Myth: Only Young People Get Anorexia Nervosa
“I was 45 when I got anorexia.”
Andy Jones is not the sort of person most people picture of when they think of anorexia nervosa. Andy, a middle-aged man and a proud Arsenal supporter, had decided to join a slimming club to lose a bit of weight as he wanted to improve his health. At first, the diet seemed to be working as Andy had expected. He carefully checked the calories in the foods he was eating, making sure to stick to the advice he’d been given, and his weight began to drop. “It felt fine, but within six months I was obsessive.” The calorie counting became all-consuming and, although Andy’s body shape had begun to change dramatically, he still saw his higher-weight self in the mirror.
Until the 1980s, eating disorders were seen solely as an illness of the young and a diagnosis of anorexia nervosa in any person over 30 was rare. It’s easy to see how this idea came about because anorexia often does first appear in young people. The age of onset is typically thought to be between 12 and 25. But why is this? And why do some like Andy develop the condition, or relapse, later in life?
Anorexia is born of a perfect storm of environmental and biological elements. If you accept that these are negative energy balance (as a result of insufficient food and weight loss) and a biological predisposition to the illness, likely caused by genetics, then it makes sense that the disorder could appear at any age. But it’s more likely to happen in young people for a number of reasons:
When we go through puberty the body changes. Often this includes rapid growth spurts. It’s easy to imagine that someone might not change their diet sufficiently to allow for their body’s need for extra fuel.
While most parents do their best to ensure their children eat well and at regular times, when a teenager is given the freedom to make his or her own decisions around food, they may eat erratically, skipping meals for example or perhaps substituting alcohol for food.
The teenage years are a time when many young people begin to alter the way they eat, maybe trying a vegetarian or vegan diet but not ensuring that it’s sufficiently nourishing. Or they may become more concerned with body image and make a conscious decision to lose weight for the first time in their life.
It’s possible that Andy, while having a biological predisposition to anorexia, just never went into negative energy balance during his youth. This would explain why the eating disorder popped up for the first time when he did — after joining a slimming club, aged 45, eating fewer calories than he was expending and losing weight.
Eating disorders expert Dr Cynthia Bulik points out that some environmental triggers may be present in midlife when they weren’t an issue in that person’s youth: In desperate attempts to fend of aging, women and men can start engaging in extreme practices (extreme exercise, cosmetic surgery) to try to maintain a youthful look and feel, and these things can be the first steps towards a full blown eating disorder. And of course, people in later life can be prone to more health problems than younger people, such as cancer or diabetes, which might also be a path to anorexia.
Andy realised he had developed a problem and sought the advice of his GP. The doctor’s reaction was one of surprise: “It’s odd,” he said as Andy described what was happening. “You’re old and a man!”
Andy was referred to the local mental health unit to see an eating disorders specialist but his weight continued to plummet, to dangerous levels. Although he had lost an enormous amount of weight in a short space of time, and was clearly struggling, Andy was not admitted to hospital because he was told that no beds were available in his area, the East Midlands. It was cold comfort for Andy to learn that this was not related to his age: there were not enough beds for everyone who needed them, regardless of age. It’s a tragically familiar story.
Anorexia can also strike in an older person after lying dormant for years. Rhona Balfour first developed the condition aged 14 “after losing weight due to a nasty case of flu”. Around puberty, she had faced criticism from many relations as she had gained a little ‘puppy fat’. “I was never overweight, but I then lost weight as a result of the illness and was praised for ‘looking so slim’.” On reflection, Rhona says that the reality was that she looked “very ill”.
Rhona didn’t see a doctor for help with the weight loss. “My mother (a single parent) felt great shame at the fact I was not eating.” Aged 17, she developed bulimia and this continued until she moved in with her husband at the age of 27.
Rhona remained healthy for the following 13 years. She was occupied by being a mum to twins, and the eating disorder seemed to fade from her life. Then, aged 40, after being bullied at work, Rhona relapsed and anorexia loomed large in her life once more.
For Rhona, living with anorexia is like fighting in a war every day. “I dislike my emaciated appearance,” she says, “yet my AN voice still has me fearful about gaining weight. It is like having two voices battling one another daily.”
Aged 50, Rhona sought professional help for her eating disorder in her home town of Glasgow. Sadly, two years later she was discharged, the service labelling her as ‘treatment resistant’.
Now, just a quick word on this term ‘treatment resistant’— and this applies to all people with anorexia, whatever their age happens to be. To tell someone they’re ‘treatment resistant’ is at worst harmful and at best simply inaccurate. If you were to treat a person who has a cancer with chemotherapy and that didn’t destroy the tumour, you wouldn’t say that the patient was resistant to treatment; you’d say the cancer was. And you’d probably try something else because that particular treatment had not worked. Likewise, if someone hasn’t recovered from anorexia, that’s because the combination of the treatment and the people delivering it hasn’t been successful at that particular time. That does not mean that the person with anorexia is beyond hope, nor that they can’t recover. And it certainly doesn’t mean that it’s their fault that they’re still unwell.
Rant over.
Perhaps unsurprisingly, after she was discharged Rhona fell into despair, relapsed badly and was admitted to her local psychiatric hospital for three months. Since then she has been under the care of a community psychiatric nurse, a psychiatrist and a dietician. Rhona says that she was “doing well pre-lockdown.” Then once again she relapsed.
It’s important for health care providers to be on the lookout for anorexia in older people not just because living with a restrictive eating disorder is miserable — though that is reason enough — but also because the physical damage can be worse in an older person than in someone who is not in the first flush of youth. As Dr Bulik points out: “…gastrointestinal problems, cardiac problems, bone health, dental health all take an even greater hit in a maturing body.”
Sadly, I suspect that there are lots of people living with anorexia way beyond middle age who remain unseen and unheard. There will be many who have struggled with the condition for much of their lives, have never given it a name and have never sought help. And there will be others who develop anorexia after the big changes that come with age, such as the death of a partner or the move into a care home, when their eating patterns and nutritional intake suddenly change.
Hopefully in future there will be more research on anorexia in older people, more recognition of the condition in men and women over 30 and more help offered. Anorexia is a devastating, life-changing illness no matter what stage of your life you happen to be at when it knocks on your door. Everyone deserves help to overcome it, and it is possible to recover no matter what age you are or how long you’ve lived with the illness.
It’s never too late.
Andy’s condition did improve after the initial onset of the eating disorder, and he spent a few years free of the obsessive thoughts about food, until last year when anorexia came back with a vengeance. These days Andy is a tireless campaigner to end the stigma of mental illness and talks with great honesty on his vlog about what it’s like to live with anorexia as a middle-aged man.
“An eating disorder is not a choice,” says Rhona, and it is “not about vanity. People of all ages, sexes and ethnicities develop eating disorders due to a wide variety of reasons and we should not feel shame at being ‘old enough to know better’.”