As a psychologist at the University of North Carolina Center of Excellence for Eating Disorders, Cristin Runfola had heard lots of horror stories about the lengths many of those with eating disorders had to go in order to find effective help. But one person’s story stuck in her mind more than many others.

A middle-aged woman with a severe eating disorder was recounting her nearly decade-long struggle and told of some of her early efforts to seek help through her primary care physician. But the doctor brushed off her concerns, telling her flat-out she was far too old to have an eating disorder since those were problems of adolescence. So she stopped reaching out and her illness worsened until she wound up in the hospital with life-threatening complications.

The encounter sparked Runfola’s interest in midlife eating disorders. Long thought to be nonexistent, new research is showing that far from being an issue of teenage girls, eating disorders can affect people throughout the lifespan. A new paper in the journal Maturitas, co-authored by Runfola, now at Stanford University, and Jessica Baker at UNC shows that, peri-menopause, like puberty, may be another high-risk period of the development or return of eating disorders.

“Physicians and the general public have had this long-term belief that midlife women are somehow immune to eating disorders, and that’s just not true,” Baker said.

The image most people have of someone with an eating disorder—young, white, thin, wealthy—is nothing more than a stereotype. Eating disorders, says Claire Mysko, CEO of the National Eating Disorders Association, affect people of all body weights, races, ethnicities, genders, and age groups.

But the stereotype has been so tenacious that clinicians and the lay public, even those with eating disorders, continue to believe that older adults can’t possibly develop eating disorders. New research is showing that many women and men don’t stop worrying about weight and shape as they age. A 2012 study in the International Journal of Eating Disorders led by psychologist Cynthia Bulik, director of the UNC eating disorders center, found that 70 percent of women aged 50 and older are trying to lose weight, 60 percent say that their concerns about weight and body image have a negative impact on their lives, and 13 percent have symptoms of an eating disorder, such as extreme dieting, binge eating, excessive exercise and/or purging.

In the past decade, however, more and more adults in midlife and beyond have begun seeking treatment for an eating disorder. For some of these individuals, the eating disorder is a new problem that didn’t begin until their 40s or 50s. Others had an eating disorder as a teen or young adult and recovered, only to relapse in midlife. Still others have been chronically ill since adolescence.

With no formal epidemiological studies on the subject, it’s still not clear whether the actual number of older adults with eating disorders is on the rise or they are simply more likely to seek help for their eating problems. In 2003, one-third of inpatient admissions at one specialized eating disorder treatment center were for women over age 30. In the past decade, the Renfrew Center has reported a 42 percent increase in the number of women aged 35+ seeking treatment.

Although eating disorders are, overall, less common in older adults than in adolescents, the core eating disorder symptoms remain the same and have an equally devastating impact on the person’s quality of life, says Ellen Fitzsimmons-Craft, a psychology postdoc at Washington University in St. Louis who studies eating disorders in different age groups. They are also significantly more likely to suffer from medical complications related to their disorder, such as osteoporosis, gastrointestinal and cardiac issues, and tooth loss.

“It’s not surprising—for some women, these disorders have been going on for decades. And our bodies just get less resilient as we get older,” she said.

The symptoms might be similar, but many middle-aged people with eating disorders report different triggers and concerns than adolescents. Instead of being concerned solely with body size and shape, older adults with eating disorders are also concerned with showing normal signs of age, such as wrinkles, saggy skin, and body shape changes. They can also be trying to manage feelings of loss as children grow up and leave home, divorce, caring for aging parents, and even their own mortality.

“Dieting and weight loss are painted as solutions to everything in our culture, and it’s easy to grab onto that and have it spiral into an eating disorder,” Mysko said.

In their new paper, Runfola and Baker point to an emerging area of research that could also help explain the occurrence of eating disorders in this age group. Psychologist Kelly Klump of Michigan State University has spent the last two decades looking at some of the genetic factors that can contribute to eating disorders. Much of her work has focused on the hormonal changes that occur at puberty and how hormonal changes across the menstrual cycle can affect eating disorder symptoms.

In particular, as sex hormones come online in full force at puberty, it seems to switch on the genetic risks for eating disorders. Throughout a women’s reproductive life, the monthly hormone swings also appear to affect rates of emotional eating and body dissatisfaction, according to a 2014 study in the International Journal of Eating Disorders, with both of these being the highest immediately before and during a woman’s period. A subsequent study showed that the hormone changes around ovulation also affect the relative influences of genetic and environmental factors on disordered eating behaviors like binge eating, fasting, and body dissatisfaction.

Peri-menopause is also accompanied by large hormone shifts, although in the opposite direction as occurs during puberty, Baker points out, although almost nothing is known about how these changes affect eating disorders. Only one study has directly addressed the issue, surveying a group of women aged 40-60 and dividing them into three groups: pre-menopausal, peri-menopausal, and post-menopausal.

The peri-menopausal women had a higher prevalence of eating disorders and body dissatisfaction than the other two groups, findings that are echoed by a separate study that measured the prevalence of eating disorders across the lifespan. Rates of eating-disorder symptoms were highest in young adulthood, dropping off in the thirties and forties, and then rising again at menopause. Runfola and Baker hypothesize that it might be the hormone shifts that occur at puberty and again at menopause that primes women for an increased risk of eating disorders and disordered eating.

“There’s pretty strong evidence that hormones play a role in causing and maintaining eating disorders,” Runfola said, and there’s no reason to think this isn’t also happening at menopause.

Raising awareness of this issue is an important first step in addressing the problem, and Runfola and Baker hope that psychologists can help to develop better treatments that address the specific concerns of this age group and help them integrate treatment into their daily lives.