Anorexia Nervosa Treatment Overview

Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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94anorexia and bulimia nervosa during pregnancy

AN and BN are typically manifested in the early postpubertal to young adult years 12 and continue throughout the reproductive years 13 . Amenorrhea is a diagnostic criteria for AN, suggesting that pregnancy is of little concern in a woman with this eating disorder. However, approximately 10 of women who sought treatment in an infertility clinic presented with AN or BN 14 . Moreover, 60 of women with oligomenorrhea had eating disorders 14 , indicating the desire for fertility despite any dysmenorrhea associated with AN or BN.

963Findings Related to Anorexia and Bulimia Nervosa

In those studies in which women with AN or BN were investigated together, risk and incidence of inappropriate weight gain 53-55 , hyperemesis gravidarum 56 , cesarean section 57 , preterm delivery 58 , LBW 56, 58, 59 , SGA 56, 58 , small head circumference or microcephaly 56 , short body length 59 , NTD 29 , and other birth defects 57 were high. In general, women who entered pregnancy in remission from their AN or BN had optimal maternal and fetal outcomes 50, 60 , while women with active eating disorders prior to conception and during pregnancy fared less well 24, 58 .

98nutrition care of women with anorexia or bulimia nervosa during pregnancy

The first step in the nutrition management of the pregnant woman with AN or BN is identification of the eating disorder. Assuming that prenatal care is sought, many women with AN or BN do not disclose their conditions at any of their prenatal visits 42, 46, 49 . In addition, most obstetricians do not inquire about eating disorders in their patients. For example, only 18 of obstetricians in prenatal clinics questioned their pregnant patients about AN and BN 67 . The secrecy of these disorders and lack of inquiry lead to suboptimal care of these pregnant women.

Eating disorders and body image

During adolescence women's bodies go through enormous changes as our sexual characteristics develop and our body reaches its full adult size. These changes to our body can affect how we see ourselves, how happy we are with what we see and they can contribute to the development of an eating disorder. For most women, watching their body change in shape is not easy. The majority of women are probably 'watching what they eat' and so eating in pregnancy can be problematic for most. Every woman will resolve this challenge in different ways. The early pregnancy can be most difficult, as once women 'look pregnant' they become more accepting of their changing shape.

2 Eating Disorders Definitions

Two eating disorders are recognized by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders (1). Anorexia nervosa (AN) is characterized by (a) refusal to maintain a normal body weight and weight that is 85 or lower than expected for age and height (b) intense fear of gaining weight or becoming fat, even when underweight (c) disturbance in the way in which one's body weight or shape is experienced, extreme influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight and (d) loss of menses for 3 mo or never getting menses. AN has two subtypes restricting type and binge-eating purging type defined by the absence or presence of binge eating and compensatory purging behaviors, such as vomiting or laxative use. Bulimia nervosa (BN) is defined by (a) recurrent episodes of binge eating twice weekly for 3 mo with loss of control, (b) recurrent inappropriate compensatory behavior (e.g., vomiting,...

5 Detection And Assessment Of Eating Disorders

There is evidence that women with AN or BN are reluctant to reveal their symptoms and behaviors to health care professionals. In fact, eating disorders are frequently undisclosed to clinicians and may be undetected in clinical settings up to 50 of the time (23,24). An early study by Martin and Wollitzer (25) conducted in a family practice clinic found that 21 of female patients had a confirmed history of purging, and of these 58 had never told anyone about their purging and only 2 had discussed it with a family physician. Available data suggest that suboptimal recognition may be attributed to a variety of factors, including a lack of patient disclosure of symptoms (26), a low index of clinical suspicion for these disorders (23), and the clinical stereotyping of eating disorders as primarily affecting non-Hispanic, white girls and women (27). Only two studies have examined disclosure patterns in reproductive health settings. In a small case study, women were found to be reluctant to...

