When you think about an eating disorder, one image that naturally comes to mind is a rail-thin teenage girl pushing away from the dinner table and making a beeline to the bathroom. And rightly so, since the vast majority of the estimated eight million Americans suffering from disordered eating problems are between the ages of 12 and 25. However, health professionals nationwide are seeing a growing trend in eating disorders that's rising up from the ranks of women in their 30s, 40s, 50s, and beyond. In this episode of Second Opinion, we'll explore the phenomenon of eating disorders in older adults, examine the causes and symptoms, and look at what you can do to break free of these persistent and potentially deadly health problems.
At any age, an eating disorder stems from feelings that your life is out of control. Compulsive food management, whether it's extreme dieting, purging, or binging, gives you an emotional "fix" that puts you back in control – but only until the next crisis comes crashing down. Many experts are now pointing to a collection of stress factors that commonly occur in midlife as powerful catalysts for the onset – or reemergence – of eating disorders in later-life. These include:
- Relationship problems
- Parenting troubles
- Death of a parent
- Career difficulties
- Financial strain
- Empty-nest syndrome
- Emotional and physiological changes brought on by menopause
- Fears associated with aging
- Desires to look younger and slimmer than your age may allow
While the rise in midlife eating disorders is disturbing, experts are heartened that growing numbers of older adults are seeking professional help to deal with their eating problems. Unlike many younger people with eating disorders, those from the "baby-boomer" generation seem to be much more open to recognizing that when they have a problem it's smart to get help.
According to Donald McAlpine, M.D., a psychiatrist and the director of eating disorders services at Mayo Clinic in Rochester, Minn. (and a member of our panel of experts), "Denial, so common in younger women with anorexia nervosa, seems to be less common in older women. Denial is replaced by thoughts such as, ‘You've got to help me with this, it's ruining my life.' Older women, worn down by years of symptoms, may be more motivated to seek help. Motivation for change often leads to a more successful outcome in treating the illness."
For people of any age who suffer from eating disorders, counseling and psychotherapy can be a valuable source of assistance with becoming more self-content, more self-confident, and more knowledgeable about developing healthy strategies for coping with the issues that underlie disordered eating behaviors.
Not Just a Teen Thing
While 90 percent of those who develop eating disorders are females between the ages of 12 and 25, they can afflict people of all ages and both genders from all ethnic, cultural, economic, and educational backgrounds. What may surprise you is how prevalent disordered eating problems have become among older segments of the female population.
- While eating disorders usually develop in adolescent and young adult females, they can begin in some women during their 30's, 40s, and beyond.
- Some females first develop eating disorders in their teens, recover, and then relapse in middle age.
- Some studies suggest that nearly 80 percent of anorexia-related deaths occur in women who are over the age of 45.
Eating Disorders at a Glance
An eating disorder is a serious psychiatric illness – an intense preoccupation with weight or food that can lead to extreme disturbances in eating patterns and behaviors, as well as dire medical consequences. The three best-known eating disorders – anorexia nervosa, bulimia nervosa, and binge eating disorder – are variations on a theme that also have their own unique characteristics.
People who intentionally starve themselves have an eating disorder known as anorexia nervosa. The disorder, which usually begins around the time of puberty in young people, involves extreme weight loss – at least 15% below a person's ideal body weight. People with the disorder may look emaciated but are convinced they are overweight. Many must be hospitalized to prevent starvation, dehydration, and other complications. In severe cases, anorexia can lead to death.
Research suggests that about 79 percent of the deaths related to anorexia occur in women over the age of 49.
People with bulimia nervosa consume large amounts of food and then purge their bodies of excess calories by vomiting,using laxatives or diuretics, taking enemas, or exercising obsessively. Some combine of all these forms of purging. Because many people with bulimia "binge and purge" in secret and maintain normal or above-normal body weight, they can often conceal the eating disorder from others for years.
Experts believe that the onset of bulimia is common in middle-aged women.
Binge Eating Disorder
Like bulimia, binge eating disorder is distinguished by episodes of uncontrolled eating. This disorder differs from bulimia in that binge eaters do not purge their bodies of excess food. People with binge eating disorder feel that they lose control of themselves when eating. They eat large quantities of food and don't stop until they're uncomfortably full. Usually, they have more difficulty losing weight and keeping it off than people with other serious weight problems. Most people with the disorder are obese and have a history of weight fluctuations.
