Body image and eating issues in midlife: A narrative review with clinical question recommendations

Abstract

Midlife is a period of transition that is influenced by multiple biopsychosocial and cultural factors. Eating and body image issues are common at this life stage. The purposes of this narrative review are to explore: 1) the aspects of midlife that make individuals vulnerable to eating issues and body image concerns and 2) how these factors may be influenced by weight, cultural background, and socioeconomic status. Within this review, we aim to explore nuances of how eating and body image issues present in some historically marginalized groups at midlife. The aim is to provide clinicians who care for midlife individuals with practical tools to initiate conversations regarding body image and eating issues. Ideally this will facilitate early intervention and assessment for individuals who are struggling with new, chronic, or relapse of symptoms of disordered eating.

1. Introduction

Midlife is a period of transition that is influenced by multiple biopsychosocial and cultural factors [1]. Eating and body image issues are common at this life stage. Eating disorders (EDs) comprise a group of serious psychiatric illnesses with core symptoms centered on dysregulated eating patterns (e.g., binge eating, extreme restriction of food intake, self-induced vomiting), body image concerns, and significant medical and psychiatric morbidity [2–4]. The ED field has been highly skewed toward investigation into risks, clinical presentations, and treatment of individuals that fit a historical stereotype: young, white, affluent, thin, women and girls. EDs have been understudied among individuals who differ from this inaccurate stereotype. Indeed, a recent review found that no treatment trials were designed for older adults and only 3 treatment trials even allowed participants age > 65 [5].Yet, a bourgeoning body of literature has started to document that EDs and associated risk factors (e.g., body dissatisfaction) are more prevalent among midlife and older women than once thought [6–8].

For instance, in an online sample of women aged 50 and above (N = 1849), approximately 13 % reported at least some current core ED symptoms; 7.8 % of participants reported purging in the absence of binge eating in the last 5 years, and 3.5 % endorsed currently binge eating at least once per week [8]. Among women aged 40–60 years, 4.6 % of women met DSM-IV criteria for an ED, while an additional 4.8 % endorsed subthreshold ED symptoms. Across the spectrum of ED symptoms in midlife, binge eating appears to be the most common, with between 11 %–25 % of women (age ≥ 50) [6,8–13] reporting recurrent binge eating. Furthermore, 60–89 % % [12,14–16] of midlife women report body dissatisfaction, which is a core ED risk factor [17].

Given the pervasive nature of ED symptoms and risk factors in midlife, it is critical to identify the common and unique biopsychosocial risks for ED onset, behavioral topography of EDs, and treatment considerations, among individuals at this life stage. Therefore, the purpose of this review is to describe the state of the literature regarding body image and EDs among midlife women, including risks for EDs and/or body image concerns in midlife, unique and overlapping facets of clinical presentations in midlife, and considerations for screening, medical complications, referrals, and treatment (Fig. 1).

Fig. 1.

Midlife biopsychosocial factors that contribute to eating and body image issues.

2. Method

We conducted a comprehensive PubMed and Google Scholar search for articles over the past decade, 2013–2023, published in the areas of midlife, menopause, body image and eating issues. We also incorporated relevant clinical reference guides published within this period. Our aim was to select books and articles that incorporated information regarding nuances based on size, cultural background and socioeconomic status.. Greater consideration was given to publications with superior scientific quality that incorporated a diverse study population and included our specific groups of interest. This included searching “cited by” and “related articles” for relevance to our topic. The articles included for this review represent a snapshot of the most relevant articles which address the topics of midlife eating and body image issues and address weight stigma as it relates to cultural background and socioeconomic status (Table 1).

Table 1.

Table of eating disorder medical complications that are exacerbated in midlife.

ED medical complications exacerbated in midlife
•  Electrolyte imbalances
•  Menopause symptoms
•  Decreased bone mineral density
•  Cardiac dysfunction
•  Cognitive impairment
•  Dermatologic changes
•  Reduced hormone levels
•  Chronic pain
•  Osteoarthritis
•  Decreased muscle mass/sarcopenia

3. Results

Using the methods outlined above, we identified approximately 100 possible relevant articles of which 38 articles and 1 book were chosen for the review based on our inclusion and exclusion criteria. Greater consideration was given to publications with superior scientific quality that incorporated midlife women from marginalized groups (i.e., higher weight, lower SES, LGBTQIA+, women of color). The inclusion criteria utilized included: English language and associations in midlife with race, ethnicity, gender, sexual orientation, socioeconomic status, eating issues, and body image issues. We included systematic reviews, meta-analyses, clinical trials, cross-sectional studies, post hoc analyses, cohort studies, chart reviews, case-control studies, narrative reviews, books, and articles. Our exclusion criteria included: language other than English, outside of the 2013–2023 time frame, age range other than midlife. Table 2 provides a high-level overview of the articles selected.

