Midlife a Critical Risk Period for Eating Disorders in Women

Liam Davenport

January 20, 2016

UPDATED January 21, 2016 // Middle-aged women may be at risk of developing eating disorders (EDs) around the time of menopause, warn US investigators, who call for further research into the causes and treatment of EDs in this population.

They believe that EDs may be triggered in midlife by hypersensitivity to menopausal fluctuations in estrogen levels, which may combine with social pressures to conform to female ideals at a time of bodily change to create a "perfect storm" for the development of ED symptoms.

"Contrary to popular belief, midlife does not render women immune to EDs. In fact, perimenopause may be a critical risk period for the development or redevelopment of binge eating–type EDs in women," the investigators note.

"It's been overlooked because eating disorders are traditionally, or stereotypically, thought to occur only in young adults and adolescents, so I think providers, when they are talking to midlife women, are not aware that they are at risk of eating disorders," lead author Jessica H. Baker, PhD, in the Department of Psychiatry, University of North Carolina at Chapel Hill, told Medscape Medical News.

"Clinicians [and] lay people really need to know that midlife women are not immune to developing an eating disorder," she stressed.

The research was published online January 7 in Maturitas.

Lack of Research

Dr Baker and Cristin D. Runfola, PhD, also in the Department of Psychiatry, University of North Carolina at Chapel Hill, conducted a comprehensive search of articles published in PubMed on midlife EDs, as well as the hormonal etiology of EDs and other psychiatric disorders, including depression.

The team then critically reviewed each publication to create a snapshot of the current literature on midlife EDs and to develop hypotheses for testing in future research.

Despite the general lack of research into midlife EDs, the researchers determined that the prevalence of EDs, such as anorexia and bulimia nervosa, in midlife women is approximately 4%. Including binge-eating disorders showed that up to 10% of perimenopausal women are affected.

These EDs were of three types: an early-onset, chronic condition without prior recovery (ongoing ED); the relapse of a remitted disorder; or a late-onset ED in patients with no prior history.

Although the chronic-condition and relapse profiles may be more common, late-onset EDs also occur, Dr Baker and Dr Runfola point out.

In one review of 48 adults older than 50 years with EDs, 69% (n = 33) in whom disease onset occurred later in life had had no prior diagnosis.

The prevalence of ED symptoms is higher during the perimenopausal period than either before or after, which suggests that fluctuations in estrogen levels may be an important factor, they say.

However, the team also notes that although the majority of women experience estrogen fluctuations, only a small number develop EDs.

They therefore propose that perimenopausal ED is primarily characterized by binge eating, in which women who are hypersensitive to estrogen fluctuations react strongly to changes in estrogen levels around the time of menopause.

Perfect Storm

Speaking to Medscape Medical News, Dr Baker suggested that an individual's genetic background may drive hypersensitivity to estrogen.

"We see that the risk for eating disorders increases exponentially during puberty, when another period of significant reproductive and estrogen change is happening," she said.

"There's been some research in the young adulthood literature showing that estrogen might play a key role in turning on the genes responsible for eating disorders."

Another factor that may play a role in the development of EDs is that of social pressure to conform to a perceived ideal female body shape.

"We've seen this shift in society of placing more emphasis on looking perfect, staying young looking, and having the perfect body at midlife.

"I've seen some articles that have called it the 'desperate housewives' effect, that now, women as they age are expected to stay young looking and look perfect," said Dr Baker.

"The menopause, like puberty, might represent this 'perfect storm' of risk, where you have the genetic risk for sensitivity to estrogen fluctuations, you have the estrogen fluctuations happening, and then you have the societal pressure on you to stay perfect looking, even though you are going through all of these different biological changes that change the way your body looks," she added.

Dr Baker emphasized that further research is needed to confirm these hypotheses.

"I think what we need now is to do some of the research that has been done in adolescent and young adult populations in midlife populations to see if we do see some of the same effects of estrogen and ovarian hormones on ED symptoms.

"For example, in the young adult literature, there's been some work following both individuals with EDs and community samples that are clinically based, looking at how ED symptoms or eating behaviors fluctuate across the menstrual cycle, and then how those ED symptom fluctuations across the menstrual cycle are related to changes in estrogen levels and progesterone levels."

Following that, women in midlife should be studied across the menstrual cycle, with estrogen levels collected so that fluctuations in ED symptoms can be related to changes in estrogen levels. In addition, experimental studies to manipulate estrogen levels may shed further light on EDs in midlife women.

In conclusion, Dr Baker said that she and Dr Runfola wrote the article to call attention to midlife EDsso that these women can be provided with the "best form of treatment and care."

Dr Runfola received support from the Global Foundation for Eating Disorders and the Hilda and Preston Davis Foundation. Dr Baker has disclosed no relevant financial relationships.

Maturitas. Published online January 7, 2016. Abstract

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