About 1% of women – including 30% of those who seek treatment to lose weight – have binge eating disorder.
Signs of an Eating Problem
Increasing awareness of the dangers of eating disorders – heightened by ongoing medical research and widespread media coverage – has encouraged many people to seek help. Unfortunately those with eating disorders often deny they have a problem and don't get treatment on their own. However, friends and family can learn to recognize a problem and encourage treatment. Here are some of the warning signs:
- Preoccupation with food, weight, or exercise
- Continual dieting, fasting, or restricting food
- Persistent, negative comments about the way they look
- Expressions of shame and guilt about eating behavior and body weight
- Use of diet pills, laxatives, and/or diuretics for the purpose of weight loss or perceived figure enhancement
- Linking successes or failures in life to weight
- Constant comments about their own, or other people's weight
- Belief that reaching a "perfect" weight is essential to be happy
- Wearing baggy clothes or changes in clothing style
- Loss or disturbance of menstrual periods
- Increased mood changes and irritability
- Frequent excuses not to eat
- Heightened interest in preparing food for others
- Social withdrawal or avoidance of social situations involving food
- Excessive or fluctuating exercise patterns
- Obsessive eating rituals, like eating only from a certain plate
- Trips to the bathroom after meals
- Disappearance of large amounts of food
- Obsessively reading fitness or beauty magazines
According to ANRED, Anorexia Nervosa and Related Eating Disorders, Inc, people with eating disorders:
- Tend to be perfectionists. They have unrealistic expectations of themselves and others. In spite of their achievements, they feel inadequate, defective, and worthless.
- See the world as black and white, with no shades of gray. Everything is either good or bad, a success or a failure, fat or thin. If fat is bad and thin is good, then thinner is better, and thinnest is best – even if thinnest is 68 pounds in a hospital bed on life support.
- May use the behaviors to avoid sexuality. Others use them to try to take control of themselves and their lives. They are strong, usually winning the power struggles they find themselves in, but inside they feel weak, powerless, victimized, defeated, and resentful.
- Often lack a sense of identity. They try to define themselves by manufacturing a socially approved and admired exterior. They have answered the existential question, "Who am I?" by symbolically saying "I am, or I am trying to be, thin. Therefore, I matter."
- Often are legitimately angry, but because they seek approval and fear criticism, they do not know how to express their anger in healthy ways. They turn it against themselves by starving or stuffing.
The statistics surrounding eating disorders in the U.S are sobering. Research suggests that:
- Eating disorders are more common than Alzheimer's disease (five to 10 million people have eating disorders compared to four million with Alzheimer's disease).
- Anorexia nervosa has the highest premature death rate of any psychiatric disorder and the majority of deaths are caused by to physiological complications.
- About four percent (or four out of 100) college-aged women have bulimia.
- Five to 15 percent of people with anorexia or bulimia are male, and males account for about 35 percent of all those with binge-eating disorders.
- About one percent of all women – and as many as 30% of women in medically supervised weight control programs – have binge eating disorder.
- Without treatment, up to twenty percent of people with serious eating disorders die. With treatment, that number drops to between two and three percent.
Biochemistry plays a role in eating disorders. People with eating disorders have imbalances in neurotransmitters – chemicals that allow brain cells to communicate and also serve to control appetite and digestion, sleep, mood, thinking and memory. Similar imbalances are known to cause psychiatric disorders, such as depression. Since many people with eating disorders also develop depression, scientists believe there may be a link between these disorders. Research has demonstrated that:
- In the central nervous system, chemical messengers known as neurotransmitters control hormone production. Neurotransmitters called serotonin and norepinephrine, which function abnormally in people who have depression, are also found at lower levels in people with anorexia and bulimia.
- Some patients with anorexia may respond well to antidepressant medication that affects serotonin function in the body.
- People with anorexia or certain forms of depression seem to have higher than normal levels of cortisol, a brain hormone released in response to stress. Excess levels of cortisol, both in people with anorexia and those with depression, are caused by a problem that occurs in, or near, the hypothalamus of the brain.
