Eating Disorders in Middle-Aged Women

Transcription

1 The Journal of General Psychology, 2008, 135(4), Copyright 2008 Heldref Publications Eating Disorders in Middle-Aged Women ELIZABETH MIDLARSKY GEORGE NITZBURG Teachers College, Columbia University ABSTRACT. Eating disorders are generally viewed as afflicting females during adolescence and early adulthood. However, in recent years there has been a growing recognition that these disorders may occur during midlife as well. When eating disorders have been observed in middle age, they have often been believed to be associated with depression. In an Internet survey, responses by middle-aged women (N = 290; aged years) indicated that the factors significantly associated with eating pathology body image dissatisfaction, sociocultural pressures to be thin, and perfectionism closely parallel those reported for younger people. Furthermore, in the presence of these factors, depression and concerns about the effects of aging on appearance are not significantly related to eating pathology. Keywords: aging and eating pathology, body dissatisfaction, middle-aged women, midlife eating disorders EATING DISORDERS are generally considered to occur almost exclusively among adolescent and young adult females, and current diagnostic systems support that perception. For example, because both the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) and the International Statistical Classification of Diseases and Related Health Problems (10th rev.; ICD-10; World Health Organization, 1992) list amenorrhea as a criterion for anorexia nervosa (AN), AN cannot be diagnosed in postmenopausal women, even when all other criteria are met (Mermelstein & Basu, 2001). Instead, when the DSM-IV-TR is used, patients are diagnosed with eating disorder not otherwise specified (EDNOS). One important consequence of this practice is that postmenopausal women are likely to be underrepresented in epidemiological studies, which tend to exclude people diagnosed with EDNOS (Hoek, 2006). Nevertheless, there is evidence that reports of eating disorders have been on the rise. In a longitudinal epidemiological study, Lucas, Beard, O Fallon, and Address correspondence to Elizabeth Midlarsky, Teachers College Counseling & Clinical Psychology, Columbia University, 525 W. 120th St., Box 148, New York, NY 10027, USA; em142@columbia.edu ( ). 393

2 394 The Journal of General Psychology Kurland (1991) found a substantial increase in reported incidence of AN among 15- to 24-year-olds from 1935 to 1989, with a particularly steep increase in the 1970s and 1980s. Recent findings have suggested that at least 1 out of every 10 patients diagnosed with an eating disorder is over the age of 40 (Hoek, 2006; Hoek & van Hoeken, 2003; Nielsen, 2001). According to Wiseman, Sunday, Klapper, Harris, and Halmi (2001), there were twice as many admissions of 40- to 49-year-old women to the Cornell Eating Disorders Program in 1998 as there were in If the actual number and not just reports of cases of eating pathology is increasing among younger adults, then this is apt to result in an actual increase in the number of middle-aged women with eating disorders. Even among people who ultimately manage to develop normal eating habits, the developmental stresses associated with the transition into middle adulthood could lead to a relapse. In other cases, eating disorders may occur for the first time during midlife (Keith & Midlarsky, 2004). If eating-disordered youth are able to survive the devastating long-term medical consequences of AN or bulimia nervosa (BN), it seems only logical that they may continue their disordered eating patterns into middle age. Even when considering that the rate of death may be as high as 18% (Birmingham, Su, Hlynsky, Goldner, & Gao, 2005; Hoek, 2006), 82% of patients would therefore survive and either recover from or continue living with their eating disorders. An individual diagnosed with AN at age 24 in 1989 would be 43 years old today, and an individual diagnosed with AN at 15 years of age in 1970 would be 53 years old today. Further, if eating disorders indeed persist beyond adolescence and young adulthood and if new cases occur, then clinically significant eating disorders may be a concern in middle-aged women. In their review of the literature, Keith and Midlarsky (2004) found a total of 21 case studies of eating disorders in postmenopausal women aged 54 to 92 that were published between 1976 and The studies provide anecdotal evidence that there were middle-aged and older women who either manifested late-onset eating disorders or were diagnosed with eating disorders at an early age and then relapsed later in life. These documented cases also suggest that when AN does occur among postmenopausal women, it appears to be similar to AN in younger women in both symptoms and correlated factors (Keith & Midlarsky). It is also noteworthy that in 10 of the 24 cases the postmenopausal women also reported experiencing life stress, typically concerning issues of loss, as well as concomitant depressive symptoms. On the basis of qualitative evidence suggesting that food-restricting women between the ages of 25 and 69 with no prior history of eating pathology appeared to be primarily experiencing life stress (i.e., loss) and depression, Russell and Gilbert (1992) argued that these women should not be diagnosed with AN. Instead, they suggested that they should be viewed as manifesting a form of pathological grief. Berry and Marcus (2000) also pointed to the putative role of life stress and its associated depressive symptoms and suggested that in older age groups the term anorexia nervosa should be replaced with the term tardive anorexia.

