January/February 2021

Eating Disorders in Older Adults
By KC Wright, MS, RDN
Today’s Geriatric Medicine
Vol. 14 No. 1 P. 18

Clinicians often overlook these disorders in their older patients.

Eating disorders (EDs) are common mental health issues and a major burden on public health in the United States. Almost 10% of the US population has struggled with an ED during their lifetime.1 That’s some 30 million people—20 million women and 10 million men.

Traditionally, the occurrence of EDs has predominantly been considered to be an issue among adolescents and young adults. Yet, evidence increasingly suggests this is a stereotype and that EDs don’t discriminate based on age, gender, race, or demographic. And research indicates that EDs and body dissatisfaction occurring later in life are on the rise,2 particularly for women.3 Although the rate of EDs in older adults is hard to determine due to limited epidemiological data, the prevalence of EDs is about 3.5% in older (>40 years of age) women and 1% to 2% in older men. Cultural standards of what is attractive, especially thinness; warnings of the health effects of overweight and obesity; and unrealistic body images portrayed in the media all contribute to this phenomenon. Unfortunately, EDs in older adults are overlooked in the health care system, even in primary care, and especially among men.4

Types of EDs
To better understand the influential factors leading to EDs in older adults as well as how to screen for and treating them, it’s important to consider the four diagnoses contained within The Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V): anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and other specified feeding and eating disorders (OSFED). Each of these EDs shares two common threads. First, for each diagnosis, a patient has extreme feelings and behaviors focused on body weight and food. Second, every ED has significant physical and mental health implications, including life-threatening consequences. Some patients may exhibit symptoms that overlap more than one diagnosis, yet each ED has unique criteria.

Patients with AN restrict calorie intake as well as types of foods, leading to significantly low body weight. They also have an intense fear of gaining weight, while placing undue importance on their own shape and weight. Some people with the AN may exercise excessively, purge via vomiting or laxatives, and/or binge eat.

BN is characterized by a cycle of food bingeing and compensatory behaviors such as self-induced vomiting. An episode of binge eating is defined as eating in a set period of time an amount of food that’s much larger than that which most people would consume during a similar period and circumstance. Someone with BN also feels a lack of control over food and eating during the episode.

Patients with BED also have recurrent episodes of binge eating larger amounts of food than normal and experience a lack of control. But patients with BED do not typically display compensatory behaviors. Rather, those with BED often endure feelings of shame, disgust, and guilt after overeating. BED is more prevalent than AN and BN combined,5 with a lifetime prevalence between 1% and 3%.3

OSFED was known as eating disorder not otherwise specified (EDNOS) in past DSM editions, but patients so classified were sometimes denied insurance coverage for treatment, perhaps because the condition may have been considered less serious. Yet, as with other eating disorders, OSFED is serious, life-threatening, and treatable. OSFED encompasses individuals who do not meet strict diagnostic criteria for AN or BN, yet still demonstrate ED behaviors that cause clinically significant distress and impairment.

Although not formally recognized in the DSM, the term “orthorexia” was coined in 1998 and defines an obsession with eating only “healthful,” “pure,” and/or “clean” food and describes those who compulsively check ingredient lists and nutritional labels. People with orthorexia may avoid an increasing number of food groups, considering sugars, carbs, or animal foods taboo. Someone who adamantly seeks and will only eat organic food or who will eat only food that supports sustainable food system principles, may have orthorexia. Body image concerns may or may not be present; rather, an unusual interest in health is evident. Public nutrition education as well as recent emphasis on consuming locally grown foods may be contributing to the incidence of orthorexia and case presentations in older adults.

It’s important to understand that many people who have idiosyncrasies related to body image and food may exhibit some disordered eating behaviors. Individuals who engage in disordered eating may demonstrate ED behaviors, but not as often and to a lesser degree. Furthermore, disordered eating behaviors can develop into a full-blown ED. Midlife and older women appear to most commonly experience BED, OSFED, and subthreshold disordered eating.6 In males, excessive sports activity can mask eating pathology. Muscularity-oriented disordered eating has been described as a new male-specific issue in contrast to the traditional weight-phobic eating disorder.4

Influential Factors
Although symptoms of EDs in older adults are similar to those diagnosed earlier in life, and evaluation remains the same, the context and circumstances differ with age. EDs beyond midlife have been recognized in three distinct categories.6 Many adult women have endured disordered eating since adolescence and have retained the issue into later life. More than 15% of women at midlife have continually struggled with EDs throughout their lives.7 Others had a clinical eating disorder in early life, were treated, and either partially or fully recovered but then experienced a recurrence or relapse in later life. A subset of this group, perhaps with subclinical symptoms, were never diagnosed until midlife or had food and weight issues for years, which eventually became incapacitating. Older adults who experience the initial onset of an eating disorder later in life without any history of symptoms comprise a minor category of patients. As noted, more women are suffering later in life with EDs, and body dissatisfaction may go unrecognized and untreated, and become chronic.