- There are biochemical similarities between people with eating disorders and those with obsessive-compulsive disorder (OCD). And patients with OCD frequently have abnormal eating behaviors.
- A hormone called vasopressin, another brain chemical found to be abnormal in people with eating disorders and OCD, are found in elevated levels in patients with OCD, anorexia, and bulimia.
*Quick Facts have been reviewed by Medical Advisors and are current as of October 2005.
Ask Your Doctor
This list of questions is a good starting point for discussion with your doctor. However, it is not a comprehensive list.
1. Have you helped other people with eating disorders? If not, can you refer me to another healthcare provider who has?
2. How serious are my symptoms?
3. What health complications do I need to be concerned about?
4. Can I reverse any damage that has been done as the result of my eating disorder?
5. What are my options for treatment?
6. How would you describe your approach to eating disorders?
7. Is treatment for depression called for?
8. Will you involve my family?
9. What role, if any, will medication play? What can I expect from the medications?
10. What can I expect during a counseling session?
11. When, if ever, do you hospitalize patients?
Key Point 1
While eating disorders typically affect younger women, they can persist into, reoccur, or even begin later in life. Unfortunately, eating disorders are a serious health issue for women at midlife.
An eating disorder can affect every cell, tissue, and organ in the body and can lead to irreversible physical damage and even death. They can wreak medical havoc at any age, but the complications for older adults can be particularly perilous. Your body is older, less resilient, and more vulnerable to the brutal punishment that accompanies extremes in eating behaviors and exercise.
The following is a list of some of the physical and medical dangers associated with disordered eating problems.
Anorexia's cycle of self-starvation denies your body of the essential nutrients it needs to function normally. The body is then forced to slow down all of its processes to conserve energy, leading to serious medical consequences.
- Abnormally slow heart rate and low blood pressure. This means that your heart muscle is changing. The risk for heart failure rises as your heart rate and blood pressure levels sink to lower and lower levels.
- Reduction of bone density (osteopenia), which results in fragile bones.
- Muscle loss and weakness.
- Severe dehydration, which can lead to kidney failure.
- Fainting, fatigue, and overall weakness.
- Dry skin and hair, with loss of hair.
- Growth of a downy layer of hair called lanugo all over your body, including the face (your body's response to being cold much of the time).
- Body chemistry disturbances resulting in the potential for life threatening arrythmias or seizures.
The recurrent binge-and-purge cycles that characterize bulimia can affect your entire digestive system, leading to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions.
- Electrolyte imbalances, dehydration and loss of potassium, sodium and chloride as a result of purging behaviors, can lead to life threatening arrythmias or seiures and possibly heart failure and death.
- Potential for gastric rupture during periods of binging (a rare occurrence).
- Inflammation and possible rupture of the esophagus from frequent vomiting.
- Tooth decay and staining from stomach acids released during frequent vomiting.
- Chronic irregular bowel movements and constipation as a result of laxative abuse.
- Peptic ulcers and pancreatitis.
- Laxative abuse bowel disorder.
Binge Eating Disorder
Binge eating disorder often results in many of the same health risks associated with extreme obesity, particularly the risk of heart disease and stroke.
- High blood pressure.
- High cholesterol levels.
- Heart disease as a result of elevated triglyceride levels.
- Type II diabetes.
- Gall bladder disease.
- Accelerated vascular disease.
Key Point 2
Eating disorders are a challenging and disturbing multifaceted problem with biological, psychological, and cultural roots. Understanding their complexity is essential for recovery.
While many people think of an eating disorder as an unhealthy quest for "the perfect body," they really have little to do with vanity and weight. According to mental health experts, eating disorders are complex psychological illnesses in which people try to control life's conflicts and stresses by controlling food. The food, weight, and body image issues are merely surface symptoms of more deeply rooted problems that are often difficult to identify.
People who develop eating disorders typically live in a state of perpetual emotional turmoil. They want to be in control but feel they are not. They tie their anxieties, self-doubt, and feelings of failure or inadequacy to the way they look. They become preoccupied, even obsessed, with food and weight. These and other factors, which vary from person to person, can lead to extreme and often dangerous behaviors including self-starvation, bingeing, purging, and compulsive exercise.
