Menopause Attitudes, Body Image, And Eating Disorders Affect Quality Of Life
Overview
The experiences and quality of life during menopause can greatly differ among women. While menopause is often linked to adverse effects on eating habits and body image, the impact on quality of life based on eating disorder risk status is not well understood. This study aimed to examine how menopausal symptoms and quality of life vary between women at high and low risk of eating disorders, and to assess the potential protective role of body appreciation.
This cross-sectional survey analyzed menopausal quality of life, body appreciation, and body dissatisfaction among women categorized as high- or low-risk for eating disorders. The study was part of a broader survey on aging, health, and psychological issues during midlife, involving 255 women aged 40 to 60 years. Risk status for eating disorders was determined using Eating Attitudes Test-26 (EAT-26) scores. Differences between the groups were evaluated using the Menopause-Specific Quality of Life Questionnaire (MENQOL), Body Shape Questionnaire (BSQ-16), and Body Appreciation Scale-2. Additionally, the relationship between quality of life at menopause and body appreciation was investigated.
The high-risk group (n = 111) reported significantly lower menopause quality of life compared to the low-risk group (n = 144), with notably higher scores on the sexual, physical, and psychosocial subscales of the MENQOL. They also exhibited significantly greater body dissatisfaction and lower body appreciation.
Women at higher risk of eating disorders appear to experience more difficulties during menopause. Effective treatment and prevention of menopause-related eating disorders should focus not only on reducing body dissatisfaction but also on enhancing body appreciation and supporting the various aspects of the menopausal transition, including sexual, physical, and psychosocial factors.
Introduction
Puberty significantly influences the onset of eating disorders in adolescence and early adulthood, and similarly, the menopausal transition may be a critical risk factor for developing eating disorders in midlife (Mangweth-Matzek et al., 2023, 2021). Evidence indicates that eating disorders affect individuals across all ages and genders, not just young women (Mangweth-Matzek et al., 2023). Although the connection between eating disorder pathology and the menopausal transition is a relatively new area of research, recent studies have underscored the importance of menopause symptoms in assessing midlife women for eating and body image disorders (Mangweth-Matzek et al., 2021).
Menopause marks the gradual end of menstruation over several years due to the cessation of ovarian reproductive function. This transition involves hormonal changes in estrogen, progesterone, and testosterone, causing various physical, psychological, sexual, and vasomotor symptoms that impact women’s quality of life (Gatenby & Simpson, 2024). These changes can negatively affect body image through weight gain and altered body composition, sometimes leading to dissatisfaction and lower self-esteem. However, menopause can also bring positive changes in body image, including reduced self-objectification and body monitoring, as women gain more life experiences (Rubinstein & Foster, 2013).
Early research suggests a peak in eating disorder vulnerability during the perimenopausal phase, characterized by fluctuating estrogen levels. Women can experience either a gradual decline or more erratic hormonal changes, affecting body weight, composition, and shape (Tepper et al., 2012; Fenton, 2021). This variability may explain inconsistent findings regarding body image perceptions across different menopausal stages. Estrogen variability during perimenopause can significantly impact body image, as sudden physical changes may deviate from Western beauty ideals, affecting body satisfaction (Pearce et al., 2014; Rubinstein & Foster, 2013).
Baker and Runfola (2016) proposed that women are most susceptible to eating disorders during perimenopause due to volatile estrogen levels. This hypothesis is supported by findings that perimenopausal women report higher prevalence of eating disorders, greater body dissatisfaction, and more frequent feelings of being overweight compared to premenopausal women (Mangweth-Matzek et al., 2014). Additionally, perimenopause has been linked to increased binge eating compared to other menopausal stages (Khalil et al., 2022). However, some studies have found no significant differences in eating pathology across menopausal stages, possibly due to symptom overlap and challenges in classifying menopausal status (Sherman, 2005).
Recent research indicates that severe menopausal symptoms, rather than the menopause stage, are more predictive of eating pathology (Mangweth-Matzek et al., 2021). Measures like the Menopause-Specific Quality of Life Questionnaire (MENQOL) may better capture the impact of menopause than age or menstrual status (Hilditch et al., 1996). Poor menopausal quality of life can exacerbate eating pathology through mechanisms like emotional binge eating and food restriction for emotional control (Anaya et al., 2023; Thompson et al., 2022). Severe menopause symptoms may contribute to eating disorders by these mechanisms.