6 Assessing The Suspected Presence Of An Eating Disorder

Because there are no reliable laboratory indicators for the signs of eating disorders, detection depends on careful questioning and vigilance on the part of the provider. High levels of shame and secrecy are common in eating disorders, making it important that questions are asked in an open-ended and nonjudgmental manner in order to maximize the chance of honest responses. Particular questions may be more likely to yield disclosure. For example, Freund et al. (31),in a primary care setting, found In addition, a number of screening tools are available that assess eating-disorder symptomatology. The most reliable and valid instruments include the Questionnaire for Eating Disorder Diagnoses (Q-EDD) (32) and the Eating Disorder Examination questionnaire (33). Both are relatively short and provide diagnoses of AN and BN. Studies have found that both have good discriminant validity, internal consistency, and concurrent validity (for a review of the reliability and validity studies for these...

8 Course Of Pregnancy For Women With Eating Disorders

There are no studies investigating the course of pregnancy in women with eating disorders. Based on clinical accounts (28), several issues appear to be relevant with regard to the course of pregnancy in a woman with an eating disorder. These include issues specific to the three trimesters and center around weight gain, eating-disorder symptom change throughout and beyond pregnancy, and preparation for parenthood. The goals of the clinician (whether mental health or medical) are to help and support the patient to eat adequately throughout pregnancy decrease or eliminate anorexic or bulimic behaviors and explore feelings about pregnancy, childbirth, and parenting in a caring and empathic way. These issues surface in various ways over the course of pregnancy.

4 Impact Of Eating Disorders On Pregnancy Course And Outcome

The empirical literature summarizing the effects of anorexic and bulimic symptoms during pregnancy is somewhat limited because many published studies are primarily retrospective and have been conducted with relatively small sample sizes. The most often cited complications of pregnancy in anorexic and bulimic women include inadequate or excessive weight gain, miscarriage, and hyperemesis (11,12). There have also been case reports of vaginal bleeding, hypertension, and postepisi-otomy suture damage in pregnant women with eating disorders (13). The most frequently described obstetric and delivery complications include premature delivery, LBW, and low Apgar scores (14). Reports detailing prenatal mortality, fetal abnormalities, stillbirth, breech delivery, and cleft palate have also been recorded in women with eating disorders (15,16). The rate ofmiscarriage has been found to be higher in women with eating disorders than in normal healthy control women (12,17). Abraham (17) reported that...

922Bulimia Nervosa

Individuals with BN engage in binge eating episodes, followed by compensatory behaviors to prevent any increases in body weight. Purging behaviors include self-induced vomiting or self-prescribed use of enemas, laxatives, or diuretics. Nonpurging behaviors include fasting and excessive exercise. While clinically diagnosed BN occurs in approximately 5 of the female population, up to 20 of women have reported bulimic behaviors in their lifetimes 6, 7 . Clinical features of BN include Russell's sign, dental enamel erosion, dental caries, and enlargement of the parotid glands in those who use self-induced vomiting as a purging behavior. Use of enemas, laxatives, and diuretics as well as vomiting can lead to electrolyte imbalances, cardiac dysfunction, and other neurologic disorders. Gastrointestinal symptoms may range from constipation to esophageal or gastric rupture. In those who engage in nonpurging behaviors, electrolyte imbalances, renal and cardiac dysfunction, and gastrointestinal...

Anorexia nervosa

The psychology of anorexia and bulimia is complex and looking at how and why it develops is beyond the scope of this book. However, it is helpful to look at how women with eating problems may approach pregnancy. As discussed earlier, few young women today allow themselves to eat freely and many young women and men are preoccupied with dieting and body shape. Most women are striving to be a bit thinner, to have a smaller bottom or would like bigger breasts or fuller lips. However, despite their dissatisfaction, most just get on with their lives and these issues just tend to surface at certain times. In anorexia nervosa the issues run much deeper many women have a totally debilitating obsession with controlling their eating which is the driving force in their life. Often this means they are never able to form adult attachments or have children. For some their starvation has led to infertility. The seriousness of anorexia is sometimes under-estimated and if you do become pregnant while...

