When eating disorders or body image conflicts are mentioned, the face we imagine is one of youth. It may be a preteen, an adolescent, or a young adult woman, but seldom do we visualize the face of an aging woman. Yet, contemporary western culture consistently values women's bodies and appearance above other attributes, and sexualized images of female bodies saturate mass media, shaping the prevailing ideal.^[1-5] Of course, women of all ages who live in this culture are affected.^[6]

Adult women are on display; they are often criticized for transgressing that ever-shifting fine line between being too sexy or not sexy enough, and they often are completely dismissed when they no longer look young. It goes without saying that older female faces are not particularly popular images in film, fashion, advertising, print media, or television, unless the reference is breast cancer, menopause, or some other medical condition that predominantly affects older women. Moreover, this is an age when the female body can be "fixed" via medical technology, whether it be through laser hair removal, botox injections, chemical and surgical face/neck lifts, nose jobs, breast implants, surgery for "correction of the buttocks,"^[7] and liposuction. This is an age when cosmetic plastic surgery can even be purchased at a mall during a lunch hour (eg, botox injections, laser skin resurfacing, dermabrasion, chemical peels, permanent eyeliner). The point is that these procedures are now offered in retail centers, so it's like buying a new dress – it has been normalized, despite the potential risk and the meaning -- that is, chemically or surgically changing one's body.

Many women have come to believe that they can (and should) be in complete command of their bodies. In this era of body control and unrealistic beauty images, the rhythmic cycles of the female body, many of which are associated with weight gain, such as premenstrual bloating, pregnancy, and the slower menopausal metabolism, present great challenges. If a woman's power is still defined in terms of beauty and a youthful body, the 8 to 12 pounds she naturally gains at menopause can be a source of great distress and anticipated disempowerment. And the current reality is that more and more, older women who are approaching or beyond "midlife" are struggling with their bodies and their eating and are in need of professional help.

Hard data on eating disorders in adult women are limited, but we do have compelling information about the extent of dieting and body image concerns, both of which can be precursors to clinical eating disorders. For example:

• Approximately 43 million adult women in the United States are dieting to lose weight at any given time; another 26 million are dieting to maintain their weight.^[8-10] Body image dissatisfaction in midlife has increased dramatically, more than doubling from 25% in 1972 to 56% in 1997.^[11]
• Comparable levels of dieting and disordered eating are found across the spectrum of young and elderly women.^[12] When asked what bothered them most about their bodies, a group of women aged 61 to 92 identified weight as their greatest concern.^[13]
• A major research project found that more than 20% of the women aged 70 and older were dieting, even though higher weight poses a very low risk for death at that age, and weight loss may actually be harmful.^[14,15]
• In 2003, one third of inpatient admissions to a specialized treatment center for eating disorders were older than 30 years of age (Davis W, personal communication, 2004).
• 60% of adult women have engaged in pathogenic weight control; 40% are restrained eaters; 40% are overeaters; only 20% are instinctive eaters; 50% say their eating is devoid of pleasure and causes them to feel guilty; more than 90% worry about their weight.^[16]

Eating disorders are more common than many other serious and debilitating illnesses, such as schizophrenia or Alzheimer's disease, but they receive much less attention in the healthcare system and far less money for research, treatment, and prevention. Current estimates are that 5 million people in the United States suffer from eating disorders, whereas Alzheimer's afflicts 4.5 million and schizophrenia, 2.2 million.^[17] Eating disorders were once considered to be characteristic of upwardly mobile, white adolescent females in technologically advanced nations such as the United States and western Europe; today, the effects of rapid globalization have made eating disorders a worldwide condition. Appearing in every economic, racial, and ethnic stratum of American culture and in at least 40 countries worldwide, clinical eating disorders, body image despair, severe dieting, and weight preoccupation are no longer restricted to certain high-risk groups in limited geographic localities.^[18,19] This growing list includes places as unlikely as China, India, Mexico, Nigeria, South Africa, South Korea, and the former Soviet Union.^[18]

Descriptions of eating disorders have been part of the psychiatric literature for centuries; eating too much, too little, or not at all, and various forms of purging have long been a means for expression of pain or protest. Today, clinical eating disorders, pathogenic weight control, and body image concerns are of epidemic proportion in women. In light of the number affected by these serious conditions, medical providers must increase their understanding of these illnesses, screen for them in their patients, and learn how to help patients to manage and recover from these illnesses.

Facts About Eating Disorders

The American Psychiatric Association estimates that between 0.5% and 3.7% of women in the United States will have anorexia nervosa in their lifetime and between 1.1% and 4.2% will have bulimia nervosa. Ninety percent of those suffering from eating disorders (ie, anorexia nervosa and/or bulimia nervosa) in the United States are women.^[20] At least one third of those treated in eating disorder clinics are diagnosed as "eating disorder not otherwise specified" (EDNOS), sharing some but not all of the features of these diagnoses.^[21] Fewer data are available regarding these cases, despite their prevalence. See Table 1 for a description of the diagnostic criteria for anorexia nervosa, bulimia nervosa, and EDNOS.^[22]

Table 1. Diagnostic Criteria

Among psychiatric conditions, anorexia nervosa is associated with the highest morbidity, with an estimated 10% mortality at 10 years of symptom duration^[23] and 20% at 20-year follow-up.^[20] Anorexia is the leading cause of death for young women aged 15 to 24 years, with a general mortality 12 times greater than the expected and a suicide rate 75 times greater.^[24] Alcohol abuse in conjunction with an eating disorder increases the risk of death from both medical causes and suicide.^[25] The longer a person suffers, the greater the risk for death. Furthermore, bodies are less resilient as they age and are more likely to break down with ongoing years of abuse.

