Practical Advice for Caring for Women With Eating Disorders During the Perinatal Period

Amy A. Harris, CNM, MS

Pregnancy is a critical time for women struggling with disordered eating and weight concerns. For the majority of women with eating disorders, symptoms improve during pregnancy. Other women, particularly those with either subclinical or binge eating disorders, are at risk for an escalation of pathologic behaviors, putting both mother and fetus at risk for negative birth outcomes. Routinely screening for eating disorders will help identify those women who will most benet from specialized care. Attention must be paid to possible harmful comorbid behaviors found in women with eating disorders, such as smoking, alcohol use, abusing laxatives or herbal supplements, and self-injurious behavior. This article reviews the mixed research ndings of the impact of eating disorders upon pregnancy and identies key times in prenatal care where nutritional counseling and specic interventions will increase the likelihood of positive pregnancy outcomes. The postpartum period is another critical time for provider intervention that may lower womens risks for eating disorder relapse, postpartum depression, and breastfeeding difculties. J Midwifery Womens Health 2010;55:579586 2010 by the American College of Nurse-Midwives. keywords: anorexia, binge eating disorder, bulimia, eating disorders, ED-NOS, nutritional counseling, pregnancy, prenatal care

INTRODUCTION It is estimated that 5% to 6% of women in the United States have or have had anorexia nervosa, bulimia, or eating disorder not otherwise specied (ED-NOS) in the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV-TR).1 Therefore, it is very likely that womens health care providers will provide care for women with these eating disorders and will need to tailor their usual preconception, prenatal, and postpartum care accordingly. A comprehensive review of specic eating disorders is beyond the scope of this paper, but readers are referred to the review of diagnostic criteria and epidemiology in an article by Mitchell and Bulik2 in a previous issue of this Journal. Briey, women with these disorders have a severe anxiety driven obsession with body image, shape, and food. Women with anorexia nervosa do not maintain their body weight above the minimum of 85% of the recommended weight for their height and weight. The additional criterion of amenorrhea for 3 consecutive months is not applicable to pregnant women with eating disorders. A subclinical disorder may meet all of the other criteria for anorexia and put a pregnancy at risk. Bulimia nervosa may be missed more frequently than anorexia because women may have a normal weight while engaging in bulimic behaviors. Bulimia is characterized by recurrent episodes of binge eating (an unusually large amount of food in a discrete period of time) that are accompanied by feelings of being out of control and a need to engage in purging behaviors, such as self-induced vomit-

ing, laxative or diuretic abuse, excessive exercise, or periods of fasting.3 An additional category of eating disorders described in the DSM-IV is ED-NOS, which is estimated to comprise 3% to 15% of women receiving obstetric care.4 Binge eating disorder falls within the ED-NOS category of the DSM-IV. This disorder is characterized by eating an unusually large amount of food in a discrete period, while feeling out of control, without using compensatory measures described with bulimia. For the remainder of this article, these subtypes are collectively referred to as eating disorders. Up to 70% of women have improved symptoms of eating disorders during pregnancy.4 This amelioration may occur as some women turn their obsession with weight loss and body image inward to focus on their fetus. Conti et al.5 report that purging behaviors decreased more quickly during pregnancy than restrictive behaviors in pregnant women diagnosed with eating disorders in the 12 months before their pregnancies. Some researchers report the onset of binge eating disorder for the rst time during pregnancy.6,7 SCREENING FOR EATING DISORDERS AND ASSOCIATED BEHAVIORS There is evidence that eating disorders largely go unrecognized by health care providers, with less than half of obstetricians asking about body weight control or disordered eating.8 Only 45% of people with eating disorders seek treatment themselves.1 Women with each of these disorders are often intensely ashamed of their eating behaviors and terried of losing control without their coping behaviors.9 Pregnancy can seem particularly terrifying for many women with eating disorders because they may feel as if they have lost of control over their body, their ability to control their weight, and their perceived ability to control their own life. A qualitative study of women with a history
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1526-9523/$36.00  doi:10.1016/j.jmwh.2010.07.008

