IN THIS ISSUE
Young or old, no age group is immune to eating disorders – including women in their childbearing years. In fact, given the overlap in age range during which eating disorders (EDs) are often diagnosed and the time period during which women can reproduce, pregnancy and EDs frequently co-occur.1,2 And unfortunately, research has shown that there is an increased chance of complications when a pregnant woman has been diagnosed with an ED. Considering the serious problems that can result, it is imperative that EDs are properly identified in pregnant women and that precautions are taken to keep both the mother and developing child safe.
Rates of pregnancy and birth in the eating disorder population
Historically, women with anorexia were thought to be unable to conceive due to menstrual irregularities or amenorrhea, a common side effect of the eating disorder.3 This has since proved false; although women with irregular menstrual cycles experience decreased rates of pregnancy (the rate of pregnancy among women with anorexia is less than half the rate of healthy women4) women diagnosed with anorexia and other EDs are able to become pregnant and give birth.3 Still, women with EDs are significantly less likely to have children compared to control groups.4 One reason for this difference is that fertility is compromised in women with lifetime anorexia and lifetime bulimia.5 Adverse reproductive health outcomes, including increased rates of miscarriage and induced abortions, also appear to be factors.4
The elevated risk of miscarriage exists among populations diagnosed with bulimia, anorexia, and binge eating disorder3,4,6-9 This is in line with the general knowledge that miscarriage occurs more frequently in women with extremely high or low BMIs.10,11 One study found that miscarriages were especially common in women with binge eating disorder (46.7% of women with binge eating disorder experienced miscarriages compared to 23% of women in the control group).4 Studies also show that women with bulimia and anorexia are more likely to report that their pregnancies were unplanned 3,12 and also experience increased rates of induced abortion.3,6 Researchers speculate that in women with bulimia, who often carry impulsive personality traits, this may be due to risky sexual behavior and subsequent unplanned pregnancy.4 With anorexia, researchers speculate that the trend may be a result of inadequate use of contraceptives as a result of menstrual absence or irregularity creating a false sense of security.3
Impacts on maternal and fetal health
Given the severe toll EDs can take on an individual’s body, it is perhaps unsurprising that these disorders carry a greater risk of pregnancy complications and adverse health effects for both mother and child. Among the most commonly cited maternal risks are increased rates of cesarean section10,11 suboptimal nutrition14,15 and postpartum depression.13,16 Expectant mothers with anorexia are more likely to experience hyperemesis gravidarum, or severe pregnancy sickness (nearly one third compared to 9% of controls), and be diagnosed with anemia (nearly 50% versus 12% of controls).17
Women with past or active EDs also have a greater risk of delivering infants with low birth weight, smaller-than-average head circumference, and microcephaly.17 And it appears that these infants don’t “catch up” as time goes on; developmental delays in these cases tend to persist throughout the child’s life.18 One phenomenon, seen almost exclusively among women diagnosed with bulimia, is “slimming,” which involves a mother projecting her distorted body image onto her baby, perceiving it as overweight. Mothers in this situation may try to restrict feedings, administer suppositories, or induce vomiting.19
Sometimes pregnancy can also cause changes in ED symptoms, ranging from a complete remission of the disorder to exacerbation of symptoms.20,21 Women who experience symptom reduction – which may be permanent or transient following the birth – often cite the well-being of their baby. These women have better birth outcomes, heavier babies, and higher five-minute Apgar scores 22 (a measure of the physical condition of a newborn infant). A less common outcome is that ED symptoms increase during pregnancy. When this does occur, it is often sparked by an excessive fear of weight gain and changes to the body.20 In contrast to those whose symptoms diminish, women who experience increased symptoms often give birth to smaller babies with lower five-minute Apgar scores.22
It is not always immediately evident that a pregnant woman has an ED. The women themselves, especially teens, may not disclose their condition. Or, healthcare providers may overlook the consideration due to the fact that the woman was able to conceive and was therefore in seemingly good health.23 In order to avoid serious health consequences for both mother and child, EDs should be identified and factored into the care plan for the mother-to-be.23
Healthcare providers can often recognize a history of disordered eating alongside a woman’s reproductive record.23 Assessing menstrual cycle regularity is a good indicator of food restriction and unhealthy body weight. Clinicians should also pay special attention to weight recorded at prenatal visits and ask questions like, “What is it like for you to be weighted at every visit?” or “How are you feeling about your physical changes and weight gain?” in order to detect the presence of an ED.23
If an ED is suspected or identified, the OBGYN care provider should be prepared to collaborate with a multidisciplinary team well-versed in ED management.23 Together, they can provide a proper nutrition plan, discuss a healthy weigh-in procedure, provide fetal development education, and screen for post-partum depression.23 They can also work together to offer encouragement during maternal weight gain to reinforce a positive association with the mother's changing body shape.23 With multidisciplinary, specialized support behind her, the expecting mother will be better prepared to avoid reproductive complications and have a healthy pregnancy and baby.
