🪟Looking Through the Window of Vulnerability - Menopause & Eating Disorders
Most often, eating disorders don’t look like the stereotypes we’ve come to hold.
Menopause and midlife can be a time of increased risk of eating disorders and disordered eating. We’re often left without the words and resources to talk about this challenging subject.
Let’s change that.
Tune in to this episode to hear -
An exploration of eating disorder facts & myths
Why eating disorder awareness is crucial within the neurodivergent community
Recognition of the research gap in menopause and eating disorders
Exploring menopause and eating disorders through a biopsychosocial lens
Next steps to assess and raise awareness around menopausal eating disorders, disordered eating, and body image distress.
Episode References & Resources:Who Coined the Term Neurodiversity? It wasn’t Judy Singer; some autistic academics say. Article referenced in this essay by Jesse Meadows -
KevinDoesARIFD (Instagram link)
Project Heal - https://www.theprojectheal.org/eating-disorder-statistics
Project Heal Source Papers:
Flament MF, Henderson K, Buchholz A, Obeid N, Nguyen HN, Birmingham M, Goldfield G. Weight Status and DSM-5 Diagnoses of Eating Disorders in Adolescents From the Community. J Am Acad Child Adolesc Psychiatry. 2015 May;54(5):403-411.e2. doi: 10.1016/j.jaac.2015.01.020. Epub 2015 Feb 16. PMID: 25901777.
Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58. doi: 10.1016/j.biopsych.2006.03.040. Epub 2006 Jul 3. Erratum in: Biol Psychiatry. 2012 Jul 15;72(2):164. PMID: 16815322; PMCID: PMC1892232.
Diemer EW, Grant JD, Munn-Chernoff MA, Patterson DA, Duncan AE. Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students. J Adolesc Health. 2015 Aug;57(2):144-9. doi: 10.1016/j.jadohealth.2015.03.003. Epub 2015 Apr 28. PMID: 25937471; PMCID: PMC4545276.
Guss CE, Williams DN, Reisner SL, Austin SB, Katz-Wise SL. Disordered Weight Management Behaviors, Nonprescription Steroid Use, and Weight Perception in Transgender Youth. J Adolesc Health. 2017 Jan;60(1):17-22. doi: 10.1016/j.jadohealth.2016.08.027. Epub 2016 Oct 28. PMID: 28029539; PMCID: PMC8091135.
Eating Disorders Neurodiversity Australia - “Eating Disorders & Neurodiversity: A Stepped Care Approach”
Frazier LD, Bazo Perez M. Unpacking eating disorder risk and resilience during menopause: a biopsychosocial perspective. Menopause. 2025 Mar 4. doi: 10.1097/GME.0000000000002511. Epub ahead of print. PMID: 40036552.
FREE Course! Monash University, Menopause and Eating Disorders
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Melinda Staehling
[00:00:00]
Welcome or welcome back to our second episode. I'm your host, Melinda Staehling, Certified Nutrition Specialist, and here at Departure, menopause educator, body image coach, and your perimenopausal copilot. Thanks for joining me, and thank you for reaching out after our first episode with your comments and support.
It's so good to be in this conversation. On my perimenopausal front this week, it's been a week of luteal phase bed sweating, sleep deprivation, and hormone therapy brand switching as I needed to change pharmacies. Cool, cool, cool.
Departure Menopause is a space to explore health change and body image from a neurodivergent-affirming and weight-inclusive approach.
I come to menopause with a different sort of focus, thinking how this pivotal life stage intersects with neurodivergence and how we can move past the big menopause wellness bullshit to look beyond diets when we think about health. While we're going to dive deep into regular eating in our next episode, if you're wanting to take what I think might be one of the very first steps to reconnect with your body and brain and menopause, and when I say that, I mean from peri- to post, you can download the free Regular Eating Guide.
If you find yourself caught in a cycle of daytime restriction and then feeling challenged with evening eating, then this free training is for you.