While no one is really sure what causes eating disorders, many experts believe that they develop over time and involve a combination of biological, psychological, socio-cultural, and other factors.
- There may be a genetic predisposition in some families for eating and other compulsive disorders.
- When eating disorders appear to run in families, female relatives are most often affected.
- Scientists are investigating possible links between disordered eating and biochemical changes associated with psychiatric disorders that are common among people with eating disorders.
- Research has indicated that, in some people with eating disorders, there is an imbalance of certain chemicals in the brain. Such an imbalance may precede the onset of the disorder but starvation, itself, can create brain chemical changes.
- Low self-esteem.
- Feelings of lack of control in life.
- Feelings of inadequacy.
- Depression, anger, or anxiety.
- Major life events (i.e. loss of a family member or friend, moving, schools or jobs)
- Accumulation of stress without adequate strategies to cope.
- Stress and fear of the responsibilities associated with jobs, parenting, or caring for an aging relative.
- Portrayal of men's and women's body shapes in the media and other elements of popular culture that are not representative of "real" men and women.
- Cultural and peer pressure to achieve the "perfect body" and stay in shape.
- Valuing of people based on outward appearance, not their inner qualities.
- Mixed messages about health and fast food; confusion about good nutrition and healthy eating.
- Occupations that put emphasis on a certain body shape and size.
- Pressure to achieve and succeed.
- Belief that love is dependent on high achievement.
- Poor communication between family members.
- Difficulty expressing emotions and feelings.
- Troubled personal or family relationships.
- Sexual or physical abuse.
- History of teasing or bullying based on weight or shape.
- Ineffective coping strategies.
- "Modeling." Young girls, in particular, model behaviors on people they admire, such as their mothers, popular peers, fashion models and musicians and actors.
Key Point 3
Even for women at middle age – and perhaps especially for women at middle age – there are good treatments available. However, the complexity of the problem requires a multifaceted approach to treatment – an approach that stresses nutritional issues as well as thoughts and feelings.
Eating disorders tend to be long-term medical problems. While it's difficult for relatives and friends to figure out ways to help, denying or ignoring the problem can have far more serious consequences. Don't expect an eating disorder to go away by itself. Seek immediate help from a qualified professional. You should have no problem getting referral to an eating disorders specialist from your family physician, a social worker, or a mental health agency in your area.
Eating disorders are most successfully treated when diagnosed early and when the individual is committed to change. Often, a complete physical examination is necessary to determine if there is immediate medical danger and to rule out other illnesses. There are several different types of treatment available. Many experts believe that a combination of therapies yields the best result.
- Individual, group, and/or family psychotherapy
- Cognitive and behavioral therapy (CBT)
- Motivational therapy
- Nutritional counseling/therapy
If Emergencies Arise
Call 911 immediately if someone with an eating disorder:
- Complains of chest pains
- Experiences dizziness or passes out
- Vomits blood or passes blood in the urine or a bowel movement
- Is suicidal or talks about dying
Tips for Dealing with an Eating Disorder In a Family Member or Friend
- Be aware of the long-term nature of the illness and muster your patience.
- Don't blame yourself or anyone else (including the patient) for the eating disorder.
- The person with the eating disorder is responsible for behavior that affects others.
- Don't urge, watch or monitor eating, and don't discuss food intake or weight. Your involvement with eating can create opportunities for manipulation.
- Don't monitor the behavior of a person with eating disorders, even if you're invited to do so.
- Avoid turning mealtimes into a battleground. Minimize discussion about food issues.
- Be willing to negotiate on activities involving food.
- Do everything you can to encourage initiative, independence and autonomy.
- Don't use put-downs or comparisons with others who are more "successful."
- Don't neglect your family or others who are important in your life. Focusing on the person with the eating disorder can perpetuate the illness and destroy relationships.
- Don't play therapist. Let a professional handle it.
- Your obligation is to help the person get into treatment. Getting well is his/her job.
- Don't be afraid to support a recommendation for residential treatment or hospitalization.
- Seek help for yourself. Join a family support group or get individual therapy to help you through this difficult time.
Conduct an off-site search for Eating Disorders information from MedlinePlus. These up-to-date search results are based on search terms specific to Second Opinion Key Points.