Table 2.

Body image and eating issues in midlife: A narrative review with clinical questions recommendations.

Highlight = item did not meet inclusion criteria, but was cited for historical perspective or context rather than narrative review.

	Reference	Objective/aim of the study	(Findings/suggestions/conclusions/important points)
1	Sergeant, J et al 2017	This study explores the impact of menopause on women's identity and considers the effect of sociocultural factors on their experience of this stage of life.	This study suggests that perimenopausal period is the transitional phase of a mid-life women which is influenced by multiple biopsychosocial and cultural factors. It suggests that interventions for women at midlife would usefully include countering negative expectations about menopause, supporting women to question cultural narratives, reducing shame and embarrassment about menopause, strategies to manage flushes in work and social situations, addressing sleep difficulties, supporting healthy lifestyle choices, and providing women with space to talk about their experience, priorities, and choices.
2	Diagnostic and statistical manual of mental disorders: DSM-5™, 5th ed.	DSM is intended to serve as a practical, functional, and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental disorders.	This clinical manual is a diagnostic tool to assist with formal eating disorder diagnosis.
3	Hambleton, A et al 2022	The article aimed to summarize the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.	High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviors, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.
4	Iwajomo, T et al 2021	To investigate all-cause mortality in a population-based cohort of individuals who received hospital-based care for an eating disorder (anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified) in Ontario, Canada.	Patients with EDs diagnosed in hospital settings experience five to seven times higher mortality rates compared with the overall population.
5	Burnette, C B et al 2022	The goal was to evaluate the reporting, inclusion, and analysis of sociodemographic variables in ED psychotherapeutic treatment randomized controlled trials in the US through 2020.	This study found that there is the limited research in the field of EDs in the minority and mid-life women. Although racial and ethnic diversity improved somewhat, progress appeared to stall in the last decade and the inclusion of Black individuals did not change. Very few papers considered sociodemographic variables in their analyses (e.g., within-group treatment effects), and these ana-lyses were underpowered when conducted
6	Mangweth-Matzek, B et al 2014	To study about the prevalence and correlates of eating disorders (ED) in middle-aged women.	These studies suggest that ED and its associated factors (i.e. body image issue) are more common in mid-life and the prevalence is increasing. Also, among the EDs, binge eating disorder is the most common.
7	Keel, P K et al 2010	This study reports 20-year outcome of bulimia nervosa and related eating disorders not otherwise specified and point prevalence of BN and EDNOS for a cohort of women and men in late adolescence, adulthood, and mid-life.	Despite patterns of improvement in women, 4.5% reported a clinically significant ED at mid-life, suggesting the need for more research on potential risk factors in this age group, such as pressures for women to maintain a youthful appearance.
8	Gagne, D A et al 2012	This study conducted an online survey to characterize eating disorder symptoms and attitudes and weight and shape concerns in women in midlife to older adulthood and concerns in women ages 50 and above.	Disordered eating occurs well into midlife and older adulthood. The most endorsed symptoms were current binge eating and purging in the absence of binge eating in the past 5years.
9	Wilfred, S A et al 2021	The original study aimed to investigate BE prevalence, frequency, and health correlates in a sample of older adult women.	This study suggests that, among the EDs, binge eating disorder is the most common. Results suggest that binge eating is related to negative health indices among older women
10	Kilpela, L S et al 2022	To examine associations between BE severity and health indices.	This study suggests that binge eating disorder patients have poor health-related quality of life and poorer psychological health.
11	Thompson, K A et al 2023	To examine the impact of social media use and comparison on disordered eating among middle-aged women.	Finding suggests that social media-specific social comparison may be driving the disordered eating pattern in mid-life.
12	Mangweth-Matzek, B et al 2006	The aim of the study is to examine eating behavior and body attitude in elderly women.	Body image issue is the core associated factor with ED in mid-life. Although EDs and body dis-satisfaction are typical for young women, they do occur in female elderly.
13	Marcus, M D et al 2007	The aim is to examine (a) the prevalence of binge eating, inappropriate weight control behaviors, and weight and body image concerns among middle-aged community women; (b) whether rates of eating disorder symptoms vary among ethnic groups and are associated with socioeconomic status, weight-related variables, current depressive symptoms or history of major depression, substance abuse or dependence, or childhood abuse; and (c) whether the association between ethnicity and eating disorder symptoms persists after adjustment for covariates.	This study found that high BMI, depression, and history of childhood/adolescence abuse were significantly associated with the Binge Eating and Preoccupation with Eating, Shape and Weight subscale scores.