Less is known about the mortality associated with bulimia nervosa in part due to diagnostic limitations. For example, as many as half of those with anorexia will develop bulimic symptoms but will still be diagnosed with anorexia.^[21] Even less is known about those diagnosed as EDNOS, although their symptoms, treatment needs, and outcomes may be just as serious.

The incidence of eating disorders in males has also increased; in fact, a 1994 report by Powers and Spratt^[26] suggested the number of males with bulimia nervosa surpassed the number of females with anorexia nervosa. Males also account for 25% of the cases of binge-eating disorder, a provisional diagnosis in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.^[22]

Subclinical eating disorder is the term used to describe those who may be symptomatic sporadically or whose symptoms do not quite meet the criteria for a full-blown clinical eating disorder, although some may later emerge into full syndrome eating disorders.^[27] Although estimates of the incidence of subclinical eating disorders are inconsistent, comprehensive studies provide compelling data regarding the common use of pathogenic weight control techniques in teenagers whose bodies are still developing and growing. A 1998 survey of more than 80,000 9th and 12th graders in the United States found that 56% of 9th grade females and 28% of males are engaged in unsafe dieting practices, including skipping meals, ingesting diet pills or laxatives, inducing vomiting, smoking cigarettes (for the purpose of affecting their weight and food intake), and binge-eating. Among 12th graders, 57% of females and 31% of males practice dangerous dieting, with Hispanic and Native American students reporting the highest rates.^[28]

Subclinical eating disorders seem to be as endemic among adult women as they are among teens and young adults. Because of serious gaps in research regarding the health and nutritional status of older adult women, however, we do not have reliable statistics describing the true range and impact of eating disorders in this population.

Several different patterns emerge in the lives of adult women with eating disorders. Some have struggled with body image loathing since their youth and have never escaped the grip of these obsessions. Others had an eating disorder in their teens but recovered, only to relapse when they were older. Some may have been preoccupied with food and weight for years but were never incapacitated when younger; or, they may be women who, faced with the challenges of adulthood and loss of status in a youth-obsessed world, begin to diet for the first time in their lives. Furthermore, the "war on obesity" and the misinformation promulgated by the diet industry intensify many women's concerns about health at and beyond midlife, contributing to restrictive dieting that may lead to full-fledged eating disorders.

Just as for young women, eating disorders in older women range in kind and severity, from anorexia to bulimia, EDNOS, binge-eating disorder, and subclinical eating disorders, including orthorexia. (Orthorexia refers to a fixation with "righteous eating." Orthorexic individuals obsess about eating correctly to the point that they can become depleted nutritionally due to a lack of balanced intake of protein, fat, and other nutrients. This can lead to depression, anxiety, and social isolation, as well as to physical problems).^[29]

Many common threads can be found among women of different ages suffering from significant eating and body image issues. They often share ambivalence about their power and place as women, with deep conflicts between their masculine and feminine strivings. They all must navigate a path in an overwhelming consumer culture that teaches them to want and to need, but not to know their true wants and needs. The bombardment by strict and unrealistic media images of beauty does not end at adulthood. In fact, for many women, the focus on appearance and youth intensifies as their bodies age and progress through the natural stages of change that include weight gain, graying hair, and wrinkled skin. The pressure to pursue the "perfect body" persists, functioning to distract women from more significant issues in their lives.

Coexisting Issues

Eating disorders often co-occur with other psychiatric issues that may not be immediately apparent to primary care providers. For example, personality disorders appear more frequently in individuals with eating disorders than expected, with rates of co-occurrence varying from 27% to 93%.^[30] Posttraumatic stress disorder is also frequently found to accompany the diagnosis of an eating disorder. Research indicates that between 20% and 50% of women who present with eating disorders have experienced previous trauma.^[31] These experiences, which include childhood sexual abuse, emotional or physical neglect or abuse, separations from caregivers, witnessing domestic violence or extreme family chaos, increase the possibility of a range of psychological problems.

As a response to trauma, eating disorder symptoms may function in various ways to self-soothe and calm the individual. For example, dieting may be a means to:

• transcend basic human needs in order to feel "in control" and to need nothing from others;
• purify the self;
• repulse potential perpetrators through an emaciated body;
• give an illusion of power and invincibility;
• provide meaning, predictability, and structure amidst chaos or confusion; and
• feel successful and valued by others.

Bingeing may serve to:

• fill internal emptiness;
• comfort and nurture the self;
• escape pain, anger, despair, inadequacy, shame; and
• create a behavioral armor to repulse others.

And purging may serve to:

• purify, cleanse the body and soul;
• set limits;
• express anger;
• punish the self; and
• distract from psychic pain by inducing physical discomfort.

Many women suffer from both substance abuse and eating disorders. Women with eating disorders are 5 times as likely to abuse alcohol or drugs. And, alcohol- or drug-abusing women are 11 times more likely to have eating disorders.^[32] Alcohol or drug abuse may be an attempt to manage emotional pain, stress, anxiety, guilt, depression, anger, shame, and isolation, or, to suppress weight/appetite, to purge, or to calm self in order to sleep or end a period of bingeing. Commonly abused substances include the following:

• alcohol;
• amphetamines, including diet pills;
• anti-anxiety agents;
• aspirin;
• caffeine (soda, coffee, caffeine in pills);
• cannabis;
• cigarettes;
• cocaine;
• diuretics;
• herbal supplements promising weight loss and increased metabolism;
• heroin;
• glue and other inhalants;
• laxatives;
• pain killers;
• syrup of ipecac; and
• various other prescription drugs (eg, thyroid meds, insufficient insulin).

