As the pandemic ravaged routines and rituals, it also disrupted many patients' eating behaviors. When COVID-19 struck the U.S., the National Eating Disorders Association helpline saw a more than 40% increase in usage, the group reported on its website.
Clinics that treat patients with eating disorders are also seeing an increased demand for their services—that is, if patients can continue to access them. “My clinical experience is that more people are suffering more from eating disorders during COVID,” said Jennifer L. Gaudiani, MD, an outpatient internist and certified eating disorder specialist at the Gaudiani Clinic in Denver.
At Melrose Center in St. Louis Park, Minn., many patients are experiencing exacerbations of their eating disorders, said associate medical director Deborah Mangham, MD, FACP. There has also been an increase in requests for evaluations of new patients. “COVID has been an incredible life changer for our patients,” she said. “Eating disorders often function as ways of dealing with stress, and 2020 has been a time of unprecedented stress.”
That pandemic-related stress comes in many forms. “Those with eating disorders are facing challenges such as accessibility to their support systems, finding foods that comply with their meal plans, and access to appropriate medical care,” Dr. Mangham said. They were already isolated and struggling with their eating disorders before the pandemic, Dr. Gaudiani added. But now, she said, they are “even more challenged by the overlay of quarantine, a shifting economic climate, inconsistent schooling for their children, and, above all, deep loneliness and longing for connection.”
With eating disordered behaviors on the rise, internists should be aware that they are not limited to female adolescents, Dr. Mangham said. “It is a common misconception that eating disorders only impact young women. … Older people can also have eating disorders, either pre-existing or developing de novo, [and] medical complications are more serious in the older age groups.”
Fortunately, internists are well positioned to spot eating disorder symptoms in older adults, said Jessica H. Baker, PhD, an associate professor of psychiatry at the University of North Carolina (UNC) at Chapel Hill and associate research director of the UNC Center of Excellence for Eating Disorders. “Medical doctors are often the first line of detection, so it is important for internists to screen for eating disorder symptoms.”
For National Eating Disorders Awareness Week, which runs from Feb. 22 to 28, experts explained which adult patients may be vulnerable to developing eating disorders in midlife and offered tips on detecting symptoms and sequelae.
Prevalence, potential contributors
The overall prevalence of eating disorders (according to DSM-5 criteria) in patients older than age 40 years is around 3.5% in women and 1% to 2% in men, according to a review of the evidence published in November 2017 by Current Opinion in Psychiatry. However, exact numbers remain unknown because midlife individuals are underrepresented in research on eating disorders, Dr. Baker noted. “The prevalence of eating disorders does appear to decrease with age,” she said, “but they do not disappear.”
While eating disorder symptoms are indeed more common in younger patients, they also occur during middle age. Epidemiological and clinical reports have suggested three profiles of midlife eating disorders: 1) an early-onset, chronic condition without prior recovery, 2) a relapse of a remitted disorder, and 3) a late onset with no prior history, said Dr. Gaudiani.
In one study that surveyed nearly 2,000 U.S. women ages 50 years and older, about 13% reported at least one current eating disorder symptom (e.g., low body weight, recurrent binge eating, compensatory behaviors), according to results published in the November 2012 International Journal of Eating Disorders. About 28% of participants reported past symptoms. More recently, a study of more than 5,500 U.K. women found that about 15% met criteria for an eating disorder by midlife, according to results published in January 2017 by BMC Medicine.
For patients meeting DSM-5 criteria, the two most common eating disorders at midlife are other specified feeding and eating disorders (OSFED) and binge eating disorder, according to the evidence review. OSFED (formerly known as eating disorder not otherwise specified) functions as a catchall category, with the DSM-5 listing the following clinical examples: atypical anorexia nervosa, bulimia nervosa or binge eating disorder of low frequency and/or limited duration, purging disorder, and night eating syndrome.
Men are vulnerable to the same disordered eating behaviors as women. Among individuals with eating disorders, men represent 25% of those with anorexia nervosa, 36% of those with binge eating disorder, and 25% of those with bulimia nervosa, the National Eating Disorders Association reported.
