Striving for ‘perfection’: influences, prevalence and dangers of eating disorders in expectant mothers

Eating disorders, especially anorexia nervosa (AN) and bulimia nervosa (BN), are characterized by the individual having an unsatisfied body image and an extreme fear of weight gain. Despite this, AN is primarily characterized by a weight of 15% less than the recommended weight for age and amenorrhea (loss of menstruation for at least three consecutive months). Women with only the former criteria are considered to have a subclinical diagnosis of AN. By contrast, BN is harder to distinguish as it can be present in women with any bodyweight, but it is marked by recurrent episodes of binge eating followed by purging.

Influences

Eating disorders result from a complex interaction between biological and environmental factors [1]. Research suggests that eating disorders run in families and, therefore, the onset of such disorders may be due to a genetic component [1–3]. However, our current understanding of genetic factors contributing to eating disorder is scant. Among the proposed candidates are genes that are responsible for regulation and/or function of the serotonergic neurotransmitter system, melanocortin pathway, uncoupling protein-2 (UCP2) or -3 (UCP3) and estrogen β-receptors. Mutations in these genes may impact appetite regulation, mood, energy expenditure and bodyweight [4]. Similar to other diseases, an individual’s susceptibility to eating disorders is probably determined by the interaction between several genes, modulated by environmental factors, rather than alterations in a single gene [1]. For example, parental behavior and attitude, with respect to establishing an individual’s eating habits and outlook of their weight and shape, may be attributed to genotype, the environment or both. Moreover, one’s own genetic personality traits and ability to cope with criticism related to body image and weight may also significantly affect the occurrence of such disorders [1,5].

In addition, culture and mass media place an unprecedented emphasis on physical appearances and weight control by constantly promoting that the slender body type is the norm and that thinness equates to beauty, success and happiness. Magazines, the internet and TV are inundated with articles and advertisements on diet, exercise and pictures of women who weigh significantly less than average. More alarming is the easy access to the growing number of websites dedicated to pro-eating disorders that could initiate and/or validate unhealthy behaviors, including dieting and concealing the symptoms [6,7]. Research indicates that women who are exposed to the mass media’s ‘perfect’ ideal develop a negative body image [8], and are more likely to engage in unhealthy weight-control behaviors, such as fasting, smoking, purging and laxative use [9]. It is, therefore, not surprising that the constant pressure to be thin can facilitate eating disorders.

Prevalence

The exact prevalence of eating disorders in females is difficult to ascertain as many fail to report their condition to their healthcare providers [10]. Studies among women from Western countries indicate that the prevalence of AN ranges from 0.1 to 5.7% and BN from 0.3 to 7.3%. Among women from non-Western countries, estimates range from 0.05 to 0.9% and from 0.1 to 3.2% for AN and BN, respectively [11]. As eating disorders commonly occur during a woman’s reproductive years, they significantly affect reproductive physiology. Research suggests that eating disorders are associated with menstrual dysfunction, polycystic ovarian syndrome and infertility [12,13]. While it is recommended that such women should wait until their illness is in complete remission, many can still conceive and carry a pregnancy to term [14].

Furthermore, little is known regarding the prevalence of eating disorders during pregnancy. Even though some studies have shown that eating disorders have a tendency to improve or remit completely during pregnancy [15], in a large study from the UK, 1.4% of women reported AN, 1.6% reported BN and 0.7% reported both disorders during the first trimester [16]. Moreover, the number of expectant mothers with an active or a history of eating disorders may be increasing as a result of improvements in the treatment of eating disorders and infertility [11].

Dangers

Pregnancy is often associated with substantial changes in body shape and weight and, although most women view pregnancy as a temporary change that is usually positive, it can be a particularly stressful time in women with eating disorders, where their perception of their body may inhibit adequate weight-gain during pregnancy. This is a major concern because the nutritional status of pregnant women has important implications for the risk of maternal and fetal morbidity. Studies that have evaluated this relationship have found positive associations with suboptimal outcomes, such as preterm labor, low birthweight, fetal growth restriction, fetal abnormalities, low Apgar scores, anemia, genitourinary tract infections and cesarean delivery [17–20]. The postpartum period is generally recognized as a high risk period for the development of serious complications and psychiatric disorders [11]. Women with eating disorders (regardless of their remission status) during pregnancy are susceptible to relapse of eating disorders, often with worsening symptoms, and the development of depression in the postpartum period [11].

An additional and growing concern is that some women with eating disorders may lack the desire to breastfeed or may fail to adequately breastfeed (as a result of being unable to maintain lactation demands), and maybe also restrict the child’s calories, have irregular eating schedules for their children or limit the availability of food to mealtimes, resulting in stunted growth, low weight for height and developmental delay [1,11,14,21].

Diagnosis & treatment

As only 20% of gynecologists and obstetricians feel confident in successfully diagnosing eating disorders, it is crucial that they incorporate clinical practice guidelines for screening eating disorders during prenatal care [12]. Prenatal screenings for both cognitive and behavioral indicators through asking questions that assess the patient’s perception of their weight gain, body-image, excessive exercise and eating patterns, which includes asking about extended periods of food restriction, can help to distinguish an eating disorder [12,14,20]. Clinical symptoms of eating disorders may include prepregnant weight below the ideal bodyweight, dental caries, acrocyanosis, hypothermia, swollen joints, pitting edema, bradycardia, hypotension, osteoporosis and skeletal fractures. Laboratory findings may consist of euthyroid sick syndrome (normal thyroid-stimulating hormone, but low thyroxine and triiodothyronine), anemia, hypoglycemia, hypochloremia, hypokalemia and hypophosphatemia [4]. Special evaluation needs to be given to candidates for fertility treatment seeking hormonal induction of ovulation, as 17% of women attending an infertility clinic had an eating disorder [12]. Thus, routine assessment for eating disorders in this population is highly recommended as multiple pregnancies, as a result of fertility medication, can increase the psychological strain in these women [12,13,21]. In addition, attention should be given to women who fail to gain appropriate weight during pregnancy or to those who present with intractable vomiting and purging [18]. Given a high risk of relapse in the postpartum period, screening and early detection by weight-monitoring is important in women with a history of eating disorders.

The management of a patient with an eating disorder should ideally be a multidisciplinary collaboration between a gynecologist, psychiatrist and nutritionist [12,14,21]. Pharmacotherapy is not normally used as a major treatment vehicle, owing to a limited efficacy and increased susceptibility to side effects among people with eating disorders. However, psychotherapy has been shown to be the most effective treatment [22]. Repeated counseling that reassures that weight gain during pregnancy is normal, monitoring of both macro- and micro-nutrients, and education on fetal development and growth can motivate and reinforce the need of healthy-eating practices [10,12,13]. By providing the much needed informative and educational resources, along with effective management and constant monitoring, expectant mothers with eating disorders can, indeed, have a healthy pregnancy and a healthy child.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.