Eating Disorders and Pregnancy

By:  Courtney E. Sanders

 

 

  

Introduction

            Pregnancy has often been viewed as a period of great developmental change for women.  This is also a period in which previously dormant psychological issues rise to the surface and when current issues have the potential to worsen.  Because anorexia nervosa and bulimia nervosa occur primarily in young women, many of whom are of childbearing age, it is important to evaluate the potential medical and psychological consequences when an eating disordered woman becomes pregnant.  During pregnancy, conflicts about body changes, alterations in roles, additions of responsibility, and concerns about a woman’s own mothering abilities are prevalent. Many of these concerns are also of great importance to the psychology of eating disorders.  Thus, it is not surprising that anorexic and bulimic women have unique problems during their pregnancies (Franko and Walton 1993).

            The potential for pregnancy to exert a positive or negative influence on eating disorder symptoms is inconclusive.  Some studies report a decline in symptoms, while other report heightened symptomatology.  However, it has been found that when an eating disorder is present during a pregnancy, the risk of complications is increased (Conti 1998).

 

 

Anorexia Nervosa and Pregnancy

Pregnancy in patients with anorexia nervosa is rarely suspected.  Amenorrhea (lack of menstruation) is invariably present and is often accompanied by sensations that resemble symptoms of pregnancy.  These symptoms include a bloated abdomen, nausea, vomiting, and fatigue.  The detection of conception in anorectic patients is often delayed, and the consequences can be severe (Bonne, Rubinoff and Berry 1995).

The course of pregnancy for anorexic patients is laden with complications.  In most cases the woman refuses to gain adequate weight during pregnancy, resulting in a low birth weight baby and the potential for growth retardation.  Less common are cases in which the misuse of diuretics has resulted in the deaths of mother and child.  Also found was that the use of excessive exercise in anorexic patients has shown an increase in the risk of miscarriage and premature birth.  Overall, the most common complications associated with anorexia nervosa during pregnancy include low birth weight, delayed development, premature death, and prenatal death of infants (Franko and Walton 1993).

            Pregnancy has also been suspected as a cause of anorexia nervosa in young mothers.  One case study (Benton-Hardy and Lock 1998) had as its subject a 17-year-old female who was a symptomatic prior to pregnancy.  Most psychological and social theories of anorexia nervosa have focused on the developmental pressures that challenge adolescent girls.  Pregnancy, which causes profound physical, emotional, and cognitive changes, could represent an amplification of these developmental pressures.  Physically, pregnancy shares some features with puberty – dramatic hormonal shifts, weight gain, confirmation of one’s sexual potential.  To survive this challenge requires flexibility of character and confidence in one’s body to undergo a dramatic but temporary transformation.  It is possible that pregnancy, especially in adolescents, creates a feeling of being out of control and overwhelmed.  Hence, pregnancy could result in the development of anorexia nervosa as a means of control and normality (Franko and Walton 1993). 

 

 

Bulimia Nervosa and Pregnancy

            Data on bulimia nervosa and its effects on pregnancy are somewhat controversial.  In some cases, bulimic activity during pregnancy did not increase the likelihood of complications.  Most studies, however, have obtained results to the contrary.  Women who are symptomatic during their pregnancies usually gain significantly less weight and have infants with lower birth weights than those whose symptoms remitted during pregnancy (Franko and Walton 1993). 

            Lacy and Smith (1987) studied twenty actively bulimic women.  Each of these women had given birth in the last two years.  Nineteen of the twenty reportedly decreased the frequency of binge eating and purging over the course of their pregnancies.  However, most women experienced a resurgence of disordered eating behavior post-delivery.  Nearly half of the women reported that their eating behavior was more disturbed after birth than before conception.  Despite the improvement of bulimic symptoms during pregnancy, the incidence of complications among the women was much higher than expected in a normal population.  These complications include the stillbirth, low birth weight, breech delivery, and cleft palate of infants.         