Isnt the decision different for everyone

Most people are now aware of the possibility of post-natal depression following the birth of a baby and many try to take steps to have extra help and support at this time. We do, however, tend to overlook the fact that many women become pregnant while experiencing emotional difficulties or these problems develop in the pregnancy. Some women may be depressed, they may have had a manic episode that required hospital treatment, they may be struggling with an eating disorder or dealing with the effects of a difficult relationship the list is endless. This may be related to the pregnancy in some way there may be fears about the health of the baby, the pregnancy may have been ill-timed or these psychological difficulties may have been due to external factors the loss of a job, relationship difficulties, family problems, financial worries, and so on. One could try to time a pregnancy when there are fewer pressures around but it would be almost impossible to plan a pregnancy at a time when...

Taking a different path

Martha had struggled with anorexia throughout her adult life. She couldn't remember a time when she had ever eaten freely and she had been treated as an inpatient numerous times. At 39 Martha looked more like a woman in her sixties. Her skin had aged dramatically, she remained very thin and slightly stooped her body clearly displayed the effects of a lifetime of starvation. However, at 35 Martha's life had taken a massive leap forward when she had met Ted who was 50 and divorced. Within a year they married. Martha had never given up the hope of having a baby and at 42, after seven years of trying, she finally fell pregnant and successfully delivered a son.

What does it mean to be a mother Changes for women

Kara came to see me for help with an eating disorder. She tended to diet and then binge on alcohol and food. She would use laxatives and vomit when she sobered up. In the course of our sessions Kara became pregnant. (She had been using the contraceptive pill, which is clearly not recommended as a contraceptive for women with such eating problems.) The father was her flatmate and they had had a 'fling' during a drinking binge. From what looked like a disastrous situation Kara was able to decide that she needed to take control of her life and sort out her problems in a different way. The pregnancy helped her to get some control over her eating problems. She struggled greatly but accepted the idea of eating regular meals and the binging decreased very quickly. Her flatmate helped her to cut down on her drinking but he was not keen on becoming a father. Kara suddenly decided to return home to her parents in Argentina and I did not see her again.

241 Nausea and vomiting in pregnancy

The pathogenesis of NVP has been attributed to multiple factors such as elevated levels of 3-hCG, prostaglandin levels (by relaxing the gastroesophageal sphincter), gastric dysrhythmia, vitamin B6 deficiency, and hyperolfaction. Psychological factors (depression, anxiety, eating disorders), once considered the only etiology of NVP, might in fact be a result of the NVP. A genetic predisposition has been suggested based on the concordance in monozygotic twins, variation within ethnic groups, and the fact that siblings and mothers of patients with NVP are likely to have experienced NVP themselves (Goodwin 2002).

Sharon M Nickols Richardson

Summary Anorexia nervosa (AN) and bulimia nervosa (BN) present high-risk situations during pregnancy. These conditions have been associated with poor energy and nutrient intakes, notably total energy folate vitamins B6, B12, and A calcium iron and zinc. Electrolyte imbalances are also of concern. Inadequate or excessive weight gain, spontaneous abortion, intrauterine growth restriction, preterm delivery, and low birth weight, among other adverse outcomes, have been reported in pregnant women with AN or BN and their offspring. Screening and assessment of women for these eating disorders during prenatal clinic visits is recommended. An interdisciplinary approach to care during pregnancy, the postpartum period, and beyond is critical to the successful management of AN or BN and optimal pregnancy outcomes. Keywords Anorexia nervosa, Binge eating, Bulimia nervosa, Compensatory behavior, Purging

97changes in behaviors

A relapse in eating disorder symptoms in women who were previously in remission may occur during pregnancy 56 . In active AN or BN, body dissatisfaction and low body esteem may worsen during pregnancy 61 in addition to an increased frequency of restricting, binge eating-purging, and nonpurging behaviors 36, 44, 46, 51, 58 . Conversely, AN or BN symptoms and behaviors improved during pregnancy in women receiving treatment 45, 46, 53, 54 and not currently receiving treatment 47, 49, 55, 61-63 . Yet, postpartum resumption of AN and BN behaviors occurred with some regularity 45, 46, 48, 49, 54, 55, 62, 63 . Postpartum depression (PPD) requires assessment in women with AN or BN as this mood disorder is tightly linked to eating disorders 64, 65 . While most studies report an increased incidence of PPD in women with AN or BN 24, 57, 64, 65 , one study reported fewer symptoms of depression in women with treated BN who delivered infants compared to women with treated BN who had not given birth...