Body dissatisfaction is prevalent in midlife women and can be influenced by negative stereotypes about aging in Western society, which can impact self-worth and body satisfaction (Ng, 2021). Many women engage in extreme dieting to delay aging signs and avoid social situations due to poor body esteem (McLaren & Kuh, 2004). Higher body dissatisfaction is associated with negative affect, psychosocial impairment, reduced physical activity enjoyment, and lower quality of life (Kilpela et al., 2023). Menopausal changes and symptoms significantly influence body image disturbances (Mangweth-Matzek et al., 2021; Nazarpour et al., 2021).
Positive body image aspects, such as body appreciation, may protect against menopausal eating disorders by reducing the impact of unrealistic body standards and self-objectification (Quittkat et al., 2019; Koller et al., 2020; Linardon et al., 2022). Although not specifically studied in menopausal women, body appreciation is likely crucial in this life stage where body image is vulnerable (McLaren & Kuh, 2004; Ng, 2021).
This study aimed to determine if women at high risk of eating disorders exhibit more severe menopausal symptoms and lower menopausal quality of life than low-risk women, and if they show greater body dissatisfaction and lower body appreciation. It also explored whether menopausal quality of life predicts body appreciation. The study hypothesized that high-risk women would report poorer menopausal quality of life, higher body dissatisfaction, and lower body appreciation. Additionally, it was hypothesized that poorer menopausal quality of life would predict reduced body appreciation.
Methods
This study employed a cross-sectional design using an anonymous online survey hosted on Online Surveys to gather data on eating disorder pathology, body dissatisfaction, body appreciation, and menopausal quality of life. The survey was advertised from November 2022 to February 2023 through virtual posters on social media platforms (Facebook, Twitter, and LinkedIn) and physical posters in various social spaces around a UK town center and university campus. Participants could access the survey via a QR code or URL on the posters. An opportunity sample of 286 women aged 40 to 60 completed the survey. After excluding ineligible participants (e.g., assigned male at birth), incomplete responses, and those insufficient for classification into eating disorder categories, a total of 255 participants were included in the analysis. All participants provided informed consent, and the study received approval from the Ethics Committee of Loughborough University (Review Reference: 2023-13264-12696).
Collected data included weight, height, marital status, employment status, birth year, ethnicity, number of children, and notable caregiving responsibilities through self-report.
The Eating Attitudes Test-26 (EAT-26) questionnaire assessed the risk of eating disorders by asking participants to rate the frequency of 26 eating-related behaviors and thoughts. The EAT-26 includes three subscales: dieting, bulimia and food preoccupations, and oral control. Scores were summed to classify participants as “high-risk” or “low-risk” for eating disorders, with a cut-off score of 11 indicating high risk. The test demonstrated good internal consistency with a Cronbach’s alpha of .87.
The 16-item Body Shape Questionnaire-16 (BSQ-16) assessed body shape dissatisfaction and preoccupation, which are commonly associated with eating disorders. It evaluated domains such as weight/shape preoccupation, embarrassment, self-consciousness, and feelings of fatness after eating. Responses were scored on a 6-point scale from “Never” to “Always,” with higher scores indicating greater concern with body shape and weight. Cronbach’s alpha was .97, indicating excellent internal consistency.
The Body Appreciation Scale-2 (BAS-2) measured positive body image, assessing acceptance and favorable opinions toward one’s body through 10 questions scored on a 5-point Likert scale from “Never” to “Always.” Higher scores indicated greater body appreciation, with a Cronbach’s alpha of .96, demonstrating excellent internal consistency.
The 29-item Menopause-Specific Quality of Life Questionnaire (MENQOL) assessed menopause-specific quality of life across four domains: vasomotor, psychosocial, physical, and sexual symptoms. Symptoms were rated for their presence and, if present, their bothersomeness on a 7-point scale from “not bothersome” to “extremely bothersome.” Higher scores indicated poorer menopausal quality of life.
This study provides insight into the interplay between eating disorder pathology, body dissatisfaction, body appreciation, and menopausal quality of life among women aged 40 to 60, emphasizing the importance of considering these factors in health research and interventions.
Statistical Analysis
Data analysis was conducted using IBM SPSS V.28.0, with statistical significance set at p < .05. Variables were checked for normality using Kolmogorov-Smirnov tests and histograms. Gamma generalized linear models (GzLM) were used for pairwise comparisons due to non-normal data distribution. GzLM analysis cannot handle negative or null values, so data with null or negative scores were adjusted by adding a constant factor (+1). Age and BMI were included as covariates to account for their potential influence on outcomes.
Secondary analyses employed simple linear regression to investigate the predictive relationship between menopausal quality of life and body appreciation, controlling for age and BMI. An a priori power analysis determined that a sample size of 89 was needed to detect a medium effect with 80% power at α = .05. The obtained sample size of 255 was deemed sufficient to test the study hypothesis.