           

ED-NOS and Pregnancy

A retrospective study of eighty-eight women delivering low birth weight babies (Conti 1998) addressed this concern.  After obtaining biographical information about mother and child, researchers gave the women a modified version of the Eating Disorder Examination (EDE) and the Eating Disorders Inventory (EDI).  From these tests, it was determined that 32% of the women who had given birth to low birth weight babies were diagnosed with a clinical eating disorder in the three months prior to pregnancy.  Women with a past history of an eating disorder but who were in remission had no greater risk of delivering a low birth weight baby. 

It was also found that there was a decline in clinical eating disorders during pregnancy, and that eating disorders of the purging subtype declined more quickly than those of the restricting subtype.  This does not indicate that the eating disorders were in remission.  Instead, many of the women previously diagnosed with clinical eating disorders prior to pregnancy received the diagnosis of ED-NOS (eating disorder not otherwise specified) during pregnancy.  For example, the diagnosis of ED-NOS (restrict) would be given to a previously anorexic woman who during pregnancy failed to gain the proper amount of weight due to lack of eating, excessive exercising, etc.  Likewise, a diagnosis of ED-NOS (binge-purge) would be given to a previously bulimic woman who during pregnancy continued to binge, but who was unconcerned about what she ate due to involuntary vomiting throughout the pregnancy. 

The results of this study indicate that women diagnosed with a clinical eating disorder shortly before pregnancy who continue to express disordered eating behaviors during pregnancy had a much higher incidence of low birth weight babies.  Problematic variables included low maternal pre-pregnancy weight, low maternal weekly gain, and elevated EDI (bulimia subscale).  These women also reported elevated eating disorder psychopathology post-delivery (Conti 1998).

A study by Turton (1999) found similar results.  In her study, Turton examined the questionnaires of 492 women who agreed to participate.  Among the items included in the questionnaire were the Edinburgh Postnatal Depression Scale and the 26-item Eating Attitudes Test.  Like Conti (1998), Turton found that overall eating disorder symptom levels were lower in pregnancy than in the two years prior to conception.  Although this decline in symptoms was present, nearly one third or the women reported disordered eating behavior during pregnancy.  This would suggest that as many as 1% of women may suffer from some form of an eating disorder during their pregnancies.

 

 

Post-Delivery Effects of Eating Disorders and Pregnancy

            Several studies have focused on the relationship between women’s disordered eating during pregnancy and the early interaction between these women and their infants.  Foster, Slade, and Wilson (1996) conducted a study on body image, fetal attachment, and breast-feeding.  They examined 38 women between 32 and 38 weeks pregnant by means of the Maternal Fetal Attachment Scale, the Eating Disorders Examination (EDE), and the Body Satisfaction Scale.  After reviewing the data, they found that women intending to bottle-feed had a higher level of body dissatisfaction and a lower maternal-fetal attachment score.  The woman’s attitude toward her body, rather than actual body size, seemed to predict feeding intention.  Higher body satisfaction is associated with higher probability of breast-feeding.

            A number of studies have also looked at the children of mothers with past and/or current eating disorders.  As infants become toddlers, the feeding process increases in complexity.  Studies have found that in general, women with eating disorders display behaviors such as restricting the amount of food in the house, not cooking for their children, not eating in front of their children, and limited mother-child interaction during mealtime.  Mothers with eating disorders also appear more likely to be dissatisfied about the weight or shape of their children. 

            Stein, Woolley, Cooper, and Fairburn (1994) examined the mealtime behavior of mothers with a current or past eating disorder.  They found that in comparison to control mothers, the index mothers were more intrusive and less facilitating during mealtimes and expressed more negative emotion and more conflict with their infants.  The index mothers’ infants were less cheerful during the meals and tended to weigh less.  This study provides some evidence that actual feeding environment may be problematic in the development of healthy eating behaviors in infants of eating disordered women.      

A study by Waugh and Bulik (1999) examined the offspring of women with eating disorders as well.  The focus of this study was on early childhood experiences with food and eating behavior, as it is becoming increasingly clear that eating disorders are familial and that genetic and cultural factors play a significant role in the familial transmission of eating disorders.   