910monitoring and evaluation

At each prenatal visit, eating disorders screening may be conducted (see Table 9.4) along with measurement and documentation of parameters or outcomes related to nutrition interventions and diagnoses. Body weight and rate of weight gain should be tracked and evaluated. Adjustments in energy intake should be based on appropriateness of weight changes. Eating behaviors and dietary intake should be examined at each prenatal visit to assess the adequacy of dietary composition and patterns of intake. Changes in purging and nonpurging behaviors should be noted and addressed. Fingersticks to check hematocrit and glucose may be useful in the monitoring of iron status and hypoglycemia or hyperglycemia. In women with established eating disorders, urinalysis may detect starvation or dehydration as noted by urinary ketones, elevated specific gravity, and alkaline urine. Vital signs will show any change in general health status. Glucose tolerance testing should be conducted in the 24th to 28th...

911planning for postpartum care

Relapses in eating disorders often occur in the postpartum period 46-50, 55 . Moreover, the rate of PPD in women with eating disorders is high (see Chap. 19, Postpar-tum Depression and the Role of Nutritional Factors ). Changes in estrogen status and estrogen-beta-receptor function or other gene-nutrient interactions may be responsible for observed relapses. The registered dietitian should work closely with the patient toward the end of pregnancy to set realistic goals for dietary intake, weight loss, eating behaviors, and expectations during lactation.

9111 Interdisciplinary Care

Nutrition care is but one part of treatment for AN or BN. These complex disorders require multidisciplinary and integrated care, due to the multifactorial etiology and wide scope of signs and symptoms. The obstetrician, nurse practitioner, psychologist or psychiatrist, dietitian, dentist, social worker, family therapist, occupational therapist, pharmacist, certified exercise physiologist, and other allied health care professionals must openly and cohesively interact with one another and most importantly with the patient to provide effective treatment. Cognitive-behavioral therapy is used to modify anorexic and bulimic behaviors. Medications may be used in treatment, but a risk-benefit assessment for use during pregnancy should be completed (Table 9.7). An increased frequency of prenatal visits is warranted in these high-risk conditions. Monitoring of fetal heart rate and more frequent ultrasounds may shift the center of attention from the mother's AN or BN Selected Medications Used in...

Survivors of childhood sexual abuse

With increasing awareness of the occurrence of the sexual abuse of children, more women and some men too are willing to come forward and seek help in dealing with the consequences of abuse in childhood. Often women come for help with depression or an eating disorder and later on in the therapy reveal that they were abused. Many women I have worked with have been able to have a sexual relationship with someone where they were very 'detached' or cut off from their feelings but it was when they become involved in a serious relationship that the sexual relationship triggered anxiety, flashbacks or depression. For some women the thoughts of being pregnant and going through labour are terrifying women may fear feeling out of control or are terrified of being examined or touched. These fears can trigger intense anxiety or flashbacks. Many survivors of childhood abuse also worry about their ability to be a parent will they be too over-protective of a child Or they worry about not being able...

Osteoporosis Associated with Pregnancy234

This is a rare condition in which women present with severe back pain and height loss due to vertebral collapse, usually in the third trimester of pregnancy. Often the diagnosis is not made until after delivery. Lateral spinal X-rays will show vertebral collapse. The aetiology is not clear but may be related to previous prolonged amenorrhoea, anorexia nervosa or mild forms of osteogenesis imperfecta. Osteogenesis imperfecta is an inherited bone disorder due to defective collagen known colloquially as 'brittle bone disease' that results in fractures of varying frequency and severity.