3 Midlarsky & Nitzburg 395 Eating Pathology in Midlife: Development Across the Lifespan This study was motivated in part by the need for an empirical investigation designed to systematically explore the association between psychological factors found to be correlated with eating disorders in younger women and eating pathology during midlife. The transition into middle age is associated with social and biological changes similar to, in certain respects, the developmental stresses of puberty (Crisp, 1980; Lewis & Cachelin, 2001). Indeed, Saucier (2004) recently found that whereas women of all ages are prone to anxiety about their body image, women entering midlife become increasingly conscious of that concern. Life transitions, such as the transition to middle age, may constitute a form of stress that can combine with predisposing risk factors to trigger eating disorders. Women and adolescent girls both may be subject to sociocultural pressures to be thin, which may be compounded in midlife women by age-related concerns about the body. The biologically related weight gain that occurs until about age 60 among most women and the increase in body fat at menopause, combined with the weight increases associated with certain medical illnesses and medications used to treat those illnesses all may add to the distress and dissatisfaction experienced by women at midlife (McLaren & Kuh, 2004; Zerbe, 2003; Zerbe & Domnitei, 2004). Thus, body image dissatisfaction, perfectionism, life stress, and depression may potentially affect eating in both age groups. Sociocultural pressures to be thin. Sociocultural pressures to be thin have been implicated in the development of eating disorders in younger age groups. In Western society, the mass media (e.g., television, movies, magazine advertisements) expose women to idealized images of ultra-thin models. Such ubiquitous exposure sends powerful, implicit messages that to have good looks women must develop and maintain an often impossibly slim physique. When women strive to obtain such goals of thinness, their efforts may eventually result in eating disorders (Polivy & Herman, 2004). If these messages about thinness are powerful enough to affect the behavior patterns of many young people, it is also reasonable to assume that, when directed at older age groups, they can affect the attitudes and behaviors of middle-aged adults as well. Some researchers propose that as women age, they become less objectified by society and are therefore less likely to be affected by pressure to be thin. As a result, there may be a decline in the likelihood that they become eating disordered (Tiggemann & Lynch, 2001). However, others note that sharp increases over the past decade in the demand for skin creams and cosmetic surgery (Ring, 2000) may indicate that older adults are becoming increasingly interested in retaining an attractive appearance, which in turn would increase their susceptibility to eating disorders (Keith & Midlarsky, 2004). In recent studies, evidence has been presented that middle-aged women are no less susceptible than are adolescent girls to sociocultural pressures to be thin (Forman & Davis, 2005; Pryor, 2008; Robinson