Part of the reason bingeing behaviors are so common in both men and women is that they can temporarily calm and soothe, said Theresa Rohr-Kirchgraber, MD, FACP, professor of clinical medicine and pediatrics at Indiana University (IU) and an internist at the IU National Center of Excellence of Women's Health in Indianapolis. “Bingeing, in some ways, makes you calmer. Think about after Thanksgiving: You feel tired. … The binge eating can also be a sign of self-harm. If you binge, it makes you hurt at the end,” she said, adding that many of these patients have a tendency not to eat in front of others.
Of women older than age 40 years who present for outpatient treatment for eating disorders, the majority are diagnosed with OSFED (33%), followed by bulimia (30%) and binge eating disorder (25%), Dr. Baker reported. On the other hand, anorexia nervosa is the least prevalent of the eating disorders (which is consistent across the lifespan) and comprises the remaining 12% of these patients, she said.
Rates of eating disorder behaviors in middle-age patients have increased over time, potentially more quickly than in other groups. While disordered eating increased from 1998 to 2008 across all demographic sectors in a sample of Australian participants, it increased at a faster rate in men, people of lower socioeconomic status, and older participants, according to results published in September 2014 by BMC Public Health. Specifically, extreme dieting and purging both increased in participants ages 45 years and older.
Patients at highest risk for developing an eating disorder at midlife are those who experienced an eating disorder or disordered eating at younger ages, Dr. Baker said. On the other hand, adult men and women without a history of eating disorders can also present with them, typically after big life changes, said Dr. Rohr-Kirchgraber.
“What we found is … there is something that triggered them—usually a relationship problem, like getting a divorce or because your spouse is cheating [with] somebody, or a death of a partner or spouse or a good friend, a change of job, a loss of job, retirement, things like that,” she said.
Another life change that can trigger disordered eating behaviors in women is menopause. In addition to significant hormonal changes, perimenopause is characterized by both physical (e.g., age-related weight gain and body changes, change in adiposity) and psychological changes (e.g., role transitions, increased body dissatisfaction, grief and loss, stressful life events), Dr. Baker noted.
As women enter role transitions at perimenopause, they may question their changing identities as mothers, workers, and partners, Dr. Gaudiani said. “Women face a withering combination of existential role … as well as all-too-common physician inexpertise in ameliorating symptoms that arise from hormone changes,” she said.
Emerging research has found that there may be a metabolic component to eating disorders as well, said Karen L. Samuels, PhD, a licensed psychologist practicing in Central Florida who specializes in the treatment of midlife eating disorders and publishes and presents on this topic nationally. “I believe that we're really zeroing in on [establishing] that the entrance and the exit from reproductive life are both windows of vulnerability for eating disorders. … Perimenopause and menopause resemble puberty, with major hormonal, psychological, physical, and metabolic changes.”
In her practice, Dr. Rohr-Kirchgraber said she is seeing more and more women present with eating disorders in midlife. “I think with menopause, just like with puberty (especially for women), our bodies change, and … you don't have the ability to really change that,” she said. “So consequently, you start to reach for things. You start to try to find new solutions. You start to do things that you never had to do before.”
Underlying all these potential contributors to eating disorders is the social pressure to be thin and look youthful, experts said. “Small wonder that years of diet culture might crest into a clinical eating disorder at this stage, or that a previous eating disorder that seemed to have resolved might come roaring back,” said Dr. Gaudiani.
But disordered eating behaviors are not just a stubborn determination to be “small enough” or “thin enough,” Dr. Samuels noted. “There really is a complex bio-, psychosocial, relational, [and] metabolic component to these disorders,” she said. “And they're life-threatening—especially when we see people who have been struggling for decades.”
Recognizing medical complications
The medical complications of an eating disorder are serious across the lifespan, but older people are more susceptible to certain sequelae, experts said. Osteoporosis appears to be the most common physical comorbidity among women ages 50 years or older with eating disorders, Dr. Baker noted.
Bone mass begins to decline after about age 30 years, and malnutrition (regardless of whether the patient is thin) can decrease the amount of muscle pulling on those bones, added Dr. Rohr-Kirchgraber. “That's going to make the osteoporosis worse, so be thinking about women who have had a fracture who shouldn't have had,” she said. “And if you see some early osteoporosis in somebody who really isn't at increased risk, you should definitely ask about their eating disorder behaviors.”
