Eating disorders in women
For some, aging may bring on — or rekindle — an eating disorder.
Most people who develop eating disorders — an estimated 90% — are female. Typically associated with adolescents and young women, eating disorders also affect middle-aged or elderly women — although, until fairly recently, not much was known about prevalence in this older age group.
Secrecy and shame are part of the disorder, and women may not seek help. This is particularly true if they fear being forced to gain unwanted weight or stigmatized as an older woman with a “teenager’s disease.”
Despite underdiagnosis of eating disorders in older people, clinicians at treatment centers specializing in such issues report that they’ve seen an upswing in requests for help from older women. Some of these women have struggled with disordered eating for decades, while for others the problem is new. The limited amount of research on this topic suggests that such anecdotal reports may reflect a trend.
In community surveys conducted in 1995 and again in 2005, for example, Australian researchers found that while younger women reported eating disorder behaviors more often than older women did, the rate of these disorders in older women increased dramatically between the two surveys, while it remained stable for young women. In women ages 65 and over, strict dieting, fasting, and binge eating all tripled, while purging quadrupled. In the same surveys, rates of strict dieting or fasting and purging also increased dramatically in women ages 45 to 64. A study of Canadian women surveyed in the general population likewise found that women ages 45 to 64 were more likely to binge on food, feel guilty about eating, and be preoccupied with food compared with younger women.
In the most severe cases, patients develop life-threatening complications, such as cardiac arrhythmias, kidney failure, and liver failure. This is one reason that anorexia nervosa is one of the most deadly psychiatric disorders, killing 5.6% of patients for every decade that they remain ill. Treatment is challenging because starvation not only severely damages the body, but also harms the brain — causing changes in thinking, emotions, and behaviors that may be difficult to reverse.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes two subtypes of anorexia nervosa. In the restricting subtype, patients drastically reduce food consumption. They may also exercise excessively in an effort to lose weight. In the binge-eating/purging subtype, patients lose weight by forcing themselves to vomit or by using laxatives, diuretics, or enemas.
Once weight decreases to the threshold required for a diagnosis of anorexia nervosa, patients may experience changes in thinking processes, such as difficulty concentrating. They may develop odd food rituals, such as cutting food into tiny pieces, eating only at certain times, and weighing food. Weight gain may eventually improve these psychological problems, but it seldom eliminates them completely — which is why maintenance treatment is so important.
Bulimia nervosa. Bulimia nervosa is characterized by a cycle of binge eating followed by some type of compensatory action to avoid weight gain. Researchers estimate that one to three women out of 100 will develop bulimia nervosa at some point in their lives. In men, the rate of diagnosis is only about one-tenth the rate in women.
Although many Americans overeat by consuming too many calories per day (which helps explain why more than one in three are obese), binge eating involves consuming extreme amounts of food within a restricted time frame — usually within two hours. While on a binge, a patient may eat an entire cake rather than one or two slices, or a full gallon of ice cream rather than a bowl.
The DSM-IV describes two subtypes of bulimia nervosa, based on the strategy a patient uses to rid herself of excess calories. Patients diagnosed with the purging subtype, the most common form, may make themselves vomit or use laxatives or diuretics. This diagnosis overlaps with the binge/purge subtype of anorexia, but people with bulimia do not have the same preoccupation with maintaining a low body weight. In the nonpurging subtype, patients may exercise excessively or stop eating for a day or longer.
If a vicious cycle of overeating and deprivation takes over, patients may eat to the point of physical pain, then compensate so dramatically that they feel ravenously hungry. When the binge-and-compensation cycle occurs at least twice a week for three months, patients meet DSM-IV diagnostic criteria for bulimia nervosa.
Binge-eating disorder. Binge eaters regularly binge, usually in secret and accompanied by feelings of guilt or shame. Unlike bulimics, they don’t follow a binge with a purge, so they may be overweight or obese, and their eating disorder may remain unrecognized. In the DSM-IV, binge-eating disorder is categorized as an “eating disorder not otherwise specified,” but it is proposed for inclusion as a freestanding diagnosis in the next edition of the diagnostic manual. Many older women do not fit the strict definitions for eating disorders, yet they deserve treatment.
