"I can't participate in the practicum," Judith Shaw told her yoga instructor. She was training to become an instructor herself, but she had fallen and broken her pubic bone.
"You're going to continue to break bones if you don't feed yourself," the instructor told her.
For Shaw, that was the moment. After a 15-year battle, she returned home that night and finally admitted out loud, "I am anorexic and I need help."
In 2006, soon after her acceptance of the disease, Shaw checked herself into a residential treatment center for eating disorders. The mother of two was a bit different than her fellow patients, though. At 53, among teens and 20-somethings, most of her peers could have been her children.
Shaw's anorexia appeared later than most who have battled the same illness. At 39, she became a "gym rat," but that routine soon led to excessive workouts and years of starving herself. With hindsight and years of therapy, Shaw looks back at the onset of her eating disorder and said it was triggered by a lifetime's sense of self-worthlessness.
"I became obsessed with exercise," Shaw, now 59, said. "I wanted to show an exterior of strength that was able to mask the hollowness and vulnerability that I felt on the inside."
She received recognition and praise as a result of her extreme exercises. Coupled with barely-there food intake, the praise of her body image gave her "a sense of meaning in a life that felt directionless, alone and isolated."
While many attribute eating disorders to teen girls and young women, experts say there may be a growing number of older people who experience the same struggles. Whether there is more awareness and diagnoses remains unclear, but many clinical experts said they have seen a spike in women over 40 seeking treatment in recent years.
The triggers may be different among different age groups, but traumatic life events tend to trigger or contribute to eating disorders, no matter the age, said Susie Roman, program coordinator at the National Eating Disorders Association. When older women experience eating disorders, most of the time it is due to an earlier eating disorder that has resurfaced, but not always. New cases and those that resurface can be triggered by divorce, death of a loved one or children moving away.
"Older women who have eating disorders that return can often have a harder time changing since the behaviors are so a part of them but whether the eating disorder is different is not clear," said Connie Diekman, director of university nutrition at Washington University at St. Louis.
Shaw whittled away to "well under 100 pounds," but she said she doesn't like to talk pounds when discussing eating disorders.
"It's so much more than that," she said.
"A common perception of eating disorders is that it's all about food and weight," said Sarah Parker, director of anxiety and eating disorders at the Reeds Treatment Center in New York. "On the surface, they are, but it is issues related to significant interpersonal stressors, and they end up coping with these stressors by controlling what they eat or how they look."
More than 10 million Americans suffer from bulimia, anorexia or other types of eating disorders, according to the National Eating Disorders Association, and millions more suffer from binge eating.
For Shaw, it was her husband asking for a separation after 35 years of marriage that likely contributed to the disease.
"My body was crumbling as my life was crumbling," said Shaw.
Older women often fly under the radar with their disorders, though. Doctors are much more apt to notice eating disorders in teens who have lost an excessive amount of weight, or, if a young woman stops menstruating, a telltale sign of anorexia, a doctor will investigate further. Parents are usually involved with the feeding and care of teens, and because of this, family, friends and physicians are more likely to become skeptical of a change in eating and exercise habits.
Shaw's period stopped in her early 40s, but doctors chalked it up to early menopause. She was anemic, but doctors treated her lack of healthy red blood cells as an isolated incident. Her bone density deteriorated, but, again, physicians treated the osteoporosis on its own. Friends admired her weight loss and exercise tenacity.
While the health risks of an eating disorder are damaging at any age, older women are at an even increased risk because their bodies have aged more, said Parker.
"There can be significant damage to the heart and heart muscles," said Parker. "In really severe cases, the heart can stop functioning. Fat stores in the brain can become depleted and affect cognitive and neurological functioning. It can also result in osteoporosis and organ failure."
If friends or family do suspect a person is suffering from an eating disorder, Parker encouraged people to remember that the illness is an "expression of pain."
"Families and friends tend to say, 'you should eat more,' or 'you need to exercise less,' but that can turn into a negative cycle very quickly," said Parker. "Try to respond to the pain over the behavior by saying something like 'it seems like you're not doing very well, can we help you speak with a therapist or minister?'"
When she finally received treatment for the disease, Shaw began sculpting as a therapeutic way of coping. She'd bring her sculptures to therapy session, and her art soon became a springboard for a more in-depth look into her disordered eating habits.
Her series, which she titled, "Body of Work," has now been featured in exhibits at several top medical schools, including Washington University School of Medicine, Columbia University Medical Center and New York University School of Medicine. Many professors have used her work as a teaching tool, to show medical students in a "visceral way" what patients experience when they suffer from an eating disorder.
"I never went to college, and that's where some of my feelings of worthlessness came into play," she said. "I always wanted to be a doctor. That may never happen, but it's a bit ironic. In a way, I found my way into medical school because my art is inspiring doctors to understand this disease. That definitely gives me a sense of worth and purpose."