Address correspondence to Amy A. Harris, CNM, MS, Planned Parenthood of Northern New England, 970 Forest Avenue, Portland, ME 04101. E-mail: amyaharris@gmail.com

Journal of Midwifery & Womens Health  www.jmwh.org

2010 by the American College of Nurse-Midwives Issued by Elsevier Inc.

of diagnosed eating disorders before pregnancy quoted women as saying they were never asked about their disorder or their eating habits over the course of their pregnancy.10 Womens health care providers should routinely incorporate screening questions for eating disorders into their initial assessment of all new prenatal patients and also ask several times throughout the pregnancy as womens comfort level might increase. Questions related to reproductive history, such as history of amenorrhea lasting longer than 3 months, might signal a possible eating disorder and necessitate further investigation. Screening questions suggested by Mitchell and Bulik2 include, How do you feel about your weight? and Are you engaging in any weight control efforts now? In addition, asking about a womans lowest and highest weight, what she has used to control her weight, and specically inquiring about the use of vomiting and laxatives are means to show the clinicians true interest in issues related to a womans weight and eating behaviors. There are screening questionnaires designed to specifically screen for women meeting DSM-IV criteria for anorexia nervosa, such as the Eating Attitudes Test (EAT), or for bulimia, such as the Bulimia Investigatory Test (BITE). These tests have good sensitivity and specicity but do not identify individuals with subclinical symptoms who nevertheless could be at risk for pregnancy complications.11 A general screening questionnaire designed for clinical practice is the SCOFF (Figure 1), which consists of ve easy questions.12 One point is given for each yes answer and a score of two or more indicates that the presence of an eating disorder is likely.12 The number of studies validating the SCOFF is limited, but the ease of administration makes it a realistic screening tool for busy clinical practice.11 Unfortunately, current screening tools including the SCOFF may miss the more subtle binge eating disorder and other subclinical disorders falling under the ED-NOS category. Screening women preconceptionally as part of routine gynecologic care could help women nd treatment before getting pregnant, restoring them to a better nutritional status for pregnancy. Some providers advise women with eating disorders to wait to conceive until the eating disorder is in complete remission.13 Asking some of the questions listed above at a womans initial visit will help alert the provider to potential body image and weight issues. A subclinical eating disorder may be responsible for polycystic ovary syndrome, menstrual irregularities, and infertility.14 Therefore, women presenting with infertility should be screened for eating disorders. Any woman with a body mass index (BMI) less than 18 should be

S- do you make yourself sick because you are uncomfortably full? C- do you worry about loss of control over your eating? O have you recently lost one stone (14 pounds) in 3 months? F - do you believe you are fat although others say you are thin? F would you say food predominates your life? Reprinted with permission from Morgan et al, 2000. 12

Figure 1. The SCOFF screening tool for eating disorders. Source: Morgan
et al.12

Amy A. Harris, CNM, MS, is in clinical practice at Planned Parenthood of Northern New England, Portland, ME.