The guide includes a list of prompts to help you dig deeper into why your eating might be irregular assessments to work through, and tools to gently assist you in planning your specific yet flexible eating structure going forward. Link to the guide is in the show notes at Departure Menopause dot club backslash regular dash eating dash guide.
My goal for these first shows is to touch on topics that I think matter a lot to menopause, some of which are vastly understudied or underpromoted or just not discussed. Last week we talked about the big umbrella concept here at departure of connecting the dots and the overlapping intersections between weight-inclusive care, a neurodivergent-affirming approach, and body image.
So with that, I have my first podcast updates, or the first is a potential correction. Last week I introduced the term neurodiversity and credited Judy Singer, and just at time of recording was reading an article by Jesse Meadows on their substack, sluggish that credits some other earlier online autistic communities for originating that term.
[00:03:00]
I'll link to that article in the show notes.
Also, our first episode was on my Venn diagram concept, and I forgot to mention, chat about my inspo for doing said episode, and pretty much coming up with the concept of this podcast. One of my values is citing my sources, and so I wanted to mention two Venn diagram makers that have inspired me and really more than just the podcast, my own neurodivergent perimenopause journey and discovery.
The first is Katy Higgins Lee, who is a marriage and family therapist. They're a multiply neurodivergent therapist and supervisor and course creator, and I'm pretty sure I found their work on Instagram. I'm guessing that was in the fall of 2023, because I started on a big, deep dive into giftedness then, and I know this Venn diagram was a part of that Aha.
So they have this Venn diagram, which they're sort of internet famous for, I think, in the neurodivergent community. And it takes ADHD and autism and giftedness as a three-circle Venn diagram and lays out where certain traits overlap and where they might be more specific to one neurotype or the other kind of thing.And I know they've done a ton of work of updating this graphic with new versions to make the language more clear.
And then the second Venn diagram, who is an author, podcaster, researcher, therapist. All of the things is Dr. Megan Anna Neff of Neurodivergent Insights, and they're pretty known for making these graphics and have this whole series of Venn diagrams that look at different neurodivergent identities, where they tease out the traits and the overlap.
And that series is called Misdiagnosis Mondays, and I will link to both of these in the show notes.
So my vision for the podcast is we take that Venn diagram I talked about last week, and over time we're mapping the episodes and the concepts and the ideas with these intersections with menopause in the center and weight-inclusive care, a neurodivergent affirming approach and body image in the outer rings.
And this week we're going to discuss eating disorders and disordered eating. In my Venn diagram, this topic is right in the center where everything is overlapping. I don't think we can. I mean, I guess we do all the time, but I don't think we should talk about menopause without being eating disorder aware.
I know this topic can feel sensitive and bring up a lot.
This entire episode is about eating disorders and disordered eating, so please take care of yourselves and check in with your body and listen when it feels like the right time for you. Another thing before we get into it today is a note on language.
I wanna bring up identity first language versus person first language, because I noticed I'm switching back and forth a lot between the two in this upcoming conversation, and I thought it deserved a mention in case this was a newish thing to you.
[00:06:00]
So I'm switching back and forth between identity first and person first language. Person first. language was developed out of the disability rights movement and AIDS activism, and later written into law with the ADA in the nineties. This person first language around body size is what's taught in med school and was what was taught to me in my nutrition education, so I had some unlearning to do. However, language is evolving, and identity first language then also came out of the disability community identity. Person first language is just that, putting an identity first.
Like, I'm tall, and I'm a tall person, and we wouldn't say person with tallness.
So there's been a lot of reclaiming of identity, first language from what was previously more person first. Some examples of this are deaf people wanting to be called deaf and autistic people autistic and not people with autism. Like it's a part of the identity. So lead with that. This shows up in the weight-inclusive space where larger bodied or fat people will use fat as a neutral descriptor instead of something like person with fatness. Because I'm a straight sized person, I usually defer about using the word fat until I know what the person in front of me wants me to say and say larger-bodied person, because I know not everyone has reclaimed the word fat and fatness in the same way.
