For Sarah Jones*, it all started with a resolution to get healthy in her 20s. She began training for triathlons and set a goal to lose 10 pounds. Looking at food as fuel, she switched to eating only organic, whole foods—things she perceived as “clean.”
As her fitness routine intensified, she began tracking the calories she consumed from different food groups and how many she burned during her workouts. Then things began spiraling out of control.
By the time Jones was 34, she was training for hours each day, subsisting on a spartan diet (there were only 15-20 things she would eat) and weighing herself every couple hours. “I would bring up a spreadsheet on my computer to plan my workouts and how many calories I would consume,” she recalls. “I was always trying to create a deficit so I could continue losing weight.”
Her self-imposed rules became more and more regimented. If she wanted to eat something sweet or loaded with carbs (such as pasta), she could do so only within two hours of her longest workout of the day. She started chewing and spitting out food so she wouldn’t absorb the calories.
“This obsession crept in slowly under the cover of something that’s pretty widely respected [competing in triathlons],” says Jones, who grew up in Arlington and has completed two Ironman competitions and five Ironman half-triathlons. “Friends and family members kept telling me it was great that I was challenging myself…but it got to the point where I was so worried and regimented about what I ate that it started interfering with the non-triathlon part of my life.”
She started making excuses not to go out to restaurants with friends. If she was invited to someone’s house for dinner, she’d bring her own food.
It wasn’t until she got stuck in a nighttime eating pattern that she realized she needed help. “Restricting what I ate had become such a comfortable habit that when I ate at night, it didn’t feel like I had control over food anymore,” Jones says, recalling how, as a middle-schooler, she had watched her mother’s own battle with anorexia.
Even though her “binges” were mild compared to some—she’d eat two or three bowls of whole-grain cereal with milk, for example, or two apples with low-fat peanut butter—“I would feel so awful doing it,” she says. “There were times when I’d be crying while I was eating the food, because I hated being out of control.”
As it turns out, Jones is far from alone in her struggles with food. Of the estimated 24 million people in the U.S. with eating disorders such as anorexia, bulimia and binge-eating disorder, the vast majority (85 to 90 percent) are women, according to the National Association of Anorexia Nervosa and Associated Disorders. And while it isn’t known how many are on the north side of 30, experts have noted a marked increase in the number of older women seeking help in recent years.
“The peak had been between 13 and 19, [when girls were] moving into adolescence, then moving into college,” says Margo Maine, a psychologist in West Hartford, Conn., and co-author of The Body Myth: Adult Women and the Pressure to Be Perfect. Now we are seeing them again during or after pregnancy and as women hit other life transitions such as divorce, menopause or an empty nest.”
Over the past decade, the Renfrew Center, the country’s largest network of eating disorder treatment facilities, has seen a 42 percent increase in the number of people 35 and older entering its residential program in Philadelphia. Nearly half of the women seeking treatment at the University of North Carolina Eating Disorders Program are over 35.
Women with a history of eating disorders are particularly vulnerable to flare-ups during times of stress or change. Many engage in extreme behaviors such as self-starvation, repeated weighing, calorie-counting, laxative abuse and obsessive exercising in an effort to preserve their youthful figures, prevent middle-age spread and forestall other aspects of aging, Maine says. “Whenever there’s a lot of change happening externally in your life that can shake up how you feel about yourself internally.”
Poor body image is a common phenomenon. In a study involving more than 4,000 women ages 25-45, researchers at the University of North Carolina at Chapel Hill found that 75 percent had unhealthy thoughts and feelings about their body weight and shape that interfered with their happiness. Many of these women also had disordered eating behaviors: 31 percent of those who had never had a problem with anorexia or binge-eating confessed that they had engaged in purging to control their weight.
“We see three patterns: people who have suffered all their lives and are still suffering with chronic eating disorders; people who had eating disorders when they were younger and recovered, but relapsed in midlife; and new-onset eating disorders,” says psychologist Cynthia Bulik, director of the University of North Carolina Eating Disorders Program.