referred for assessment by a clinician well trained and experienced in the diagnosis and treatment of eating disorders. Once pregnant, eating disorders should be a differential diagnosis for all women who do not gain sufcient weight in their pregnancy. Hyperemesis gravidarum, lack of weight gain over two consecutive prenatal visits in the second trimester, unexplained hyperkalemia or other electrolyte abnormalities from use of laxatives, dental problems related to the erosion of dental enamel from frequent emesis, and an abnormal BMI are all physical signs or symptoms of a possible eating disorder.15 Providers need to keep in mind that women who were actively purging before pregnancy may revert to binge eating disorder as a protective measure for the fetus and therefore might deny purging when screened during pregnancy.3 In women reporting a history of or an ongoing eating disorder, it is important to look for concurrent harmful behaviors, such as smoking, alcohol use, or selfinjurious behavior. These comorbid coping methods have the potential to negatively affect birth outcomes.7 Bulik et al.7 reported that 14% to 37% of mothers with anorexia, bulimia, binge eating disorder, and ED-NOS reported smoking compared to only 9% of women without any history of an eating disorder. Women with eating disorders scored higher than women without eating disorders on scales of nicotine dependence used by the researchers, indicating that it might be more difcult for women with eating disorders to quit smoking, even when pregnant. Shoplifting is also commonly observed in women with disordered eating, particularly in those women with bulimic symptoms.16,17 One proposed explanation is that low self-esteem may make these women ambivalent about whether or not they deserve something; therefore, they cannot bring themselves to pay for a desired item.16 In Goldner et al.s16 case control study of women with eating disorders compared to female undergraduates and women with other psychiatric diagnoses, 11 out of 12 women reporting current shoplifting behavior (within the past 6 months) had an eating disorder.16 Women using laxatives reported higher rates of current shoplifting, and of those who were currently shoplifting and using laxatives, 85.8% reported shoplifting laxatives.16 Researchers suggest that among
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women with eating disorders, the presence of stealing behaviors may in fact, be used as a marker of eating disorder severity.17 Similarly, low self-esteem and an inability to negotiate their own emotions may drive women with disordered eating to self-injurious behavior (used interchangeably with the terms self-harm or self-mutilation). Less than 1% of the general US population engages in self-mutilation, but the prevalence of such behavior in individuals with eating disorders rises to 25% to 45%.18 Research does not indicate that there is any difference in prevalence of self-injurious behavior between bulimia and anorexia.18 Self-harm behaviors are also highly correlated with substance and alcohol abuse in individuals with eating disorders.18 Providers caring for women with eating disorders report that they sometimes see an exacerbation in shoplifting or self-harm activities as progress is made in the treatment of the eating disorder. Pregnant women may replace caloric restriction or purging with shoplifting or self-mutilation as safer coping mechanisms. Therefore, providers caring for pregnant women with a history of disordered eating should inquire about smoking status, look for signs of self-mutilation, and ask about shoplifting, and these assessments may be worth repeating over the course of the pregnancy. Another separate type of eating disorder that could have implications for pregnancy and maternal and fetal health is a disorder called diabulimia. First named in 2007, this condition is characterized by type 1 diabetics deliberately withholding insulin so that calories are purged through glucose in the urine for the purpose of weight loss. An estimated 30% of women who have type 1 diabetes skip or alter insulin doses to control their weight, and this percentage is likely to be higher in adolescents with type 1 diabetes given the higher prevalence of eating disorders in adolescence.19 Health consequences of diabulimia are serious and include increased diabetic ketoacidosis, long-term vascular disease, peripheral nerve damage, and nephrologic complications contribute to a threefold increased risk of mortality, even after controlling for baseline age, BMI, and A1C.19 Thus far there have been no studies looking at the prevalence of this practice in pregnant women. It is not known how pregnancy would affect diabulimic behavior in women with type 1 diabetes. Another question is whether women with insulin-dependent gestational diabetes (with or without a history of an eating disorder) could adopt diabulimic behaviors for the rst time in pregnancy. Infants born to mothers restricting their insulin would likely be at risk for the same complications experienced by pregnant women with uncontrolled diabetes: birth defects early in pregnancy, macrosomia, preeclampsia, stillbirth, and neonatal morbidity. Screening for this behavior in diabetics can be as simple as asking Do you take less insulin than you should? This single question adequately capJournal of Midwifery & Womens Health  www.jmwh.org