But when I'm speaking about anti-fat ness, or I'm in spaces that are led by fat people where I know that word is accepted and preferred with neutrality, then that's what I'll say. We say short and we say tall. And on the other hand, with eating disorders, I do mostly use person first language because an ED is usually something people are in the process of or in recovery with.
With avoidant restrictive food intake disorder or ARFID, which we'll talk a little bit more about today, a lot of people are coming to claim this as a neurodivergent identity and use like a ARFIDers or FIDers, which I think Kevin from Kevin Does Arfid on Instagram coined. So what I'm saying here is that language is personal and collective and evolving, and today I'm going to switch back and forth where I think it's best and I am not the language enforcer.
And that if you're confused about what an individual, someone prefers in the neurodivergent world or the eating disorder or body shape and size or disability space, then you can ask them.
One more note on language is that I'm trying to keep this podcast as gender neutral as possible as we have diverse gender experiences with menopause. But if the research is based on women, I will say women, to keep it consistent with what was researched.
So today we're going to go over some facts supporting why I think menopause and eating disorders should be on everyone's mind at this stage of life; this is the awareness is prevention show.
[00:09:00]
Eating Disorders: Facts & Myths
We are going to start with talking about eating disorders and some facts and figures around general eating disorder awareness, and then we're going to talk about neurodivergent awareness and how that dovetails with eating disorders and menopause and weight-inclusive care if it's in here, because we need to think about who is getting offered treatment for eating disorders and who is being steered towards the weight loss industry.
Since we're still new around here, I want to give my privilege disclaimer, I'm arriving today in a straight-sized body. I'm white. I have housing and food security. I'm cis-het and partnered. That's an incredible amount of privilege, like soaked in privilege, which I think is important to bring to the forefront of our eating disorder conversation.
I also want to say that I'm showing up here today on the podcast with my education and information hat on, but I do work day to day in eating disorder private practice. Eating disorder education is eating disorder prevention, and the more we talk about eating disorders at this menopause stage, instead of hiding or stigmatizing or normalizing disordered eating behavior instead of hanging out in the unawareness zone, the better.
You might be thinking, what in the world does menopause have to do with eating disorders? Or you might think, wow, wow, wow, we really need more awareness about this topic from a menopause perspective. I am pointing out here that while numbers-wise, those with a diagnosed eating disorder are going to be a small percentage of the population, disordered eating behaviors and negative body image thoughts and emotions occur at much higher rates.
The most common eating disorders are anorexia, bulimia, binge eating disorder, avoidant restrictive food intake disorder, which is ARFID, and other specified feeding and eating disorders, also known as OSFED. OSFED is an umbrella diagnosis, which includes atypical anorexia, which we'll talk about in a minute. OSFED can be applied as a diagnosis when someone might not meet the full clinical criteria for say, anorexia or bulimia or binge eating.
That doesn't mean that the diagnosis is any less serious or deserves less treatment.
So here are some eating disorder statistics. This feels sort of like myth-busting. This is from Project Heal’s website, which is a fantastic eating disorder nonprofit, and I'll link to that post, which has all the citations in the show notes.
In one adolescent study with an average age of 14, less than 6% of those surveyed with a diagnosed eating disorder were medically underweight. In the survey, in the people that reported an eating disorder, less than 6% were medically underweight.
This is such an important point, and I don't think we can really see eating disorders fully until we think about how much energy and attention we give to who we think might have eating disorders, which is white, thin, young girls, and who they are really affecting, which is everyone else.
[00:12:00]
I think this is important when talking about eating disorders in midlife because we still still carry around this perception even as we're entering menopausal and midlife age, that eating disorders are only happening to underweight white women, and that's just not the case.
This lack of awareness about what type of body has an eating disorder leans into the common idea that people aren't sick enough for treatment because they don't fall into what society thinks is an eating disorder. I'm not gonna be able to do service to this topic right now, but here's a place where I want to bring up atypical anorexia.
Atypical anorexia falls under that umbrella, which is OSFED. This is anorexia without low BMI. First, this is a stigmatizing name for this presentation because it's not atypical. It's in fact more common than anorexia nervosa.
