eating
b. Delve into sexual abuse history
c. Work on severe depression issues
d. Talk to the client’s friends about her emotional issues
e. None of the above

10. How can activities such as yoga assist in the recovery of midlife eating disorders?
a. Allow for greater body appreciation
b. Encourage spiritual expression
c. Increase a sense of control
d. Stress reduction
e. All the above