by Carol Peterson, Ph.D., Chief Training Officer at The Emily Program
According to an oft-repeated Chinese proverb, "learning is a treasure that will follow its owner everywhere." As clinicians working in the mental health field, learning is inherent in our profession, given the privilege of our ongoing education provided to us by our clients as we collaborate with them in their pursuit of recovery. In addition, we have the opportunity to learn formally in the context of organized training and informally from colleagues, supervisors, and mentors. Indeed, many of us were drawn to our work initially–and continue to find it rewarding–because of our intense curiosity. In the context of our demanding schedules, how can continue to develop our skills, deepen our understanding of our work, revel in learning, and expand our knowledge?
1. Join a consultation group: Consultation groups usually consist of clinicians who provide feedback, information, and support to one another. Often, members will present case information or discussion topics on a rotating basis as consultation groups typically meet at regular intervals (e.g., monthly or quarterly).
2. Start a reading group: Interested in reading an article or book on a clinical topic? Consider inviting colleagues, peers, and students to read it too and discuss it as a group. Some reading groups meet once and others meet on an ongoing basis. In addition to clinical and research topics, some reading groups discuss novels that focus on mental health topics. Similarly, "movie groups" view and discuss films with specific themes (e.g., the portrayal of psychiatric and psychological treatment).
3. Seek online resources: Educational information is often available online (e.g., YouTube, websites like Khan Academy), especially for academic courses and lectures. In addition, online resources can be found for a number of evidence-based treatments. For example, do you want to learn more about cognitive-behavioral treatment for eating disorders? The Centre for Research on Eating Disorders at Oxford's website (credo-oxford.com) includes information about cognitive-behavioral treatment as well as assessment forms and handouts that can be downloaded for clinical use.
4. Set aside one hour per week for learning and block it in your calendar: Designating time within your schedule to devote to learning can support self-care as well as professional development. Although this time can be allotted for "required" education (e.g., continuing education activities for licensure), consider including learning opportunities that spark passion (even if the topic is outside of your typical expertise).
5. Attend workshops, lectures, and webinars: Structured learning activities can be especially valuable for developing a new skill or understanding a topic more comprehensively from an expert in the field.
6. Take or audit a class: Community education, local and on-line colleges/universities, and learning communities can provide a range of courses.
7. Consider teaching or lecturing: Serving in the teacher role provides an ideal opportunity to strengthen knowledge in the context of course preparation as well as during student interactions.
8. As much as possible, surround yourself with colleagues, students, mentors, supervisors, and teachers who share your passion for learning. Enthusiastic curiosity is often contagious and can serve as a foundation of formal and informal communities.
Appreciating small moments of learning can be especially helpful amidst busy schedules (e.g., at the end of the work day, checking in and asking ourselves to reflect on one experience that provided learning and growth that day). For some of us, education beyond our professional scope of work can be as valuable as work-related training. Learning a new skill (e.g., gardening, car repair) or topic (e.g., art history, astronomy) can be rejuvenating and inspiring to us as clinicians, and as humans.
Interested in free CEUs and other continuing education opportunities? Check out all of our upcoming events here.
- The Emily Program recently welcomed new staff members to our care team in Spokane! Patti Zimmerman, MSN, ARNP, serves as a Medical Nurse Practitioner in our Spokane, WA office. Patti provides medical clearance for programming clients and follows up on issues that need further attention during the treatment recovery process, coordinating care with outside medical providers. Her expertise in women's health care and her calm, supportive manner have been a great addition to the team. Sarah Bergen, PMHNP-BC, serves as a Psychiatric Nurse Practitioner. Sarah provides psychiatric care to all of our programming clients, conducting client assessment, managing medications and coordinating with the rest of the care team and community providers to provide comprehensive care. With her working knowledge of eating disorder treatment and willingness to step in when needed, Sarah is an excellent fit at the Spokane office.
- Jennifer Shannon, M.D., Child and Adolescent Psychiatrist, is expanding her role to spend more time working with our Seattle Adolescent and Family Intensive Program (AFI) and Seattle Residential in 2017.
1.Crow, S.J., Keel, P.K., Thuras, P., Mitchell, J.E. (2004). Bulimia symptoms and other risk behaviors during pregnancy in women with bulimia nervosa. The International Journal of Eating Disorders, 36(2): 220-223.
2. Franko, D.L. & Spurrell, E.B. (2000). Detection and management of eating disorders during pregnancy. Obstetrics & Gynecology, 95: 942-946.