134 acceptable physical activity and exercise plans

In addition to adequate calorie and nutrient intake, and appropriate exercise and physical activity, various lifestyle factors should be considered when planning for appropriate weight gain during pregnancy. Occupation, leisure activities, stress level, and habitual dietary behaviors (i.e., eating out, eating cues, binge eating) are important considerations for weight management programs. Behavior modification strategies may need to be implemented for women who have problems with habitual unhealthy dietary behaviors (See Chap. 9, Anorexia Nervosa and Bulimia Nervosa during Pregnancy ). All of these factors should be taken into consideration in consultation with a registered dietitian and in collaboration with the supervising physician.

1353Very Low Calorie Plans

By definition, very low-calorie diet plans provide approximately 400-900 kcal daily. Clearly, the aforementioned discussion, coupled with the information provided in Part 1 of this book, demonstrates the inappropriate nature of such an approach to weight management during pregnancy. Even the most proficient registered dietitian could not design a nutritional care plan that provided all of the essential nutrients required for a normal, healthy pregnancy with so few calories. Pregnant women must be cautioned against undertaking any type of reduced calorie plan that compromises energy and nutrient intake to this extent. If such behaviors were to persist, the practitioner must consider further evaluation or referral for eating disordered behaviors (see Chap. 9, Anorexia Nervosa and Bulimia Nervosa during Pregnancy ).

Disorders of bone and mineral metabolism during pregnancy and lactation

The pathogenesis of pregnancy-associated osteoporosis (presenting with vertebral compression fractures) and transient osteoporosis of the hip differs. In a few cases of the former, secondary causes of bone loss could be identified, including anorexia nervosa, hyperparathyroidism, osteogenesis imperfecta, and corticosteroid or heparin therapy 87,88,90 . One report described pregnancy-associated osteoporosis after oocyte donation in a woman with ovarian failure 94 . Serum calcium and phosphate levels were normal, and no consistent abnormalities in the calciotropic hormones were reported 87,88 . Bone biopsy specimens obtained in some cases have confirmed the diagnosis of osteoporosis, and no osteomalacia was found 87,88 . Bone density tended to be low when measured 86,88 . In a series of 24 patients, the mean Z-score was 1.98 (+1.5, n 15) at the lumbar spine and 1.48 (+1.5, n 15) at the total hip 88 . In transient osteoporosis of the hip, radiographs or MRI revealed reduced bone density...

7 Treatment Guidelines

Treatment for eating disorders is most effective with a multi-disciplinary team approach that includes medical, mental health, and nutrition professionals (35). When an eating-disordered patient is pregnant, the importance of communication among the obstetrician, mental health professionals, and dietitian cannot be overemphasized, and the patient's agreement with this collaboration must be sought. The mental health clinician coordinates the treatment team and makes appropriate additional referrals. The most important role of the obstetrician is to support the patient and to encourage her to remain in treatment with the team. Several authors (8,15) have reported positive results with an actively bulimic patient who was treated by a multidisciplinary team throughout her pregnancy. Although the medical staff will not be the provider of psychological treatment for the eating-disordered patient, it may be useful for physicians, nurses, and midwives to have the following general treatment...

102 Breast Feeding and Feeding Issues

As the new mother struggles in her efforts to lose weight, she may also have difficulties in feeding her baby. To date, there are seven studies of four samples of eating-disordered mothers and their offspring (45-51). In summary, these studies find that, compared with controls, the children of women with eating disorders weigh less at infancy and at 1 yr, have more difficulty with breast-feeding and bottle-weaning, and have more emotional difficulties and eating behavior disturbances (inhibited, secretive, or overeating). During mealtime, interactions are characterized by more conflict in eating-disorder dyads, and mothers were found to make fewer positive comments during mealtimes. One study (49) found that 20 of the variance in weight at 1 yr was accounted for by conflict during mealtime. The eating-disordered mothers reported more negative affectivity in their children and more concern for their daughter's weight and preferred thinner babies. A recent review ofthis literature...

