'Surprising' Number of Midlife Women Develop Eating Disorders

Batya Swift Yasgur, MA, LSW

January 19, 2017

Eating disorders (EDs) affect a surprising number of women in midlife, new research shows.

A team of researchers led by Nadia Micali, MD, PhD, medical director and associate professor of psychiatry at the Eating and Weight Disorders Program, Icahn School of Medicine at Mount Sinai, New York City, found that approximately 15.3% of a cohort of 5655 women in their 40s and 50s met the criteria for a lifetime ED, with 3.6% reporting an ED within the past 12 months.

Dr Micali, who is also senior lecturer and honorary consultant psychiatrist, Department of Psychiatry at University College, London, told Medscape Medical News that the findings were unexpected.

"The number of women who suffered from an eating disorder at some time in their past was slightly higher than we had anticipated, and there were many women with a current eating disorder, including some that developed it at midlife."

The study was published online January 17 in the open access journal BMC Medicine.

Understudied Population

Estimates of the lifetime prevalence of EDs, using DSM-5 diagnostic criteria, and period-prevalence estimates have varied dramatically across studies, the researchers write, leaving a gap in understanding the evolution of these disorders across the lifespan.

In addition, "no previous studies have investigated the period or lifetime prevalence of EDs amongst women in the fourth and fifth decade of life, after most individuals would be considered to have passed through the primary window of risk."

This motivated the investigators to conduct the first-ever study of the prevalence, risk factors, and healthcare utilization of midlife women who experience EDs.

Participants were drawn from the UK Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based prospective study of women who had been pregnant and had expected to deliver their babies between April 1, 1991, and December 31, 1992.

In phase 1 of the study, Dr Micali and colleagues sent questionnaires to participants in the ALSPAC study and received 5655 responses. The average age of the participants was 47.78 years (SD, 4.5).

In phase 2, respondents who screened positive for EDs (n = 524) and a randomly selected sample of respondents who screened negative (n = 518) were interviewed using validated structured tools to determine DSM-5 ED diagnosis.

"The two-phase epidemiological design, one of the best approaches to estimate prevalence of disease, and the survey analytical techniques allowed more accurate estimates to be obtained using our entire Phase I sample," the researchers write.

EDs included in the study were anorexia nervosa (AN), subdivided into restrictive anorexia (AN-R) and anorexia nervosa binge-purge (AN-BP); bulimia nervosa (BN); binge eating disorder (BED); subthreshold BN and BED; purging disorder (PD); and other specific feeding and eating disorder (OSFED).

The weighted lifetime prevalence of any eating disorder was 15.33% (95% confidence interval [CI], 13.48 - 14.72); the 12-month prevalence was 3.61% (95% CI, 3.00 - 4.35). Notably, 41.5% of current EDs were new-onset cases.

AN was the most common lifetime full-threshold eating disorder (3.64%), with the lowest median age of onset (16 years; range, 11 - 39 years). The median age of onset was highest for subthreshold BED (26 years; range, 13 - 44 years).

Risk Factors

The investigators examined a variety of early risk factors potentially associated with the onset of an ED, including childhood unhappiness, parental divorce or separation, early sexual abuse, life events, and bonding with parents.

The death of a caregiver in childhood was associated with an odds ratio (OR) of 7.12 (95% CI, 2.32 - 21.85; P < .0001) for PD. Overall childhood unhappiness was most closely associated with AN-, BN, and BED (OR, 2.52; 95% CI, 1.19 - 5.34; OR, 4.58; 95% CI, 2.56 - 8.20, and OR, 3.66; 95% CI, 2.01 - 6.68, respectively; P < .0001).

Interpersonal sensitivity was associated with all EDs (95% CI). The highest statistical significance was found in association with AN-BP, BN, and BED (OR, 1.05; 95% CI, 1.03 - 1.07; OR, 1.06; 95% CI,1.04 - 1.08, and OR 1.04 95% CI, 1.02 - 1.06, respectively; P < .0001). Childhood sexual abuse was most strongly associated with AN-BP, BN, BED, and subthreshold BED (OR, 3.81; 95% CI,1.95 - 7.43; OR, 4.70; 95% CI, 2.60 - 8.50; OR, 3.42; 95% CI,1.95 - 5.99; OR, 8.11; 95% CI, 2.74 - 23.94, respectively; P < .0001).

Childhood life events were positively associated with almost all eating disorders, with a 4% to 10% increase per unit score. Women who reported experiencing maternal warmth had 20% decreased odds of developing bulimia, compared to those in the lowest 75% range.

"I was more surprised by the similarities than by the differences between risk factors for the various eating disorders," said Dr Micali. "Life and stressful events in childhood and adolescence and sensitivity to social issues were common to all eating disorders."

By contrast, childhood sexual abuse was "most closely associated with disorders such as bulimia and binge eating, and poor maternal care was associated with bulimia," she said.

Dr Micali added that it was especially noteworthy that "although we expected to see a larger set of risk factors associated specifically with anorexia, this did not turn out to be the case."

The researchers found that only 27.4% of women with eating disorders reported seeking help or receiving treatment for their condition.

"Many women we interviewed told us they had never sought help or spoken to a healthcare professional about their eating problem at any point in their life, suggesting potential healthcare barriers or lack of awareness among healthcare providers. It is important for the scientific community to be aware of this," said Dr Micali.

Low Treatment Rate a "Shocker"

Commenting on the findings for Medscape Medical News, Diane Mickley, MD, assistant clinical professor, Department of Psychiatry, Yale University School of Medicine, and director of the Wilkins Center for Eating Disorders, Greenwich, Connecticut, said the study "has an elegant design, with an unusual opportunity to study a large database that included decades of data."

However, the original ALSPAC cohort from which the current study participants were drawn was limited to pregnant women.

"Women with an eating disorder who were too thin or psychiatrically compromised to be pregnant were excluded from the cohort. [This] might have created a small selection bias that could account for the fact that there were fewer anorexics in the study than one would expect," said Dr Mickley, who was not involved with the study.

Nevertheless, this limitation "does not skew the overall findings," she said.

She also questioned the phrase "low maternal warmth" used in the study.

"People with eating disorders are extremely sensitive and may not have perceived their mothers' warmth accurately. Historically, mothers have been blamed for their children's illnesses, and it is important not to come away with the misconception that poor parenting causes eating disorders," she said.

Dr Mickley acknowledged that it was a "shocker" to her that more than 70% of midlife women with EDs had never received treatment.

Dr Micali agreed, emphasizing, "It is important for clinicians to be aware that eating disorders should be considered, even in midlife women, and binge eating and purging are more common than anorexia."

She suggested that women in midlife require interventions for EDs different from those administered to adolescents. "CBT has a strong evidence base for this population," she said.

The UK Medical Research Council, the Wellcome Trust, and the University of Bristol provide core support for the ALSPAC. This study was funded by the National Institute of Health Research and Wellchild. Dr Micali and Dr Mickley report no relevant financial relationships.

BMC Med. Published online January 17, 2017. Full text

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