tured women restricting insulin in larger-scale studies of nonpregnant women.19 Close observation and coordination of care for all younger pregnant women with type 1 diabetes between endocrinologist, psychotherapist, dietician, and prenatal care provider would decrease the likelihood of insulin restriction being missed. PREGNANCY AND NEONATAL OUTCOMES IN WOMEN WITH EATING DISORDERS Studies examining the impact of eating disorders upon pregnancy outcomes are limited somewhat by study group size, lack of appropriate control groups, and conicting ndings. The secretive nature of women with eating disorders and their intense shame, especially when pregnant, prevent those most ill from participating in studies. For example, in one of the largest studies of pregnancy among women with active and quiescent bulimia, 92% of women agreed to study participation, but only 38 of 204 agreed to have the information they provided veried by a family member or primary care physician.20 In a case control study of 49 women with a history of bulimia, anorexia, or atypical eating disorders, of whom 11 (22%) relapsed during pregnancy, eating disorder was associated with higher rate of spontaneous abortion, fetal growth restriction, infant microcephaly, and low birth weight (LBW) infants.21 Women in that study also had a higher incidence of hyperemesis and poor episiotomy wound healing. In another cohort study, results were analyzed by a history of anorexia (n = 171), bulimia (n = 199), both diagnoses (n = 82), or other psychiatric diagnoses (n = 1166).13 Adjusting for confounders such as smoking, there were no differences between groups for preterm birth, but women with a history of anorexia had infants that weighed less, and women with a history of bulimia had an increased risk of spontaneous abortion (relative risk, 2.0). Of note, 20% of women with eating disorders smoked in the second trimester and 11% to 24% drank alcohol in the rst trimester, with the higher percentage occurring among those with both anorexia and bulimia. These behaviors are strongly associated with birth weight, and with preterm birth in the case of smoking. These data illustrate how important it is for studies to adjust for smoking and alcohol consumption. Also of note, only 57 of the 395 (14%) women in this cohort reporting a history of an eating disorder reported active eating disorder behavior during the present pregnancy.22 Women with active eating disorder behavior were more likely than the general population to use selfinduced vomiting or laxatives by 18 weeks of pregnancy (odds ratios, 50 and 52, respectively).22 Examining anorexia alone, Wentz et al.23 found that women who had recovered from adolescent-onset anorexia (mean age of 32 with 18 years since eating disorder) did not differ from matched controls in terms of miscarriages, pregnancy complications, rate of cesarean birth, amount of
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weight gained in pregnancy, infant feeding problems, or offsprings delayed development or risk for autism. Other studies show that pregnancy outcomes do not change significantly depending on whether anorexia nervosa was in an active phase or remission at time of pregnancy.24 In a large cohort of women (10,000) in Sweden who had documented hospitalization for anorexia, the follow-up pregnancies showed no difference from the general population of women, except that women with a history of anorexia were less likely to have an operative birth.25 In the same population, women with more severe disease (dened as $6 months of hospital care for eating disorder at any point in their lives) did not have any higher risk for complications such as small for gestational age (SGA), low Apgar score, or instrumented birth. A shorter recovery time from anorexia (<3 years from rst hospitalization) was related to a tendency for lower birth weight. Women giving birth to LBW infants, when compared to women giving birth to infants weighing more than 2500 g, report a higher prevalence of clinical eating disorders in the 3 months before pregnancy.5 One of the larger studies looking at bulimia in pregnancy found that women with active bulimia in their pregnancy (dened as binging and purging three times a week) had twice the rate of miscarriage, ve times the rate of gestational diabetes, three times the risk of preterm birth (23% vs 8%), and more hyperemesis when compared to women with a history of bulimia who were not engaging in these behaviors during pregnancy.20 More than one-third of women with active bulimia experienced postpartum depression.20 In this same study, three women with bulimia had an infant with a cleft lip or palate, compared to none in the control group. One of the largest population-based studies of the impact of eating disorders on birth outcomes to date found that women with binge eating disorder might be more likely to have an induction of labor, large for gestational age (LGA) infants, and cesarean births.7 Other research shows that women with binge eating disorder exhibiting greater worry about weight gain in pregnancy actually gained more weight during pregnancy and were more likely to have children born with higher birth weights, when compared to women with anorexia, bulimia, and ED-NOS who reported the same amount of worry about pregnancy weight gain.26 The authors hypothesize that worry about weight could lead to dietary restraint attempts during pregnancy that could fail or rebound and ultimately lead to more weight gain than if no restriction was attempted. In contrast, women with anorexia were more likely to have lower birth weight infants compared to women with bulimia and binge eating disorder with the same level of anxiety about pregnancy weight gain. Is the etiology of eating disorders related to in utero exposures or events? A retrospective study of 114 women with anorexia nervosa, 73 with bulimia nervosa, and 554 women without an eating disorder examined the birth