4 396 The Journal of General Psychology & Callister, 2006). Thus, the prevailing view that sociocultural pressures may be responsible for increased susceptibility to pathological eating behaviors, along with evidence that middle-aged women are vulnerable to such pressures, formed the basis for the decision to include sociocultural pressures to be thin as one of our body image variables. Aging-related concerns about appearance. Individuals who were concerned about maintaining a thin physique during their younger years may become concerned about keeping a thin and youthful appearance during middle age. In studies by Gupta (1994; Gupta & Shork, 1993), the drive for thinness was significantly related to concerns about the effects of aging on appearance. Using a prospective study design, Gupta also found that older women who received active drug treatments to prevent aging skin reported less drive for thinness and body dissatisfaction than did controls. This evidence of relationships among body dissatisfaction, aging-related concerns, and drive for thinness in older adult samples was the basis of the rationale for including aging-related concerns about appearance as one of our body image variables. Body dissatisfaction. Although the presence of body dissatisfaction alone is not sufficient to make an eating disorder diagnosis, it is viewed as a necessary factor in the development and maintenance of eating disorders (Goldfein, Walsh, & Midlarsky, 2000; Polivy & Herman, 2002). There is evidence that body dissatisfaction remains stable across the lifespan (Robinson & Callister, 2006; Saucier, 2004; Stevens & Tiggemann, 1998; Tiggemann & Lynch, 2001). In a study of 180 women aged years who rated figure drawings to indicate their current versus their ideal body shape and size, Stevens and Tiggemann found that women in all age groups reported a significant discrepancy between their current and ideal figure ratings. Overall, these women preferred thinner ideal body shapes and sizes in comparison with their current body shape and size. The finding that body dissatisfaction remained stable across age groups was replicated in a larger cross-sectional study of 322 women aged years (Tiggemann & Lynch). Research findings have also underscored the existence of body image dissatisfaction in middle-aged women. This dissatisfaction was reported whether or not body mass index was in the normal range and even if any weight gains were attributable to medical illness or natural biological processes (McLaren & Kuh, 2004). Thus, our rationale for including body dissatisfaction as one of our body image variables was based on currently held views that body dissatisfaction is a fundamental risk factor for eating disorders alongside evidence that it remains stable throughout the lifespan. Perfectionism. Dissatisfaction with body shape or size, vulnerability to sociocultural pressures to be thin, and concerns about aging-related changes in appearance all rely on the belief that there exists a perfect state of being that one should

5 Midlarsky & Nitzburg 397 attempt to attain. Perfectionism has been shown to be a distinguishing characteristic of AN (Halmi et al., 2000) and an important personality trait in individuals suffering from BN (Lilenfeld et al., 2000). In a study of 123 eating disordered inpatients, Davis (1997) found that perfectionism interacted with body esteem (i.e., the overall appraisal of body image) to predict eating disorder symptomatology. Perfectionism may play a simple role, acting together with body image variables to predict eating pathology. Alternatively, it may play a complex role in the process of internalizing the discontent with one s body image (i.e., by interacting with body shape and size, effects of aging on appearance, and with influence of sociocultural pressures). In either case, such discontent may ultimately be expressed through eating disorder symptomatology. Evidence that perfectionism is a distinguishing personality characteristic of AN, and that it may be related to eating disorders among women at a wide range of ages (Forman & Davis, 2005; Pryor, 2008), provided the rationale for including perfectionism among our study variables. Furthermore, evidence that the levels of perfectionism exhibited by middle-aged mothers are similar to levels for their college-aged daughters (Vieth & Trull, 1999) indicates that the relationship of perfectionism with eating behavior may be fruitfully investigated. Life stress and depression.there is also evidence that middle-aged adults encounter significant life stress and depression. Life stresses may include the death of a loved one, the empty nest, and the perceived loss of youth and, presumably, of attractiveness (Zerbe, 2003). Midlife may also be a time during which people experience depressive symptoms associated, for example, with the loss of their parents (Bumpass & Aquilino, 1995). Prior research has found a significant relationship between eating pathology and depression (Braun, Sunday, & Halmi, 1994), suggesting that depressive symptoms may be associated with increased rates of eating pathology. Although there is a paucity of empirical studies on eating disorders in middleaged women, as the baby boomers age it may be increasingly important to gain an understanding of eating pathology in middle-aged and older women. This study was designed to investigate psychological factors that may be associated with eating disorders among women at midlife. We hypothesized that disordered eating in middle-aged women is associated with variables related to eating disorders among adolescent girls and young women. The variables were sociocultural pressures to be thin, body dissatisfaction, and perfectionism. In addition, we included concerns about aging, life stress, and depression. Concerns about aging were studied because of the possibility that women may strive to be thin to retain or regain a youthful appearance, in a culture in which youth and thinness are paired. The rationale for including life stress and depression was based on the potential importance of those variables during midlife, combined with prior assertions that tardive anorexia, a product of life stress and depression, is the most appropriate appellation for AN that occurs beyond young adulthood (Berry & Marcus, 2000).