In this study, ten women with current or past diagnoses of anorexia nervosa and/or bulimia nervosa and their children aged between 12 and 48 months were examined.  Information was gathered by means of maternal interviews and self-reports, health and development records, a three-day food diary, and a videotaped lunchtime interaction.  Researchers found that children of women with eating disorders had significantly lower birth weights and lengths than control children.  Mothers with eating disorders had more difficulty maintaining breast-feeding.  They also made significantly fewer positive comments about food and eating than control women during the mealtime observations.

Perhaps the most concerning finding in this and other studies is the nature of the mealtime interaction.  The absence of positive comments during the meals and the failure to eat with their children indicates that food and mealtimes continue to be an uncomfortable experience for the women with histories of an eating disorder.  Both modeling and encouragement are important components of teaching children how to eat rich and varied diets.  Genetic predisposition or not, the lack of eating behavior socialization in early childhood may contribute to the later development of eating disorders among these children.   

 

 

Conclusion

            Though data gathered from various studies regarding eating disorders and pregnancy can seem inconclusive, there are consistent findings.  Studies show that women with a current or past eating disorder experience more difficulties during pregnancy.  While the difficulties are primarily psychological in nature for women with past eating disorders, they are both psychological and physical in women who are active anorexics and bulimics during pregnancy.  Risks associated with active anorexia nervosa/anorexic behaviors and bulimia nervosa/bulimic behaviors during pregnancy include increased incidence of miscarriage, still birth, premature birth, low birth weight, cleft palate, and breech delivery.  Similarly, there is evidence to support the theory that children of women with past or current eating disorders experience less socialization as to proper eating behavior.  These children are also of lower weight in the toddler years than control children.  There has been no extensive research regarding the long-term outcome for these children. 

            Pregnancy is by no means an appropriate route to the cessation of an eating disorder.  Many women believe that becoming pregnant will force them to overcome their eating disorder, because the baby’s health is at stake.  We have seen, however, that although disordered eating behavior tends to decrease during pregnancy, the disorder itself often resurfaces post-delivery and can actually increase in severity. 

On the positive side, pregnancy is a time when women are already in contact with medical services.  Thus, they may be more prepared to seek medical treatment out of concern for the health of their infant.  Pregnancy may be an ideal time for intervention, not only to alleviate the mother’s suffering, but also to decrease the risk of harming the unborn child and to reduce the intergenerational transmission of disordered eating behaviors to the infant (Franko and Walton 1993).

 

 

 

 

 

References

 

 

 

Bonne, Omer B., Benjamin Rubinoff and Elliot M. Berry.  “Delayed Detection in

            Pregnancy in Patients with Anorexia Nervosa: Two Case Reports.”  International

            Journal of Eating Disorders. 1996 Dec; Vol. 20(4): 423-425.

 

Conti, Janet, Susan Abraham and Alan Taylor.  “Eating Behavior and Pregnancy

            Outcome.”  Journal of Psychosomatic Research.  1998; Vol. 44(3-4): 465-477.

 

Foster, S.F., P. Slade and K. Wilson.  “Body Image, Maternal Fetal Attachment, and

            Breast Feeding.”  Journal of Psychosomatic Research. 1996; Vol. 41(2): 181-184.

 

Franko, Debra L. and Barbara E. Walton.  “Pregnancy and Eating Disorders: A Review

            and Clinical Implications.”  International Journal of Eating Disorders.  1993 Jan;

            Vol. 13(1): 41-48.

 

Lacey, J.H., and Smith, G. “Bulimia Nervosa: The Impact of Pregnancy on Mother

            and Baby.” British Journal of Psychiatry.  1987; Vol. 150: 777-781.

 

Stein, A., H. Woolley, S.D. Cooper, and C.G. Fairburn.  “An Observational Study of

            Mothers with Eating Disorders and Their Infants.”  Journal of Child Psychology

            and Psychiatry.  1994; Vol.35 (4): 733-748.

 

Turton, Penelope, et al.  “Incidence and Demographic Correlates of Eating Disorder

            Symptoms in a Pregnant Population.”  International Journal of Eating Disorders. 

            1999 Dec; Vol. 26(4): 448-452.

 

Waugh, Elizabeth and Cynthia M. Bulik.  “Offspring of Women with Eating Disorders.” 

            International Journal of Eating Disorders.  1999 Mar; Vol. 25(2): 123-133.

 

 

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