Biogenetic Contributions

Although specialists agree that eating disorders seem to run in families, the explanations for this differ. According to a review of genetic studies, the lifetime risk of developing an eating disorder is 6% for those who have a first-degree relative who has suffered from one. The risk is only 1% for those without this shared familial background.^[33] Some theorists and researchers believe these data point to a significant genetic loading for eating disorders, but the susceptibility to eating disorders surpasses sheer genetic influences. Even those writing about the genetic contributions to eating disorders state: "Genetics loads the gun. The environment pulls the trigger."^[34] Just as people with high risk of alcohol addiction due to genetics will only become addicted if the environment provides and endorses alcohol use, living in a culture that glorifies thinness and dieting, promotes the language of fat, and objectifies women's bodies can function as the trigger for a woman with genetic risk for an eating disorder.

The research on the genetic contributions to eating disorders is in infancy, but the consensus is that genetics most likely impose indirect effects creating a vulnerability to eating disorders. Personality characteristics -- such as perfectionism, obsessive behavior, anxiety, sensitivity to criticism, and a family history of depression, anxiety, or addiction -- may have genetic roots and may place an individual at risk. The social environment and psychosocial stressors will either prevent or exacerbate the effect of these risk factors. These include family functioning and communication patterns, parent-child relationships, teasing, body preoccupation, and stressful events such as loss, illness, or abuse.^[35]

Clinical work often reveals an intergenerational pattern of body image distress and preoccupation, restrictive dieting, and various attempts to sculpt the body to meet an unrealistic ideal. Women struggling with eating and body image problems often describe a family history -- that their grandmothers and mothers dieted chronically, exercised excessively, and even pursued cosmetic plastic surgery. Some also report a similar preoccupation with weight, shape, exercise, and appearance in their fathers, grandfathers, brothers, and other male relatives. Thus, the attitudes and behaviors surrounding body image, weight management, and food seen in women with eating disorders may be handed down from one generation to the next, socially and interpersonally, but not necessarily via genetics.

Culture-Bound Illnesses

The increased prevalence of eating disorders in recent decades as well as the changing incidence patterns suggest that understanding their origins and solutions requires more than a medical model; a bio-psychosocial framework is important. These illnesses appear in technologically advanced, westernized nations and in those that are rapidly changing as a result of the impact of globalization. Although social changes always create stress, those associated with globalization may impact women disproportionately, increasing the risk for body image and eating problems. Culturally transformative trends, such as sophisticated and fast-growing economies and rapid technological and market changes, exert an enormous effect on the status of women, introducing a powerful global consumer culture, with expectations about appearance and beauty, as well as dramatic revisions in women's social roles.^[18]

With greater access to education, increased involvement in the workplace, and the accompanying gender equity issues, women's lives and family roles are in a period of unprecedented transformation. To this add the significant differences in today's western diet, filled with prepared foods higher in calories and fat, and the sedentary lifestyle of the West, factors that have led to an increase in obesity. The result is that the reality of the body and the beauty ideal are increasingly in conflict in women of all ages.^[18]

The fast-paced life inherent in current culture emphasizes adaptation, achievement, and appearance, leaving little time to reflect on these new roles and expectations. Instead of identifying, verbalizing, or describing their complex emotions, needs and appetites, contemporary women may translate these into a "language of fat." Surrounded by a sociocultural environment that has labeled fat as bad, "feeling fat" may easily become a cover for all discomfort, anger, disappointment, and other "bad" feelings.^[36] Unfortunately, globalization has now made the language of fat universal for women.

A dramatic example of the impact of globalization and media images on attitudes and behaviors surrounding food and women's bodies occurred in Fiji after television was introduced. With startling speed, strong Fijian traditions and values were overturned and women began speaking the once-foreign language of fat. Historically, this island culture had valued large female bodies for their strength and contribution to the family and community life and had celebrated and enjoyed food long associated with rich traditions and meanings. Eating disorders were basically nonexistent in 1995, and there was little talk about dieting or weight, but after less than 3 years of limited exposure to western network television shows, a study found that 11% of the women in the study used self-induced vomiting, 29% were at risk for eating disorders, 69% had dieted to lose weight, and 74% felt "too fat."^[37] The Fiji experience demonstrates the importance of sociocultural influences in the factors that contribute to eating disorders. These are truly culture-bound, bio-psychosocial illnesses.

Today's Pioneers - Midlife Women With Eating Disorders

We have found that contemporary midlife women often feel motherless, that they lack role models who have gone before them and mastered the challenges of women's lives in today's complex, rapidly changing culture. The reality of women today is that the emphasis on appearance and body control is substantially different from the way it was during their mothers' midlives. Opportunities and expectations are unprecedented for contemporary midlife women, but as a result their bodies are very much in the public eye; and indeed, midlife women often feel that in the public realm they are in direct competition with younger women, in contrast to the general experience of midlife women of previous generations. In addition, the meaning of success and what it is to be "good enough" are profoundly different notions for today's women, and they have no guidance from mothers and grandmothers, and few, if any, other role models to help them chart their course through this complicated frontier. In this sense, contemporary midlife women might be considered pioneers.

