Mid-life eating disorders and the workplace: more and more women aged 30 and older are presenting with eating disorders, and EAPs can play an important role in minimizing the impact on the workplace.

Why is this lovely 49-year-old woman in front of me throwing up nightly?

As I listen to this well-groomed, well-spoken woman, I am trying to understand what has happened in her life that would lead her to believe and act in ways that define a clear-cut diagnosis of bulimia. Granted, all of us have complex relationships with food and eating and our body images throughout our lives. Food needs, preferences, and eating patterns start at day one; by the time we can speak, we are talking about our bodies in ways that include and exclude satisfaction with how we look and feel. Most of us do not develop eating disorders, however.

Of those who do, about 95 percent are women. Although the public associates eating disorders with teenage girls and women in their twenties, health care providers are starting to tell a different story. According to eating disorder specialist Margo Maine, Ph.D, author of The Body Myth: The Pressure on Adult Women to be Perfect (2005), one-third of inpatient center admissions in 2003 were over 30 years of age.

A NEED FOR RESEARCH

The rise in mid-life eating disorders has significant implications for the workplace and especially for industries and professions that employ large numbers of women. But what are the underlying causes of it? Are we seeing an actual increase in mid-life eating disorders or simply an increase in diagnoses of it?

Holly Grishkat, Ph.D., who runs six inpatient groups for "over 30" women at the Renfrew Center, says that about a third of them have longstanding eating issues, while slightly more had eating disorders at a younger age that went into remission but were later triggered by stress. In my own experience with this population, about half come in asking for help specifically with eating disorders and about half come in for a different reason but eventually describe symptoms severe enough to warrant an additional diagnosis.

Thus far, talk of eating disorders has not been backed up by research. The following information about mid-life eating disorders is largely anecdotal and attempts to explain the increased incidence we are seeing:

Fear of aging. Historically, we have not valued the older woman in American culture. Wisdom and experience do not bestow the same benefits as beauty and youth.

Competition for jobs and mates. There is evidence that jobs often go to the more attractive candidate, and attractiveness is closely related to slimness in our society. Also, because many divorces occur during mid-life years, women seeking new mates feel pressure to "spruce up" their looks by dieting.

Multiple demands and a subsequent desire for controls and rewards. The demands of work, children, spouses, personal lives, and (increasingly) aging parents can accumulate quickly and make even the most capable woman feel she is losing control. Micro-focusing on food, weight, and appearance can satisfy the need for control and can lead to food being used as an instant reward for completing tasks--with all the subsequent guilt for not maintaining control.

Hormone and metabolism changes. Women's metabolism changes during the perimenopausal years (the "bookend" to the onset of puberty), and weight gain is frequently a result. In a society that values slimness and youth, perimenopause and menopause can present a physical and psychological challenge to many women. To prevent weight gain, most women must reduce their intake of calories and exercise more frequently, including training with weights to preclude muscle loss.

Greater awareness of diet, weight, and health. Many illnesses are related to what we eat and what we weigh. As we age, we become more aware of the impact of our eating decisions. Trying to practice healthy eating habits without getting obsessed in an "eating disordered way" is important to good physical and emotional health.

LOOKS CAN DECEIVE

Little research exists to indicate how mid-life eating disorders affect workforce productivity, performance, or morale, but the costs of many co-morbid conditions (e.g., anxiety, depression, and substance abuse) are documented and huge. Additional costs reveal themselves in a variety of ways. Shirley Brown, Ph.D., a psychologist and former dentist in Philadelphia, says her practice includes many mid-life women with eating disorders whose teeth have required extensive repair from vomiting-induced damage.

The symptoms of mid-life eating disorders are likely to be hidden at work or fit within the "normal spectrum" of dieting and interest in food, weight, and appearance. In most cases, one should expect a range of experiences that are too widespread to be attributable specifically to an eating disorder. The varied diets and exercise regimens that look odd to some do not qualify as symptoms in and of themselves.

Some symptoms, on the other hand, resemble personality traits and behaviors that can affect relationships with co-workers. Most are not attributable to eating disorders alone but are present in a variety of problems and personalities (for instance, self-perfectionism, unrealistic expectations of others, irritability, nervousness and anxiety, lack of focus, and disorganization). The presence of an eating disorder can exacerbate any of these characteristics or behaviors.