Sometimes food issues manifest themselves differently over time. “Someone can struggle with anorexia in their teens, then in their 30s they may develop bulimia,” says psychotherapist Felicia Kolodner, director of Reflections, an eating disorder treatment center that opened in March 2010 at Dominion Hospital in Falls Church.
Others engage in borderline patterns that are disruptive but not as extreme as full-blown eating disorders. These folks are skipping meals, cutting way down on fats or carbs, avoiding social situations involving food, or cruising from one exercise class to the next to burn as many calories as possible.
“One of the reasons it’s so hard for women to acknowledge they have a problem is because they’re surrounded by women who are doing the same things,” Maine says.
And there’s often a fine line between dietary discipline and fixation. One of the newest additions to the lexicon is “orthorexia,” an obsession with eating only healthy foods. Like the other disorders, orthorexia becomes problematic when it leads to nutrient deficiencies, excessive weight loss or rigid behaviors that negatively affect a person’s relationships. Some experts fear that a severely limited “healthy” diet may serve as a bridge to anorexia or other points on the eating disorders spectrum, as it did for Jones.
“For a lot of women, this has been going on as long as they can remember,” says Isabel Kirk, a psychotherapist in Arlington who specializes in treating eating disorders. But at some point the behavior reaches a tipping point.
Although more women appear to be confronting their issues with food, the uptick doesn’t fully reflect the prevalence of the problem. Only 34 percent of people with anorexia, 43 percent of those with bulimia and 44 percent of those with binge-eating disorder ever receive treatment, according to the National Institute of Mental Health (NIMH). And that’s unfortunate, because eating disorders can have deadly consequences.
People with anorexia are 18 times more likely to die prematurely than their peers, according to NIMH research. “With malnutrition, every organ in the body is affected, including the heart, the kidneys, the liver and the brain,” notes David Herzog, director of the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital in Boston, and an endowed professor of psychiatry at Harvard Medical School.
“Some data show that even when nutrition is replenished, [patients] continue to show neuropsychiatric consequences [such as problems with memory and attention] in the brain,” he says. Osteoporosis and fertility problems can occur with poor nutrition and low body weight. Anorexia is also associated with higher rates of suicide and alcohol abuse.
Bingeing and purging can erode tooth enamel and cause electrolyte imbalances that can trigger heart arrhythmias. In some cases, the force of repeated vomiting can cause esophageal rupture. Laxative abuse can lead to gastrointestinal problems such as gastroparesis (delayed emptying of the stomach) or chronic constipation.
Some women have an underlying genetic susceptibility. “We know that eating disorders are heritable,” notes Bulik. “But we also know that in many cases, it is the environment that serves as a trigger for the underlying genetic predisposition. Genes load the gun; environment pulls the trigger.”
Negative body image can be a contributing factor, but it’s usually not the only one. Stress, depression, anxiety and other unpleasant emotions can also spark antagonism toward food as a coping mechanism. “It becomes an escape from what they’re feeling or what’s bothering them, whether it’s boredom or anxiety, lack of fulfillment or lack of emotional intimacy,” Kirk says.
That’s what happened to Clarendon resident Cary Larson in her early 20s. Her father became terminally ill, her career path was uncertain and a boyfriend cheated on her with a friend. After gaining 5 pounds, she went on a diet and quickly became hooked. “You can be genetically primed to react to a diet by becoming addicted to it and it can go south very quickly,” she says. “I was on such a high because I would feel like, ‘Oh, this is awesome! I can control something!’ ”
Over a three-year period, Larson, who is 5 feet 4 inches tall, dropped from 115 pounds to a fragile 87 pounds. When her research advisor expressed concern about her ability to make it through graduate school, she started binge-eating to gain a little weight and appear healthier.
“But the binge-eating was demoralizing, whereas the self-starvation was invigorating,” she recalls. “The binge-eating made me feel so out of control that I went to a therapist and a 12-step program for help.” At the same time she started exercising for hours each day to offset what she ate. “That was my way of purging,” she explains.
When Larson’s boyfriend of two years asked her to marry him in 2007, it threw her for a loop. “I started realizing there’d be this person around all the time, and that scared me. Within a month, I started relapsing by exercising excessively and restricting my food intake during the day and bingeing at night,” says Larson, now 31. “When night fell and all of the stress from the day would hit me, it was hard to turn off that eating disorder voice.”
