DOI: 10.31038/AWHC.2023614

Abstract

Disordered eating has been a heavily studied topic for many years, especially among the younger female population. Recently, however, there has been an increase in research dedicated to studying the prevalence of disordered eating among aging women. Specifically, studies have demonstrated that women in the perimenopausal, menopausal, and postmenopausal age groups are susceptible to disordered and restrictive eating patterns. This paper discusses and analyzes recent studies that focus on perimenopausal, menopausal, and postmenopausal women and the factors that may contribute to the increasing prevalence of disordered eating among this population. This paper also provides a comparative approach with women and the prevalence of disordered eating across the lifespan.

Keywords

Disordered eating, Eating disorders, Restrictive eating, Body image dissatisfaction, Menopause, Perimenopausal, Postmenopausal

Major Life Changes in a Woman’s Life: Adolescence and Menopause

Adolescence is a major life change for young women and generally occurs during the ages of 10-18, or from puberty to adulthood [1]. This transitional period in life is characterized by hormonal fluctuations, which lead to physical growth and changes in body weight and shape. It is also during adolescence that a young girl experiences many social, emotional and psychological changes, all of which can lead to a drive for control over these changes. Disordered eating patterns, such as restrictive eating, may manifest during this period in life as a means to limit weight gain or as a means to lose weight in an attempt to return to a pre-adolescent weight [2]. Other unhealthy compensatory behaviors, such as compulsive exercising, use and abuse of weight loss pills and/or laxatives, and smoking can also increase during this time.

Another major life change for women is that of menopause. According to the National Institute of Aging [3], menopause is a point in time 12 months after a woman’s last period. The transition to menopause is a natural process of aging for women and generally begins in their 40’s or 50’s. This transition period is called “perimenopause.” It is during this transition time, hormone levels fluctuate once again, and as a result, women in perimenopause can experience various negative symptoms. These symptoms can include hot flashes, night sweats, disturbed sleep patterns, low energy levels, decreased libido, vaginal dryness, changes in body composition (especially increased abdominal fat and loss of muscle), and mood disturbances. Mood disturbances can manifest into depression and anxiety [4]. Similar to adolescence, women find themselves trying to cope with these physical and mental changes. Some may adopt unhealthy, compensatory behaviors, like disordered eating patterns (e.g. restrictive eating and dieting) and excessive exercising to control for changes in body composition [5]. Individuals who have a history of restrictive or disordered eating patterns are at an increased risk for lapsing into pathological eating disorders [5,6].

Clinical eating disorders include anorexia nervosa, bulimia nervosa, and binge eating disorders. However, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) individuals may not fit the specific diagnostic threshold for these three clinical eating disorders. They, therefore, will fall into the category “other specified feeding and eating disorders” [7]. Thus, an apparent continuum may exist, and even though an individual does not fit into a clinical eating disorder, their behaviors still elicit attention. Furthermore, eating disorders often present with other mental disorders, most commonly mood and anxiety disorders, obsessive-compulsive disorder, and alcohol and drug abuse problems. Given the symptomology that surrounds the time of menopause (including peri- and post-), clinicians and other health professionals who work with women in this life stage, should be well aware of the possible development of disordered eating patterns and/or clinical eating disorders.

Much of the literature about eating disorders, body image dissatisfaction, and body image distortion target the younger, adolescent female population. Given the similarities between the major life changes in adolescence and the major life changes in perimenopause, (e.g. hormonal, physical, and psychological changes) research into the prevalence of disordered eating and body image dissatisfaction among older women has gained interest over time.

Causes of Disordered Eating in Older Women

Disordered eating refers to a range of irregular eating behaviors that may or may not warrant a diagnosis of a specific eating disorder [8]. Causes of disordered eating among women have been identified in the research to include sociocultural (the thin ideal or defined standard of beauty), biological (body weight and shape), and psychological (self-esteem, depression) factors [9-11]. The literature supports a connection between self-esteem, negative emotions (e.g. depression) and body image satisfaction [11]; furthermore, body image dissatisfaction is strongly correlated with increased disordered eating behaviors among younger women [12]. Depressive disorders and symptoms are common among middle age women, as are increased reports of anxiety. However, it is unclear as to what causes the increased depression and anxiety. Llaneza and colleagues determined that there is interplay of multiple factors that women experience during the transitional period of menopause, which can lead to increased depression and anxiety; however, depression and anxiety can also influence the clinical course of menopausal symptoms [9].

In an effort to assess how women respond to the transitional period around menopause, Makara-Studzinska and colleagues measured various psycho-social variables among women aged 45-65 years old [10]. They used the Menopause Rating Scale (MRS), which divides symptoms into three categories: psychological symptoms, somato-vegetative symptoms, and urogenital symptoms. Psychological symptoms include feelings of depression, irritation, anxiety and fatigue. Somato-vegetative symptoms include physical symptoms, such as hot flashes, heart palpitations, sleep disorders and muscular complaints. Urogenital symptoms include sexual problems, urological problems, and vaginal dryness. Subjects were asked to identify the symptoms they were experiencing, and rated the symptoms on a given scale of intensity. The results showed that depressive mood was most observed across all age groups, with 82.9 percent of the subjects experiencing the symptom, followed by physical discomfort in the muscles and joints (82.4%), and physical and mental fatigue (82.4%).

