Lisa Boltman is 43 and a mom of three boys. She’s a self-confessed perfectionist and “people pleaser.” But she’s also surprisingly frank when it comes to her eating disorder, anorexia nervosa, which doctors have told her might kill her. At 5 foot 5, she currently weighs “in the 90s” and can fit it into kids’ clothes.
“People say ‘Get over it,’” says Boltman, but “it’s not a choice.”
Boltman had always managed to keep her anorexia in check. Diagnosed in her 20s when her weight fell to 81 pounds, she had received treatment for laxative abuse — a common practice among those with eating disorders to lose weight — and kept her weight at 125 pounds during her 30s. Then in 2014, something changed. “I was feeling uncomfortable in my skin — it’s this empty feeling.” She started taking hundreds of laxatives daily and over-exercising. Her weight fell dramatically.
At a weight too low to qualify her for a private eating disorder clinic (some programs require a Body Mass Index [BMI] of 16 for admission), Boltman sought help at an eating disorder outpatient program at a nearby hospital. But she felt the program wasn’t a good fit since it wasn’t customizable (every patient got the same meal plan) and she left after just two days.
She now manages her disorder with the support of her family. She gets herself and the kids out of the house to avoid ruminating about her illness. She works as an administrative assistant to keep herself busy. And she constantly forces herself to eat. But she confesses that it’s difficult, and doctors have told her she may die from a heart attack or kidney failure if she continues restricting food and abusing laxatives.
She says there’s an internal dialogue at every meal. “I have to say to myself: ‘Today is the day you’re going to be normal.’”
Boltman is one of 600,000 to 990,000 Canadians — 80 percent of them female — who suffer from an eating disorder, primarily anorexia nervosa, bulimia nervosa or binge eating disorder, according to the 2014 House of Commons Standing Committee on the Status of Women. According to the committee’s report, anorexia nervosa has the highest overall mortality rate of any mental illness, with 10 to 15 percent of individuals with the illness succumbing to it; about five percent of bulimia nervosa patients die from the disease. Combined, these two disorders kill an estimated 1,000 to 1,500 Canadians per year, the report finds.
While these eating ailments are commonly diagnosed among women in their 20s, health-care experts are now seeing more women relapsing with age and, sadly, falling through the cracks of care.
“Over half of the people that we see are over 35,” says Deborah Berlin-Romalis, executive director of Sheena’s Place, a support centre that provides free services to people over 17 with eating disorders, as well their families, caregivers and communities. She says women hit their 40s and they’re overwhelmed by careers, child-rearing, divorces or caring for elderly or sick parents. With anorexia, symptoms come roaring back — or yo-yo dieting precipitates full-blown binge eating. “It’s like a merry-go-round that you can’t get off of,” she says.
Despite this, eating disorders — particularly anorexia in women over 40 — are under-represented in ED programs and services. “Adults in midlife are not showing up to treatment,” says Leslie McCallum, a PhD candidate at the University of Toronto studying this group. As a result, older women who relapse in middle age often get missed by family members and clinicians — and they hide their illness and suffer in silence. When they do visit a physician, GPs attribute their anorexia symptoms — weight loss, abdominal pain, changes in bowel habits, hair loss — to other medical conditions.
McCallum says that it’s a complex issue. Women over 40 with eating disorders are out there, but they hide it well — and denying the severity of the illness is common among people of all ages with eating disorders. “It’s difficult for older women to step forward and ask for help due to misconceptions about eating disorders being a younger women’s illness,” she adds. She says the secrecy around these illnesses is compounded in women in their 40s and older. “They think: ‘I should know better — I’m a mature woman,’” she says. Plus, some enjoy the compliments a slim figure can bring.
“Their lives are much more complicated,” says McCallum. “The stakes are so much higher. We really need to pay attention to this group.”
When an eating disorder such as anorexia or bulimia resurfaces in middle age, or a binge eating disorder is newly diagnosed, the first step is addressing the other mental health issues, such as anxiety or depression, that often accompany the disorder, says Dr. Lara Ostolosky, assistant clinical professor at the University of Alberta. “An eating disorder doesn’t exist on its own,” she says, adding that drug abuse, excessive spending or other addictive behaviours can also be present.
McCallum agrees. She says that many women with eating disorders have experienced some sort of trauma that needs to be addressed through therapy.
The second step is accessing treatment. For those with anorexia who have very low BMIs and are in danger of dying, hospitals may take them in on an emergency basis and offer refeeding.