Not wanting to carry the pattern into her marriage, she temporarily left Arlington for a 30-day stay in a residential treatment program in San Diego. Upon her return in March of 2009, she started Rock Recovery, an Arlington-based nonprofit that provides community education and support for people with eating disorders.
For other women, kids provide the motivation to make peace with food. Many moms seek treatment out of a desire to be healthy for their children’s sake—or to avoid passing on their disordered eating patterns through negative modeling.
“Children are influenced by their mother’s views towards food and their body image,” Kolodner points out. “When those messages become repetitive, they can stay with children and become part of their belief system. The children may start eating in a certain way or viewing themselves critically in the mirror because that’s what their environments have taught them.”
Indeed. A study at Western Oregon University found that teenage girls were more likely to have body image problems and/or disordered eating patterns if their mothers made negative comments about their eating behavior or figures and/or if the moms themselves had dysfunctional eating habits.
Concern about the hand-me-down effect is what led Emily Roberts*, who spent nearly two decades vacillating between anorexia, bulimia and over-exercising, to seek treatment. “My daughter was the inspiration for my getting help,” says Roberts, who lives in D.C. “When I thought of her crying for Mommy while I was in the hospital with an eating disorder—I just couldn’t bear that. And I didn’t want this to affect her. My goal is to be the best example for her, and to do that, I need to feed myself and be healthy.”
In the realm of treatment for eating disorders there are two therapeutic mainstays. Family-based treatment involves family members as a source of support and help in recovery. Cognitive behavioral therapy helps individuals develop healthier coping strategies and at the same time addresses psychological problems that may be contributing to their disordered eating habits.
But experts stress that eating disorders must be treated not just psychologically but also physiologically for treatment to be successful. Nutritional therapy often involves gradually introducing new foods and reintroducing familiar foods in larger portions along with talking through the feelings tied in with the disordered eating. (Sometimes medications are used to treat underlying depression or anxiety.)
For anorexia, the conventional wisdom has been that one-third of people who have it recover fully, one-third partially recover and one-third never recover, Kirk says. “People get hooked like with any other addiction, and that’s when people can’t stop it and it becomes dangerous.”
Recovery rates for bulimia and binge-eating disorders are higher, experts say, provided treatment is sought. Once triggers are identified, therapists and nutritionists can help normalize eating patterns with meal plans, and by helping the patient see that there’s no such thing as a “good” or “bad” food.
Therapists can also help their clients find healthier ways to deal with stress and uncomfortable emotions such as anger, loneliness or emptiness.
Overwhelmed by the feeling that her life was disintegrating, Sarah Jones sought help at the Renfrew Center in Philadelphia for two months in the summer of 2009. That’s when she discovered how sick she really was. “I just thought I needed help to stop bingeing,” she explains. “But once I was away from my regimented life, I saw how cold and lonely and restrictive it was and how my habits were controlling me, instead of the other way around.”
In treatment, Jones was required to broaden her dietary repertoire, eat the balanced meals she was served and learn how to engage in “intuitive eating,” meaning feeding her body when she was hungry and stopping when she felt satisfied. She was forced to take a hiatus from exercising and to confront uncomfortable emotions—including those that stemmed from a sexual harassment situation at work—instead of tamping them down with exercise or food rituals.
“It was a really difficult experience but it has completely changed my life,” says Jones, now 38 and a school counselor in Alexandria. Today she works out just a few times a week and eats a more varied diet.
“I had to learn how to take care of my body instead of fighting it all the time, and to develop eating habits that are more emotionally healthy. I’ve done that, and it’s had a positive impact on the rest of my life, too,” she says. “Now I look at things with a totally different perspective and I have a much more connected life with much stronger relationships.”
*Names have been changed to protect privacy.
Stacey Colino is an award-winning writer specializing in health and psychology. Her work has appeared in Newsweek, Self, Health, MORE, Real Simple, Cosmopolitan and other national magazines.