14	Bedford, J L et al 2006	This study compared body image dissatisfaction and weight control practices; evaluated associations among body image dissatisfaction, societal influences, and concern for appropriateness; and identified the most important correlate of body image dissatisfaction among younger and older women.	Body image issue is the core associated factor with ED in mid-life. Pressure from the media was the most significant correlate of body image dissatisfaction.
15	Jackson, S E et al 2014	Examined cardio-metabolic and psychological changes following weight loss in a cohort of overweight/obese adults.	Weight loss over four years in initially healthy overweight/obese older adults was associated with reduction in cardio-metabolic risk but no psychological benefit.
16	Runfola, C D et al 2013	This study characterizes the profile of women ages 50 and over who report body size satisfaction on a figure rating scale.	Women with body size satisfaction report better overall functioning, including less use of dieting and fewer unhealthy weight control behaviors. However, body size satisfied women appear to exert considerable effort to achieve and maintain this satisfaction.
17	Stice, E et al 2002	This paper reviews theory and empirical findings regarding the putative origins and consequences of body dissatisfaction on eating pathology.	Body image issue is the core associated factor with eating disorder. This review provides support for the claim that sociocultural processes foster body dissatisfaction, which in turn increase the risk for bulimic pathology, and suggests that prevention and treatment interventions might be enhanced by focusing greater attention on body image disturbances.
18	Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C., & Agras, W. S. (2004).	Article which discusses coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy.	Cited to provide historical support for eating disorder risk factors
19	Mangweth-Matzek, B et al 2013	Examined the association of menopausal status with EDs and body image in women.	The perimenopausal women reported a significantly greater prevalence of EDs as compared to premenopausal women.
20	Baker, J H et al 2019	The objective of this pilot study was to examine the effect of ovarian hormone estradiol and progesterone on eating disorder symptom change in midlife women during early perimenopause.	Ovarian hormones may play a role in ED etiology across the lifespan. Progesterone levels shape the impact of ovarian hormone estradiol on ED symptoms.
21	Voda, A M et al 1991	Overview of body composition changes of women during menopause	Foundational study that discusses the body composition changes that occur with menopause.
22	Kilpela, L S et al 2015	This paper aims to provide an up-to-date review of the current literature on the relationship between body image and associated mental and physical health problems and behaviors in adult women.	Body appearance changes may influence body dissatisfaction and, subsequently, increased risk for EDs.
23	Goodman, E L et al 2018	Examined weight suppression and weight elevation, the opposite of weight suppression and their associations with eating psychopathology in women aged 50+.	The risk of body image issue may increase by the weight fluctuation in the forms of either weight suppression and/or weight elevation; indeed, both weight deviances were associated with increased ED symptoms among women aged 50+.
24	Mangweth-Matzek, B et al 2021.	Presented new findings regarding the menopausal transition may represent a window of vulnerability for EDs in women.	Data augment existing evidence that the menopausal transition may be associated with eating and body-image disturbances. Menopause Rating Scale scores showed strong associations with most measures of the Eating Disorder Examination Questionnaire, as well as with questions regarding satisfaction with body image.
25	Hooper, S C et al 2022	The current study examined older (60+) postmenopausal women's mental health and quality of life as a function of retrospective menopausal symptom severity.	Time since menopause and body mass index were significantly associated with binge eating severity.
26	Astudillo, R B et al 2018	To describe women in adulthood with eating disorders, in relation to their epidemiological, clinical, evolutionary and therapeutic characteristics.	Clinical characteristics and most of the risk factors (biological, psychological, sociocultural) are similar to those found in younger women and may be more likely the continuation of a previous ED or a late onset of the pathology.
27	Samuels, K L et al 2019	Reviewed the evidence for the reported increase in disordered eating and body image disturbance occurring in women in middle age and later life, their contributing factors, bio-psycho-social, treatment considerations, screening tools for evaluation, and treatment recommendations for this special population suffering with EDs.	Eating disorder symptoms and body image preoccupation have been identified in increasing numbers of women over age 50. Reports indicate that women are seeking treatment for chronic, recurrent, or late onset EDs. The health care providers generally have not screened for EDs, and often pursue other medical diagnoses.