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records of their mothers. The authors found, with a doseresponse effect, that the risk of having an eating disorder was higher in women whose mothers experienced obstetric complications either during pregnancy or at the birth.27 These researchers postulate that some kind of neurodevelopment impairment occurring as a result of pregnancy or birth complications (as with hypoxia) might be causally linked to the pathogenesis of anorexia, as is hypothesized for the etiology in schizophrenia. The same study found that women with bulimia were more likely to have had restricted fetal growth in utero (as measured by birth weight, length, and head circumference). Other studies have examined similar links between insufcient fetal growth and mood disorders, suicidality, cardiovascular disease, diabetes, and obesity in offspring. The etiology of eating disorders lies interwoven among genetic, biologic, social, and environmental factors that health care providers cannot attempt to unwind in 40 weeks. Care provided over the course of a womans pregnancy may however help to alleviate some of those risk factors associated with eating disorders in offspring. MIDWIFERY CARE FOR WOMEN WITH EATING DISORDERS Prenatal Care As part of routine gynecologic and preconception care, pregnant women will have ideally been screened for eating disorders. Pregnant women with either an active eating disorder or history of an eating disorder are best cared for by a well-coordinated treatment team consisting of a midwife, obstetrician, dietician, mental health provider, perinatologist if needed, and in some situations a family or couples therapist.24,28 Although not always possible in busy clinical practices, ideally the same provider would see women with eating disorders for every visit to help build providerpatient trust and consistency in treatment plans. Seeing women with a history of an eating disorder more frequently, especially if they have a current eating disorder, should be considered. Given their increased risk for hyperemesis, frequent visits up to 16 weeks are warranted. Research shows that women with hyperemesis and an eating disorder respond less favorably to treatment and may spend more days in the hospital during pregnancy for treatment.27 Women who induced vomiting in order to purge will need extra counseling regarding the nausea and vomiting of early pregnancy, and reassurance that these symptoms are pregnancy-related and should not be seen as a return of eating disorder behavior or a setback in their recovery.4 Together with their patients, providers can set small goals to help increase the likelihood of success. Achieving small goals will help increase a womans sense of self-efcacy. Prenatal teaching may be more successful when a single topic is covered at each visit, such as the size of the womans uterus at that particular visit and
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what physical changes she could feel as a result. Women with eating disorders have learned to ignore all physical sensations, including hunger, and may need help increasing body awareness. Helping women reconnect with their bodies and making the growing fetus real (possibly with fetal models or pictures) can sometimes help motivate women to provide adequate nutrition for her infant, if not for herself. Education about the signs and symptoms of preterm labor, given that women with eating disorders, and especially bulimia, are at greater risk for preterm labor, is particularly important.5,21,24 The process and frequency of weighing women needs to be carefully negotiated. For some women, being weighed in the presence of others is terrifying. Not all women need to be weighed at each visit. For some women, seeing their weight on the scale is very stressful, so agreeing to weigh them with their back to the scale and only mentioning their weight if necessary may be another strategy. Trying to ensure that a woman is weighed by the same person as much as possible can help to reduce anxiety. Some women feel empowered when they are given a target or safe range of weights. Finally, discussing the sometimes uneven pattern of weight gain over the course of a normal pregnancy and the fact that there is individual variation in this pattern may alleviate patient concerns. By reducing some of womens worries about weight gain early in pregnancy, providers may actually be able to reduce the amount of weight gained and decrease the likelihood of women who have bulimia or a binge eating disorder having a LGA infant.7,26 Midwives should be watchful for adequate intrauterine growth and consider serial ultrasounds if any concerns about fetal growth arise. Frequent prenatal visits provide opportunities for providers to give useful facts about the role of nutrition in healthy bodily functioning. Women may not know that their fatigue, irritability, or depression could be directly related to changes in mental functioning from starvation. For anorectics, cold intolerance, hair loss, and bone density will all improve with a balanced, healthy diet. Bulimics may not know that vomiting after a binge still retains 1100 to 1200 calories of those consumed, or that laxatives only decrease calorie absorption by about 10%.29,30 In fact, the acute weight loss observed with extreme laxative use results from uid loss and can lead to dehydration and various electrolyte disturbances. Providers should persist in repeatedly providing information about why weight gain and/or stopping purging are essential for the health of a woman and her fetus. Anticipating obstacles is helpful, such as informing women that an increased food intake may initially result in some gastrointestinal discomfort. Women with eating disorders tend to count calories or grams of fat obsessively, so meal planning or constructing sample meals may be more helpful than giving women daily caloric requirements. Working with women to create model
Journal of Midwifery & Womens Health  www.jmwh.org