A hunger for familiarity and security may lead women to the rituals of disordered eating, weight preoccupation, and body image despair. Aspiring to meet the culture's narrow "beauty" standard may feel like the safest or surest way to acculturate and organize their lives. Rather than embracing the uncertainty and potential of this new frontier, contemporary midlife women may measure success by how strictly they manage their bodies and restrict their eating.

The Midlife Transition

Much has been written about the numerous contributions to eating and body image issues in young women's lives. We recognize the intense pressures and troubling transitions as females move from being a girl to a preteen, teen, and young adult. We have paid far less attention to the issues that adult women face. But this half-changed world demands that women compete in the masculine world while also fulfilling all the traditional feminine tasks, especially regarding appearance. Furthermore, adulthood brings ongoing developmental issues -- the complications of an aging body; multiple role changes from career to marriage, mothering, empty nesting, caring for older parents; and health and mortality issues, among others. These can be as challenging as (or more so than) those faced in adolescence, but the rituals that mark the developmental milestones of youth are missing. Instead, women often find themselves dealing with these pressures in isolation, with little support or validation.

The "deadline decade," the years between 35 and 45,^[38] can be particularly disruptive. For some, the biological clock is ticking away, and decisions about relationships and childbearing are heightened. For others who have focused on family, their career clock may be ticking as loudly. For the women who have tried to do it all, the "what-about-me" clock is ticking. To complicate their experience, women may be in their sexual prime at this age and their appetite for and interest in sexual relationships may be heightened, which may result in guilt and confusion. This decade is potentially transformative, but it is also filled with many obligations, responsibilities, and stress for most contemporary women, leaving little time to reflect on the impact of all these events and transitions. Consider the following case.

Case 1 – A Not So Perfect Life

At 39 years of age, Sally had been the ultimate "good girl" her entire life, always living for others -- especially in order to feel that she had her father's approval. Few achievements of her dutiful life pleased her at the level of her individual self. Her appearance had always been important to her, and she dieted. But dieting was also a way for her to meet her father's stated expectations of women. Until now, her dieting had had never been out of control. It seemed as though Sally had it all -- a great education, exciting career, supportive extended family, 2 young children, and marriage to a well-respected, equally accomplished man. But this "perfect life" and the accompanying persona she portrayed were in fact disconnected from any real desire, happiness, and self-satisfaction. She was attractive and thin, but not as thin as she had been before her pregnancies. This bothered her, and she began to question whether her husband was still attracted to her as they seemed to spend less time together as a couple.

Never permitting herself to acknowledge, let alone act on, any impulses, Sally was not prepared for the strong attraction she developed for a colleague at work. Their high-powered, fast-moving business demanded long hours and energy. Sally plunged into an extramarital affair, while feeling guilty and overwhelmed at her transgressions. She cared deeply about both men, but she was also ashamed. Sally stopped eating to numb these feelings. A close friend who recognized Sally's weight loss and anxious mood convinced her to seek therapy.

Gradually, Sally began to come to terms with the reasons for her affair, to be able to deal more directly with her emotions, and to make decisions about herself and her marriage. A pivotal moment in therapy occurred when I mentioned to Sally that as she was in her late 30s, she was actually at the peak of her sexuality. This normalized and legitimized her feelings and helped her make sense of her affair.

Through therapy, Sally has become much more aware of her own needs and feelings, allowing more room in her life and psyche for recognizing her true hungers. We have labeled her weight loss as an ultimately positive event -- not because it made Sally "look better," but because it led her into therapy, which eventually gave her permission to explore her deepest desires and needs. Sally is still unsure what her ultimate decisions will be regarding her marriage, but she is dealing with her issues directly rather than using the starvation of anorexia to avoid them. And, for the first time, she is allowing herself to live without a "superwoman script" for her future, meeting everyone else's needs but not her own.

A woman's life transitions are often shaped by feelings like "my life is out of control." When things are changing, feel ambiguous, and look uncertain, we all seek a solution -- something stable or something to control.

Case 2 – "My Life is Out of Control"

Bulimic for several years, Ann was in her late 50s and married 35 years before she sought my help. A successful businesswoman with 3 adult children and a grandchild, Ann had seemingly navigated many twists and turns in life: raising a family, running a business, experiencing the illness and death of her parents. Before menopause, she felt fortunate and satisfied with her life in many ways. She was weight conscious, but not pathologically so. Looking around at her female friends, Ann observed that dieting and body discontent were the norm, but she easily controlled her weight without resorting to risky behaviors.

After menopause, however, Ann gained a few pounds that she could not seem to shed. "My old tricks didn't work anymore," she said. "I made a conscious, intellectual decision to start making myself vomit. I had seen many magazine articles about purging and watched made-for-TV movies about bulimia. It seemed normal. I saw vomiting as an option, on the same level as Weight Watchers or the Atkins diet."

When I described the health risks of bulimia, Ann was deeply affected and motivated to change her behavior. Because her bulimia was not yet deeply embedded in her identity, these changes were easier than for many other patients. She saw bulimia as an "add-on" to her life, a response to her aging, and it still felt foreign to her.

Very early in treatment, Ann stopped vomiting and began to address the problems that seemed to underlie her bulimia. Her busy and very full life had not allowed her much time to reflect on the impacts of the multiple transitions she had experienced in the past few years. For the first time, she admitted to being afraid of menopause, becoming a grandmother, and of her life in retirement without the daily feedback of her successful business career. She felt lingering grief over the death of her parents and the loss of her own youth. Even with many positive things in her life -- a stable marriage, family, grandchildren, friends, financial resources, and a strong presence in her community -- Ann still encountered great difficulty navigating the important adult passage of menopause. Before entering therapy, she had only been able to articulate feelings about the "loss of control" in relation to her weight.