28	Roberts, T A et al 1997	This article offers objectification theory as a framework for understanding the experiential consequences of being female in a culture that sexually objectifies the female body.	This article states that girls and women are typically acculturated to internalize an observer's perspective as a primary view of their physical selves. This perspective on self can lead to habitual body monitoring, which, in turn, can increase women's opportunities for shame and anxiety, reduce opportunities for peak motivational states, and diminish awareness of internal bodily states.
29	Becker, C B et al 2013	The current study investigated whether “old talk,” a hereto un-described form of body image talk, appears to be a parallel, but distinct, form of body image talk that taps into the young dimension of the thin-young-ideal standard of female beauty.	It states that fat talk, old talk was significantly correlated with body image disturbance and eating disorder pathology, albeit at a lower rate than fat talk in the total sample.
30	Hooper, S C et al 2023	This pilot study sought to identify psychosomatic, cardiometabolic, body composition, and physical function characteristics of postmenopausal, older adult (age ≥60 years) women with BED.	Rates of comorbid depression, anxiety, sleep problems, and a history of severe menopausal symptoms were high in peri and post-menopausal women. Evidence suggests that BED is highly comorbid with other chronic health conditions and may complicate treatment of these conditions.
31	Heiden-Rootes, K et al 2023	This scoping review was designed to gather and examine the research with transgender and nonbinary adults who experience eating and body image related problems, as well as clinical studies on the effectiveness of treatment approaches.	Future research is needed that centers on nonbinary and genderqueer populations, as well as those from minoritized racial and ethnic groups to inform culturally appropriate concerns, needs, and treatment modalities.
32	Mangweth-Matzek, B et al 2023	Reviewed the recent literature on the epidemiology and treatment of eating disorders among middle-aged and older women and men.	Eating disorders do occur in middle and older age of both sexes. Shame and stigmatization have decreased, and medical awareness and explicit assessment of eating behavior in all age groups have developed.
33	Becker, C B et al 2017	The primary aim of this study was to investigate eating disorder pathology in those living with food insecurity. A secondary aim was to investigate whether any-reason dietary restraint, weight self-stigma, and worry increased as level of food insecurity increased.	Consistent with hypotheses, participants with the highest level of food insecurity (i.e., adults who reported having hungry children in their household) also endorsed significantly higher levels of binge eating, overall ED pathology, any-reason dietary restraint, weight self-stigma, and worry compared to participants with lower levels of food insecurity.
34	Maine, M D et al 2015	This paper will examine how the biopsychosocial experiences throughout adult developmental stages create risk for eating disorders, without the framework of specific age categories.	Adult women with eating disorders often experience an onset or exacerbation of symptoms during developmental transitions including entry to college, career, marriage, pregnancy, divorce, menopause, midlife, retirement, and their later years. In addition to improving the awareness and skills of primary care and mental health providers regarding the increasing incidence of eating disorders in adult women, the field needs to provide more treatment options that meet the requirements of this special group of patients.
35	Kilpela, L S et al 2023	This study explored the characteristics of older women (aged 60+ years) with objective binge episodes (OBE) in later-life, including age of onset, distress, and frequency of OBE.	Regarding distress, older women with OBE in later-life reported themes of age-related self-blame surrounding eating, loss of control, and cognitive fixation on satiation.
36	Middlemass, K M et al 2021	The primary aim of this study was to investigate self-reported reasons for engaging in dietary restraint (DR) in a food insecure urban population. It also tested whether DR was associated with increased ED pathology when DR was broadly assessed	Intentional efforts to limit food intake in this sample were correlated with increased ED pathology. Results indicated that participants engaged in dietary restraints for several reasons, including minimizing the effect of hunger for other family members (i.e., children), "stretching" food to make it last longer, and prioritizing medical expenses.
37	Miller, L M S et al 2020	Assess the association of health challenges and financial worry with food insecurity status and determine whether these associations differed by age group, while adjusting for poverty, sex, race/ethnicity, education, family structure, social security, and food assistance.	Unlike younger and older adults, however, adults in midlife showed high levels of food insecurity regardless of financial worry. Findings suggest that food insecurity in midlife may be more severe than previously thought.
38	Hooper, S C et al 2023	Investigating prevalence rates of ED pathology and differences in ED pathology between midlife and older adult food bank clients.	Significantly more midlife adults reported night eating and skipping ≥two meals in a row versus older adults. Additionally, FI severity level was associated with higher risk of night eating, BE, skipping ≥two meals in a row, and laxative use in midlife adults.
39	Hunger, J M et al 2020	We test the hypothesis that weight discrimination has an indirect association with ED symptomatology through anticipated stigma.	As hypothesized, weight discrimination was indirectly associated with greater disordered eating symptoms via its association with anticipated weight stigma.