6 398 The Journal of General Psychology Participants and Procedure Method Our sample of 290 middle-aged women aged years was obtained using an Internet survey. The survey research instrument was placed on the Columbia University Web site following approval by the Institutional Review Board. The informed consent procedure included information that the study was being conducted by a research team at Columbia University, and contact information was provided. The purpose of the study was described as an exploration of the relationship between eating behavior and factors such as body image in adults at various ages. We also stated that the survey was designed for people over the age of 18 and that only the data provided by people citing an age over 18 years would be retained in our files. No other inclusion or exclusion criteria were employed. To inform the widest range and number of people about the survey, we used a variety of means. For example, the survey was advertised on radio and television programs throughout the United States. Posters advertising the study were mounted in public venues such as fitness centers, beauty parlors, subways, bus stations, and supermarkets. We printed business cards describing the study and providing the Web address and placed these, along with posters and placards, in medical centers and offices of primary care physicians. We advertised the study across the United States by posting classified ads using online message boards, online forums, and public Web sites such as craigslist.org. As a result of these efforts, a total of 4,600 people completed the survey. Of this number, 320 middleaged women began the survey, with 290 (90%) completing it. The 290 middle-aged women ranged in age from 45 to 60 years, with a mean age of years (SD = years). In regard to race and ethnicity, 91.8% were White, 2.8% Hispanic or Latina, 2.1% Black or African American, 1.1% Asian/ Pacific Islander or Asian American, and 2.1% responded as other. Concerning the highest level of education completed, 34.3% had completed graduate study, 45.3% had completed undergraduate school, 19.4% had completed high school, and 1.0% had completed grade school. Descriptive data for study demographics are presented in Table 1. Measures Disordered eating symptomatology. Disordered eating was measured by the Eating Attitudes Test 26 (EAT-26), a scale borrowed from the public domain, that was designed to measure the frequency of disordered eating behaviors and attitudes (Garner, Olmstead, Bohr, & Garfinkel, 1982). Participants responded using a Likert-type scale in which response choices ranged from 1 (always) to 6 (never). Examples of items include avoid eating when I am hungry, eat diet

7 Midlarsky & Nitzburg 399 TABLE 1. Descriptive Data for Study Demographics Demographic % Range M SD Age Ethnicity White 91.8 Hispanic/Latina 2.8 Black/African American 2.1 Asian/Pacific Islander 1.1 Other 2.1 Highest level of education completed Grade school 1.0 High school 19.4 Undergraduate study 45.3 Graduate study 34.3 foods, and like stomach to be empty, among others. Cronbach s alpha for this measure in the current study was.858. Sociocultural pressure to be thin. Sociocultural pressure was assessed using an 8-item scale inquiring about both direct pressure and strong messages to lose weight, borrowed by permission from the authors (Stice, Maxfield, & Wells, 2003). Participants responded using a Likert-type scale, in which the response choices ranged from 1 (always) to 5 (never). Examples of items include I ve felt pressure from the media (e.g., TV, magazines) to lose weight and I ve noticed a strong message from my family to lose weight. Cronbach s alpha for this scale was.882. Aging-related concerns about appearance. Aging concerns were assessed using a 5-item scale (Gupta, 1994) borrowed from the public domain. Participants responded using a Likert-type scale in which response choices ranged from 1 (completely disagree) to 7 (completely agree). Examples of items included I try very hard to prevent my body from aging and Having young skin is important for good looks. Cronbach s alpha for this scale was.834. Body dissatisfaction. Body dissatisfaction was assessed using the 2-item Contour Drawing Rating Scale (Thompson & Gray, 1995), borrowed by permission of the authors. Using numbered drawings of either male or female figures from 1 (figure with the lowest weight) to 9 (figure with the highest weight), participants chose the number corresponding to figures that most accurately depicted their current and ideal body sizes. The discrepancy between participants current and ideal body size was calculated and used as a measure of body dissatisfaction. As