No employee assistance professional, let alone a supervisor or manager, can simply look at someone and diagnose an eating disorder. You can estimate that someone is of excessive weight, but you cannot look at an overweight person and assume an underlying binge eating disorder. It is rare to witness dramatic symptoms such as vomiting in public bathrooms, although that is exactly how one of my patients was identified.

Even a very thin person with continued weight loss cannot be diagnosed with an eating disorder. I was involved in a case where a severely thin woman was believed by many to have an eating disorder. She claimed she could not eat without nausea, which is not an uncommon claim by anorexics; in addition, she appeared depressed. She was admitted to a psychiatric unit where I was an attending physician. After the many tests ordered by her gastroenterologist came back with normal results, a repeat set of tests revealed a pancreatic tumor. The lesson: It is important to leave diagnosing to professionals who have time, tools, and experience.

In the long run, the low self-esteem, obsession with food and appearance, and co-morbid psychiatric illnesses of those with eating disorders play out in a variety of ways that make for a less productive worker and colleague. They often avoid meetings and gatherings (such as birthday or holiday celebrations) where food and eating are involved, meaning they do not contribute to or benefit from the synergy, creativity, and connections that result from such activities.

USE A TEAM APPROACH

The best way an EAP can help is to be familiar with local, regional, and national treatment professionals and facilities. EAPs can also encourage awareness and understanding of eating disorders in general and mid-life eating disorders in particular. Education about eating disorders as part of broader health-related programming will often help prompt an employee to come in for a private discussion.

EAPs known for respecting and protecting confidentiality will be even more valued and utilized, as eating-disordered workers feel shame and embarrassment on several levels. They know, in a way younger patients often deny, that their behavior is costing them a lot.

Treatment for eating disorders is best provided through a team approach, even if a patient starts with a single therapist. I recommend that treatment be provided by an eating disorder specialist who values the team concept and can incorporate that approach into the treatment process at an early stage.

Who should join the team? An eating disorder therapist is the centerpiece. A good internist/family doctor or holistically-oriented OB-GYN is critical to provide a thorough medical evaluation--missing a diagnosis of hypothyroidism, diabetes, metabolic syndrome or hormonal fluctuations and abnormalities is not acceptable and can squander weeks or even months of treatment. Anutritionist is very important as well, preferably one with eating disorder expertise.

A good psychiatric evaluation frequently is necessary By the end of the evaluations--depending on the severity of the disorder and the motivation of the employee--the psychiatrist should have developed a treatment plan that reflects the severity of the problem This plan may start with inpatient treatment at a specialized facility and transition to something as non-intrusive as hi-weekly visits with a nutritionist.

Good treatment always includes a component of cognitive, interpersonal, and behavioral supports and interventions. As a certified Kundalini yoga and meditation teacher, I am increasingly impressed with the need for a variety of body-centered treatments as well as meditation options. These are often offered as "stress management" therapies in many medical centers. These interventions can play an important role in the treatment of eating disorders and many other illnesses.

EDUCATION IS IMPORTANT

The opportunities for EAP to be helpful in addressing eating disorders are abundant. Until further data on the extent of the problem are available, education is important. Helping work organizations provide education about the illness in general and specific resources is an important role.

As is the case with all psychiatric illnesses and many "physical" illnesses, encouraging choices that include specialists is very important. Particularly for eating disordered patients, who often have difficulty creating healthy boundaries, the importance of avoiding intrusive or overly involved monitoring is important. Case management should be minimal unless help is needed to procure care and/or the worker requests additional help. Finding treatment that addresses work performance problems and care that will help ameliorate specific problems should be sufficient unless the worker asks for more.

An EAP knowledgeable about resources and discrete in helping facilitate excellent care can be invaluable to an employer and a blessing to a mid-life worker with an eating disorder. If the worker gets good care, the return to work should fall in place with minimal involvement by the EAP, if any.

Barbara Wingate, M.D., M.S.W.

Barbara Wingate is medical director of Mandala Healing Center, a holistic psychiatric practice in Philadelphia. She was medical director at the Renfrew Center, the first freestanding facility in the United States devoted exclusively to the treatment of eating disorders, from 1991-1993 and served as the consult-liaison at the University of Pennsylvania Medical Center from 1993-1998. She can be reached at [phone] or through www. mandalahealingcenter.com.