3. Bulik, C.M., Hoffman, E.R., Von Holle, A., Torgersen, L., Stoltenberg, C., Reichbom-Kjennerud, T. (1999). Unplanned pregnancy in women with anorexia nervosa. Obstetrics & Gynecology, 116: 1136-1140.
4. Linna, M. S., Raevuori, A., Haukka, J., Suvisaari J.M., Suokas J.T., and Gissler, M. (2013). Reproductive Health Outcomes in Eating Disorders. International Journal of Eating Disorders, 46(8): 826-33.
5. Easter, A. (2011). Fertility and prenatal attitudes towards pregnancy in women with eating disorders: results from the Avon Longitudinal Study of Parents and Children. International Journal of Obstetrics and Gynecology, 118(12): 1491-1498.
6. Abraham, S. Sexuality and reproduction in bulimia nervosa patients over 10 years. (1998). Journal of Psychosomatic Research. 44: 491-502.
7. Bulik, C.M. Sullivan, P.F., Fear, J.L., Pickering, A., Dawn, A. McCullin, M. (2007). Fertility and reproduction in women with anorexia nervosa: A controlled study. Journal of Clinical Psychiatry, 60: 130-135.
8. Micali, N., Simonoff, E. Treasure, J. (2007). Risk of major adverse perinatal outcomes in women with eating disorders. The British Journal of Psychiatry, 60: 130-135.
9. Morgan, J.F., Lacey, J.H., Chung, E. (2006). Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: retrospective controlled study. Psychosomatic Medicine, 68: 487-492.
10. Metwally, M. Ong, K.J., Ledger, W.L., Li, T.C. (2008). Does body mass index increase the risk of miscarriage after spontaneous and assisted conception? A metaanalysis of the evidence. Fertility and Sterility, 90: 714-726.
11. Maconochie, N. Doyle, P., Prior, S. & Simmons, R. (2007). Risk factors for first trimester miscarriage—results from a UK-population-based case control study. British Journal of Obstetrics and Gynaecology, 114 (2),: 170-186.
12. Morgan, J.F., Lacey, J.H., Sedgwick, P.M. (1999). Impact of pregnancy on bulimia nervosa. Br J Psychiatry, 174:153-140.
13. Franko, D.L, Blais, M.A., Becker, A. E., Delinsky, S.S., Greenwood, D.N., Flores, A.T., Ekeblad, E.R., Eddy, K.T., & Herzog D.B. (2001). Pregnancy complications and neonatal outcomes in women with eating disorders. The American Journal of Psychiatry, 158(9), 1461-1466
14. American College of Obstetricians and Gynecologists. Nausea and vomiting of pregnancy. (2004). ACOC Practical Bulletin, 52, 1-15.
15. Roem, K. (2002). Hyperemesis gravidarum—a serious complication of pregnancy. Nutrition & Dietetics, 59, 144-146.
16. Mazzeo, S.E., Slof-Op’t Landt, M.C., Jones, I., Mitchell, K., Kendler, K.S., Neale, M.C., Aggen, S.H. & Bulit, C.M. (2006). The International Journal of Eating Disorders, 39(3), 202-211.
17. Koubaa, S., Hallstrom, T., Lindholm, C., Hirschberg, A.L. (2005). Pregnancy and neonatal outcomes in women with eating disorders. Obstetrics & Gynecology, 105(2), 255-260.
18. Park, R.J., Senior, R. Stein, A. (2003). The offspring of women with eating disorders. European Child and Adolescent Psychiatry, 12 (suppl), 100-119.
19. James, D.C. (2001). Eating disorders, fertility and pregnancy: relationships and complications. The Journal of Perinatal & Neonatal Nursing, 15 36-48.
20. Lemberg, R. & Phillips, J. (1989). The impact of pregnancy on anorexia nervosa and bulimia. International Journal of Eating Disorders, 8, 285-295.
21. Blais, M.A., Becker, A.E., Burwell, R.A., Flores, A.T., Nussbaum, K.M., Greenwood, D.N, et al. (2000). Pregnancy: outcome and impact on symptomatology in a cohort of eating-disordered women. International Journal of Eating Disorders, 27, 140-149.
22. Stewart, D.E., Raskin, J., Garfinkel, P.E., MacDonald, O.L., Robinson, G.E., (1987). Anorexia nervosa, bulimia and pregnancy. American Journal of Obstetrics and Gynecology, 157 (1194-1198).
23. Newton, Mandi S., and Lesa Chizawsky L. K. "Treating Vulnerable Populations: The Case of Eating Disorders during Pregnancy." Journal of Psychosomatic Obstetrics & Gynecology 27.1 (2006): 5-7.