Lesley Williams, MD
Senior Associate Consultant / Eating Disorder Specialist
Department of Family Medicine, Thunderbird Clinic Site Lead, Mayo Clinic Arizona

Sally is an avid runner. Running makes her feel happy and in control. Her running started when she was on the high school track team. It was a great way to make friends. She also began being recognized for her speed and dedication to the sport. A bonus was the attention Sally received from her teammates when she lost weight because of all the training she was doing. As time went on, maintaining her runner's body shape became a big part of Sally's identity.

She was no longer on a track team but running became a part of her daily routine. She would run regardless of the time of day or weather, when she was in pain, and even if she was supposed to rest due to an injury. Sally missed important life events because she did not want to change her running schedule. Despite running several miles per day, Sally would restrict herself to one small meal per day.

As the years passed, running felt less like something she wanted to do and more like something she had to do. Sally would feel anxious and out of control if she did not have her run for the day. She would immediately begin having negative thoughts about her self-worth and feeling body image distress. Eventually, Sally confided in a friend about her struggles and her friend helped her find a doctor to talk to. Sally was diagnosed with an eating disorder and received treatment from a team of doctors, dieticians, and counselors in her mid-twenties. Sally went through treatment and continued to better manage her mental and physical health over the years with the support of both healthcare professionals and her friends and family. She continued running but developed a healthy relationship with her exercise and eating routine.

Sally is now nearing her 50th birthday and her youngest child just moved away to attend college. Sally feels lonely and unsure about to navigate her new role as an empty nester. Sally's mother is also getting older, and her health is declining which has made Sally and her siblings discuss the option of getting her mother the support she needs in an assisted living facility. She is also worried about turning fifty and the changes she might expect with transitioning into midlife. Everything she has heard from her friends about losing muscle mass and gaining fat in menopause petrifies her.

Sally feels out of control and is having a hard time coping with her emotions. She begins limiting the amount of food she eats and begins running several miles a day again. She continues this for many month and experiences a relapse in her eating disorder symptoms.

Sally soon goes to the doctor complaining of hip pain. She was running in icy conditions when she fell and landed on her right hip. She is very concerned because the pain is keeping her from running. Sally says that even after not running for the past few days, she can tell that her body is changing. She uses crutches her brother had from a prior ankle injury to help her get around. The nurse tries to help Sally get on the scale to check her weight. She gets frustrated because she struggles to balance on the scale with one crutch without putting any weight on her injured hip. Despite this, she insists on getting weighed. She is very concerned that her weight has increased due to recent inactivity.

Is it possible to exercise too much?

The benefits of physical activity for our mental and physical health are well-known and documented. However, there are times when excessive exercise is considered compulsive and potentially harmful.

The National Eating Disorder Association (NEDA) defines excessive exercise as one or more of the following:

• Exercise that significantly interferes with important activities, occurs at inappropriate times or in inappropriate settings, or when the individual continues to exercise despite injury or other medical complications
• Intense anxiety, depression, irritability, feelings of guilt, and/or distress if unable to exercise as planned
• Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury
• The type, volume, and intensity of exercise are often monotonous and inflexible and are not in line with what is scientifically proven to be safe and effective methods of training
• Discomfort with rest or inactivity
• Exercise used to manage emotions
• Exercise as a means of purging (needing to “get rid of” or “burn off” calories)
• Exercise as permission to eat
• Exercise that is secretive or occurs despite recommendations otherwise
• Significant difficulty or an inability to modify exercise routine when advised
• Feeling as though you are not good enough, fast enough, or not pushing hard enough during a period of exercise, overtraining
• Withdrawal from friends and family

How do eating disorders impact bones and muscles?

Good nutrition is required to maintain healthy bones and muscles. Regardless of the type of eating disorder or age, if the body is not receiving adequate nutrients, the muscles and bones will weaken . Bone strength and muscle mass decrease with aging. Individuals in midlife who struggle with disordered eating are at an especially high risk of having thin bones, known as osteopenia and osteoporosis, and decreased muscle mass seen in sarcopenia. A bone mineral density test, known as a DEXA scan, can measure the strength of bones and assess an individual's risk of injury.

Maintaining bone and muscle health is vital to protecting yourself against musculoskeletal injuries and dangerous fractures.

