The Complexity of Midlife: Eating, Body Image, and the Need for Clinical Attunement

By:  Autumn Backhaus, PhD 

We have good intentions.
We follow the science.
We promote prevention, longevity, and healthy aging.

But our training reinforces a narrow frame:

We screen young people for eating disorders.
We screen older adults for metabolic risk.

And that leads to a serious blind spot.

Because in actuality, midlife is a second high-risk window for disordered eating.
Not just for relapse, but for onset—especially during perimenopause, when hormonal shifts affect appetite regulation, mood, body composition, and identity.

A growing body of research confirms:
– Women in their 40s and 50s report clinically significant eating pathology at rates similar to younger populations.
– Perimenopause mirrors puberty in its hormonal volatility—and in its vulnerability to food and body distress.
– Restriction, rigidity, and compulsive control often fly under the radar, masked as “wellness” or “healthy habits.”

The Women We Miss

The women we’re missing aren’t visibly unwell.
They’re high-functioning. Health-literate. Doing everything “right.”

But for some, midlife brings something new—or revives something old.
A disordered relationship with food, body, or self begins to surface.

And here’s where nuance matters:
It’s not just about age or stress.
It’s about hormones—and how they reshape appetite, mood, and identity.

Perimenopause is a neuroendocrine inflection point, much like puberty.
Shifts in estrogen, progesterone, leptin, cortisol, and ghrelin affect:
– cravings
– satiety
– emotion regulation
– body perception

And those internal changes show up externally.
Midlife hormones alter fat distribution and body composition.
Women may see a new shape, often around the abdomen—one that doesn’t respond to the strategies that used to work.

The change is biologically normal. But in our culture, it’s deeply destabilizing.

In puberty, we expect emotional upheaval and body distress.
In midlife, we tell women to get it under control.

And that’s exactly how we miss them.

Why This Matters Clinically

When we screen narrowly—focusing on overeating, inactivity, and metabolic risk—we not only overlook midlife disordered eating, but may inadvertently reinforce it.

Standard health-focused recommendations can collide with, and exacerbate, restrictive or shame-based eating patterns—especially during hormonally vulnerable periods like perimenopause.

And let’s be clear:
The clinical risk is not lower in midlife.
Medical complications, suicidality, and long-term psychological distress all remain elevated, particularly in women whose disordered eating is chronic, subclinical, or socially reinforced.

The Clinical Shift We Need

The shift we need is one that’s more flexible, more expansive, and more curious—not immediately prescriptive.

Midlife women need clinicians who recognize that:
– Disordered eating doesn’t end in early adulthood
– Hormonal transitions amplify vulnerability
– Restriction often presents as health-seeking
– Control can be a coping strategy, not just a behavioral target

Let’s broaden our lens.
Let’s ask nuanced questions.
Let’s stop assuming we already know which direction the risk is coming from.

Midlife is not a diversion from disordered eating—it’s a critical point in its course.
If you’re already attending to metabolic health, you’re doing important work.
Let’s also stay attuned to the women who are just as in need of our expertise—but less likely to be seen.

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. Archives of General Psychiatry, 68(7), 724–731.

Forman-Hoffman, V. L., et al. (2020). Prevalence and correlates of eating disorders in midlife women: A nationally representative sample. International Journal of Eating Disorders, 53(3), 300–310.

Mangweth-Matzek, B., Hoek, H. W., & Pope, H. G. (2014). Pathological eating and body dissatisfaction in middle-aged and older women. Current Opinion in Psychiatry, 27(6), 431–435.

Micali, N., Martini, M. G., Thomas, J. J., Eddy, K. T., Kothari, R., Russell, E., Bulik, C. M., & Treasure, J. (2017). Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: A population-based study of diagnoses and risk factors. BMC Medicine, 15, 12.

Midlarsky, E., & Nitzburg, G. (2008). Eating disorders in middle-aged women. Journal of General Psychology, 135(4), 393–408.

Peat, C. M., Peyerl, N. L., & Muehlenkamp, J. J. (2008). Body image and eating disorders in older adults: A review. Journal of General Psychology, 135(4), 343–358.

Thompson-Brenner, H., et al. (2021). Eating disorder symptomatology and treatment response across the lifespan: Results from a large clinical sample of adult women. International Journal of Eating Disorders, 54(3), 308–319.