When Anorexia Strikes in Midlife

When Denise Folcik, a Wisconsin mother of four, agreed to take her 16-year-old to the mall, she saw it as bonding time with her youngest daughter. But on the drive home, Folcik suddenly lost consciousness at the wheel; her daughter rushed to take control and get her mother to an emergency room. After hours of tests, Folcik finally confessed the secret she had been hiding for years: She had bulimia nervosa and purged several times a day. She was 43.

That night, another daughter called from college and made her mother promise never to throw up again. “I didn’t want to break my promise,” Folcik says. “So that’s when I became anorexic.”

Though she checked some of the boxes—white, female—Folcik didn’t exactly fit the eating disorder (ED) mold. The conditions, which include anorexia, bulimia, and binge eating disorder, are often framed as problems battled by teenage girls, postpubertal and consumed with self-consciousness. The perception isn’t entirely misguided: The National Eating Disorders Association (NEDA) reports that people under 30 comprise two-thirds of inpatient admissions to an eating disorder clinic. Puberty itself is considered a major risk factor for the disorders’ onset.

But Folcik represents an under-reported phenomenon: eating disorders that arise in midlife or later, particularly in women. As many as 13 percent of women over age 50 engage in disordered eating behaviors, according to the International Journal of Eating Disorders. Some older sufferers are relapsing years after recovery, but many have found themselves confronted with the disorders for the first time in their 30s, 40s, and beyond. Like those afflicting younger patients, midlife eating disorders can wreak enormous havoc on the lives of sufferers—but remain misunderstood, underdiagnosed, and unsuited for treatments geared more toward teens.

Too Old for Anorexia?

Clinical psychologist Margo Maine, author of Body Wars, has spent her career providing family therapy to adolescents with eating disorders. Years ago, she noticed that many of her patients’ parents—particularly the moms—were consuming extreme diets, engaging in punishing exercise regimens, and abusing laxatives—even as their offspring underwent treatment. Over the years, countless mothers have called her, reporting that witnessing their child get help had encouraged them to disclose their own disorder. “One woman who was in her fifties,” Maine says, “had had two husbands and three children—and no one knew.”

Most of the women Maine heard from had kept their struggles entirely to themselves, often for years. “What struck me was the degree of shame they lived with,” she says. They chided themselves for struggling with a “teenage disorder,” and embarrassment, she notes, is a factor that prevents many older sufferers from seeking help. Triggers distinct to midlife can reactivate a long remitted disorder or set off a new one: divorce, the death of a parent, an empty nest, and a visibly aging body, coupled with societal pressure to stay thin and youthful.

Now 58, Folcik says her eating disorders began after the birth of her fourth child, when she experienced a fierce desire to lose weight. Diets weren’t helping; then, she remembered a friend’s sister had bulimia. “I didn’t know a lot about eating disorders,” she says. “It just sounded like the perfect diet.”

What started as a weight-loss trick became a reliable crutch when life threw challenges her way. At the time that she replaced her bulimia with anorexia, her marriage was foundering and she was worried about the possible effects of divorce on her children. “It became my coping method—my drug.” Maine notes that it’s common for EDs to change with age, with binge eating becoming more prevalent.

Elizabeth Audette was struggling through her own painful divorce when, at age 37, she developed both anorexia and bulimia for the first time. A successful elementary school principal and self-described “perfectionist,” Audette felt like a failure as her marriage unraveled. She compensated, she says, by restricting food and purging.

The same perfectionism that drove her career success fueled her ED. For seven years, she cut out foods, purged what she did eat, and obsessed over menus so she could plan her food intake before outings. She worked diligently to hide her behaviors from family and friends. “I needed to take control—be an independent woman, stay healthy and fit,” Audette, now 44, says. “I had to figure this out.”

Hormonal Havoc

That Audette and Folcik were of similar age when they hit rock bottom—mid-40s—may not be coincidental. The hormonal changes that occur in women during this period may play a role in late-onset EDs, recent research suggests.

ED symptoms in women are most common during adolescence, dip between 25 and 34, and rise again from 45 to 54, the peaks coinciding with puberty and perimenopause. The extreme estrogen fluctuations of perimenopause are thought to be one culprit in midlife eating disorders, says psychologist Jessica Baker of the University of North Carolina. “Women who are susceptible [may] have a heightened sensitivity to fluctuating hormones.”

Eating disorders likely have genetic roots as well, recent findings suggest. But whether the cause is hormonal, genetic, or psychological, older adults often find their disordered eating overlooked—even applauded—in a society that values thinness and fears the weight gain that often comes with age. “People with eating disorders get compliments on their eating habits, as well as their shape and size. As a result, it’s hard for people to take EDs seriously,” says psychologist Stephanie Zerwas, also at UNC. Genetic findings may give the disorders medical legitimacy, she adds. “That will, hopefully, lead to more treatments.”

But for now, ED research is sparse—especially studies of older adults. Researchers struggle to get funding, although EDs have the highest mortality rate of any mental illness. In 2015, federal support equaled just 73 cents per affected individual—and most studies recruit younger subjects, primarily female. No surprise, then, that little is known about midlife EDs or how the conditions affect males.

Teenage Treatment

Diagnostic criteria for EDs have traditionally been based on patients’ body mass index (BMI). But those measures “have no real science behind them,” Maine argues, and relying on BMI alone renders many ineligible. With age, people may gain weight that keeps them in a healthy BMI range, though they’re still engaging in purging or other disorder-specific behaviors. In addition, much training of professionals centers on teens.

Affordable treatment options, too, can be lacking. “A lot of folks don’t have access to ED providers who accept their insurance,” Baker says. And as a whole, treatment caters to a younger crowd. “No one in group therapy was my age,” Audette recalls. “I couldn’t relate to them; they couldn’t relate to me. The only thing that kept me from quitting was that an older woman joined.” Folcik’s experiences were similar. “I was there to work with the program, but many young girls were not ready for recovery,” she says. “There were so many times when I wished I was with women my age who understood me.”

Treatment for younger patients typically takes a top-down approach, with the professional in charge. Older adults may benefit more from a less linear patient-clinician collaboration to decide on treatment priorities, Maine says, as well as scheduling flexibility to account for work and family responsibilities. Age-related issues also need to be incorporated into treatment. “Their bodies are changing, with natural weight gain and slowing metabolisms. Patients need to understand these processes—not pathologize them.”

Bridging the Gap

Research on success rates also tends to focus on young patients, but emerging evidence suggests that midlifers can benefit from treatment that addresses body image and disordered eating, as well as aging, grief, and loss. Though her own treatment had ups and downs, Folcik credits the therapist she saw after leaving the ER with saving her life. “She told me if I didn’t make changes, I was going to die,” Folcik says. “She asked if my kids would be worse off if I were divorced or if I were dead.” The blunt question was a wakeup call. “That’s when I knew I had to take this seriously.”

As researchers like Baker and Zerwas expand the field’s focus to include older adults, some progress has been made: Genetic data promise both reduced stigma and more individualized treatments; a wider range of therapy types is taking root; and insurance companies are being pushed to expand coverage of evidence-based programs. A quick screen for EDs during routine physicals could also keep older patients from slipping through the cracks, adds psychologist Ellen Fitzsimmons-Craft, of Washington University School of Medicine.

But more awareness of midlife onset and the steps needed to sustain recovery—a word for which the world of eating disorders still doesn’t have a clear-cut definition—is still desperately needed, patients say.

“I eat now,” Folcik says. “But there’s still that voice in the background saying, ‘Be careful.’”