So atypical anorexia is anorexia in average weight or higher weight people, which includes the same serious potential medical complications of anorexia nervosa of restrictive eating. This is a long list of medical complications that affect every system in the body and co-occurring psychological concerns. But here often because of weight stigma with atypical anorexia, it can take longer for diagnosis and treatment because of the bias toward higher-weight people and what we think looks like anorexia.
I am the queen of disclaimers here, but this obviously does not lessen the need for treatment for medically underweight people of all races, sizes, genders, and ages, which we all know can have severe consequences.
Next up with facts and myths. Binge eating disorder is more common than anorexia nervosa and bulimia nervosa combined, and that comes from a prevalent survey of 9,000 people, which is linked in that Project Heal post. This is another one that I think is really important, and maybe think of this as like a pie chart with anorexia and bulimia being relatively small pies, and then binge eating disorder being the larger piece.
I am going to speak from some clinical personal experience here that quite often people with binge eating disorder have fewer resources or get redirected by their medical team toward weight loss more often and because of body size, and this could be a whole range of body sizes, and a lot of people simply don't wanna talk to their medical providers about binge eating.
I also want to bring some awareness around the restriction component of binge eating, which is common, well, it's called binge eating disorder, and that's sort of how we characterize it because it's baked into the name and the DSM behaviors. There's usually a restriction component that's physical and psychological going on as well, and that restriction piece is super important to address and it's also super normalized in our society.
From another study quoted from that Project Heal post, trans and gender non-conforming individuals are at least four times as likely to struggle from an eating disorder than their cisgender counterparts.
[00:15:00]
However, some experts expect that number is likely much higher with trans and gender non-conforming individuals, eight times as likely to struggle from an eating disorder.
I am popping in with my commentary that the rates of trans and non-binary individuals are high in the neurodivergent community. And a reminder that the menopause experience includes a whole range of gender identities and is unique to everyone. Another point from Project Heal. While eating disorders typically onset in adolescence or early adulthood, they often persist into older adulthood, especially when untreated. At one eating disorder program, at least 13% of people in their residential treatment were aged 41 to 55.
We do have awareness around eating disorders and puberty. We have research around treatment styles and dedicated spaces for treatment. This body of research work, and these treatment options just don't exist in midlife.
And my last facts from the Project Heal post, black women are 25% less likely to be diagnosed as white women with the exact same eating disorder behaviors. Only 17% of black women, 41% of Latino women, and 44% of white women are accurately diagnosed by doctors when presenting with an eating disorder.
So those are some facts to think about as we launch off in our eating disorder discussion. We talked last time about how there's both weight gain around the menopausal timeline and that can be usual and expected in the population. But we have this very common approach right now that any weight gain and midlife is the primary concern.
So this can lead to both providers missing the mark as far as screening for eating disorders and disordered eating, and encouraging seeking help, and the patient also thinking that weight loss needs to be pursued at all costs.
So that was a lot of numbers in my call for awareness.
Eating Disorders & Disordered Eating
There is a part of the population with diagnosed eating disorders, and there's a much wider group of people with disordered eating and negative body image, and I'm going to take a minute to define that and explain why it's so crucial to understand the link. When we think about eating disorders.
It might be helpful to think about the continuum of what I think as regular eating or usual eating behavior on one side, with disordered eating and eating differences sort of in the middle and eating disorders with a clinical diagnosis or not falling at the other end of the spectrum, the lines of disordered eating to eating disorder can get really blurry.
And if you've ever looked at some of the DSM criteria for eating disorder diagnoses, you might see that too. I think the same can go for a lot of ED conditions in mental health. A note on diagnosis, sometimes a diagnosis might seem helpful for either personal identification or for insurance benefit coverage, where I know for others it can feel stigmatizing, disordered eating and eating disorders can straddle that line for diagnosis.
[00:18:00]
To dig in more to a definition. Disordered eating might take on a lot of the same behaviors and characteristics of an eating disorder, but with less frequency or severity.