Result
Using scoring guidelines from the EAT-26 (Garner et al., 1982), 111 participants were classified as “high risk” for an eating disorder (score > 11), while 144 were categorized as “low risk” (score < 11). The demographic profile of the participants showed that 90% identified as White, 78% had one or more children, 76% were married or in a partnership, and 19% had significant caring responsibilities. The mean age of the high-risk group was 50.41 years (SD = 4.74), compared to 51.87 years (SD = 4.93) in the low-risk group, revealing a significant age difference, t(255) = 2.389, p = .018. The high-risk group had a mean BMI of 29.20 (SD = 6.62), while the low-risk group’s mean BMI was 26.69 (SD = 6.57), indicating a significant difference, t(255) = −3.01, p = .003.
Regarding menopausal quality of life and body image, the high-risk group scored significantly higher on the MENQOL total score (M = 4.86, SD = 1.42) than the low-risk group (M = 4.14, SD = 1.33). The high-risk group also scored higher on the sexual (M = 4.74, SD = 2.24), physical (M = 5.11, SD = 1.47), and psychosocial (M = 5.50, SD = 1.82) subscales compared to the low-risk group (M = 4.06, SD = 2.14; M = 4.25, SD = 1.39; and M = 4.67, SD = 1.71, respectively). No significant difference was found between high-risk (M = 4.11, SD = 4.16) and low-risk (M = 3.55, SD = 1.86) groups on the vasomotor subscale of the MENQOL. Additionally, the high-risk group exhibited greater body dissatisfaction and lower body appreciation, scoring significantly higher on the BSQ-16 (M = 63.91, SD = 17.62) and significantly lower on the BAS-2 (M = 24.40, SD = 8.78) compared to the low-risk group (M = 35.79, SD = 15.72; and M = 33.10, SD = 7.99, respectively).
The study demonstrates the bivariate correlations between all variables, with all being significant at p < .002, except for EAT-26 and MENQOL vasomotor (p = .052) and MENQOL social (p = .087). Simple linear regression analysis revealed that menopausal quality of life significantly predicted body appreciation, with the overall regression being statistically significant (R² = .177, F(1, 255) = 54.572, p < .001). Higher MENQOL scores, indicative of poorer quality of life, were found to significantly predict lower BAS-2 scores (β = −.421, p < .001), indicating lower levels of body appreciation.
Conclusion
In a survey of 255 women, nearly half met the EAT-26 cut-off score, indicating a high risk for an eating disorder. Women in this high-risk group scored significantly higher on the MENQOL and BSQ-16 scales, indicating a poorer menopausal quality of life and greater preoccupation with body shape and weight, and significantly lower on the BAS-2, reflecting less body appreciation. High-risk women reported more severe sexual, physical, and psychosocial symptoms of menopause, suggesting these symptoms may contribute to their eating disorder risk by exacerbating body dissatisfaction and lowering self-esteem.
The study highlights the potential for menopause symptoms like body composition changes, reduced libido, and loss of self-identity to heighten the risk of eating disorders, even in women without prior eating disorder behaviors or cognitions. This risk may be driven by the perception that their appearance is deviating from Western cultural ideals of youth, thinness, and femininity. The negative impact of societal ageism and stereotypes on midlife women could further increase susceptibility to eating disorders, similar to how the “Thin Ideal” influences body image globally.
Interestingly, vasomotor symptoms such as hot flashes did not significantly differ between high-risk and low-risk groups, possibly because they are viewed as temporary and more anticipated aspects of menopause. This contrasts with more permanent physical, sexual, and psychosocial changes that may be less accepted and more distressing.
Educational interventions that broaden awareness of the diverse symptoms of menopause and focus on positive body appreciation, rather than merely reducing body dissatisfaction, could mitigate the adverse effects of menopause on eating and body image. Body appreciation interventions, such as fostering gratitude for bodily functions and achievements, may be particularly effective in reducing eating disorder symptoms.
The relationship between body image and menopausal quality of life is complex and bidirectional. Negative body image can predict the severity of menopausal symptoms, and vice versa. Therefore, support strategies during menopause should consider women’s unique body image perceptions. Limitations of this study include the lack of consideration of hormone-replacement therapy (HRT), which could influence the relationship between menopausal symptoms and eating disorder risk, and the underrepresentation of diverse ethnic and gender groups, which limits the generalizability of the findings.
Future research should use longitudinal designs to explore the evolution of body image and eating pathology across menopause, and mediational analyses to clarify the sequential mechanisms at play. Clinicians should consider menopausal quality of life when evaluating eating disorders in midlife women and develop interventions that enhance body appreciation and manage menopausal symptoms to reduce eating disorder risk and severity.
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