Ann's story illustrates that even seemingly successful and well-supported women who have mastered many significant life transitions in the past can still develop serious eating disorders at midlife. Menopause can be wrenching in a world that values women for how "sexy" they seem. If women are all supposed to look "Barbie perfect," there is little (if any) room for hot flashes, weight gain, or hormonal mood swings. Like the adolescent body, the menopausal body runs on its own schedule with hot flashes, slowing metabolism, vaginal dryness, and other unruly physical changes, as if it has its own mind. The body becomes the "anti-Barbie," and suddenly women like Ann feel their sense of well-being and control has vanished. Although she could not alter the other life events that the past few years had brought, she could lose weight and regain some sense of control; having a youthful body would offset all the other losses and challenges that aging had brought her.

The obstacles preventing adult women from seeking treatment for their eating disorders are many. First, the shame and self-blame that we see clinically in younger patients is far more intense at midlife and beyond. Adult women believe that they should know better and should have outgrown such "teenage" problems; they berate and chastise themselves as a result, deny their true pain and their need for help. They tend to be more embarrassed and ashamed, feeling that their problems are less legitimate than a younger woman's and not a worthwhile reason to seek help. With their multiple and complex roles, midlife women also have more serious everyday responsibilities, with more people to take care of, and, they fear, to disappoint, if they do start paying attention to themselves. Under constant stress with limited time for herself, a woman may find the ritualized behaviors of an eating disorder comforting and grounding, despite the long-term threat to her emotional and physical health.

In light of all the roles and responsibilities of adult life, it is much harder for midlife women to make the commitment to address their eating and body image disorders. In fact, with family, work, and community responsibilities, it may seem impossible to take any time to focus on their needs and their recovery. The harsh reality is that adult women have had more years of denying their true appetites, hungers, and feelings; this alone may keep them from seeking help. Of course, we must also acknowledge the secondary gain that accompanies body image obsessions and weight loss, as well as the universal desire today to look young and avoid the loss of power that an aging female body brings.

For some women, resistance to getting help is fueled by despair and a belief that they are doomed to never be truly happy. For others, a sense of omnipotence develops as they continue to dodge the bullets of serious medical consequences despite their body abuse. Add these dynamics to the medical bias that eating and body image disorders are adolescent issues, and it is easy to see why we have not grasped the extent of this issue in women's health.

Many medical professionals lack basic knowledge when it comes to eating disorders. Most get little useful training and experience, so they maintain old biases and beliefs about who is at risk. Despite how easy it would be to add a few questions at each medical visit regarding weight management, dieting, and nutrition, few providers screen patients for eating disorders, even the high-risk ones. The war on obesity has captured the attention of the medical community and skewed their perspective, severely limiting their ability to help therapists bring adult eating disorders out of the closet.

Clinical Issues - Entering Treatment

At midlife and beyond, the motivation for entering treatment may be quite different from that for a younger person. In contrast to high school and college-aged patients, adult women are more likely to seek help on their own. Although they are likely to be more self-motivated, adult women also may have lived with an eating disorder for decades. Having translated all of their negative feelings into the language of fat, they lack skills to recognize and satisfy their true needs and hungers. Midlife women with eating disorders have the same exquisite sensitivity to others that we associate with vulnerable teens and young women with eating disorders; they are easily shamed, shunned, and dismissed. They will leave treatment quickly if we do not work hard to embrace them and show that we take them as seriously as we take adolescents with these problems. Midlife women with eating disorders often feel invalidated and discouraged by the emphasis the healthcare system places on young women with these problems. Medical professionals need to react with the same sense of urgency to disordered eating in women at midlife as we do to the call about an 11- or 12-year-old child who is at risk to permanently stunt her physical growth.

In groups and formal treatment programs, midlife women often feel invisible and inconsequential if the emphasis is too heavily placed on younger patients and their developmental issues. These women also may play a maternal or nurturing role both to the younger patients and to the staff, as they are skilled in meeting others' needs and not their own. With their longstanding habit of sacrificing their needs to please others, they may pretend to recover quickly and not truly address their underlying problems; such women are at serious risk for relapse. Just as our culture tends to dismiss them, midlife women struggling with eating and body image issues readily dismiss themselves. Healthcare professionals must take a very active and direct approach with this group of patients, as they need much validation and can readily sense when we do not take their problems seriously.

Often adult women seek help when they are fearful that their eating and body image issues may adversely affect their parenting and the well-being of their children. Parenting is a very motivating subject for women with eating and body image disorders, and we can use it to the advantage of recovery. It is easy to demonstrate how their own self-care will benefit their children and to emphasize the importance of their role modeling related to weight concerns, body image, dieting and eating, especially for female children.

Case 3 – "What Kind of Role Model Am I?"

Jennifer, a 42-year-old from a perfectionist and body-conscious family, began dieting at the age of 12. She developed anorexic symptoms in college and has had some form of disordered eating since then. Seven years before seeking help, after the birth of her second child, she began purging via exercise to lose weight. When this wasn't enough for her to achieve her desired weight, she restricted her eating even more, and then began vomiting almost everything she ate. As her older daughter approached adolescence, Jennifer became concerned that she may pass her problems along to her daughter.