Women across the lifespan can experience symptoms of depression, and while inconclusive, some studies show patterns of increasing prevalence with changes in hormone levels. Large hormonal fluctuations occur particularly during three major periods in the lives of women: puberty, pregnancy, and menopause. In a review by Vivian-Taylor and Hickey, evidence indicates that the menopausal transition period yields many significant physical, psychological and social changes, but there are findings that suggest that at least in part there is a biological basis for a relationship between hormonal changes and increased depressive symptoms and disorders [13]. Similar to the findings of Llaneza and colleagues, these authors conclude that it is the interplay between all of the changes that women go through during the menopausal transition stage that put some at increased risk for the onset or recurrence of depression [9].

Depression can play a role in lower self-esteem, increased body dissatisfaction, and disordered eating, especially among women [11]. Drobnjak and colleagues identified that menopause itself is an associated factor in restrained eating among older women [14]. In their study, they examined eating behaviors and self-esteem among normal weight, middle-aged women (aged 40-66). They used the Eating Disorder Examination-Questionnaire (EDE-Q) to assess eating behaviors in premenopausal and postmenopausal women. Participants rated their self-esteem using the Rosenberg Self-Esteem Scale (RSE). The results of this study showed that restrained eating was a relatively frequent behavior among middle-aged women with 15.7% of all participants reporting restrained eating scores in a clinically meaningful range. Furthermore, they found that compared to premenopausal women, postmenopausal women reported decreased self-esteem and higher levels of restrained eating. What was most interesting in this study was that participants were of normal weight. Similarly, other studies have also demonstrated that negative body image and eating disorders may appear in older women [15]. Survey research among 60-70 year old women revealed that 48% of women with a mean BMI of 25.1 desired a mean BMI of 23.3. More than 80% controlled their weight and over 60% stated body dissatisfaction. Moreover, 3.8% met the criteria for eating disorders and 4.4% reported single symptoms of an eating disorder [15].

In a Canadian study of women 50 years and older, Gadalla examined the prevalence of disordered eating symptomatology and disordered eating symptomatology with comorbid mood disorders, anxiety disorders and alcohol dependence [6]. In this sample, 2.6% of women 50-64 years old and 1.8% of women 65 years or older exhibited elevated frequencies of dieting behaviors and preoccupation with food intake and body shape. Disordered eating symptomatology was positively associated with stress level and negatively associated with physical health. Furthermore, risk of eating disorders was strongly associated with mood and anxiety disorders.

While it is clear that several psychological factors play a role in disordered eating behaviors in both young and middle aged women, Midlarsky and Nitzburg sought to distinguish differences between the causes of disordered eating among older women compared to adolescent women [16]. They believed that stressors specific to midlife, could better explain eating pathology among older women. In a sample of 290 middle-aged women aged 45-60 years, they assessed disordered eating symptomatology, sociocultural pressure to be thin, aging-related concerns about appearance, body dissatisfaction, perfectionism, life stress, and depression. They found that eating pathology among women in midlife was associated with the same factors related to eating disorders in younger women. Results of the study showed that pathological eating by middle-aged women was a reflection of their susceptibility to body image-related factors (such as sociocultural pressures to be thin and body dissatisfaction) along with perfectionism. Depression was not related to eating pathology among this sample of older women. Thus, these authors recommend that despite age, women across the lifespan are at risk for the development of eating pathologies for the same reasons/stressors as are their younger counterparts and therefore, should not be ignored.

Objectification Theory and Older Women

Constructs of the Objectification Theory have been used to assess disordered eating among younger women. Augustus-Horvath and Tylka set out to determine if the same core constructs, which include sexual objectification, self-objectification, body shame, and interoceptive awareness, could be used to predict disordered eating in older women [17]. Objectification theory is based on “sexual objectification” and is defined by Fredrickson and Roberts [18] as occurring when “women are treated as bodies, and in particular, as bodies that exist for the use and pleasure of others.” Further, these sexual objectification messages appear in media images that define attractiveness and tell women that their appearance defines their worth. When women internalize these messages of sexual objectification, self-objectification occurs. This then leads to body shame and appearance anxiety and ultimately reduces interoceptive awareness (such as hunger, satiety, and emotions). This study separated a sample of women into two groups: aged 18-24 and aged 25-68. Results showed that the constructs of the objectification theory can be applied to older women, but what takes place within the model is different between the younger and the older women. The older women demonstrated a greater relationship of body shame to disordered eating compared to the younger women. As noted earlier physical changes occur during the menopause transition, which include increased body weight, increased body fat, especially around the abdominal area and arms, and increases in wrinkles. These authors postulate that as women age, they move further away from the cultural images of beauty, which may lead some to experience greater body shame. These women may be more likely to engage in maladaptive weight control strategies characteristic of eating disorders due to this shame.

