Eating Disorders at Middle Age, Part 2

By Kathryn Zerbe, MD, and Diana Domnitei, BS
Oregon Health and Science University, Portland
Reprinted from Eating Disorders Review
May/June 2004 Volume 15, Number 3
©2004 Gürze Books

Clinical Presentation

Eating disorders at middle life are often accompanied by addiction to stimulants or cocaine to reduce weight. Herbal remedies, over-the-counter medications, or prescribed medications are also ubiquitously used to counter the normal 5 to 10 lb weight gain of middle life. Some individuals literally exercise themselves to death, spending hours in the gym or fanatically racing from one activity to the next. These addictions may be a final common pathway to cause morbidity and mortality at middle life, an under-recognized issue in women's health care.

Just as the adolescent or young adult with body image disturbances, the individual at middle age may be unhappy with her appearance. However, because time and money are more available to them, affluent individuals may seek out plastic surgery to obliterate the signs of aging. Individuals may struggle with a psychological concern that gets channeled into an eating disorder; that is, the eating disturbance becomes a focus so that the individual avoids facing conflicts, losses, normative life-transition concerns (such as children going to college or aging parents) and even one's mortality.

Middle age is the time of life when one begins to "take stock" and to shift the focus from one's own life to encouraging and helping shape the lives of the younger generation. Psychologist Eric Erickson described the core issue of middle life as generating vs. stagnating. Any emotional or physical problem can prevent an individual from taking his or her place in the cycle of the generations. Eating disorders at middle life have both emotional and physical components that derail adaptive choices at this point in the life cycle. A focus on spirituality may enable some individuals to place greater emphasis on fundamental values, and personal transcendence, rather than on appearance, as a symbol of what constitutes a life lived well.

Treatment Recommendations

Part of the challenge in treating women with eating disorders at midlife is effectively educating them about the normal process of aging. They must come to terms with the fact that the thinness they enjoyed as younger women is probably an unrealistic goal in middle age. We recommend that clinicians tell the patient that female weight gain in midlife is a result of normal hormonal and metabolic shifts, which are likely the result of aging and menopause. Large weight gains should be avoided by exercise and an individualized nutrition plan, because fewer calories are needed than when one is young; however, for most patients some weight gain is inevitable. One of the few boosters of body image is regular exercise, which plays an even larger positive role on the body image of overweight women compared to normal-weight women. As noted before, excess exercise must be avoided.

The journey of psychological discovery into the very source of the eating disorder is usually the keystone of the treatment process. Grappling with unresolved adolescent or adult conflicts or trauma, and addressing maladaptive behaviors such as smoking, food restriction, or drug abuse, or mourning personal issues and/or idealized body image can be costly in terms of time and money but hold the most hope for improvement.

In order for our patients to gain a sense of mastery over their feelings about aging, we encourage them to focus on why "staying youthful" takes on inordinate importance to them and try to help them to understand that nothing can stop the body from slowing down. In essence, existential issues must be dealt with by gently but persistently confronting denial.

Teasing apart the potential developmental antecedents of the body image disturbance that have led to and nurtured the eating disorder into existence includes helping patients to better understand themselves and their lives and the struggles that have shaped them into who they are today. This is vital not only for discovering and understanding the life events that have shaped the patients' eating disorders, but also for fully recognizing and appreciating their own personal growth. Doing so will allow them to gain the pride and sense of internal beauty that comes from the realization that they have lived a worthwhile life. Finding meaning in one's personal history provides a unique pathway to understanding the illness and ways to begin accepting the changes that accompany aging. 5,6

Some patients ask for more specifics. We summarize these extant theories on aging and provide references for them to explore further. In particular, we direct them to the growing biographical and mental-awareness literature that describe positive modes for aging.


As women enter middle age, it becomes increasingly important that they accept the normal physical changes that accompany aging and maintain a positive body image. Because the average woman gains 5-10 lb per decade of life, the focus must shift from deriving excessive self worth from the external to personal development. These achievements include positive relationships with others and self-growth and are vital to making a successful transition into middle life. Greater awareness of the widespread body dissatisfaction among women in middle life, and particularly of those who have the additional symptoms of disordered eating and excessive exercise, will promote women's health at this crucial point in the adult life cycle.

Click here to read Part 1

References, Part 2

  1. Psychology Today, January 1997.
  2. Allaz AF, Bernstein M, Rouget P, et al. Body weight preoccupation in middle age and ageing women: A general population survey. Int J Eat Disord 1998; 23: 287.
  3. Tiggemann M. Body Image Research Summary: Body Image and Aging. Body Image & Health Inc. Research Summaries 1999.
  4. Rodin J, Silberstein L, Streigel-Moore R. Women and weight: A normative discontent. Nebraska Symposium on Motivation 1985; 266.
  5. Zerbe K. The crucial role of psychodynamic understanding in the treatment of eating disorders. Psychiatr Clin N Am 2001; 2:24.
  6. Zerbe K. Eating Disorders Over the Lifecycle: Diagnosis and Treatment. Primary Psychiatry 2003; 10: 6.