Here are some ways you can keep your bones and muscles strong and healthy.

1. Maintain a balanced diet. Make sure you are eating plenty of fruits and vegetables. Getting the recommended amount of calcium and vitamin D from your diet daily rather than taking supplements when possible is best.
2. Try to quit, limit, or avoid smoking and drinking alcohol. Its never too late to get help and the physical health benefits of quitting or limiting these substances happen almost immediately.
3. Engage in weight-bearing exercise, strength training, and stretching. A healthy exercise routine helps keep your muscles and bones strong, while stretching can help prevent injury and help maintain muscle function.

Are people in midlife vulnerable to disordered eating?

Eating disorders occur at all ages.

• 71.2% of women over age 50 say they are currently trying to lose weight
• 79.1% said their weight or shape had a “moderate” effect on or was “the most important” part of their self-esteem.
• 41% of women over age 50 have current or previous core eating disorder symptoms

As we age and mature, the body goes through normal changes. Even though change is a natural part of aging, society pressures us, making us believe that bodies should never change. Midlife is also a time in our lives when roles often change. Many people are juggling careers while caring for developing children and aging parents. The internal pressures of role shifts coupled with the external pressures of body changes can increase body image distress and make individuals feel that they need to do something to combat the changes that are outside their control. They will often eat less and/or exercise more than usual to try and maintain control amid a life stage of transition.

Additionally, it can be normal for food intake to decrease with age. Some older adults lose their appetite and subsequently reduce food intake but do not have eating disorder symptoms or mental health struggles that may cause them to decrease food intake intentionally. As a result of their undernutrition, they experience unintended weight loss, muscle loss known as sarcopenia, functional decline, loss of independence, and other adverse health outcomes. As our global aging population increases, health care providers must be aware of this syndrome and prepared to screen for it and intervene when indicated.

What happened to Sally?

Due to Sally's persistent pain, she received an x-ray. Unfortunately, it showed a significant hip fracture that needed a surgical repair. The x-ray also revealed that her bones are thinner than they should be, likely influenced by her past and current undereating and overexercising along with her older age. Sally also receives a DEXA scan, which confirmed that she had osteoporosis. Sally was devastated. She thought that hip fractures only happened to older, inactive people. How could this be happening to her? Once she recovered from the shock of the news, Sally began to panic about what surgery meant for her running.

Sally's doctor asks her if she has a history of an eating disorder, and she explains her journey as a young adult. Sally's doctor expresses her concerns that Sally may be experiencing a relapse and offers options to find Sally the help she needs. Sally's doctor connects her with a new team of specialists, including a dietitian and therapist who specialize in eating disorders in midlife, to support her in getting the nutrition that her body needs and dealing with the issues she has regarding her life stressors and body image.

Eating disorders can occur at any age or life stage; however, it is never too late to get help. Treatment options and support groups exist to support everyone's unique needs and circumstances. To find resources and learn more about getting help, visit www.womenshealth.gov/nedaw.

References and Resources

1. Gagne DA, Von Holle A, Brownley KA, Runfola CD, Hofmeier S, Branch KE, Bulik CM (2012). Eating disorder symptoms and weight and shape concerns in a large web-based convenience sample of women ages 50 and above: results of the Gender and Body Image (GABI) study. Int J Eat Disord. 2012 Nov;45(7):832-44. doi: 10.1002/eat.22030. Epub 2012 Jun 21. PMID: 22729743; PMCID: PMC3459309.
2. Aprahamian I, Coats AJ, Morley JE, Klompenhouwer T, Anker SD, on behalf of the International Advisory Board, and Regional Advisory Boards for North America, Latin America, Europe and Japan (2023). Anorexia of aging: An international assessment of healthcare providers' knowledge and practice gaps. Journal of Cachexia, Sarcopenia and Muscle, 14, 2779–2792, https://doi.org/10.1002/jcsm.13355
3. https://www.nationaleatingdisorders.org/excessive-exercise/
4. https://www.nhs.uk/conditions/dexa-scan/
5. https://www.bonehealthandosteoporosis.org/patients/treatment/calciumvitamin-d/get-the-facts-on-calcium-and-vitamin-d/