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Q. One of my patients casually mentioned that her grandfather, who is 65, is very dissatisfied and extremely critical of his appearance. He faithfully goes to a local gym several times a week. It made me wonder, are concern about body image and eating disorders unusual among older men? (B.D., Towson, MD)
A. No, eating disorders in older men are not that unique, and emerging research suggests that body dissatisfaction later in life is far more common than we think. A recent study found that 10% of older men had disordered eating related to dissatisfaction with their bodies. Dissatisfaction is higher in women; one study found that as many as 70% of women in midlife are dissatisfied with their body image (Int J Environ Res Public Health. 2023. 20:7143).
Among older men, “excessive sports activity” is a possible purging method in the context of BN, by acting as a compensation for binge-eating and as a way to prevent weight gain (BMJ.2017. doi.org,/10.1136/bmj.j1745). In one of the few studies of men with eating disorders, disordered eating was studied among 307 young, middle-aged, and older Austrian men who frequently use fitness centers (Eat Weight Disord. 2022.27:1765). Dr. Barbara Mangweth-Matzek, of the Medical University Innsbruck, Innsbruck, Austria, who has directed a number of studies of disordered eating among older men, found that 10% of the men had high rates of disordered eating, as shown by their responses on the Eating Disorder Examination Questionnaire (EDE-Q) and eating disorder symptoms on the DSM-5.
The authors also compared demographic, weight, and sports characteristics by three age groups: men 18 to 40 years of age; men 41 to 60 years of age, and men 61 to 80 years of age. The older the men, the more often they reported being married or in a partnership, to have children, to be less educated, or to have a higher body mass index (BMI, kg/m2). Sixty-six percent of the youngest age group and 54% of the middle-aged group had normal BMIs (18.5 to 24.9); 27% of the older men were greatly overweight or obese. Over three-fourths of the men reported using intensive sports activity daily or 4 to 6 times a week. The majority of men in all three age groups used sports activity to lose weight, gain muscularity, or to relax or compete. According to the global score on the EDE-Q, a lower score was reported in the middle-aged men compared to the youngest and oldest men.
Lack of awareness of the symptoms
Dr. Mangweth-Mazek and co-workers found disturbing eating behaviors in all age groups. Ten percent of all the study participants had eating disorder symptoms. The highest rates were in the youngest group, followed by the middle-aged men, then the oldest men. Binge eating was the most common symptom, followed by bingeing and purging—men with bulimic symptoms most often reported using excessive exercise to compensate for binge episodes. One important finding was the large discrepancy between eating disturbances seen on responses on the questionnaires and self-reported eating disorders, This seemed to suggest that the men weren’t aware of the pathological pattern of their eating behavior. In fact, the authors also found that a high percentage of men were satisfied with their weight, shape, and their body as a whole—in direct contrast to women of all ages. The fact that nearly 80% of the men exercised 4 to 7 times a week might be the underlying reason for their high scores on body image.
Treatment options
In an earlier article, Drs. Mangweth-Matzek and Hans W. Hoek noted a serious lack of information about treatment of eating disorders among middle-aged or older men (Curr Opin Psychiatry. 2017. 30:446). Recent studies show that the incidence of eating disorders after age 40 is around 3% to 4% among women and 1% to 2% among men. They also pointed out some of the challenges of identifying an eating disorder among older men and women. This can be caused by age-related symptoms, as well as the fact that older patients underreport eating disorder symptoms because of shame about having eating disorder symptoms at their age and the stigmatization of psychiatric disorders overall. They noted that cognitive behavioral therapy (CBT) interventions led to clear improvement after the clinicians emphasized age-related changes to appearance and improvements in sense of self-worth, body acceptance, and self-care.