Estrogen: Similar to the transition from childhood to adolescence, the shift from a woman’s reproductive years to menopause is now recognized as a high-risk time for symptoms of EDs to recur or manifest.8 As the peak onset of EDs occur during developmental periods of reproductive hormone change, changes in estrogen associated with the perimenopausal period may be a trigger for older adults. Thus, an eating disorder emerging at perimenopause indicates the impact of the aging process and gender-specific differences.

Age-related stress: Globally, Westernized cultures have idolized values of youthfulness. It’s been shown that the psychological factors associated with eating pathology in older adult women are similar to those found in younger and middle-age women.9 Those vulnerable may become hyperfocused on their own body dissatisfaction as they age, considering themselves perhaps unacceptable and seeking ways to modify their bodies. For older adults with any history of EDs, this can certainly stimulate a relapse. When a group of women aged 61 to 92 were surveyed about their bodies, body weight was reported as their greatest concern.6

Lifetime diet and weight obsession: Some women and men alike have spent most of their lives engaging in evaluations of body size, weight, and shape. Diet culture demonizes most body fat, which in turn makes disordered eating appear normal. The anticipated weight gain in menopausal women can be extremely stressful for those focused on having a thin, youthful body. More than 50% of normal weight (BMI <25) women reported increased body dissatisfaction in their 50s as compared with their younger years, even compared with their 40s.6

Pressures to defy aging: The emphasis on the human body as currency appears to have become greater across the lifespan. Many facial creams, dietary supplements, energy drinks, and exercise equipment and regimens, are marketed to fight the natural aging process. Yet illness and acute medical symptoms, as well as dramatic life events that occur with age (retirement, loss of loved ones, etc), may precipitate body dissatisfaction and EDs. Unfortunately, the majority of older women suffering with untreated EDs experience significant shame and isolation.6

Clinical Factors Unique to Older Adults With EDs
As with younger patients with EDs, almost every vital organ system of the older adult’s body is affected, as evidenced by electrolyte imbalances, neuro-endocrine irregularities (including depleted fat stores that can lead to decreased estrogen), and metabolic dysfunction causing both weight cycling and malnutrition. Yet specific to older adults with EDs, a more rapid cognitive impairment may result from dieting and significant weight decline. Increased depression and physical comorbidities are also common in older adults. Some may have lived with EDs for so long they may not be able to recognize them as a problem or to raise the issue with their health care providers. To a greater extent than younger patients, older adults with EDs may assume their behaviors are just part of their identities and believe it is too late in life to desire or seek treatment. The impact of an ED on the health of an older adult may be both sudden and dramatic. Chronic and restrictive diets, overuse of laxatives, and binge eating can result in weight cycling, which may be followed by compensatory behaviors such as purging and excessive exercise. Postmenopausal women with and ED or a history of an ED often have issues with osteopenia, osteoporosis, dental caries, and overuse injuries.4

Severe health effects of EDs include decreased bone density, dysregulation of the endocrine system, brain dysfunction, gastric and hematological complications, and nutrient deficiencies.3

The impact of BED in older adults can be especially concerning given the metabolic disturbances influencing the cardiovascular system.3 BED can lead to obesity, dyslipidemia, insulin resistance, and hypertension. Obesity itself can elicit depression and low self-esteem that can exacerbate the BED cycle, increasing severity of symptoms.

Screening for EDs in Older Adults
EDs in older adults often go unseen by primary care practitioners who are not trained to recognize them and are unfamiliar with ED assessment tools for adults at midlife and beyond. If it’s difficult for a health care provider to detect or suspect the incidence of an ED, treatment may be delayed or may not occur at all. Furthermore, providers may stereotype and consider their patients to be too old to have an active ED. Older women report that their medical care providers have never asked questions pertaining to their EDs and body image difficulties.6 John Batsis, MD, an associate professor of geriatric medicine at the University of North Carolina School of Medicine, confirms this. “In the [clinical] geriatric community, EDs are not on anyone’s radar because the focus is on many other health issues. It is less important, and, to the patient, it may not even be an issue.”

