Although hard data on adult eating disorders are absent, we do have compelling information about the extent of dieting and body image concerns, both of which are precursors to clinical eating disorders. For example:

• When asked what bothered them most about their bodies, a group of women aged 61 to 92 identified weight as their greatest concern. (Clarke 2002).
• 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. (Gaesser, 2002)
• A major research project found that more than 20 percent 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. (Berg, 2001)
• A survey of Swiss women found: 70% of women aged 30-74 dissatisfied with weight despite being at a normal weight; 62% of women over the age of 65 wanted to lose weight; 31% of them had dieted recently although most (62%) were normal in weight. (Allaz, Bernstein, Rouget, Archinard, & Morabia, 1998)
• Other studies find comparable levels of dieting and disordered eating across young and elderly age groups. (Hetherington and Burnett, 1994)
• Body image dissatisfaction in midlife has increased dramatically, more than doubling from 25% in 1972 to 56% in 1997. (Garner, 1997)
• In 2003, one-third of inpatient admissions to a specialized treatment center for eating disorders were over 30 years old. (Davis, 2004)
• 60 % of adult women have engaged in pathogenic weight control; 40 % are restrained eaters; 40 percent are overeaters; only 20 % are instinctive eaters; 50 % say their eating is devoid of pleasure and causes them to feel guilty; 90% worry about their weight. (Waterhouse, 1997)

Contemporary western culture consistently values women’s bodies and appearance above other attributes. Sexualized images of female bodies saturate everyday media, shaping the prevailing ideal. Today’s women are always on display, endlessly criticized for transgressing that ever-shifting fine line between being too sexy or not sexy enough, and completely dismissed when they no longer look young. Rarely do we see an older face, be it in film, fashion, advertising, print media or television.

In this age of body technology, when cosmetic plastic surgery can be purchased at a mall during a lunch hour, women are sold the myth that they can (and should) be in complete command of their bodies. The female body has never been more exposed while its natural processes, like the symptoms of menopause, are to be completely masked or corrected. 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, are great challenges in this era of body control and unrealistic beauty images. If a woman’s power is still defined in terms of beauty and a youthful body, the 8-12 pounds she naturally gains at menopause can be a source of great distress and anticipated disempowerment. Contemporary women struggle with the catastrophic consequences of ageism and weightism.

The Shape of Adult Eating Disorders
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 are older. Some may have been preoccupied with food and weight for years, but never incapacitated until now, 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 mid-life, potentially contributing to restrictive dieting that may lead to full eating disorders. As with young women, eating disorders come in different shapes, sizes, and severities, from anorexia to bulimia, EDNOS, binge eating disorder, and subclinical eating disorders, including orthorexia.

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 overpowering consumer culture that teaches them to want and to need, but not to know their true wants and needs. Being bombarded by strict and unrealistic media images of beauty does not end at adulthood. For some women, the focus on appearance and youth intensifies as their bodies age, progressing through the natural stages of change that include weight gain, graying hair, and wrinkled skin. The pressure to buy or pursue the right body persists and can function to distract women from more significant issues in their lives.

Case discussion- Bulimic for several years, Ann was in her late 50’s…

Adult Development
Much has been written about the multiple contributions to eating and body image issues in young women’s lives. We recognize the intense pressures and troubling transitions as they 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 ageing 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 (or more so) as 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, but more and more responsibilities and burdens. The “deadline decade,” the years between 35 and 45, 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. This decade is potentially transformative, as women may be in their sexual prime at this time, but is also filled with endless obligations, responsibilities and stress for most contemporary women, leaving little time to reflect on the impact of all these events and transitions.

Case- At 39, Sally had been the ultimate “good girl” her entire life …

A woman’s life transitions are often shaped by feelings like “my life is out of control.” When things are in transition, feel ambiguous, and look uncertain, we all seek a solution - something stable or something to control. In the era of Body Wars, the body is the answer to all angst, no matter a woman’s age.

Obstacles To Getting Help
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, denying 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.

In light of all these adult realities, it is much harder 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 ageing female body brings. For some, 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. We still confront a lack of basic knowledge in most medical professionals 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 for them. 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, even the high risk ones, for eating disorders. The war on obesity has captured their attention and skewed their perspective, severely limiting their ability to help us bring adult eating disorders out of the closet.

Case- 42 y.o Jennifer, from a perfectionistic and body-conscious family, began dieting at 12…

Clinical Issues in Midlife Women
At midlife and beyond, the motivation for entering treatment may be quite different than that of a younger person. In contrast to our high school and college-aged patients, adult women are more likely to seek help on their own. They are easily discouraged, however, since so much emphasis is placed on young women with these problems. Clinicians need to be aware of this and tailor their efforts to meet the needs of women at and beyond midlife.

Although they are likely to be more self-motivated, adult women also may have lived with this problem for decades, having translated all of their negative feelings into the language of fat and lacking skills to recognize and satisfy their true needs and hungers. Midlife women have the same exquisite sensitivity to others that we associate with eating disorders in vulnerable teens and young women; they are easily shamed, shunned, and dismissed, disappearing 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 Consequently, I now react with the same sense of urgency to a call from a woman at midlife as I 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 due to the emphasis on younger patients and their developmental issues. They also may play a maternal or nurturing role to others, both the younger patients and to the staff, as they are skilled in meeting others’ needs and not their own. Just as our culture dismisses them, midlife women struggling with eating and body image issues readily dismiss themselves. I find myself taking a very active and direct approach with this group of patients. They need much validation, and can readily sense if we don’t grasp the serious ness of their problems.