Grief. With age, people are increasingly likely to lose people they care about. Mourning can take away your appetite, and restricting food or purging can be a way to deal with distressing feelings. For example, the comedian Joan Rivers has written about the sudden onset of bulimia in her 50s after her husband’s death by suicide.
Divorce. In addition to grief and loss, the breakup of a marriage can spur a woman to view her body unfavorably in comparison with other singles or an ex-spouse’s new girlfriend.
Heightened awareness of aging. This can be particularly acute when women return to school or work or need to keep working past the traditional retirement age, especially in appearance-related fields.
Medical illness. If a short-term illness results in weight loss, a woman may receive compliments on her slender appearance and continue to restrict food after she has recovered to avoid regaining weight.
On the other hand, some older women decide to get professional help after years of disordered eating. This decision may emerge for any of several reasons.
For example, eating disorders take a physical toll on the body, and the impact is more apparent with age. Dental problems, arrhythmias (irregular heartbeats), or osteoporosis (a common complication of eating disorders) may prompt a woman to seek treatment. In an older body, forceful vomiting may result in a medical emergency, such as a stomach rupture or tear in the esophagus, which can bring a woman to professional attention.
A woman’s priorities may also shift over time. Disordered eating and attempts to hide it take a great deal of time and effort. Sometimes an unrelated health scare, death of a loved one, or other event sparks a realization of the sheer amount of psychic and physical energy required to maintain these behaviors, and a woman may finally decide that enough is enough — and seek treatment.
The goal of treating an eating disorder is to help a patient achieve a healthy weight, exercise level, and eating pattern; to eliminate binge eating and purging; and to address any contributing emotional problems or distorted thinking. This usually requires the help of a mental health professional, a nutritionist, and other clinicians.
Psychotherapy. This is the cornerstone of treatment for eating disorders. Various kinds of psychotherapy can help. Cognitive behavioral therapy (CBT) challenges unrealistic thoughts about food and appearance and helps people develop more productive thought patterns.
Other types of psychotherapy may also be useful in particular circumstances. For example, interpersonal and psychodynamic therapy can help people gain insight into issues such as role transitions, loss, and unresolved relationships that may underlie disordered eating and an excessive focus on body image.
Nutritional rehabilitation. A dietitian or nutritional counselor can help a woman recovering from an eating disorder learn (or relearn) the components of a healthy diet and can help motivate her to make the needed changes. At different stages in recovery, a nutrition professional will help plan how and when the patient should eat in a way that keeps the digestive system working well and avoids dangerous changes in electrolyte and fluid balances that can occur when a person begins eating again after a period of semi-starvation.
Medication. Fluoxetine (Prozac) is the only medication approved for the treatment of an eating disorder. At high doses (about 60 mg per day), it reduces binge eating and vomiting up to 70% in the first eight weeks, though results are much poorer if patients aren’t also receiving psychotherapy. Other antidepressants and the seizure medication topiramate (Topamax) may be prescribed for bulimia or binge-eating disorder, but fewer controlled trials have studied their effectiveness.
No medications are approved specifically for treating anorexia. Although antidepressants, seizure medications, and certain antipsychotic medications are sometimes used in treating the condition, food is considered the primary medication. No drug works well until some weight is restored. However, if depression or anxiety is also involved, medications may be prescribed to address these problems.
Hospitalization. Eating disorders are usually treated on an outpatient basis. But hospitalization may be recommended if a woman is dangerously underweight, unable to eat or stop vomiting, seriously depressed or suicidal, medically unstable (for example, because of heart arrhythmias, low pulse or blood pressure, or electrolyte imbalances), or has other medical complications that require hospital treatment.
Academy for Eating Disorders
International Association of Eating Disorder Professionals