This week has been marked as Eating Disorders Awareness week. The prevalence of different forms of Eating Disorders are increasing and being recognised and may have a significant impact during pregnancy. In this article Deanne Jade, Founder, The National Centre for Eating Disorders, provides information on how different disorders may manifest and makes suggestions of how care could improve.
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Eating Disorders
Pregnancy is a time of great joy and excitement for some; for others it can be a time of anxiety and fear. Nowadays the state of pregnancy affected by unhelpful narratives on social media. We hear too much about people who gain little, if any weight during pregnancy and who wear their athletic shape as a badge of pride; or who snap back to their pre-pregnancy size within a week of giving birth. This makes pregnancy a challenging people who have pre-existing poor body image and a difficult relationship with food.
Lisa was a successful businesswoman who secretly suffered from anorexia. Her overriding wish was to remain thin, and she could not bear to see her stomach growing and her breasts swelling. She tried to eat as little as possible and she wore a tight corset to avoid people commenting on her shape. By the time that her underweight baby was born, her mental state had deteriorated and one day shortly thereafter, she left her baby on the doorstep of the local police station.
This is an extreme case but shows the lengths that some people endure to fight against the physical demands of a pregnancy. Maternity services generally do a wonderful job of monitoring the physical aspects of the perinatal period, but unless health professionals are aware of concerns, the needs of the eating disordered mother can slip under the radar, with potentially life changing consequences for both mother and child.
An eating disorder is a serious mental condition. Concerns about body size lead to harms to a person’s health and wellbeing. There are many kinds of eating disorder and most cases are described as “mixed picture;” for example, a person may suffer from bulimia (purging) and may also be “orthorexic” (obsessed with eating pure food to an extreme degree). Eating disorders have common comorbidities such as depression or Obsessive Compulsive Disorders (OCD).
Anorexia is a relentless pursuit of thinness, where there is such severe dietary restriction that few can conceive, but some do. The pregnant anorexic person is unlikely to be able to feed herself well enough to sustain a healthy pregnancy, so there is high risk of miscarriage or a premature birth. They may fear the natural process of being weighed, or of receiving comments of any kind about weight gain. Red flags to be aware of are missed prenatal appointments or failure to put on weight as the pregnancy evolves.
A minority of people with anorexia will welcome the pregnancy as a good reason to take a holiday from their eating disorder and they may be able to eat a healthy diet, only to return to fierce dietary restriction after the birth.
Bulimia Nervosa exists where compulsive binge eating is followed by purging to get rid of excess calories and prevent weight gain. Some people living with bulimia exercise excessively and inappropriately for the perinatal period, to restrict weight gain. This is not simply getting rid of excess calories, there are profound physical consequences caused by electrolyte imbalance, disruptions to gut function, malabsorption of nutrients and effects on the neurochemistry of mood. Type 1 Diabetes and Disordered eating (T1DE) is a lethal eating disorder experienced by almost half of all pregnant women with poor body image suffering Diabetes Type1 who restrict insulin to control or lose weight.
By far the most common eating disorder is compulsive eating, which is present among people living with obesity; sadly, we estimate that almost 50% of people who engage in longstanding attempts to lose weight qualify as having a clinically significant eating disorder, although most of them would simply say that they “have no willpower”. Most of them do not recognise that they are in the grip of a potentially dangerous relationship with food. Some find their pregnancy an excuse to let go of trying to control their weight. They will say that they are “eating for two” to avoid embarrassment and explain away their ballooning size. You may recognise compulsive eating syndromes among those who have excessive weight gain in pregnancy, and it is important to know that the overeater is probably severely malnourished. It is unhelpful to chide a person for not taking care; because they may be in the grip of compulsions. Monitoring during pregnancy might offer a missed opportunity to identify compulsive eaters and to direct them to the right kind of help for their difficulties.
Perinatal malnourishment tracks through the entire lifespan of the unborn child, so there is a good case for eating disorder screening. In the short term, the potential damage to a fetus could include the following – extra small babies, impaired nervous system and brain development as a result of neurotoxicity. Diabetes and pre-eclampsia can result from uncontrolled eating or purging. In the case of the Diabetic mother, impaired glucose control can give rise to birth defects, an extra-large baby, pre-term birth, miscarriage and stillbirth.
It is unlikely that an eating disorder sufferer will admit to an eating disorder at any time during pregnancy unless their GP is already aware of a problem. Pregnant women may experience magnified feelings of shame over the potential for harm to their baby, and they will fear judgement from others. In some cases, they may not believe or admit to themselves that they even have a problem. Health professionals need to be aware of potential red flags such as excessive weight gain, typical symptoms like fainting or anaemia, or failure to gain weight, fear of being weighed, fatigue or failure of the fetus to grow sufficiently well. All women with Diabetes types 1 & 2 need to have compassionate monitoring during pregnancy with inpatient help, if there is a failure to use insulin appropriately.
Perhaps one useful first step is for maternity services to make available leaflets or literature that signpost sufferers toward appropriate support and to reassure them that disclosure will not have adverse consequences .
Finally, an eating disorder is not all bad news in pregnancy, because some people are motivated to take better care of themselves in the knowledge that they are nourishing another human being. If you want to learn more about eating disorders and their treatment, consider taking a 2-day awareness course, starting soon online. Visit www.eating-disorders.org.uk
Deanne Jade, Founder, The National Centre for Eating Disorders
[email protected] / 0845 838 2040
February 2023