Often adult women seek help when they are fearful that their eating and body image issues may adversely affect their parenting and the wellbeing 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.

Of course, we prefer that patients enter treatment totally due to self-motivation, yet we need to accept any reason that helps women to break their resistance and denial of how these issues are affecting the quality of their lives. For example, several years ago, a woman in her early 50s sought my help as she wanted to have cosmetic plastic surgery, but knew that if she continued to vomit, the effects of the surgery would be minimal. I agreed to work with her despite my concerns about her plans for surgery. We addressed her issues with ageing 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, I use a harm reduction model and integrate both psychoeducation about the risks of their symptoms as well as insight-oriented psychotherapy, informed by a feminist and relational perspective. It is critical that we help women with such severe histories to find hope. 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 us as treaters to conceptualize the difference we can make, 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 we can improve the quality of their lives.

As with our younger patients, eating disorders and body image obsessions 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. Jennifer and Sally had to explore their family dynamics, especially the relationship both had with their fathers to begin to understand their drives to perfection and the meaning their bodies had assumed. Ann had to address the impact of her father’s depression and withdrawal on her. All three 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 they lacked the skills and resources they needed to handle the challenges of adult life.

Today’s Pioneers - Midlife Women with Eating Disorders
Midlife women with eating disorders often feel motherless, despite the presence of their mothers in their lives. Their realities, especially the critical importance of appearance and body control, are substantially different than how their mothers lived. Opportunities and expectations are unprecedented, but these new roles put women’s bodies in the public eye constantly and in competition with younger women often, in contrast to the realities of previous generations. The meaning of success and “good enough” are light years beyond their foremothers’ definition. As a result, women have no guidance from mothers, grandmothers and other forbearers, and few if any role models to help them chart their course through this complicated frontier. Contemporary women are true pioneers, experiencing things women have never experienced before.

Today’s women hunger for familiarity and security and may find it in the rituals of disordered eating, weight preoccupation, and body image despair. Aspiring to meet the culture’s narrow “beauty” standard may feel the safest or surest way to acculturate and organize their lives. Rather than unlocking the secrets and potential in this land of ambiguity, as other successful immigrants do, contemporary women measure success by how strictly they manage their bodies and restrict their eating.

Conclusions
The challenges at midlife and beyond are many, but confronted with the questions of adulthood, far too many women default to the answer: “My identity is my body- this is the shape I am in.” This is a dismally inadequate response, and yet a logical and predictable one in light of the cultural ambiance surrounding contemporary women. Finally, these problems are coming out of the closet- not a moment too soon for the countless women suffering from the havoc wreaked on their bodies and their psyches after years of body image despair and disordered eating.

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 wellbeing of contemporary women, we need:

• Real data on this problem so we can better define the range of severity and the types of eating 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 clinicians and affect our ability to recognize and treat these issues in adult women.
• Treatment options that meet the needs of adult women-many 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 eating disordered women 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 (www.eatingdisorderscoalition.org) 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.
• Emphasis on eating disorders and related nutritional and body image problems as a major public health issue, resulting in a shared and genuine commitment to: no woman left behind.

REFERENCES

Allaz, A., Bernstein, M. Rouget, P. Archinard,M., Morabia, M. (1998). Body Weight Preoccupation in Middle-Age and Ageing Women: A General Population Survey. International Journal of Eating Disorders, 23, 287-94.

Berg, F. (2001). Women Afraid To Eat. Hettinger, ND: Healthy Weight Network.

Clarke, L.H. ( 2002). Older women’s perceptions of ideal body weights: The tensions between health and appearance motivations for weight loss. Ageing and Society, 22, 751-73.

Davis, W. (2004). Personal communication.

Friedman, S.S. (2002). Body Thieves: Help Girls Reclaim their Natural Bodies and Become Physically Active. Vancouver, Canada: Salal Books.

Gaesser, G. (2002). Big Fat Lies: The Truth About Weight and Your Health. Carlsbad, CA: Gurze Books.

Satisfaction in elderly women. British Journal of Clinical Psychology,33, 391-400.

Garner, D.M. (1997). Psychology Today, Feb. 1997.

R. Gordon (2001). Eating Disorders East and West: A culture-bound syndrome unbound. In M. Nasser, M.A. Katzman, R.A. Gordon, (Eds.). Eating Disorders and Cultures in Transition. N.Y. Taylor and Francis.

Maine, M. (2000). Body Wars- Body Wars: Making Peace with Women’s Bodies; An Activist’s Guide. Carlsbad, CA: Gurze Books.

Waterhouse, D. (1997). Like Mother, Like Daughter: How Women Are Influenced by Their Mother’s Relationship with Food and How to Break the Pattern. N.Y. Hyperion.

Margo Maine, Ph.D., an expert in the treatment of eating disorders, is the author of Father Hunger: Fathers, Daughters and Food and of Body Wars: Making Peace with Women’s Bodies. Cofounder of Maine & Weinstein Specialty Group in West Hartford, CT, she is Senior Editor of Eating Disorders: The Journal of Treatment and Prevention, a founder and fellow of the Academy for Eating Disorders, a founder of the National Eating Disorders Association, and board member of the Eating Disorders Coalition for Research, Policy and Action and of Dads and Daughters. Her new book, co-authored with Joe Kelly, B.S., The Shape We’re In: Overcoming Women’s Obsessions with Weight, Food, and Body Image, will be released in 2005 by John Wiley.