Conclusion

It is clear that eating disturbances and body image preoccupation occur in older women, particularly those in the menopausal transition period. Factors that contribute to this increased prevalence of disordered eating among older women have been discussed. Samuels, Maine and Tantillo re-emphasize that woman at midlife experience significant life changes, which lead to increased stress and anxiety [19]. Additionally, many women have practiced dieting and weight suppression their entire lives, which only intensify with the predictable weight gain at midlife. Finally, society itself idealizes a standard of beauty and continuously inundates women of all ages with messages of dieting and weight control, which only leads to body image despair in older women. Because older women may not be aware that restrained eating, disordered eating, or other extreme means of controlling weight (e.g. compulsive exercise or weight loss supplements) can have significant health consequences, they may not make connections to any negative symptoms (gastrointestinal disorders, muscle and joint pain, low bone mineral density). Furthermore, women may not disclose their disordered eating behaviors to their health care providers.

Risk of eating disorders is strongly associated with mood and anxiety disorders. The literature indicates that the risk of having eating disorders is a lifelong concern [6]. Depression, too, is a lifelong condition, and is associated with severe comorbid conditions. It may be advisable to monitor a woman’s mental health during the menopause transition to prevent a depressive disorder from having long-term negative consequences [9]. Health care professionals and clinicians need to be educated and prepared to screen for symptoms of body dissatisfaction, eating disorders and associated psychiatric comorbidities in older women, especially if they present with weight loss, weight phobia, and/or vomiting [15,19,20].

References

1. Stehlik T (2018) Educational Philosophy for 21st Century Teachers. Springer ISBN 978-3319759692.
2. Neumark-Sztainer D, Wall M, Larson NI, Eisenberg ME, Loth K (2011) Dieting and Disordered Eating Behaviors from Adolescence to Young Adulthood: Findings from a 10-Year Longitudinal Study. Am. Diet. Assoc 111: 1004-1011. [crossref]
3. NIH National Institute of Aging. (2021, September 30) What is Menopause?
4. Gracia CR, Freeman EW (2018) Onset of the Menopause Transition: The Earliest Signs and Symptoms. Obstet Gynecol Clin North Am 45: 585-597. [crossref]
5. Ostrzyzek A (2013) Impact of eating disorders on quality of life of women during the perimenopausal period. Menopausal Review 4: 343-346.
6. Gadalla TM (2008) Eating disorders and associated psychiatric comorbidity in elderly Canadian women. Arch Womens Ment Health 11: 357-362. [crossref]
7. Diagnostic and Statistical Manual of Mental Disorders, 5th, ed. American Psychiatric Publishing, 2013. DSM-V.
8. Anderson M (2018) What Is Disordered Eating? Academy of Nutrition and Dietetics.
9. Llaneza P, García-Portilla MP, Llaneza-Suárez D, Armott B, Pérez-López FR (2012) Depressive disorders and the menopause transition. Maturitas 71: 120-130. [crossref]
10. Makara-Studzinska M, Krys-Noszczyk K, Jakiel G (2015) The influence of selected socio-demographic variables on symptoms occurring during menopause. Prz Menopausalny 14: 20-26. [crossref]
11. Brechan I, Kvalem IL (2015) Relationship between body dissatisfaction and disordered eating: mediating role of self-esteem and depression. Eat Behav 17: 49-58. [crossref]
12. Wertheim EH, Koerner J, Paxton SJ (2001) Longitudinal predictors of restrictive eating and bulimic tendencies in three different age groups of adolescent girls. Journal of Youth and Adolescence 30: 69-81.
13. Vivian-Taylor J, Hickey M (2014) Menopause and depression: Is there a link? Maturitas 79: 142-146. [crossref]
14. Drobnjak S, Atsiz S, Ditzen B, Tuschen-Caffier B, Ehlert U (2014) Restrained eating and self-esteem in premenopausal and postmenopausal women. J Eat Disord 2: 23. [crossref]
15. Mangweth-Matzek B, Rupp CI, Hausmann A, Assmayr K, Mariacher E, et al. (2006) Never too old for eating disorders or body dissatisfaction: a community study of elderly women. Int J Eat Disord 39: 583-586. [crossref]
16. Midlarsky E, Nitzburg G (2008) Eating Disorders in Middle-Aged Women. The J Gen Psychol 135: 393-407.
17. Augustus-Horvath C, Tylka T (2009) A Test and Extension of Objectification Theory as It Predicts Disordered Eating: Does Women’s Age Matter? J Couns Psychol 56: 253-265.
18. Fredrickson BL, Roberts T-A (1997) Objectification Theory: Toward Understanding Women’s Lived Experiences and Mental Health Risks. Psychol Women Quar 21: 173-206.
19. Samuels KL, Maine MM, Tantillo M (2019) Disordered Eating, Eating Disorders, and Body Image in Midlife and Older Women. Current Psychiatry Reports 21: 70. [crossref]
20. Maguen S, Hebenstreit C, Li Y, Dinh J, Donalson R, et al. (2018) Screen for disordered eating: improving the accuracy of eating disorder screening in primary care. General Hospital Psychiatry 50: 20-25. [crossref]