40	Udo, T et al 2014	This study compared metabolic function between premenopausal women, postmenopausal women, and men recruited for treatment studies for obesity co-occurring with binge eating disorder, a high-risk population for developing metabolic syndrome.	Among obese women with BED, aging may have a more profound impact on metabolic abnormalities than menopause, suggesting the importance of early intervention of obesity and symptoms of BED.
41	Baker, J H et al 2016	Discussed the evidence that suggests perimenopause indeed may be a vulnerable period for the development or redevelopment of an ED for midlife women.	The midlife does not render women immune to EDs. Perimenopause may be a critical risk period for the development or redevelopment of binge eating type EDs in women. When individuals struggle with EDs in midlife, the associated medical complications can be more severe.
42	Elran-Barak, R et al 2015	This study examined EDs in midlife and beyond by comparing frequency of anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding or eating disorder among midlife eating disorder treatment-seeking individuals and younger controls.	This study suggests that BN is less common whereas BED and OSFED are more common among midlife eating disorder treatment-seeking individuals relative to younger controls. Midlife individuals with BN tended to have higher BMIs relative to the younger comparison group, but this difference only approached the selected level of significance.
43	Thompson, K A et al 2019	This study explored group differences in disordered eating and body image by menopausal status.	Comparing disordered eating and body image concerns across menopausal status groups, results indicated no significant group differences for either disordered eating behaviors using MANOVA or body image concerns using analysis of covariance, controlling for age. These findings remained the same even after controlling for age, race, and BMI
44	Thompson, K A et al 2019	This study provided a descriptive report of disordered eating behaviors and attitudes among older women and evaluated correlates (maladaptive perfectionism, appearance-related criticism).	An array of disordered eating concerns may be present across the lifespan. Older women endorsed a range of disordered eating attitudes; however, they did not report extreme (most pathological) possible scores among several measures (e.g., weight concern, and thinness and restricting expectancies). Maladaptive perfectionism was significantly correlated with all disordered eating attitudes assessed. However, maladaptive perfectionism was only significantly correlated with bulimic symptoms. Regarding appearance-related criticism, rates were lower in this sample of older women than in younger samples.
45	Ginsberg, R L et al 2016	This research studied the prevalence and body image dissatisfaction among post-menopausal women.	Most participants in this study were dissatisfied with their bodies because they perceived themselves as heavier than their ideal. Overall, the multiple and significant correlates of body image dissatisfaction explained of the variance in the body image dissatisfaction score, with body mass index (BMI) and change in BMI being the two most important contributors to explaining the variance.
46	Keshishian, A C et al 2019	This study examined two common comorbidities, major depressive disorder and substance use disorder, in adult women with intake diagnoses of anorexia nervosa and bulimia nervosa who participated in a 22-year longitudinal study.	Compared to those who had not fully recovered from their ED, those who had recovered were twice as likely not to be diagnosed with MDD in the past year and five times as likely not to be diagnosed with SUDs in the past year.
47	Lewis-Smith, H et al 2016	This article systematically reviews existing research on interventions among midlife women on body image and disordered eating outcomes, to inform intervention delivery and provide strategic directions for future research.	It was encouraging to find that 64% of the identified interventions reported significant improvements on body image at postintervention, with small to large effects. The interventions were based on two different therapeutic models: cognitive behavioral therapy (CBT), and acceptance and commitment therapy (ACT)
48	Tortolani, C C et al 2021	This book provides practical approaches to adapting empirically supported treatments for eating disorders for clinicians working with patients of diverse backgrounds and presentations, or within non-traditional treatment settings across levels of care.	Text offers approaches to evidence-based eating disorder treatment for novel populations, including cultural adaptations, LGBTQIA+ and middle aged and older adults.
49	Aziz, V M et al 2017	This article considers causes of disordered eating, including eating disorders, in older people.	The wide range of medical and pharmacological causes of weight loss in older people means that eating disorders may go undetected, occurring insidiously and surreptitiously. Older people with eating disorders tend to belong to one of three categories: those with a chronic disorder from a much younger age, those that were identified and treated and the disorder has recurred, and those that first develop the disorder in later life. Another risk factor for older people is body dissatisfaction as they move further from the cultural ideal of a young, thin, firm, unblemished body.