meals with the correct portions of necessary nutrients and vitamins from their own collection of foods they are already comfortable eating increases the likelihood of successful nutritional intake. By incorporating safe foods into their pregnancy meal plan, women may be more willing to slowly add in foods they have previously labeled dangerous. Meal planning can help to teach the importance of having protein, complex carbohydrates, and some fat with each meal while reinforcing that complete, satisfying, and frequent meals or snacks can help guard against overeating or binging. A study of more than 30,000 Norwegian women using food frequency questionnaires found that women with binge eating disorder before and during pregnancy had higher intakes of total energy, total fat, and monounsaturated fat, especially in the rst half of pregnancy.3 This is concerning given previous research showing that the high consumption of sweets early in pregnancy is associated with excessive gestational weight gain.31 For some women, keeping a food diary or written record of food and uid consumed helps them to feel safer and reduces anxiety. Others may nd a food diary more anxiety producing, so this should be offered as an optional part of care plans. These negotiations are time-intensive, so providers may need to either refer women to a nutritionist for additional nutritional counseling or schedule extra time for visits. Many women with eating disorders have abused laxatives, which can lead to decreased intestinal motility. Combined with the physiologic changes of pregnancy, constipation may be a signicant problem. Clinicians can anticipate this and help women maintain normal bowel functioning in pregnancy by recommending increased uid and dietary ber intake. If laxatives are needed, encourage the use of emollients that soften the stool (such as docusate sodium) or are bulk-forming (psyllium), rather than stimulants or hyperosmotic laxatives (such as bisacodyl or lactulose). Emphasize that stimulant laxatives lose their efcacy with chronic overuse. Laxative withdrawal guidelines exist and should be implemented by providers caring for women with active bulimia nervosa who are abusing laxatives.32 Providers need to question women with disordered eating about any current use of herbal supplements or weight control supplements in addition to over the counter laxatives. Sixty percent of the general population does not disclose the use of herbal medicines to their provider.33 Women with eating disorders might be more likely to turn to herbal weight loss agents when pregnant because of a misconception that such agents are safer because they are natural. Supplements and herbal products are not regulated by any government agency, so the safety or content of ingredients have not been tested. One study of 100 individuals with eating disorders found that 64% reported using an herbal product for weight loss.34 In another treatment-seeking population of 39 women with bulimia, 64% reported using diet pills. The same women listed more than 25 different types of diuretic pills used to
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control their weight.35 The most common substances found in weight loss supplements are ephedrine and caffeine. Ephedrine and caffeine can be extracted from the guarana seed, kola nut, or ma huang (ephedrine only). Although the current general opinion is that modest caffeine intake of 300 mg or less (#2 cups of 8 oz cups of brewed coffee) does not affect the risk of miscarriage, stillbirth, or birth weight (see the fuller discussion by Barger36 in this issue), higher doses have not been well studied.37,38 Stimulants such as Vivarin or weight loss products such as Dexatrim containing as much as 300 mg or more of caffeine could increase risk. Ephedrine can cause hypertension, tachycardia, seizures, stroke, and myocardial infarction.35 Supplements for appetite suppression may also contain yohimbe, which has been shown to cause hypertension, tachycardia, tremor, and vomiting.35 Bladder wrack kelp, used in some laxative supplements, is a source of iodine and therefore could potentiate hyperthyroidism. Guar gum in other laxatives can cause hypoglycemia and absorption difculties with vitamins, minerals, and some medications, including oral contraceptives. Finally, in high doses like those taken by women with bulimia for laxative effects, parsley root can increase uterine contractility and even induce abortion.34 The safety of such supplements is largely unstudied in pregnant women, so providers caring for women with a history of eating disorders need to be screening for use of herbal supplements and laxatives. Postpartum Care Multiple studies show that women with eating disorders are at much higher risk for postpartum depression. Some studies show the risk is as high as three times the general populations risk.20,39,40 Women with eating disorders are often unable to express their emotions with words (alexithymia), which drives them to develop unhealthy coping mechanisms for situations of anxiety, sadness, or anger, all of which are emotions that are commonly experienced by all women during the postpartum period.9 Women with bulimia and binge eating disorder tend to be at higher risk for postpartum depression than women with anorexia. One possible explanation for this higher risk is the link between unplanned pregnancy and postpartum depression. Morgan et al.20 reported that women with active bulimia were more likely to report unplanned pregnancies and conceiving with oligomenorrheic menstrual cycles. Prenatally, clinicians can help teach women and their partners about the warning signs of postpartum depression and help women to gather sources of postpartum support before birth. Unfortunately, women with eating disorders may more frequently be single parents.13,25 Scheduling visits with women at 1 and 2 weeks postpartum would be ideal to assess their mental health and adjustment to motherhood during this high-risk period.