8 400 The Journal of General Psychology the key measure was the discrepancy between two other measures (i.e., perceived body size vs. ideal body size), it was not possible to calculate Cronbach s alpha for this scale. Perfectionism. The measure of perfectionism was the 23-item Almost Perfect Scale Revised (Slaney, Rice, Mobley, Trippi, & Ashby, 2001), borrowed from the public domain. Participants responded using a Likert-type scale in which response choices ranged from 1 (completely disagree) to 7 (completely agree). Examples of items include My best just never seems to be good enough for me and I am hardly ever satisfied with my performance. Cronbach s alpha for this scale was.909. Life stress. Stress was measured using 8 Likert-type items about stressful life events, designed for use in this study. Participants responded concerning the extent to which they had previously experienced life and traumatic stress using a Likert-type scale in which response choices ranged from 1 (never) to 7 (always). The items inquired about life stress and traumatic stress in general terms, with no specific events employed. Examples of items include To what extent have you experienced stress in the past month? ; How much stress, overall, do you feel you have in your life? ; and To what extent have you experienced traumatic stress in the past year? Cronbach s alpha for this scale was.812. Depression. Depression was measured using the 20-item Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977), borrowed from the public domain. Participants responded with the number of days they had felt a certain way during the past week using a Likert-type scale in which response choices ranged from 1 (rarely; none of the time [less than one day]) to 4 (most of the time; all of the time [5 7 days]). Examples of items include I felt depressed, I felt hopeful about the future, and I had crying spells. Cronbach s alpha for this scale was.913. Preliminary Analyses Results Ranges, means, and standard deviations for each of the study variables are presented in Table 2. Bivariate correlations among all study variables appear in Table 3. All but three study variables were significantly correlated with one another. The correlation between aging-related concerns about appearance and sociocultural pressure to be thin did not reach significance. In addition, life stress was not significantly correlated with either disordered eating or aging-related concerns about appearance. Because the correlation between life stress and disordered eating symptomatology did not reach significance, we excluded life stress from primary analyses investigating the correlates of eating pathology.

9 Midlarsky & Nitzburg 401 TABLE 2. Descriptive Data for Study Variables Variable Range M SD Disordered eating Sociocultural pressure to be thin Aging-related concerns about appearance Body dissatisfaction Perfectionism Life stress Depression Participants responses to the EAT-26 scale were next evaluated for potentially clinical levels of eating problems. In accordance with the standard scoring method, participants with a score equal to or greater than 20 were coded as having disordered eating. In this sample, 14.8% of middle-aged women were scored as having disordered eating. Primary Analyses We used a standard forward multiple regression analysis to investigate whether sociocultural pressures to be thin, aging concerns, body dissatisfaction, perfectionism, and depression were significantly related to eating pathology when all were simultaneously entered into a single equation. The results of this analysis are presented in Table 4. This model was significantly associated with eating pathology, F(5, 284) = 16.68, p <.05, and accounted for 32.9% of the variance in EAT-26 scores. Sociocultural pressure to be thin was significantly associated with eating pathology, F(1, 288) = 8.34, p <.05, as were body dissatisfaction, F(1, 288) = 12.16, p <.05, and perfectionism, F(1, 288) = 11.79, p <.05. Each of the significant correlates maintained sufficient tolerance to be nonredundant with the other correlates in the model and thus presented no problems with multicollinearity. However, despite their significant bivariate correlations with disordered eating, depression and aging-related concerns about appearance were not significantly associated with eating pathology in the presence of the other study variables. Discussion Our findings indicate that middle-aged women may evidence disordered eating and that eating pathology may be associated with the same factors related to eating disorders in younger women. Our results indicate that body image-related factors sociocultural pressures to be thin and body dissatisfaction along with perfectionism, are significantly related to eating pathology among middle-aged women.

10 402 The Journal of General Psychology TABLE 3. Intercorrelations of Regression Variables Variable Disordered eating 2. Sociocultural pressure to be thin.37 ** 3. Aging-related concerns about appearance.30 ** Body dissatisfaction.35 **.41 **.17 ** 5. Perfectionism.45 **.20 **.43 **.25 ** 6. Life stress ** *.24 ** 7. Depression.32 **.19 **.27 **.30 **.47 **.49 ** * p <.05. ** p <.01.