4. Risk factors

Risk factors for the development of EDs include biopsychosocial vulnerabilities [18]. While the majority of risk factor research in the ED field has centered on youth, some data to date explicate various considerations regarding shared and unique risk factors for aging women. When considering EDs in the context of older age, there appear to be three pathways to EDs in later life, suggesting some windows for vulnerability to ED pathology across the lifespan [10,20,21]. The first represents a chronic, lifelong course which begins in youth and persists into midlife. The second constitutes a remission/relapse course of illness, in which ED onset occurs first in youth, remits partially or fully for a duration of time, and then recurs in midlife. Finally, some EDs in midlife represent a late onset. Thus, there likely are age-related risk factors that influence relapse or new onset of EDs in midlife, constituting age- and gender-specific biological and psychosocial risk factors relevant to course of illness.

4.1. Menopause

The menopausal transition has been identified as a period of increased risk for relapse and/or new onset ED behaviors [19], with higher rates of EDs among perimenopausal women versus pre- or post-menopausal women. Fluctuating hormone levels have been historically identified as a potential cause for the increased ED behavior risk, specifically binge eating, during perimenopause [20]. However, more recent literature suggests midlife body shape changes (e.g., increase adiposity in the abdomen) [21] rather than the hormones themselves are impacting the risk. Age-related body composition and appearance changes shift women further away from the societal young, thin-ideal standard of female beauty. Such changes may influence body dissatisfaction and, subsequently, increase the risk of ED development [21]. Another mechanism through which ED risk may increase is weight fluctuation. This can occur in the forms of either weight suppression or weight elevation. Both weight deviances were associated with increased disordered eating symptoms among women aged 50+ [23]. Furthermore, severity of menopause symptoms appears to confer increased risk for EDs [24,25]. Relatedly, self-reported impact of menopause and aging anxiety are linked to ED risk in mid and later life [26,27]. For instance, women who experience discontent following menopause-related body changes (and other aging-related changes) may begin to use maladaptive eating patterns in an attempt to modify body weight/shape. Such maladaptive eating behaviors often precede the development of EDs [27].

4.2. Interpersonal and social factors

Physical changes associated with aging shift women away from the thin-young ideal standard of female beauty in Western societies [22]. More so, the associated value of a woman's worth as an object to be viewed and admired that is tied to the thin-young ideal associated with value in Western societies [22,28], dieting and weight loss industry marketing [27], and prevalence of old talk (negative age-related body talk) [29,30] all constitute vulnerability factors to body dissatisfaction and EDs in midlife. Paired with natural, age-related weight gain and redistribution of adipose tissue, midlife women face a myriad of pressures from the diet industry [28]. Beyond diet and weight, the beauty industry targets aging women and portray images of aging women in the media that are not representative of the general population [27]. In addition to societal pressures and media influences, social roles and a woman's position in relation to others in her life change during mid and later life. Age-associated changes in interpersonal relationships or social roles (e.g., divorce, empty nest, bereavement), as well as the loss of the self as a being capable of reproduction vis-à-vis the menopausal transition, can affect body image concerns and eating behaviors [22]. Indeed, as social roles change with age, women face transitions across several domains of life during midlife, thus representing additional risk for onset or maintenance of ED behaviors [27].

5. Presentation/screening

Healthcare providers caring for midlife individuals play an important role in identifying those who may be vulnerable to developing an ED. However, they have not generally screened for eating disorder symptoms and body image preoccupation in midlife women [27]. Clinicians need to be aware of the risks associated with body image concerns and disordered eating at this life stage and ask appropriate questions to be able to identify when someone is vulnerable to ED development. Commonly used primary care eating disorder screening tests include Screen for Disordered Eating (SDE), the SCOFF questionnaire, SBIRT-ED (Screening, Brief Intervention, and Referral to Treatment for Eating Disorders), Eating Disorder Screen for Primary Care (EDS-PC). Prior studies have suggested that the SDE is helpful in older populations because it captures more binge eating behaviors which have increased prevalence at midlife [27]. To our knowledge, these screening tests have not been specifically studied to determine their sensitivity to the subtle nuances of ED presentations in midlife. Furthermore, there is specific concern regarding accuracy and reliability in LGBTQIA+ individuals and, in particular, those from marginalized racial/ethnic groups [31].

