Weight gain and body shape is a huge concern for women in pregnancy, regardless of eating history. One study in the UK found that 40% of pregnant women feared weight gain during pregnancy and 70% worried they would be unable to return to their pre-pregnancy weight. These numbers are similar in most Western countries.
An eating disorder – either anorexia, bulimia, binge eating or a combination of the three – can make conceiving a baby more challenging. However, if you have been in remission from an eating disorder and able to successfully achieve a pregnancy, you may be at risk for recurrence of symptoms.
In the US, about 1% of pregnant women struggle with a diagnosable eating disorder, but as many as 3-15% of women are likely suffering from sub-clinical symptoms. There is a general trend towards improvement of disordered eating symptoms during pregnancy. But the risk returns postpartum.
Complications of Eating Disorders during Pregnancy
Women with anorexia are at higher risk of obstetric complications because of low body weight. This includes infants with lower Apgar scores and lower birth weights and postpartum problems related to hypoglycemia and hypothermia. It could also mean delivery complications such as increased rates of cesarean section and postpartum complications for mom including depression.
For women with bulimia, there are risks of developing hyperemesis gravidarum (severe nausea and vomiting of pregnancy) and lower birth weight babies.
In fact, one study found that about a third of women with small for gestational age babies met criteria for an eating disorder.
Anorexia nervosa comes with a host of medical complications, and these can make pregnancy and delivery more challenging. These issues include lower heart rate and blood pressure, and problems with electrolytes and nutrients. A healthy baby requires many nutrients for development, including essential ones like folic acid, and the availability of these nutrients to the fetus decreases with an eating disorder in mom. Conception itself becomes a challenge because the illness changes hormone levels such as estrogen and many women have difficulty with ovulation.
Women who are in recovery from anorexia fare much better in terms of pregnancy complications. Usually this means a woman who is closer to her appropriate weight, who has had her hormones re-regulate such that she could conceive, and with normal electrolytes and other metabolic indicators.
Psychologically, women with active or history of anorexia often have a personality structure of perfectionism and needing to be in control. In pregnancy and delivery, control becomes much more difficult, and this can be a significant mental burden for a woman.
Studies of women who struggle with bulimia have recognized certain risk factors for developing the illness. These include depression, anxiety, problems with self-esteem, a history of abuse, and low life-satisfaction. Remission of symptoms during pregnancy occurs when self-esteem and life satisfaction improves. This is quite encouraging, because unlike other risk factors, self-esteem and life satisfaction are changeable and can be improved with psychotherapy!
Unlike with anorexia, women with bulimia do not usually have problems with fertility, and therefore many more pregnant women struggle with this condition.
Binge Eating Disorder
We can recognize anorexia and bulimia, but those struggling with binge eating disorder often might be a missed group. In fact, it was only in the newest diagnostic manual of mental disorders that came out in 2013 that binge eating disorder was a recognized condition.
A binge eating disorder can come on with stress, and pregnancy can certainly be stressful! Worry about pregnancy weight increases the risk of developing the condition, as do co-occurring symptoms of depression and anxiety. Other risks include low self-esteem, low life-satisfaction, and lower partner relationship satisfaction and social support.
Clinicians outside of the mental health fields are often unfamiliar with eating disorders, and therefore might not think to ask questions about eating habits and body image during pregnancy. For this reason, it is important to share with your doctor if you are struggling with any symptoms of disordered eating. That may influence which tests are ordered and how the pregnancy is monitored.
It is also the first step to treatment! Treatment for an eating disorder works best when a team is involved. The team should include a mental health specialist to work on the psychological factors related to the disordered eating – the skills to abstain from the behaviors and the cognitive focus on improving self-esteem, body image, and life satisfaction. A psychiatrist or prescribing doctor can also help manage co-occurring symptoms of depression or anxiety; there are several medications that are relatively safe in pregnancy. A dietician who specializes in eating disorders can be a useful guide for making adjustments to the eating plan as the pregnancy continues.
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Goldman, R.D. & Koren, G. Mother Risk Update: Anorexia Nervosa during Pregnancy. 2003. Canadian Family Physician 49: 425.
Berg, C.K. Factors Associated with Binge Eating Disorder in Pregnancy. 2011. International Journal of Eating Disorders 44(2):124-133.
Conti, J., Abraham, S. & Taylor, A. Eating behavior and pregnancy outcome. 1998. Journal of Psychosomatic Research 44: 465-477.