May 2024 Issue

Menopause and Eating Disorders
By Carrie Dennett, MPH, RDN
Today’s Dietitian
Vol. 26 No. 5 P. 24

Why a “Window of Vulnerability” Increases the Risk in Midlife

Women going through the menopausal transition—which encompasses perimenopause and postmenopause—are at elevated risk of eating disorders. But pervasive myths about who gets eating disorders and who doesn’t mean that these women are more likely to go undiagnosed and untreated.1

Here’s what all dietitians need to know about eating disorders in this unsettling phase of women’s lives.

“The misperception that eating disorders occur only in adolescence and early adulthood has done a huge disservice to every adult, middle age, and older woman out there who suffers from an eating disorder,” says psychologist Cynthia Bulik, PhD, founding director of the University of North Carolina Center of Excellence for Eating Disorders. “In addition, it has contributed to the absence of good epidemiologic data on how common they are across the lifespan.”

A 2012 study estimated that 13% of American women aged 50 and older have eating disorder symptoms, higher than the rate of breast cancer.2 A 2017 study found that about 3.5% of women over 40 have a diagnosable eating disorder, yet most aren’t receiving treatment.3 Data from STRIPED (Strategic Training Initiative for the Prevention of Eating Disorders) shows that among females suffering from an eating disorder from 2018 to 2019, 34% were aged 40 and above, and 20% were aged 40 to 59, encompassing the menopausal years.4

Menopause is the stage of life when a woman hasn’t menstruated for 12 months, ending the reproductive years. The average age of menopause is 51, but it may happen between the ages of 40 and 58. In the transition to menopause—perimenopause, typically lasting four to eight years—women may experience irregular periods, hormonal fluctuations, and symptoms such as hot flashes, night sweats, insomnia, mood swings, brain fog, migraines, vaginal dryness, and frequent urination.5,6

The lack of data on midlife eating disorders also makes it challenging to pinpoint which eating disorders are most common. A 2017 study found that while rates of anorexia nervosa plateau around age 26, rates of bulimia nervosa plateau at around age 47, and rates of binge eating disorder don’t plateau until the 70s.7 Binge eating disorder involves eating unusually large amounts of food in a specific amount of time, often in secret and to the point of uncomfortable fullness. Bulimia nervosa involves binge eating followed by behavior that compensates for the overeating, such as forced vomiting, excessive laxative use, fasting, or inordinate exercise. Anorexia nervosa involves severe food restriction or avoidance, often with frequent weight monitoring and the perception of being overweight even when dangerously underweight.8

A 2023 review found that most data suggests that binge eating disorder and OSFED (other specified feeding or eating disorder) are the most commonly diagnosed eating disorders in middle-aged and older women, with some research finding that atypical anorexia—anorexia without an underweight BMI—is the most prevalent diagnosis.9

Window of Vulnerability
Research suggests that the hormonal changes of perimenopause may open a “window of vulnerability” to developing eating disorders.10,11 “The transition to menopause is accompanied by dynamic and turbulent shifts in hormones,” says Val Schonberg, RD, MSCP, an Atlanta-based specialist in midlife nutrition and eating disorders, adding that puberty and the postpartum period also involve significant hormonal shifts. “There is general agreement that these are times of increased risk of mood disorders and other psychiatric conditions.”

Schonberg says perimenopausal fluctuations in estrogen and progesterone are associated with changes in eating disorder symptoms, noting a small 2019 pilot study of eight women in early perimenopause that found that increasing estrogen levels were associated with an increase in binge eating when progesterone was high but not when progesterone was low. The study also observed that increasing estrogen was associated with higher body dissatisfaction when progesterone was high but lower body dissatisfaction when progesterone was low—although this particular finding wasn’t statistically significant, possibly due to the small participant sample.12

A 2021 study found that women reporting more severe menopausal symptoms were more likely to experience disordered eating and body dissatisfaction.13 A 2019 review suggested that stress levels may moderate the association between binge eating and fluctuating hormones,14 while a 2023 review suggested that the menopausal transition may represent a period of vulnerability only in women who are especially sensitive to the fluctuations and decreases in ovarian hormones, possibly due to genetic predisposition.15

“Puberty and menopause are reproductive bookends, and both are marked by fluctuating hormones that affect not only our thoughts and moods, but also our body shapes—all of which can feed into eating disorders,” Bulik says. “We often think about the changes in girls’ bodies during puberty and how that can influence self-consciousness, teasing, bullying, and eating disorder risk. But we talk less about how those changes around the menopause transition can have a similar effect.” She says the widening of the waist and other bodily changes that come with the absence of estrogen can feed body dissatisfaction, leading to unhealthy behaviors aimed at fending off aging, which then has the potential to trigger eating disorders.