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At these postpartum visits, providers need to continue screening for eating disorders because many women experience relapses and even an increase in severity (particularly for anorectics) during the postpartum period.5,41 Relapse might be prevented by helping women nd adaptive coping strategies other than eating disorder behaviors. Reassurance that postpartum feelings and emotions are felt by all women when they become mothers can help normalize the postpartum experience and reduce anxiety for women.4 Infant feeding and growth may also be affected in women with eating disorders. It is physiologically plausible that milk supply would be affected if a woman was actively restricting caloric intake, although there are no studies to substantiate this claim.4 Earlier research indicated that infants born to women with eating disorders had faster sucking, were lower weight, and were breastfed less frequently, for a shorter duration.42 However, a recent prospective study of more than 12,050 women in the United Kingdom found that women who reported having a history of either anorexia or bulimia nervosa were more likely to breastfeed when compared to women with and without other severe psychiatric disorders. Among the women with eating disorders in the same study, women with bulimia nervosa were more likely to continue breastfeeding during the rst year of life, but their infants were more likely to be overweight when compared with controls.42 Smaller studies and case reports indicate that women with eating disorders (currently and in the past), may be overly concerned about their infants weight.23 Regardless, it will be benecial to begin teaching about breastfeeding prenatally, introduce a lactation consultant early on, and even involve the pediatrician later on in pregnancy so infant nutritional status is carefully monitored. Particular attention should also be paid to postpartum calcium and vitamin D supplementation in breastfeeding women with eating disorders because affected women may be osteopenic before conception. When addressing postpartum contraceptive needs, it is important to remember that many women with eating disorders have irregular menses and therefore mistakenly believe they cannot get pregnant. Women with eating disorders are more likely to have unplanned pregnancies, especially those with bulimia.40 Ensuring that women understand their risk for pregnancy and helping them choose a reliable form of contraception is critical. Because women may relapse to prepregnancy disordered eating behaviors, oral contraceptives may not be the best choice for women who binge and purge by vomiting. CONCLUSION As women continue to struggle with body weight, selfimage, and popular cultures lovehate relationship with food and the emulation of unhealthy body shapes, it is likely that most womens health care providers will care
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for more women with disordered eating. By routinely screening their patients, both preconceptionally, prenatally, and repeatedly over the course of the pregnancy, providers may be able to identify women with eating disorders not previously recognized. The most frequently diagnosed eating disorders, ED-NOS, are subclinical but can still have implications for pregnancy. The psychosocial stress that pregnancy brings can be a trigger for binge eating disorder, which may present for the rst time in pregnancy. Increased risks related to maternal obesity, large gestational weight gain, cesarean birth, and macrosomic infants make screening for binge eating a necessary part of prenatal care. Such screening practices will also help to identify the other possible comorbid conditions associated with eating disorders that could negatively affect birth outcomes or maternal well-being: high maternal weight gain from binge eating; smoking; alcohol use; diabulimia; self-injurious behaviors; shoplifting; and the abuse of laxatives, supplements, or appetite suppressants. To provide the kind of complex, intensive care recommended for successful pregnancy outcomes, a well-coordinated multidisciplinary treatment team is needed. Women with active eating disorders not receiving such comprehensive care have been shown to be at greater risk adverse pregnancy outcomes, although current studies on this topic have limitations. Nevertheless, the importance of good nutrition in pregnancy is well documented and may exert a protective effect against some of these adverse birth outcomes. Clinicians can help empower women to make the best nutritional choices for themselves and for their infants. Teaching good nutrition can benet these women and their children in the years following their pregnancy.