11 Midlarsky & Nitzburg 403 TABLE 4. Standard Multiple Regression Analysis for Correlates of Problematic Eating Behaviors Variable β SE B B Sociocultural pressure to be thin Aging-related concerns about appearance Body dissatisfaction Perfectionism Depression Note. Total R 2 =.329. They also indicate that, in the presence of these variables, neither depression nor aging-related concerns about appearance is significantly related to disordered eating in middle-aged women. Results from our study support previous findings that middle-aged women are susceptible to body dissatisfaction (Stevens & Tiggemann, 1998; Tiggemann & Lynch, 2001), although not all middle-aged women may share this susceptibility (Fredrickson & Roberts, 1997; Rusticus, Hubley, & Chan, 2005). They also suggest that perfectionism and sociocultural pressure to be thin are significant correlates of eating pathology in middle-aged women. In our sample, the pathological eating by middle-aged women was apparently a reflection of their effort to lose weight so they could look thin. This is similar to the results of a study of 1, year-old women, in which 80% were dissatisfied with their weight, even though half of the dissatisfied women were in the normal weight range based on their body mass index (McLaren & Kuh, 2004). Although many women in midlife experience concerns about the effects of aging on their appearance, in our sample these concerns were not significantly related to eating pathology in the presence of sociocultural pressures to be thin, body dissatisfaction, and perfectionism. Our findings about the relationships among variables in a sample of middle-aged women should not be interpreted as contradicting the findings from previous research indicating that for women who equate weight loss with youthfulness, aging-related concerns are associated with the drive for thinness and body dissatisfaction (Gupta & Schork, 1993). The middle-aged women in our sample may generally have internalized the message that thin is beautiful, but they may not have internalized the message that thin equals young. Nevertheless, for those who do subscribe to the equation of youth and thinness, concerns about aging may be related to pathological eating. In the presence of sociocultural pressures to be thin, body dissatisfaction, and perfectionism, depression was also not related to eating pathology. This finding suggests that in our sample, the eating pathology of the middle-aged women may be associated with internalized dissatisfaction concerning weight and external

12 404 The Journal of General Psychology pressures to be thin rather than with depression. Thus, in the current study, the variables significantly related to eating pathology in middle-aged women parallel those related to eating disorders in younger women found in other studies. The results of our investigation indicate that much can be learned from applying a life-span developmental perspective to the study of eating disorders. Although the notion of a developmental perspective is prominent in much of the literature of psychological science, it has been largely ignored in the literature on eating disorders. The dearth of developmental approaches to eating disorders, as well as the viewpoint that such approaches are unnecessary, has been bolstered by the limitations of current diagnostic categories, which characterize AN almost exclusively as a disorder of female youth. Missing from much of the research literature is the application of popular notions that, when confronted with developmental milestones signaling their aging, many middle-aged adults respond as though the forties are the new thirties and the fifties are the new forties (Kaufman & Elder, 2002). The primary limitations of this study are associated with the use of an Internet survey. Although Internet surveys are a cost-effective means for collecting data, they are subject to selection bias: neither random nor probabilistic sampling is possible (Andrews, Nonnecke, & Preece, 2003). Respondents tend to be young, well educated, liberal, and well off (Duffy, Smith, Terhanian, & Bremer, 2005). In regard to age, 18.4% (n = 847) of the 4,600 adults who responded were middle-aged and older. When compared with the 34.5% in this age range found in the 2000 census, and the 39.2% projected for 2010 (U.S. Census Bureau, 2004), the age composition of our sample is indeed relatively young. Among the many advantages of using the Internet, in addition to the fact that it is cost effective, is that it provides a means for standard administration to a large and geographically scattered sample in a short period of time. Furthermore, response rates have been shown to be almost as high as in mail surveys (Kaplowitz, Hadlock, & Levine, 2004). Future research is needed in the area of eating pathology among middleaged and older adults. Epidemiological studies that focus on the prevalence and incidence of eating disorders in representative random samples will meet a critical need for knowledge in this important area. The relationships between agingrelated concerns, depression, and eating disorders need further investigation. In addition, because the current study included only women, future studies should extend the scope of inquiry to eating pathology in middle-aged men. Furthermore, investigations of eating pathology among men and women over the age of 65 are needed to see if body image variables remain the best predictors of eating pathology in these older age groups, or whether the dynamics of eating pathology change from middle age to older adulthood. In light of findings that middle-aged adults are apparently susceptible to eating pathology, it is necessary to critically review current diagnostic criteria. Although diagnostic manuals describe eating disorders in adults over age 40 as rare occurrences, eating pathology may still be underreported and consequently ignored.

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