Elder Eating Disorders: Surprising New Challenge

By Juliann Schaeffer

Long thought to be confined largely to the adolescent and teen populations, eating disorders increasingly manifest themselves in older adults.

Anorexia nervosa, bulimia, and binge eating. Previously associated primarily with the younger set—preteens and teens—such eating disorders have unfortunately expanded to affect more individuals in midlife and beyond, as older age proves to be no barrier for disordered eating practices.

”To date, eating disorders have always been considered an illness of young people, predominantly females,” says Vivian Hanson Meehan, president and founder of the National Association of Anorexia Nervosa and Associated Disorders (ANAD), an internationally recognized authority in the eating disorders field. Holly Grishkat, PhD, site director of The Renfrew Center in Radnor, PA, who also runs the facility's Thirty-Something and Beyond program adds, “The 'new' face of eating disorders is younger, older, and more diverse. We are seeing the emergence of eating disorders in preadolescents, women over 30, and in people regardless of race, gender, religion, sexual orientation, and socioeconomic status.”

Even though eating disorders have pushed their way into the lives of older adults, Grishkat says they often surface early. “I think eating disorders are still primarily a disease of the youth, as most midlife women with eating disorders developed the problem prior to the age of 18. Many of those women are just now reaching out for treatment,” she says. “So while it may look like they are emerging later in life, most eating disordered women have been suffering since adolescence. The difference is that we are now working with women who have had the disorder for 10, 20, and 30 years rather than the adolescents who may have a much shorter experience with these disorders. After 30 years, the eating disorder has become almost a personality characteristic for these women, as many of them define themselves by the eating disorder.”

Grishkat says that women in midlife or older are currently part of the largest group of “new” sufferers of eating disorders seen at the facility but due to a lack of research data, it's difficult to say whether the prevalence of eating disorders in older women is increasing. “We do get them,” she says of patients over the age of 50. “I currently have a woman in my Thirty-Something and Beyond Group who is age 58. I have experienced both a 64 year old and a 72 year old in treatment at the residential facility. I believe 72 years old is the oldest that we have treated so far at Renfrew,” she says, admitting that more data on the prevalence of eating disorders in older adults is sorely needed.

Meehan, head of ANAD, a nonprofit organization dedicated to alleviating eating disorders, acknowledges the difficulty of defining the level of prevalence of eating disorders in older adults. “I know several women who have developed anorexia nervosa after they have had children and the children are older,” she says.  She recounts the stories of two women she encountered who suffered from eating disorders in older age.

“In the case of one woman—this was probably the oldest woman I know who came into treatment—she had either eight or 12 children. She kept very busy; all of her children were grown, and all had graduated from college with degrees of one sort or another. It was her children who insisted that she come into therapy, but she was worried about her husband's [health], as he was older than she was.  While he was still alive, she refused to go into treatment. Her husband died [some time after] and then she decided to go into treatment because of the pressure from her kids, but she didn't stay more than three days. Her children's pushing for her to have treatment didn't seem to matter. There was also a big question as to how long she had actually had an eating disorder because none of her family had remembered her as anything but thin. Whether or not she had the eating disorder when they were younger was unclear, but she did not receive treatment, to my knowledge, and steadfastly refused any treatment for a long time.

“[Another older woman] was very unwilling to get treatment, and her husband and doctor colluded and lied to her and told her that she was going into the hospital just for an interview at his office in the hospital. Then when she got into the hospital, she was admitted. She was very unhappy about it and couldn't make up her mind to stay, was talked into staying a day or so, and then decided that since she was there, she'd stay a little longer. She ended up staying and going through the entire treatment and recovering.”

Types of Eating Disorders
According to Grishkat, the women who come to The Renfrew Center residential facility fall evenly into three diagnoses, regardless of age: anorexia, bulimia, and eating disorder not otherwise specified.

Meehan believes that the diagnoses of eating disorder types fall evenly across the spectrum in older adults, but she notes that the patients she's known have mostly exhibited anorexia nervosa. “Now that may be because it's easy to see when a person is getting thin, very thin, and maintains their thinness over great protestations, whereas bulimics are so good at hiding it,” she says. “I remember a husband who reported that he never knew that his wife had an eating disorder, and I think they had been married for something like 15 years. One day, he came home from work early because he wasn't feeling well, and as he entered the kitchen, he saw his wife vomiting into the sink.”

After the husband confronted his wife, she denied the vomiting. “He said he wanted to believe her, but that he actually couldn't. He began to put two and two together, but she was adamant about denying her illness all through that period where he was trying to get her into treatment. I don't know if she ever did go into treatment or go into treatment successfully,” Meehan recounts.

Older adults suffering from eating disorders fall mainly into the following three categories:
• those who have suffered from an eating disorder in the past and went untreated;
• those whose eating disorder went into remission and resurfaced later in life; and
• those whose disorder emerged later in life.

Grishkat says the majority of women who suffer from later-life eating disorders have actually been dealing with them from a much younger age. “The largest of the three categories are those women who have had an eating disorder their entire lives,” she notes, adding that this category is followed by that including women who had eating disorders when they were young, that went into remission and reemerged later in life because of some stressor.