A lot of these behaviors are perfectly normalized in our culture with things like weighing yourself every day, body checking, daytime food restriction, and over-exercising as compensation. Those are all really common. Then there are disordered eating thoughts and emotions that aren't so out in the open, but can lead to a lot of distress and anxiety and guilt and shame.
I am thinking about binge eating, which we talked about as the most diagnosed eating disorder, but that behavior is kept secret by a lot of people because it brings up feelings that are hard to talk about and it doesn't fit neatly into what our social expectations of eating look like.
And really there's just so much fucking weight stigma, or with ARFID, or anywhere on that neurodivergent food spectrum differences, people can have a lot of distress towards eating in public or not having access to their safe foods. A lot of that stays hidden.
Eating Disorders & Neurodivergence
So now we're going to talk a little bit about why this is so important for the neurodivergent community. The rates of eating disorders, disordered eating and eating differences are so much higher in the neurodivergent community.
When I use the word neurodivergent, I'm using this as an umbrella for ADHD, autism and Giftedness.
I'm also including other presentations like OCD and bipolar and others in this umbrella. But to be clear, the research doesn't look at quote neurodivergence as a whole. The research here is on specific populations, say adolescents with ADHD. Here's a few facts and figures that come from Eating Disorders Neurodiversity Australia, and this is a resource called Eating Disorders and Neurodivergence, A Stepped Care Approach. This is a fantastic free resource. If you're interested in neurodivergence at all, you will geek out on this resource. It's so comprehensive and there are so many rabbit holes to explore. Whether you're a practitioner or interested independent researcher, this is really great.
I am going to start with some numbers in children and young people so we can get a foundation of prevalence. This is coming straight from that resource.
Okay, so for the general population, eating disorders occur in five to 18% of young AFAB individuals and 0.6 to 2.4% of young AMAB individuals have experienced an eating disorder. However, when we look at autism prevalence, 70% of autistic children demonstrated atypical eating behaviors.
And one study found that 90% of parents or caregivers reported their autistic child experienced feeding difficulties. Another paper cites the risk for an ADHD kiddo having an eating disorder is three times higher than that as a non ADHDer. One study compares autistic, ADHD and AuDHD children, and found that AuDHD children had the highest prevalence of restrictive eating behaviors.
[00:21:00]
Some of the same patterns continue into adulthood. ADHDers are four times more likely to have been diagnosed from any eating disorder with the most common being binge eating and bulimia.
Adult autism sees a different subset where restrictive eating disorders, mostly anorexia, are more common in adult AFAB folks. I think it's important to point out here too how autism itself is under and undiagnosed in women and gender diverse populations. I wanna mention a little more here about ARFID which is avoidant restrictive food intake disorder, and this can look like a variety of presentations of eating differences and preferences, and I'm generalizing, but usually trends toward preferences for sameness in foods or less interest in food and going for foods that have more predictable tastes and textures. Research suggests that around 20% of autistic adults present with ARFID.
There's a general unawareness about ARFID, and I'd say that unawareness is pretty high in our primarily currently Gen X menopause population, and that goes with providers in that group as well.
We talked about person first language here, and this is a place where some people self-identify with ARFID as another neurotype, and potentially a lifelong identity where it's about finding resources and support and new ways of thinking about eating and not necessarily trying to fix with food exposures.
Menopause & Eating Disorders
Now, let's get into menopause. For context, there's a research gap here. One thing I do a lot when I'm wanting to know about how a topic and the research base is, I'll type the topic into the search on PubMed. For me, eating disorders as a search on PubMed comes up with 58,251 results.
When I add menopause to that search, the number goes down to 194, all time. I hope that sort of demonstrates the research gap. There's a research void that exists for this life stage that is going to be a part of half the human population's experience.
So going into this, knowing that there isn't a lot of research, but there's also not none. One paper that came out in 2013 titled The Menopausal Transition, A Possible Window of Vulnerability for Eating Pathology is where this episode gets its title inspo.
