Eating disorders in midlife

What does an eating disorder look like? Likely to spring to mind is a young, waiflike woman strutting down a catwalk, bones protruding under her clothing. Yet her older sisters aren't immune to anorexia, bulimia, and binge eating. Weight-control efforts veer into dangerous territory in more women at midlife and beyond than popular images suggest.

It's no secret that most of us have dieted at some point — some of us on a regular basis — but women can face unique stressors as we age that increase our risks of eating disorders, Harvard experts say. The rigors of calorie restriction or binge-purge cycles on an older body, in particular, can also lead to worsened health effects.

By age 40, one in five women has dealt with an eating disorder, twice the proportion identified in women at age 21, according to a 2019 study in JAMA Network Open. Many cases are likely a resurgence of a long-simmering pattern from earlier years that may have flown under the radar, says Dr. Holly Peek, associate medical director of the Klarman Eating Disorders Center at Harvard-affiliated McLean Hospital.

"Many women with eating disorders in midlife have had the problem for most of their lives," Dr. Peek says. "And a lot are going through major life transitions starting around age 40 that are all different from those of a teenage or young woman."

Disordered eating that barely skirts the line between normal and problematic is also highly common, more so than diagnosed eating disorders. "Up to midlife, it could look like chronic dieting, yo-yo dieting, or excessive exercise. Sometimes women get wrapped up in this identity of being a gym rat who eats very clean, and menopause-fueled body changes make them ramp it up even more," Dr. Peek says. "It may not even feel like a problem to them. It gets really complicated."

Midlife risk factors

Many variations of eating disorders are possible, but three types dominate: anorexia nervosa, characterized by extreme food restriction; bulimia nervosa, gorging followed by purging through vomiting or laxative use; and binge eating disorder, eating huge amounts past the point of feeling full.

Anorexia becomes less common after age 26, but bulimia rates don't top out until age 47, according to a November 2017 study in the International Journal of Eating Disorders. Meanwhile, binge eating disorder — the most common eating disorder in all adults — can continue to be a problem for women in their 70s.

What fuels such pathologic preoccupation with food and weight through the decades? Midlife and older women may be trying to stay competitive in the workplace, where thinness may be associated with youth, or re-emerge on the dating scene after divorce or widowhood. The jolt of an empty nest may also propel body-redefining efforts.

"The importance of body image seems to be a key feature that makes women either return to or start an eating disorder," says Dr. Bettina Bentley, a primary care physician at Harvard University Health Services. "With aging, many women are also disturbed by the lack of control over the ways their body is changing."

Indeed, estrogen shifts related to the menopause transition can heighten eating disorder risks. "We know that estrogen plays a role in developing an eating disorder on both ends of the age spectrum, but in terms of why, the jury is still out," Dr. Peek says. "Women during menopause are more likely to gain weight, and you may feel your body is working against you."

Array of health effects

Even when invisible to others, eating disorders can take a toll on the body. At a minimum, women with eating disorders are often deficient in some nutrients, particularly iron, vitamin B₁₂, calcium, and vitamin D, says Margaret Schrier, a registered dietitian and head of nutrition at Harvard University Health Services. "Supplements can help with deficiencies and are usually well tolerated by patients," Schrier says. She advises taking them with food, since they may not be absorbed as well on an empty stomach.

Extreme weight loss, purging, and malnutrition can also lead to these problems:

Bone loss. The risk of bone fracture is seven times higher in someone who's had anorexia than in the general population, Dr. Bentley says. While bone density testing isn't routinely recommended for women in their 50s, she orders it for those she thinks might have an eating disorder as well as those who've broken bones.

Heart problems. Lower electrolyte levels from disordered eating can lead to an irregular heartbeat. Women in midlife are also more likely to take medications for chronic conditions, which can increase this risk. "It's more of a recipe for a medical emergency, because your body just isn't as resilient as when you were 16," Dr. Peek says.

Lung conditions. Chest muscles become weaker over time, especially in people who repeatedly force themselves to vomit. This raises pneumonia risk.

Gastrointestinal issues. Reflux, bloating, nausea, vomiting, constipation, or diarrhea may be dismissed as consequences of aging but instead may be related to an eating disorder.

Diabetes. People with binge eating disorder have far higher rates of diabetes, likely fueled by frequent blood sugar spikes after gorging, Dr. Bentley says.

Skin breakdown. Poor wound healing and profound facial wrinkling is common in people with longstanding anorexia, Dr. Bentley says. This probably reflects overall poor nutritional status.

While eating disorders claim more lives than any other type of psychiatric illness, only 27% of those affected seek professional help. A team of health professionals that include a dietitian and therapist can help shepherd patients to better physical and mental wellness. If you suspect you have an eating disorder, don't be afraid to have a frank conversation with your doctor. She is trained to assess and treat eating disorders as she would any other medical condition, without judgement.

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