While substantial epidemiological data are lacking, there is evidence to suggest that binge eating is the most common ED behavior among midlife and older women [32]. Similar to younger populations, midlife and older women can experience significant body dissatisfaction [33], including self-blame, stigma, isolation, and shame [27,34,35]. Yet, midlife and older women also face ageism – both external messaging (e. g., hearing that EDs are only relevant in younger women) and internalized ageism (e.g., believing they are too old for a young person's illness) that adds a new layer into the distress and clinical picture [27,35]. Secondary to internalized ageism and the general perception of the public that midlife and older women do not suffer from EDs, many women themselves do not conceptualize their eating struggles as ED behaviors [27].

Although eating disorders are common in midlife, in clinical practice, we find that many women do not recognize when they are entering this life stage. Additionally, primary care clinicians do not routinely discuss midlife changes as they occur. Older women who receive treatment for an ED have reported that their medical provider never asked them about eating or body image concerns [27]. We recognize that menopause status is not the only factor that impacts the development of eating and body image concerns at this life stage. However, regardless of the underlying factors, clinicians should be aware that women in midlife are vulnerable to these issues and feel comfortable inquiring about them. Primary care clinicians often state that they avoid broaching the topics of eating and body image concerns due to fear that they will say something harmful or triggering. As a result, the topics are avoided completely. The practical questions offered in Appendix A serve as conversation starters to help open the door to more dialogue between patients and clinicians. The questions are designed to help both parties feel more comfortable with the topics. The questions are not designed to be used as a diagnostic tool. The goal is to aid in recognizing midlife women who are vulnerable to eating and/or body image issues and facilitate prompt assessment.

6. Special considerations for historically marginalized groups

6.1. Food insecurity/lower SES

Food insecurity (FI) is more common in those of lower socioeconomic status (SES). A higher level of FI has been correlated with increased risk for ED behaviors [36]. Women with FI and midlife factors such as overlapping caregiver roles (taking care of children, grandchildren and aging family members) have an increased risk of disordered eating patterns like skipping meals to feed others [36]. Food insecure midlife women are also at greater risk for engaging in night eating, laxative use, binge eating and compensatory behaviors. Black women with FI are more likely than Latina women to report night eating behaviors [38].

6.2. Higher body weight/weight elevation

Weight stigma and discrimination are defined as being treated differently or denied certain privileges based on your body size. Higher body weight women of all ages experience weight stigma which is a risk factor for disordered eating [39]. Weight stigma compounded with the other midlife transitions impacting body shape, likely increase disordered eating and body image concerns. Midlife women with weight elevation (current weight higher than their lowest weight) are also at an increased risk for disordered eating symptoms [23].

6.3. Women of color

Women of color may experience ED-related health disparities for several reasons. First, women of color are less likely to seek medical care for menopause symptoms [43], which is worrisome as more severe menopause symptoms confer increased risk for certain ED behaviors (e. g., binge eating). Additionally, women of color and those at higher body weight have an increased risk for metabolic dysfunction which is more common in midlife than younger adulthood [40]. If women of color are less likely to seek care for menopause symptoms, this may delay ED screening and identification. The recognition of metabolic dysfunction symptoms may be what initially prompts these individuals to present to their healthcare providers. The traditional weight-centric approach to addressing metabolic dysfunction has been to recommend weight loss via calorie restriction. Yet, calorie restriction can be a risk factor for ED development. Therefore, midlife women presenting for medical care due to new onset of metabolic dysfunction may benefit from screening for potential eating and body image issues as well as treatment from a weight neutral/size inclusive approach. Recognizing the increased risk of eating and body image concerns in the population, healthcare providers should be educated on strategies to encourage health promoting behaviors for this life stage rather than focus exclusively on weight loss or calorie restriction.