Gradually, she admitted to herself that her life was out of control, and ultimately decided to go to her primary care provider to ask for help. She had lost 20 pounds since her last visit a year earlier, putting her weight at the low end of normal but significantly below her body's natural weight range on the basis of her body type and genetics. She had read about bulimia and finally was frightened enough to admit she may have this illness.

At this visit, with Jennifer seeming so desperate for help and confused about her behavior, the office and nursing staff immediately praised her for her weight loss, asking for advice about dieting. Then her doctor walked in and asked, "How does your husband like your new body?" Jennifer was devastated and left without telling him why she was there. She was deeply depressed as she knew how ill she was but felt absolutely helpless, believing she would be like this the rest of her life. Eventually, she found my name on the Internet.

Two years later, with the help of individual therapy, nutritional counseling, medication, and a period of group therapy, Jennifer is much better, but not fully recovered. Physically she is stable, she has regained her weight, but she is very ambivalent about it. Exercise is still obsessive but much less so. Eating remains a struggle and she goes through cycles of greater restriction and of purging again. But she does know she wants to be there for her children and is managing her daughter's adolescence and body concerns fairly well. Her eating disorder has deeply affected the quality, and possibly the length, of her life. In the meantime, as Jennifer is no longer at immediate risk medically, her managed care company has begun to refuse reimbursement for her visits. This has confused her as much as the ominous visit to her PCP did. She knows she is still ill but her normal body weight masks that, just as her weight loss had masked her pain. I have educated her about the criteria that drive the decisions of third-party payers, urging her to not personalize this, and we have appealed the decision.

Clinical Issues - The Harm Reduction Approach

Healthcare providers need to accept any reason that helps women to break their resistance and denial of how eating disorders and body image issues are affecting the quality of their lives. For example, several years ago, a woman in her early 50s sought  help as she wanted to have cosmetic plastic surgery, but she knew that if she continued to vomit, the effects of the surgery would be minimal. Issues were  addressed concerning aging and how these had affected her longstanding eating disorder and body image concerns. Despite a 30-year history of daily bulimia, she achieved some degree of recovery.

With such a long history of symptoms, a harm reduction model can be useful, for which the goal is attempting to decrease the behaviors, or "the harm," rather than to terminate them. A harm reduction perspective helps women to see progress in the small steps they can take to change their behavior and challenges the dichotomous thinking found in women of all ages with eating disorders. It also helps professionals to conceptualize what treatment can achieve, despite the severity and duration of the problems we see in those women who have suffered over decades. Some may recover quite fully, others less so, but, in most cases, treatment can improve the quality of their lives and decrease the risk to their health.

It is also important to provide both psychoeducation about the risks of their symptoms as well as insight-oriented psychotherapy, informed by a feminist and relational perspective. Healthcare providers must educate midlife women with eating disorders about the potentially severe impact on health and longevity, while also instilling the notion that there is hope for recovery.

As for younger patients, eating disorders and body image obsessions in midlife women can both reflect significant family issues as well as contribute to them. Midlife women struggling with these issues need to contextualize their symptoms within their cultural experience as women, but also within their families. Addressing family of origin issues is just as critical as it is with younger patients. The 3 cases presented here, Jennifer, Ann, and Sally, had to explore their family dynamics to begin to understand their drives to perfection and the meaning their bodies had assumed. All 3 women came from families that had difficulty dealing with uncomfortable affect. The drive to achieve and excel was emphasized while feelings and emotions were minimized, so these women lacked the skills and resources they needed to handle the challenges of adult life. Recovery requires exploring how their current relationships reflect their unhealthy earlier family dynamics and how these relationships also need to change to support recovery.

Adults suffer from the same medical sequelae of eating disorders as do younger patients. Every system in the body can be affected as a result of the nutrient deficiencies associated with anorexic and bulimic behaviors. Medical complications can occur quickly, despite long-term medical stability and normal laboratory values, and can result in sudden death. Electrolyte imbalances create risk for cardiac arrhythmias and arrest. Endocrine dysfunction leads to menstrual irregularities, decreased bone mineral density, increased risk for osteopenia and osteoporosis, and a compromised immune system.^[39,40]

In addition, eating disorders cause some unique medical issues in adult women. As they approach menopause, estrogen production declines, leading to symptoms such as hot flashes, sleep problems, vaginal dryness, and mood swings. Depletion of fat stores exacerbates the declining estrogen level and causes more menopausal symptoms. Excessive dieting also causes muscle wasting, which can reduce the metabolic rate and hasten the natural neuromuscular decline associated with aging.^[41]

Obstetrician/gynecologists, primary care physicians, and other women's healthcare providers have an important role in the identification and management of eating disorders. Several simple screening questions can be added to routine medical visits. For example:

• Has your weight fluctuated during your adult years?
• Are you trying to "manage" your weight? If so, how?
• What did you eat yesterday?
• How much do you think or worry about weight, body shape, and eating?

The answers to these benign questions can reveal a pattern of disordered eating or a clinical eating disorder. It also indicates the provider's concern or interest about this issue. This may make it easier for a patient to break out of her shame and denial and begin to discuss these problems.