7. Bulik CM, Von Holle A, Siega-Riz AM, Torgersen L, Lie KK, Hamer RM, et al. Birth outcomes in women with eating disorders in the Norwegian mother and child cohort study (MoBa). Int J Eat Disord 2009;42:918. 8. Abraham S. Obstetricians and maternal body weight and eating disorders during pregnancy. J Psychosom Obstet Gynaecol 2001; 22:15963. 9. Halek C. Eating disordersThe role of the nurse. Nurs Times 1997;93:636. 10. Little L, Lowkes E. Critical issues in the care of pregnant women with eating disorders and the impact on their children. J Midwifery Womens Health 2000;45:3017. 11. Jacobi C, Abascal L, Taylor CB. Screening for eating disorders and high-risk behavior: Caution. Int J Eat Disord 2004; 36:28095. 12. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: A new screening tool for eating disorders. West J Med 2000; 172:1645. 13. Micali N, Simonoff E, Treasure J. Risk of major adverse perinatal outcomes in women with eating disorders. Br J Psychiatry 2007;190:2559. 14. Leddy MA, Jones C, Morgan MA, Schulkin J. Eating disorders and obstetric-gynecologic care. J Womens Health (Larchmt) 2009;18:1395401. 15. Franko DL, Spurrell EB. Detection and management of eating disorders during pregnancy. Obstet Gynecol 2000;95(6 Pt 1):9426. 16. Goldner EM, Geller J, Birmingham CL, Remick RA. Comparison of shoplifting behaviours in patients with eating disorders, psychiatric control subjects, and undergraduate control subjects. Can J Psychiatry 2000;45:4715. 17. Baum A, Goldner EM. The relationship between stealing and eating disorders: A review. Harv Rev Psychiatry 1995; 3:21021. 18. Eberly M. Understanding self-injurious behaviors in eating disorders. The Remuda Review: The Christian Journal of Eating Disorders 2005;4:2630. 19. Goebel-Fabbri AE, Fikkan J, Franko DL, Pearson K, Anderson BJ, Weinger K. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care 2008; 31:4159. 20. Morgan JF, Lacey JH, Chung E. Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: Retrospective controlled study. Psychosom Med 2006;68:48792. 21. Koubaa S, Hallstrom T, Lindholm C, Hirschberg AL. Pregnancy and neonatal outcomes in women with eating disorders. Obstet Gynecol 2005;105:25560. 22. Micali N, Treasure J, Simonoff E. Eating disorders symptoms in pregnancy: A longitudinal study of women with recent and past eating disorders and obesity. J Pschosom Res 2007; 63:297303. 23. Wentz E, Gillberg IC, Anckarsater H, Gillberg C, Rastam M. Reproduction and offspring status 18 years after teenage-onset anorexia nervosaA controlled community-based study. Int J Eat Disord 2009;42:48391.

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