7. Medical complications at midlife

When individuals struggle with EDs in midlife, the associated medical complications can be more severe [41]. Compared with younger patients with eating disorders, those with EDs in midlife reported higher levels of medical comorbidity. Of those surveyed, 60 % of midlife women with anorexia, 46 % with midlife bulimia nervosa, and 83 % with midlife binge eating disorder, reported at least one comorbid medical condition [42]. The health consequences of EDs may be exacerbated in midlife and older women because older chronological age is associated with attenuated physiologic resilience and reserve; EDs thus may further amplify existing medical morbidities and geriatric syndromes. Clinicians may be inclined to embark on an extensive medical work up when they are not aware about a patienťs underlying ED. Limited research has documented the health burden of EDs in the aging body. Existing research suggests that binge eating disorder in later life is associated with depression in older women, lower quality of life, less consumption of nutritious foods, and sleep problems [9,10,33]; these relations hold when controlling for BMI [10]. Aging anxiety, body comparisons, and perfectionism have been associated with EDs in midlife and beyond, while weight change and weight cycling are associated with body dissatisfaction [43–45]. Furthermore, EDs in midlife are highly comorbid with mood disorders, anxiety, and substance use disorders [46]. Thus, the clinical presentation of EDs in later life share common (e.g., depression, body dissatisfaction) and unique (internalized ageism) factors with EDs in younger populations.

8. Referral/treatment

The primary goal of this review has been to identify those midlife individuals at risk for ED development to improve rates of early recognition and prevention. Once an ED diagnosis is suspected, referral to a provider for formal diagnosis and treatment planning is recommended. Of note, the screening measures provided in this review, as well as the suggested questions to start the conversation with patients, are not sufficient for a formal ED diagnosis. When considering referral pathways, the recommended best practices for patient care incorporate the complexity of these illnesses. This review offers some recommendations for treatment planning, as well as considerations for working with midlife and older adults. Specifically, due to the high mortality and morbidity rates, the Academy of Eating Disorders (AED) recommends treatment by a comprehensive multidisciplinary team including clinicians, psychiatrists, psychologists, and dietitians. ED treatment goals include medical management of acute and chronic conditions, nutritional rehabilitation, normalization of eating behavior, and psychosocial stabilization. The AED offers a free resource that is publicly available for more information about the recommended best practices for ED assessment and care (https://www.aedweb.org/resources/publications/medical-care-standards last accessed October 21, 2023).

Despite these informative resources, additional treatment considerations for individuals in midlife are warranted. For instance Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) demonstrated superior outcomes over mindfulness, walking, yoga, and dancing for improved body image among midlife women (age 35–55) without a current ED [47]. Kilpela et al. suggests treatment with interpersonal therapy, problem-solving therapy, and acceptance strategies may be beneficial to midlife women [48]. Midlife women with EDs experience unique barriers to treatment including shame, embarrassment, multi-aged treatment groups (older individuals being placed in a group with younger individuals), and comorbidities (such as depression, anxiety, sequela of excessive exercise, alcohol misuse, use or addiction to stimulants, and unnecessary plastic surgery). Thus, it is important to treat comorbid conditions as well as the psychological issues and interpersonal factors specifically related to midlife. In addition, providers should consider referring patients with a suspected ED to providers who routinely care for older patients (as opposed to ED specialists who exclusively treat children and adolescents). The various roles that midlife women fulfill make it challenging to dedicate time away from the home for ED treatment. The development of virtual/e-Health treatment represents an emerging opportunity to increase access to care for midlife women of various backgrounds and geographic locations.

9. Conclusion/future directions

Midlife is a vulnerable time for ED development or relapse. Clinicians caring for patients at this life stage should be able to recognize nuances in how eating and body image issues present in this population. Special attention should be paid to midlife individuals from marginalized groups who have historically been overlooked in the literature. Early detection of midlife vulnerability to eating and body images issues may help improve patient awareness and lead to timely intervention to avoid progression to an ED. More research needs to be done on eating and body image issues in midlife men, LGTBQIA+ and historically marginalized groups and the impact that early intervention may have on decreasing midlife ED prevalence.

Supplementary Material

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.maturitas.2024.108068.

Abbreviations:

ED

eating disorder

EDS-PC

Eating Disorder Screen for Primary Care

FI

food insecurity

LGBTQIA+

lesbian, gay, bisexual, transgender, queer (or questioning), intersex & asexual

SBIRT-ED

Screening, Brief Intervention, and Referral to Treatment for Eating Disorders

SDE

Screen for Disordered Eating

SES

socioeconomic status