This was a smallish questionnaire based study based in Australia. They always seem to be a few miles ahead in the eating disorder research, the study found an increase in eating disorder behavior and negative body image, beginning with perimenopause and into menopause compared with premenopausal women.
One reason I mentioned this paper is because I think the title stuck and window of vulnerability has become a common phrase to use to describe the menopause transition from a mental health perspective.
[00:24:00]
So with menopause and eating disorders, there are a few possibilities that can play out. The first is that someone has an eating disorder earlier in life and recovers. Then the hormone, chaos and life stage of menopause re-triggers that ED.
Or there's the possibility that they have never recovered or had the opportunity for treatment, that the eating disorder has been a part of their story throughout life up until menopause.
And then there are some people which seem to be in smaller numbers that develop an eating disorder in menopause for the first time.
One way I think we might view menopause and eating disorders is from a bio-psychosocial lens. Eating disorders are biologically, psychologically, and socially based, and so is menopause. It's common to look at eating disorders and menopause from this bio-psychosocial perspective, and by now, you know I love a framework because we can see how all these puzzle pieces fit together.
I am thinking here how the physical changes and risks of both midlife and eating disorders overlap. And then how on more of the mental health side, we have the risk of both disordered eating, but also anxiety and depression. On the social side, both menopause and eating disorders can take up a lot of room with how we interact with the world.
I'm going to link to a new paper in The Menopause Society Journal by Frazier and Bazo Perez titled, unpacking Eating Disorder Risk and Resilience During Menopause, A Bio-Psychosocial Perspective.
Thanks to Val Schoenberg, who brought this paper to our attention in her journal club this month. This paper provides some support for eating disorder risk being higher in the perimenopausal phase than pre or post menopause, and that makes sense with all the hormone rollercoaster and things feeling just well out of this world.
The authors also say that body image dissatisfaction and the quote, thin ideal, are independent predictors of eating disorders. This is quoted right from the paper. They report that 70% of menopausal women are trying to lose weight, and that 41% of women scrutinize their bodies daily.
So I'm not gonna go into the data of the paper itself. I'm fine to admit that I don't understand the data here.
But one thing that's sort of cool about this study is that they provided the 500 or so participants with a lot of screening tools. That was the method of the paper.
There really wasn't an interview portion of this study. I know when I personally do a screener, it's always more helpful for me when I have a practitioner to talk about the results with, but I think sometimes taking the screeners can be like an aha moment in and of itself.
And I wanna wrap up here today with these screeners because this might be an actionable tool for you.
Here are the assessment tools that the study had. The participants take the Attitude Towards Own Aging Subscale, the Menopause Health Questionnaire from the Menopause Society, the Body Image Concern inventory. The Eating Disorder Exam questionnaire or the EDE-Q, which is a pretty common eating disorder screener, the EAT 26 is another tool commonly used in addressing disordered eating behaviors, and the Intuitive Eating Scale.
[00:27:00]
So these are all tools that are available to help. They're validated tools and you can take them to a therapist or a healthcare practitioner or a friend. Sometimes it can be easier to get support when you have some of this info and it's a validated questionnaire and it's like, hey, here's what I see and here's what's going on.
So that's one resource. And then my final resource to share with you that I discovered in my departure trails on this episode is this course from Monash University, once again in Australia. And this course is specifically on menopause and eating disorders. And did I mention that it's free, so I'll link to the Monash course also.
I want to restate what I said throughout the episode, and that's that we need research. We need less stigmatizing medical care. We need a more fair and just society for eating disorder prevention. I don't want you to leave this feeling like it's on you, listener because it shouldn't be, and I hope some of these resources help.
So that was our tour of eating disorder facts and myths, and a look into eating disorders and neurodivergence. And then we wrap with menopause and some resources to explore. If you wanna take this work a little further, please take some grounding breaths.
By becoming aware of what eating disorders look like and not shying away from disordered eating and eating disorders and menopause, we're all in a better place to continue this conversation. Thank you for listening to today's episode.
I'll see you back in a couple weeks for our next installment. Podcast Art is by Barb Burwell.