Older Women, Too, Struggle With a Dangerous Secret
July 6, 2004
by Bonnie Rothman Morris, New York Times
Mention anorexia or bulimia, and what comes to mind is a skin-and-bones teenager caught in a ferocious struggle to be thin.
But doctors say they are seeing a disturbing trend: a growing group of women in their 30's, 40's and 50's who have eating disorders. Most have husbands, children, jobs and aging parents. They live with their secret while trying to manage the other aspects of their lives.
Lori Varecka, 44, said she hid her bouts of starving and purging from her husband, her mother and her three children for more than two decades. But by 1997, what Mrs. Varecka was hiding was plain to see: At 5 feet 7 inches, she weighed 94 pounds. That year, she admitted to her doctor that she was ill. Eventually, she also told her family.
In some cases, experts say, older women with eating disorders know something is wrong, but they do not give a name to their problem. Some feel ashamed to have an illness normally associated with teenagers.
"Women feel so invalid. They feel that they should grow up," said Dr. Margo Maine, an eating disorders expert in Hartford and the author of a coming book on midlife eating disorders, The Shape We're In: Overcoming Women's Obsessions with Weight, Food and Body Image. No one knows how many older women have the disorders. Many have struggled with anorexia or bulimia for decades. Others vanquished their eating disorders as young women, only to relapse later. Another group first develops anorexia or bulimia in midlife.
Doctors suspect that most women who develop the disorders at midlife have been overly concerned with weight and body image throughout their lives. Sudden onset of an eating disorder is very rare, they say.
"Lots of people in our culture diet," said Dr. Walter Kaye, the principal investigator in an international study of the genetics of eating disorders. "Relatively few end up with an eating disorder."
In March, Dr. Kaye's study expanded the criteria for participation to include women who developed an eating disorder after the age of 25. The five-year study was already well into its second year when the criteria were changed. But so many older women were calling to volunteer that the researchers thought it prudent to include them.
Anorexics severely restrict their calories. Bulimics binge and then purge, either by vomiting or by taking laxatives. Both groups often exercise excessively.
Older women with eating disorders, experts say, have much in common with teenagers who suffer from the illnesses. Isolation, loneliness, lack of self-esteem and a drive for perfection are present for older women, too. What differs are the triggers that set off the disorders.
"Loss may be a particular issue for midlife women; sexuality may be a burning issue for younger people," said Dr. William Davis, vice president for research at the Renfrew Center, a Philadelphia-based residential treatment center for eating disorders.
A child going off to college, or the loss of a spouse or a close relative, can set off eating problems. In some cases, women fight against the loss of their bodies, as they gain the 10 to 15 pounds typical during the natural course of menopause.
When Valerie Garcia turned 40, she said, she "didn't want to accept that."
At the time, her 12-year-old daughter was suffering from depression and she felt powerless to help. To gain some control, Mrs. Garcia, of Valley Stream on Long Island, went on a diet. Pretty soon, she was abusing laxatives and purging.
It was Mrs. Garcia's second battle with anorexia and bulimia. At 25, she was treated in an in-hospital program and had stayed well for 15 years. Her husband encouraged her to get help each time. But some patients say their husbands have no idea they are ill.
Nancy Harris, who struggled with anorexia for decades, said her husband never said a word, though the two were business partners and rarely separated. "He just thought I had funny eating habits," said Mrs. Harris, 54, who lives in Rhode Island and is now improving.
Many primary-care doctors also do not notice. "Many doctors who have not been exposed to eating disorders really have difficulty in suspecting it and making the diagnosis," said Dr. Ira Sacker, a co-author of Dying to Be Thin (Warner Books, 1987) and the director of adolescent and young adult medicine at the Brookdale University Hospital and Medical Center in Brooklyn.
Other experts said primary-care doctors might turn a blind eye because the problem seems intractable. Chronic sufferers often do not know how to live another way: their eating disorder is their identity.
"The binging and purging becomes a habitual mode of living, of daily life," said Dr. Bart Blinder, the director of the eating disorders program at the University of California, Irvine. "It's a tension relief, anxiety relief, a mechanism of dealing with loneliness and separation."
Patients with eating disorders can suffer serious mental and physical consequences. Anorexia can lead to osteoporosis, cardiac problems, thinning hair and skin that bruises easily. Severe tooth decay and gastrointestinal problems are frequent complications of bulimia. Researchers have found that anorexia in particular is one of the most deadly mental disorders: in one study that followed patients for 30 years, 18 to 20 percent of the women died.
For middle-aged women, the physical toll may be more severe than for younger women, whose bodies are more resilient.
Older women with eating disorders can recover, experts say, but it may take years. The relapse rate is as high as 20 percent. Unlike younger patients, who may be treated at their parents' urging, adults generally seek help on their own, and can leave just as easily.
Yet doctors report that many older patients who seek treatment are highly motivated to get well.
"It's easier to treat them in that they have the insight," said Dr. Kathryn J. Zerbe, vice chairwoman for psychotherapy at Oregon Health and Science University in Portland.
In-hospital treatment programs that accept older patients - some do not - are recording an increase in patients. Recently, five or six women over 35 checked into the Renfrew Center in a single week, said Dr. Davis. At the Remuda Ranch center in Wickenburg, Ariz., the number of patients over 40 has risen to 11 percent this year, from 3 percent in 1990, when the center opened, said Dr. Edward Cumella, its director of research, education and quality.
The treatment offered by such programs is somewhat modified for older patients. Like younger women, they receive medical care, psychological counseling and nutritional counseling. Group therapy is common, but putting older patients with teenagers may not always work. Individualized therapy also works well for older patients.
But doctors say recovery is often a compromise, with patients and doctors accepting tiny slices of success.
"People don't come to treatment with the idea that they would like to change themselves, and some don't want to change much at all," said Dr. David Herzog, founder of the Harvard Eating Disorders Center at Massachusetts General Hospital in Boston.
Outside factors, like a desire to maintain a marriage or to avoid being a burden to their children, are often motivators.
After Mrs. Varecka told her family that she was ill, she was in and out of an inpatient program near her home in suburban Minneapolis four times over the next two years.
Today, she is still preoccupied with her body, and though she has not looked at a scale in two years every day is a struggle, she said.
"It's a torment; it's the devil," Ms. Varecka said. "Unfortunately, it affects other people in my life."