Body Dissatisfaction and Social Factors
A 2023 study found that body dissatisfaction—specifically, fear of gaining weight and fear of losing control over eating habits—is a core feature of eating disorder pathology during perimenopause and early postmenopause.16

Margo Maine, PhD, FAED, CEDS, a West Hartford, Connecticut-based clinical psychologist and author of Pursuing Perfection: Eating Disorders, Body Myths, and Women at Midlife and Beyond, says that most women gain an average of eight to 15 lbs during the menopausal transition. “We used to talk about the freshman 15 when we were going off to college. People have the same attitude about the menopause 15. There are a lot of women who start dieting around menopause in order to avoid that weight gain.”

Los Angeles-based Robyn Goldberg, RD, CEDRD, author of The Eating Disorder Trap and host of the podcast of the same name, says disordered eating, including food restriction and compulsive exercise, is common when a woman is going through menopause because her body is changing and she doesn’t recognize the body that she’s developing. “The thing I hear over and over is ‘I’m developing this spare tire about my midsection.’”

Maine says that while there’s fear about weight gain, that’s not all that’s going on for women around menopause. “There are a lot of changes in our social roles as we get older. We are seen as less important, less attractive to other people, and we start to internalize that. We see the changes in our body, we worry about getting older and being less attractive to our mates and spouses and significant others and people we want to attract.”

Schonberg emphasizes that these changes are happening at a time when women’s lives already may feel out of control. “Women are transitioning to a new stage in life. For some women, kids may be leaving the home. They may be dealing with aging parents, divorce, career changes, downsizing out of the home in which they raised their kids. Throw on top of this the impact of antiaging messages,17 weight stigma and weight bias in health care, and it’s really a perfect storm for the development of extreme body dissatisfaction and fear of eating, which are significant contributors to the development of eating disorders.”

Eating Disorder Onset
When women experience eating disorders around menopause, is this a retriggering or reemergence of an old eating disorder, or is it a new eating disorder? The data suggests that most midlife or older women with eating disorders experienced at least some disordered eating—if not an actual eating disorder—earlier in life.18 However, a 2017 study coauthored by Bulik found that 3.6% of midlife women had experienced an eating disorder in the previous 12 months—with 41.6% of those being new onset.19

Bulik says she’s observed three patterns: “Perhaps the most common is women who developed eating disorders when they were younger and have never fully recovered and lived their entire life with some degree of an eating disorder—some even quite impairing—always carrying the burden of eating disorders thoughts and behaviors along with them. Then we see women who had eating disorders when they were younger, did make a recovery, and then relapsed around the menopause transition. The least common group is those who truly develop an eating disorder for the first time later in life.”

Goldberg agrees that most women with eating disorders in midlife had them for most of their lives, white-knuckling their way through the discomfort. “The research shows that by age 40, one in five women has dealt with an ED.20 For many, they were never in treatment because there were areas of life that became more of a priority, like finding a partner and starting a family, so they don’t have formal coping tools and strategies. Those behaviors became dormant until something activated them later in life and then it just spiraled out of control because they never learned how to manage it.” She says women who have lived their lives this way may at some point realize, “‘I can’t control that my children are living their own lives, I can’t control that my aging parents have dementia, but I remember that when I was dieting, I had some control.’ We often see this with women who have a chronic dieting history. Maybe their intention is not to develop an eating disorder, but it snowballs into one.”

Maine estimates that 10% to 20% of eating disorders around menopause are new onset. She also says that when talking to colleagues who treat many adult women, they agree that several midlife women struggle with subclinical eating disorders or OSFED, and that because they don’t meet the full criteria for anorexia or bulimia, they don’t get identified—by themselves or by anybody else.