If a woman isn’t in immediate danger, an in-patient stay at a hospital with an eating disorders program may be an option, though waiting lists are long, and only 50 beds exist in Canada for adults with eating disorders, says McCallum. These facilities offer refeeding programs and counselling.
However, many of the anorexia treatment programs are geared towards younger women, whether through food selection or the all-or-nothing counselling approaches, says McCallum.
Women over 40 “feel quite alienated in that group,” says McCallum, adding that many women would prefer to have programs tailored to their lifestyles, which often include jobs and kids. “There’s some flexibility needed in these programs,” she says. “With a mature adult, how about saying ‘Here are three different vegetables. Pick one.’” She feels an approach more tailored to their life stage might increase help-seeking and reduce premature discharges.
Private clinics that integrate counselling, cognitive behavioural therapy (a type of therapy that challenges negative thinking), meal planning and support groups are another path to treatment. But they can cost anything from $200/hour for outpatient visits to tens of thousands of dollars for longer in-patient stays.
Kyla Fox, a former anorexic, is the founder of The Kyla Fox Centre, an eating disorder recovery centre in Toronto. She says that when she was diagnosed with anorexia in her 20s, there was no treatment available to her due to lengthy wait lists and a lack of professionals who understood eating disorders, so she could not access services that she desperately needed. Fox, who admits she was “in denial” when first diagnosed, had been severely underweight, suffering from hypoglycemia, fainting spells and hair loss, as well as panic attacks and a loss of menstrual periods. “I felt like I was on the verge of losing my life,” she says.
She began to track her eating and to analyze her toxic relationship with food. Slowly she cut back on her exercising, and started eating more calories — consuming foods she enjoyed. “I really started to educate myself about food,” she says, while surrounding herself with women she saw as mentors. She says it taught her that having role models is integral in recovery. “Find people who really understand you — and understand eating disorders.” Her private clinic, which opened in 2012, is all about flexibility. “No two people have the same recovery.”
Though it can be elusive, recovery is possible, especially for those dealing with bulimia and binge eating. “I can usually stop a person with binge eating disorder in their 40s,” says Dr. Ostolosky.
Dr. Allan Kaplan, senior clinician/scientist at the Centre for Addiction and Mental Health, and vice dean and professor of psychiatry, at the Faculty of Medicine, University of Toronto agrees: A combination of cognitive behavioural therapy and pharmacotherapy can usually treat bulimia successfully. “Bulimics can be treated and can get better,” says Dr. Kaplan.
Experts believe that for a treatment plan to work, a patient has to take ownership. One step is to identify emotional triggers. “A person has to look at their life and look at the things that are causing them stress,” says Dr. Ostolosky. “Women in their 40s tend to do more and more and eating falls by the wayside.”
Supportive friends and family are critical. “I can’t stress enough the importance of spousal support and family support,” she says. This can include help with meal planning, as well as emotional support to prevent isolation. Criticism of any kind is discouraged.
Other key strategies include the following:
Ditch the scale. “I do not see recoveries happen when people are at home weighing themselves,” she says.
Increase exercise. Exercise is encouraged to manage stress and promote a positive mood — but should not be done to excess. “Some women get into an exercise program that is far too intense — they’re not doing it for health,” says Dr. Ostolosky. She says the best approach is to exercise in groups such as on a volleyball or soccer team. “They should stay away from gyms, which can promote competition and looking at other gym goers.”
Avoid unique diets. Special diets, such as going gluten-free — which are often used to restrict calories and carbs — need to be shelved unless they have been formally diagnosed by a physician. So should overly restricted diets such as veganism, she says.
Partner with professionals. Because recovery can induce unpleasant digestive symptoms, Dr. Ostolosky advises working with a health-care expert to minimize them. These issues can include gassiness, severe bloating, abdominal pain and irregular bowel habits, as certain foods are reintroduced.
Consider counselling. Women recovering from eating disorders may also have mood swings and emotional outbursts as they cope with what they perceive to be a loss of control, says Dr. Ostolosky. Attending counselling can help with those emotions and provide much-needed support. “Women with eating disorders have isolated themselves — it takes away from their connection to people. They need to rebuild that.”
Bottom line? Dr. Ostolosky believes progress is being made with eating disorders in women over 40, but admits it’s a long process. “It’s a work in progress all of the time.
Do you have a healthy body image? Take our quiz and find out.