“The smallest group includes those who have only recently developed an eating disorder. Even with this group, when we look more closely at the history of these women, most of them have had some type of disordered eating throughout most of their lives, although it may not have risen to the point of a formal eating disorder diagnosis,” Grishkat explains.

Triggers for Disordered Eating
While some triggers of eating disorders may look similar for younger vs. older patients, there are some definite differences as the stressors in life change as one gets older. “The triggers differ for younger vs. older women in that older women are dealing a lot more with issues of loss and grieving,” says Grishkat. “Younger women's issues tend to focus more on transitions. Regardless of when you develop an eating disorder, the one common trigger is stress of some sort. The stressors just change with age. So while younger, the women may have been dealing with the transition from high school to college or from childhood to adulthood, older women's stressors include such things as empty nest, divorce, loss of parents, widowhood, retirement, chronic illness/disability, death of an adult child, and growing old/facing mortality.”

Additional triggers for older adults dealing with eating disorders can include lack of enthusiasm for life; attempts to get attention from family members; protest against living conditions, such as in a nursing home; economic hardship; and medical problems.

Meehan says certain medical circumstances can also bring on an eating disorder in older adults. She recalls one woman who she believes began disordered eating practices quite unintentionally: “I remember once I was at a college health fair, and an older woman walked in and said that she wanted to take the eating attitudes test. [After taking it,] she scored very high, and so I started asking her questions about what was going on in her life. She said that she had recently (about two years [previously]) been diagnosed with a heart attack and that [healthcare professionals] began telling her that she had to be very careful with her diet and make sure that she ate the right things. She got very anxious, and she didn't know what to eat or how she should eat and began eating less than she should. She began losing weight, and she talked to the doctors about it but they didn't seem to know [that she had a problem].

“Now whether she had fully explained to the doctors all of her fears, I don't know,” Meehan continues. “But the fact is that she was scared to death because she was afraid that she was going to die if she didn't eat the right things. And she had a hard time figuring out what were the right things. So, I don't think she had an eating disorder early on in her life; I think this developed sometime later. When she developed a heart attack, she was concerned that this was going to be it. So for her, it was fear that maintained and perhaps increased her eating disorder.”

As Grishkat says, “Eating disorders are never about weight, food, numbers, etc., but they are a way of coping with something else that the person finds extremely difficult to express, feel, or control. In this way, the role of the eating disorder is much like alcohol for an alcoholic. Both serve the same purpose—to avoid, numb, and cope. So, if as an adolescent the person learned that this was an effective way of coping, we wouldn't find it unusual that they might revert back to this unhealthy coping mechanism to deal with later life stressors, particularly if the person has never learned other, healthier ways of coping.”

Signs, Symptoms, and Treatment
It can be difficult to identify or diagnose an eating disorder in older adults, Grishkat says. But the following signs can be clues to later-life disordered eating:
• significant change in weight (up or down) over a relatively short period of time;
• changes in behavior such as disappearing after a meal or using the restroom after eating something;
• boxes of laxatives, diet pills, or diuretics;
• desire to eat in the bedroom alone rather than eating with family or spouse;
• missing food;
• sensitivity to cold; and
• excessive hair loss, dental damage, or heart or gastrointestinal problems.

“Not all patients have all of the symptoms,” Meehan acknowledges. She also notes that eating disorders often occur comorbidly with depression or other types of anxiety disorders, so these can also serve as clues to possible problems.

A lack of sufficient treatment options that provide programming for midlife and older women could be a deterrent to later-life women getting into treatment, according to Grishkat.  “Many fear being put into groups with adolescents and young adults with whom they cannot relate because they are at such a different place in their lives. Additionally, these women tend to experience more shame and self-blame around their eating disorders and feel they should be the role models for the younger girls rather than sitting in a group as one of them. We have also found in our experience that when the younger women and [older] women are treated together, the older women tend to take on a motherly role with the younger women and focus their energies on taking care of others rather than caring for themselves,” she says.

In a study conducted by ANAD, 86% of participants reported the onset of their eating disorder occurred by the age of 20, but only 50% reported being cured. “This is one reason why we find large numbers of women and men in their 30s, 40s, 50s, and beyond suffering from these illnesses,” says Meehan. But on a slightly more positive note, Grishkat says she has noticed that most of the older women she has treated tend to be very determined in their pursuit for health and wellness. “They dedicate themselves to the treatment and have many motivators that the younger women don't have—i.e., children, a family, aging, etc. As a result, these women tend to do well in treatment.”

Hope and Help
Meehan holds out hope for the possibility of recovery for older women dealing with eating disorders. “If older women seek treatment and join support groups through organizations like ANAD, they can recover and go on to lead healthy and productive lives,” she says, noting that sometimes healthcare professionals or family members need to get creative in getting older women into treatment.

In the realm of helping older adults suffering from an eating disorder, Grishkat says the advice crosses the age divide. “Women should know that there is treatment out there for them—women of any age,” she says.

— Juliann Schaeffer is an editorial assistant at Aging Well.