Health Consequences and Missed Diagnoses
As part of this conundrum, eating disorders often accompany other mental health disorders, such as depression and anxiety, and they take a toll on almost every body system, including digestive, skeletal, and cardiovascular. And aging bodies may be especially vulnerable to certain medical complications that can lead to sudden death, such as cardiac arrest or suicide.21,22 Other complications take a slower path, as with bone loss that leads to a hip fracture and a downward health spiral.23 And then there’s quality of life. Even if an eating disorder doesn’t kill someone, it makes life less than what it could have been.

What’s unfortunate is that while eating disorders are underdiagnosed at any age, they’re more likely to be missed in midlife. Women aged 40 or older admitted for treatment at an eating disorder facility tend to have had their eating disorders longer than younger women who are admitted for treatment.24,25 “We’ve had women who go to their PCP [primary care physician] saying ‘I think I have an eating disorder. and I need help’ and the PCP responds with something like ‘You’re too old for an eating disorder,’” Bulik says. “Years of misunderstanding means that they’re basically off the radar screen of providers who treat women in this age group.”

Maine says many doctors believe eating disorders exist only in “skinny bodies,” which doesn’t help. “It’s not about the body and weight; it’s about the relationship to food and to her body. And that can come in any shape or size,” she says.

Schonberg says other reasons why eating disorder diagnoses are missed in menopausal women include shame and stigma. Patients may underreport their eating disorder symptoms because of shame, while doctors may stigmatize psychiatric disorders. She also says the glorification of sports and fitness enables eating disorders to easily hide behind excessive exercise.

According to Goldberg, many of the gynecologists she works with have screening questions about dieting history or body image. Yet, because many still consider eating disorders as a young person’s disease, they quickly pass over the questions, and many women fall through the cracks. “I have clients who’ve had interventions by their grown children, their grandchildren, their spouse.”

Strategies for Dietitians
While it’s important for anyone struggling with an eating disorder to see a dietitian, Goldberg says odds are they won’t initially land in the office of an RD who specializes in eating disorders, perhaps because they’re seeking weight loss. “Even if you’re not interested in becoming a specialist in eating disorders, learn how to counsel from a place of weight inclusivity and body acceptance,” Goldberg says. “Work on the language you’re using and how you’re speaking. Try to find experts in your area that specialize in eating disorders and menopause, or get supervision from someone who does,” she says, adding, “Please don’t make recommendations to exclude a specific food or food group, or tell them times that they shouldn’t eat before or after, because that’s contributing to the problem.”

Schonberg says that due to the particular nutrition concerns of midlife eating disorders—increased risk of nutrient deficiencies, the body’s lessened ability to fight disease, negative impacts on bone and cardiovascular health—it’s important for dietitians to screen for them, take them seriously, and make referrals to eating disorder–informed providers, if needed. “It’s also important to be curious about your own views on aging, weight, and menopause,” she says. “Recognize the medicalized views of menopause symptomatology, including weight, that contribute to a narrative that it’s a dreaded disease to fix or prevent.”

Dietitians can ask questions, Bulik says, that reveal a client or patient’s motivation for wanting to lose weight or control their appetite. “Getting a good sense of why they’re eating what they’re eating, and not just what they’re eating, is a beautiful open doorway to follow up about what types of methods they’ve used to lose weight, whether they have emotional eating, loss of control eating, compulsive eating, or binge eating, and if they have a history of an eating disorder,” she says, adding that this positions dietitians to provide referrals for specialist care if they’re concerned about an eating disorder.

Maine says asking questions about their longer-term relationship with their body and weight and food and whether they’ve had periods of intense exercise or weight loss can help uncover hidden eating disorders. “One of the most important things about working with adult women with eating disorders is to understand how ashamed they are,” she says. “Shame is often one of the instigators of an eating disorder, and not just shame of her body, but shame of any need that she has, shame of herself, and then shame of her eating disorder.”26

RDs also can help clients see their disordered eating within the context of their lives, Maine says, which includes life pressures that have brought them to this point. “It’s always about trying to solve a problem, and often the problem is how inadequate they feel.” Encourage patients to get help, Maine says—whether that’s a support group, an eating disorder dietitian, a therapist, or reading recommended books—so they’re not alone with their disordered thoughts about themselves and their bodies and food. “I can’t say enough about how much women suffer alone with this, and for some it will kill them; it really will.”

— Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Non-Diet Approach to Optimal Well-Being.


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