Thus, it can be critical to detect eating disorders for early intervention and to prevent other associated health complications. Recently, a streamlined screening tool developed for primary care and integrative health care settings was validated for accuracy. The Screen for Disordered Eating (SDE) is ideal for busy, fast-paced practices, as it contains only five questions.10 It is especially efficient for screening older adults and identifies the complete range of EDs in the DSM-5.6 The SDE was developed as a more accurate measure of AN, BN, and BED. Given the increase in BED and OSFED in older adults, the SDE is considered an important screening tool.

Treatment
Treatment tends to be more effective before the disorder becomes chronic, although even people with long-standing EDs can and do recover.1 Successful treatment of EDs depends on a multidisciplinary approach. There’s limited evidence of the efficacy of pharmacotherapy in older adults, although some medications may help to alleviate physical symptoms or treat comorbidities.3 In addition to medical monitoring, a psychiatric evaluation may be warranted. Psychological counseling, particularly cognitive behavioral therapy, can be effective in treating older adults with EDs, with the goal of helping patients shift their individual body perspective. Nutrition counseling by a registered dietitian nutritionist is also vital; they can educate patients about their nutritional needs as well as help plan for and monitor rational individual food choices.

Although many programs and discussions about EDs focus on AN and BN, research and clinical practice suggest that the predominance of EDs in older adults are BED, OSFED, and subthreshold disordered eating.6 Batsis argues that there’s as much stigma related to BED as there is to obesity. Primary care practices can filter eating pathology issues, screen using the SDE, and have appropriate resources for referrals.

It’s important that clinicians from every health discipline involved in ED treatment emphasize that natural body changes occur with age. In bona fide ED patients, providers should also emphasize that an ED is an illness rather than a flaw. Encourage older adults to be the best version of themselves, and let them know that aging is inevitable and aging gracefully is a practice.

EDs in older adults can go easily undetected, as most health care providers look at the major conditions of aging when working with this population. As EDs are typically considered a young adult disease and medical professionals have little training about them, an increased awareness of EDs in the older adults is crucial.11 Finally, more research on EDs in older adults is needed for proper diagnosis and management. If health care providers employ empathy and a nonjudgmental approach, effective treatment outcomes are more likely.

— KC Wright, MS, RDN, is a research dietitian and maintains a nutrition communications practice. She can be found at WildberryCommunications.com.

References
1. Caceres V. Eating disorder statistics. U.S. News & World Report. February 14, 2020. https://health.usnews.com/conditions/eating-disorder/articles/eating-disorder-statistics. Accessed August 27, 2020.

2. Peat CM, Peyerl NL, Muehlenkamp JJ. Body image and eating disorders in older adults: a review. J Gen Psych. 2008;135(4):343-358.

3. Podfigurna-Stopa A, Czyzyk A, Katulski K, et al. Eating disorder in older women. Maturitas. 2015;82(2):146-152.

4. Mangweth-Matzek B, Hoek HW. Epidemiology and treatment of eating disorders in in men and women of middle and older age. Curr Opin Psych. 2017;30:446-451.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

6. Samuels KL, Maine MM, Tantillo M. Disordered eating, eating disorders, and body image in midlife and older women. Curr Psychiatry Rep. 2019;21:1-9.

7. Micali N, Martini M, Thomas J, et al. Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors. BMC Med. 2017;15:12.

8. Baker J, Runfola C. Eating disorders in midlife women: a perimenopausal eating disorder? Maturitas. 2016;85:112-116.

9. Midlarsky E, Marotta AK, Pirutinsky S, Morin RT, McGowan JC. Psychological predictors of eating pathology in older adult women. J Women Aging. 2018;30(2):145-157.

10. Maguen S, Hebenstreit C, Li Y, et al. Screen for disordered eating: improving the accuracy of eating disorder screening in primary care. Gen Hosp Psychiatry. 2018;50:20-25.

11. Eating disorders in midlife and beyond. National Eating Disorders Association. https://www.nationaleatingdisorders.org/eating-disorders-mid-life-beyond. Accessed August 29, 2020.