In addition to getting eating disorders out of the closet of secrecy by asking screening questions at routine medical visits, physicians should also integrate the following points into their approach to adult women:

• Convey the importance of adequate nutritional intake, especially the balance between calcium, protein and adequate fat.
• Inform patients that 40% to 70% of the factors governing weight are genetic. They need to honor their body's natural size and shape.
• Be aware of the increasing evidence that weight alone is not an indicator of general good health. People can be "fit and fat." ^[8]
• Be concerned about amenorrhea, not only for its effect on fertility but also because of the implications for compromised bone density.
• Educate patients and staff about the dangers of dieting. In summary, restricted dietary intake sets up a "binge," decreases basal metabolic rate, makes it easier to store fat, and impairs physical, psychological, and emotional functioning.
• Maintain a weight-sensitive office. Specifically, this means no jokes about eating disorders, no comments about weight, and privacy when weighing patients. Respect a woman's feelings if she prefers not to be weighed. Consider what magazines you provide, as most women's magazines only reinforce and breed body dissatisfaction, dangerous dieting, and eating disorders. Replace these with content that conveys healthier messages.
• Provide educational materials about appropriate nutrition and eating disorders.
• Bring up your concerns directly to patient, in a caring, non-confrontational manner.
• Know the resources for treatment. Refer patients for assessment to the experts in your area or to resources such as the National Eating Disorders Association (http://www.medscape.com/px/trk.svr?exturl=http://www.nationaleatingdisorders.org).
• Respect the power of the illness. These are not just diets gone awry; they are very serious illnesses. Collaborate with mental health specialists in eating disorders to establish an appropriate treatment plan. (See Table 2 listing the recommended laboratory assessments^[42] and Table 3 regarding the levels of care recommended for treatment of eating disorders.) You may have to advocate with third-party payers to ensure that your patients with eating disorders can access the appropriate level and provider of treatment.
• And finally, never underestimate the importance of your relationship with your patient. Your kind, nonjudgmental words, support, and concern may be what convince a woman that she deserves to be healthy, whole, and happy again.

Table 2. Recommended Laboratory Tests^[42]

Table 3 -- Criteria for Level of Care

*Partial hospitalization is an alternative to inpatient care. It can be a powerful treatment modality for patients with eating disorders, as they are making changes in the hospital program while also dealing with stressors at home and in their social environment. It is closer to "real life," as they are not as isolated and protected. Patients also have to make many decisions about eating and other aspects of recovery each day; so the changes are more likely to generalize after discharge. Partial hospitalization is also a good step-down from in patient care because it provides support and structure as the patient phases back into regular life. Partial hospitalization programs generally run for 6 to 12 hours/day, so meals and snacks are structured and provided with lots of support. Monitoring of their medical status, response to medications, symptom management, and group therapies focusing on the emotional issues underlying the illness and recovery process make up the balance of the day. Finally, because it's less expensive, insurance companies usually approve a longer length if stay than for the inpatient.

The implications of the increasing incidence of eating and body image concerns at midlife are many. In order to address this critical problem affecting the health and well-being of contemporary women, the healthcare system needs the following:

• Real data on these problems so we can better define the range of severity and the types of eating and body image disorders women experience at and beyond midlife;
• Training of all medical professionals, but especially providers in primary care and obstetrics and gynecology, to screen, identify, and appropriately treat and refer women with disordered eating;
• An approach to the concerns about obesity that is tailored to individual risk, lifestyle, and health factors, instead of the current inflammatory scare tactics that help to create disordered eating and body dissatisfaction;
• An awareness of how the "war on obesity," the cultural expectations for women and appearance, and attitudes toward older women resonate in us as medical providers and affect our ability to recognize and treat these issues in adult women;
• Treatment options that meet the needs of adult women (Many women cannot consider leaving their families and their responsibilities for any protracted period of time. Outpatient options and convenient treatment packages are critical.);
• Support and education for women with eating disorders in their role as mothers to create healthy home environments and role models for their children;
• Comprehensive, longitudinal research to track the most effective outreach and treatment programs for adults;
• Advocacy to assure access to and reimbursement of therapeutic services at the level of care appropriate to the individual patient. (The Eating Disorders Coalition for Research, Policy, and Action advocates at the federal level for this cause.);
• Efforts to fight for true gender equity and healthier ideals for women of all ages so that their bodies will no longer be their primary source of power;
• Optimism that we can help to improve the quality of a woman's life no matter how long she has suffered or how old she is; and
• Emphasis on eating disorders and related nutritional and body image problems as a major public health issue for women of all ages, resulting in a shared and genuine commitment to women's mental and physical health.