Dr. Rohr-Kirchgraber also suggested thinking about eating disorders in patients who are having some difficulty with their previously well-controlled chronic conditions, such as high HbA1c levels in a patient with diabetes. “You can eat a whole lot and not take enough insulin and not gain weight,” she said. “There's something called ‘diabulimia,’ where if you keep your blood sugar running a little bit on the high side, then you're able to ‘pee out that sugar’ instead of letting the insulin take that sugar and put it into storage, so it's one way for you to lose a little.”
Heart troubles, such as arrhythmias and congestive heart failure, can also occur. While a heart rate less than 50 beats per minute is often chalked up to exercise, “We don't take the next step and say, ‘How much are you exercising?’” said Dr. Rohr-Kirchgraber, adding that patients may use exercise as a way to purge calories. Other methods of purging can also cause adverse events, Dr. Mangham noted. “We have occasionally had patients with kidney failure from chronic abuse of laxatives or diuretics and resultant hypokalemic nephropathy.”
Yet another complication that can arise over time is gastroparesis, or a slow gut, most often in patients who are malnourished from anorexia or substantial diuretic or laxative misuse, said Dr. Rohr-Kirchgraber. That's because “One, you don't have enough nutrition going in there to move out, and two, you have to have the muscular strength within the wall of the intestine to actually move the food through,” she said.
Gastroparesis would be expected in a patient with a body mass index (BMI) less than 17 kg/m2, “But it's the effect, not the cause,” Dr. Rohr-Kirchgraber said. “So before ordering a gastroparesis test on patients that have a lower BMI, we need to really be asking about their dietary habits and their potential for abuse: laxative abuse, diuretic abuse, etc.”
Internists may be accustomed to praising patients who lose weight, but a low BMI in an older adult should instead be a red flag, Dr. Rohr-Kirchgraber said. “If you have a middle-aged adult with a BMI of less than 19 [kg/m2], you should definitely ask about nutrition and eating disorders,” she said. “Because of the changes that happen with menopause and middle age, it is really hard to keep your BMI less than 19 [kg/m2], and certainly less than 17 [kg/m2]. That means you're restricting a lot.”
Consequences may be especially dire in men with eating disorders, who often suffer from such comorbidities as anxiety, excessive exercise, depression, and substance use disorders, according to the National Eating Disorders Association. Various studies have suggested that men with eating disorders have a higher mortality risk than women, and hospitalizations involving eating disorders for male patients increased by 53% from 1999 to 2009, the group noted.
Most patients with disordered eating behaviors don't recognize their problem and may not bring it up to their doctors, Dr. Rohr-Kirchgraber said.
“They're afraid to. They're ashamed,” she said. “Maybe they don't even recognize the eating disorder because even if they've brought it up, they're told, ‘Oh, no. That's only in young kids,’ when in actuality, it's not.”
For internists, taking a thorough history is generally going to provide more information about disordered eating than ordering labs or tests, Dr. Rohr-Kirchgraber said. She suggested including a 24-hour diet history (i.e., What did you eat yesterday?) whenever possible and asking two simple screening questions, which appeared in the ACP Handbook of Women's Health in 2009 and may be used for all, including younger patients: 1) Are you comfortable with your current body shape and size? and 2) What have you done in the last year to try to change it? “It's helpful, especially when they tell you all the 10,000 diets that they've been on and they haven't worked,” she said.
Perhaps the most important piece for internists is knowing which local eating disorder resources and specialists are available to refer their patients to, Dr. Rohr-Kirchgraber said. “That really helps to take the load off my mind because I don't have to do it all by myself.” (See sidebar on this page for more resources.)
Physicians might also try adjusting their own expectations and biases about older women's bodies, Dr. Samuels said. The extra body fat that redistributes in the midsection has an oft-overlooked function: producing hormones that replace what is lost with menopause, she noted, adding that a patient of a colleague once said she now thinks about the roll around her middle as a life preserver, rather than a spare tire. “I tell doctors they could help their women patients feel so much better about this, with just that little bit of insight.”
Dr. Rohr-Kirchgraber acknowledged that internists are short on time for additional screening but said that increased awareness of eating disorders can be key.
“There's so much for us as general internists to think about, but it's helpful to have it in the back of our mind,” she said. “That's why we went into internal medicine: because we love getting the stories, we love doing the detective work, and we're usually well equipped to say, ‘This doesn't fit. What else should I be thinking about?’”