1. Brown JD, Halpern CT, L'Engle KL.Mass media as a sexual super peer for early maturing girls. J Adolesc Health. 2005;36:420-427.
2. Conner M, Johnson C, Grogan S. Gender, sexuality, body image and eating behaviours. J Health Psychol. 2004 ;9:505-515.
3. Field AE, Camargo CA Jr, Taylor CB, Berkey CS, Colditz GA.
4. Relation of peer and media influences to the development of purging behaviors among preadolescent and adolescent girls. Arch Pediatr Adolesc Med. 1999;153:1184-1189.
5. Field AE, Cheung L, Wolf AM, et al. Exposure to the mass media and weight concerns among girls. Pediatrics. 1999;103:E36.
6. Taveras EM, Rifas-Shiman SL, Field AE, et al. The influence of wanting to look like media figures on adolescent physical activity. J Adolesc Health. 2004;35:41-50.
7. Maine M. Body Wars: Making Peace with Women's Bodies. Carlsbad, Calif: Gurze Books; 2000.
8. Cuenca-Guerra R, Quezada J. What makes buttocks beautiful? A review and classification of the determinants of gluteal beauty and the surgical techniques to achieve them. Aesthetic Plast Surg. 2004;28:340-347.
9. Gaesser G. Big Fat Lies: The Truth About Weight and Your Health. Carlsbad, Calif: Gurze Books; 2002.
10. Mokad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA. 282;1519-1522.
11. Serdula MH, Mokdad AH, Williamson DF, Galuska DA, Mendlein JM, Heath GW. Prevalence of weight loss strategies for controlling weight. JAMA. 1999;282:1353-1358.
12. Garner DM. Psychology Today. February 1997; Document ID 994: 1-12.
13. Hetherington MM, Burnett L. Ageing and the pursuit of slimness: dietary restraint and weight satisfaction in elderly women. Br J Clin Psychol. 1994;33:391-400.
14. Clarke LH. Older women's perceptions of ideal body weights: the tensions between health and appearance motivations for weight loss. Ageing and Society. 2002;22:751-73.
15. Third Report on Nutrition Monitoring in the US, Vol 1-2, Dec, 1995. National Center for Health Statistics, NHANES III. Life Sciences Research Office, Interagency Board for Nutrition Monitoring and Related Research, US Dept. of Health and Human Services, US Dept of Agriculture.
16. Berg F. Women Afraid To Eat. Hettinger, ND: Healthy Weight Network; 2001.
17. Waterhouse D. Like Mother, Like Daughter: How Women Are Influenced by Their Mother's Relationship with Food and How to Break the Pattern. New York, NY: Hyperion; 1997.
18. Powers PS, Bannon Y. The last word: meeting the challenge of eating disorders. Eating Disorders: The Journal of Treatment and Prevention. 2004;12:91-95.
19. Gordon R. (2001). Eating Disorders East and West: A culture-bound syndrome unbound. In Nasser M, Katzman MA, Gordon RA (eds). Eating Disorders and Cultures in Transition. New York, NY: Taylor and Francis: 1-23.
20. Makino M, Tsuboi K, Dennerstein L. Prevalence of eating disorders: a comparison of Western and non-Western countries. MedGenMed. 2004;6:49.
21. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Eating disorders (Revision). Am J Psychiatry. 2000;157:(suppl)1-39.
22. Patrick L. Eating disorders: a review of the literature with emphasis on medical complications and clinical nutrition. Alternative Medicine Review. 2002;7:184-202.
23. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
24. Sullivan P. Course and outcome of anorexia nervosa and bulimia nervosa. In Fairburn CG, Brownell KD (eds). Eating Disorders and Obesity, 2^nd edition New York, NY: Guilford Press; 2002: 226-232.
25. Sullivan PF. Mortality in anorexia nervosa. Am J Psychiatry. 1995;152:1073-1074.
26. Herzog DB, Greenwood DN, Dorer DJ, et al. Mortality in eating disorders. Int J Eat Disord. 2000;28:20-26. 26. Powers PS, Spratt E. Males compared to females with eating disorders: 15 years of clinical experience. Eating Disorders: The Journal of Treatment and Prevention. 1994;2:197-214.
27. Shisslak CM, Crago M, Estes LS. The spectrum of eating disturbances. Int J Eat Disord. 1995;18:209-219.
28. Croll J, Neumark-Sztainer D, Story M, Ireland M. Prevalence and risk and protective factors related to disordered eating. J Adolesc Health. 2002;31:166-175.
29. Bratman S. Orthorexia. The Orthorexia Home Page, 2003. Available at: http://www.orthorexia.com/. Accessed May 27, 2005.
30. Livesley WJ, Jang KL, Thordarson DS. Etiological relationships between eating disorder symptoms and dimensions of personality disorder. Eating Disorders: The Journal of Treatment and Prevention. 2005;13:23-35.
31. Vanderlinden J, Vandereycken W. Trauma, Dissociation, and Impulse Control in Eating Disorders. New York, NY: Brunner-Mazel; 1997.
32. National Center on Addiction and Substance Abuse at Columbia University (CASA). Food for Thought: Substance Abuse and Eating Disorders.
33. Gorwood P, Bouvard M, Mouren-Simeoni MC, et al. Genetics and anorexia nervosa: a review of candidate genes. Psychiatric Genetics 1998;8:1-12.
34. Bulik CM. Biological, psychodynamic, and cultural factors in eating disorders: Translations to clinical practice. Paper presented at the 14th Annual Renfrew Center Foundation Conference for Professionals; November 6, 2004; Philadelphia, Pennsylvania.
35. Fishman HC. Enduring Change in Eating Disorders; Interventions with Long-Term Results. New York, NY: Brunner-Routledge; 2004.
36. Friedman SS. When Girls Feel Fat: Helping Girls Through Adolescence. Vancouver, Canada: Salal Books; 1997.
37. Becker AE. Sociocultural issues: culture, the media, and eating disorders: the view from Fiji. Paper presented at the International Conference on Eating Disorders; April 26, 2002; Boston, Massachusetts.
38. Sheehy G. Passages: Predictable Crises of Adult Life. New York, NY: Dutton; 1976.
39. Mehler PS, Andersen AE. Eating Disorders: A Guide to Medical Care and Complications. Baltimore, Md: Johns Hopkins University Press; 1999.
40. Zerbe KJ. Women's Mental Health in Primary Care. Philadelphia, Pa: W.B. Saunders Company; 1999.
41. Holt M. Eating disorders in the adult population. SCAN'S (Sports, Cardiovascular and Wellness Nutritionists) Pulse. Winter 2005: 8-9.
42. Powers PS. Standard Laboratory and Medical Evaluation. Academy for Eating Disorders Newsletter. 2000;17:2,4,5.

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