Mechanisms for infertility

Hypothalamic-pituitary-gonadal dysfunction Uncontrolled Type 1 diabetes is thought to disrupt normal hypothalamic-pituitary-gonadal function, and animal studies have suggested that poorly controlled Type 1 diabetes may adversely affect the uterovaginal outflow tract and or ovarian function. However, clinical studies do not relate this factor to menstrual dysfunction.4 Similarly, pituitary function, as assessed by basal gonadotropins and gonadotropin-releasing hormone (GnRH)-stimulated gonadotropin release, appears to be normal in young women with Type 1 diabetes. Although there is some evidence that pituitary function declines with increasing duration of diabetes, this issue has not been thoroughly investigated. Therefore, the oligo amenorrhea in Type 1 diabetes appears to be principally hypothalamic in origin and may represent intermittent (and perhaps reversible) failure of the GnRH pulse generator. This is similar to the mechanism in anorexia nervosa or in women who engage in...

2254 Infection Control

Parasitic infections such as malaria, hookworm, whipworm, and schistosomiasis can cause or exacerbate anemia, especially when the infection is moderate to heavy, and when women are coinfected with multiple parasites 64 . Helminthes attach to the intestines and or bladder and feed on blood, causing regular host blood loss due to blood loss at the site of helminth attachment, and the blood consumed by the parasite. Parasitic infections can lead to, among other symptoms, anorexia, malabsorption of nutrients, nutrient loss through fecal or urinary blood loss, nausea, diarrhea, and vomiting, which can result in depletion of iron stores and iron-deficiency anemia 65, 66 . Efforts to control and prevent parasitic infections such as the use of bed nets, routine deworming using chemother-apeutic agents, malaria prevention and control, and improved sanitation can help combat anemia (Table 22.6). Specific to pregnant women, it is likely safe to provide deworming therapy after the first trimester...

84 nutrient needs of the pregnant adolescent

The overall issue of weight gain may be problematic for teens responding to the skinny image presented in pervasive media. Croll in Guidelines for Adolescent Nutrition Services 30 presents an entire chapter dedicated to body image issues and tools to assist teens to establish a healthy appreciation for their unique appearance. She suggests that routine patient counseling should include assessment for body image concerns, and if present, teens should be provided with appropriate resources to address these issues. In her book, Croll provides specific questions to use in assessing body image, and suggests several strategies and tools to use with teens and their parents on body distortion, dieting, and media literacy. The same source 30 also has a chapter by Alton on eating disorders and offers diagnostic criteria and treatment information for these psychiatric syndromes with disturbed body images.

Sluts Vixens And Fatales

Likewise, in the popular Reviving Ophelia (1998), psychologist Mary Pipher pronounced girls a miasma of eating disorders, school phobias, self-inflicted injuries great unhappiness anxiety a total focus on looks moody, demanding, and distant elusive easily offended slow to trust sullen and secretive depressed overwhelmed symptomatic anorexic alcoholic in a dangerous place traumatized fragile saplings in a hurricane. 5 And we are not even halfway into the first chapter The first 15 pages of Rosalind Wiseman's Queen Bees and Wannabes (2002) likewise labeled girls confused, insecure, lashing out, totally obnoxious, moody, cruel, sneaky, lying, mean, exclusive, and catty. 6 Or, wrapping up everything in a single phrase, Courtney Martin tells us We are more diseased and more addicted than any generation of young women that has come before a bubbling, acid pit of guilt and shame and jealousy and restlessness and anxiety. 7

99 nutrition intervention

Nutrition education is a vital intervention component. Most women with eating disorders are well versed in nutrition facts and knowledge. However, they may be less aware of nutrition needs for healthy pregnancies. Discussion of micronutrient requirements and roles of these nutrients in fetal growth and development may redirect the mother's preoccupation with body weight and shape to fetal needs for intrauterine health. Other important nutrition education topics are listed in Table 9.6. Nutrition Education Topics during Pregnancy in Women with Anorexia Nervosa or Bulimia Nervosa

Irritabilitysensibility and maternal impressions

To some extent we might read across from the distinction between Laura and Medora in Smith's novel and that between Marianne and Elinor in Jane Austen's Sense and Sensibility. In neither case is this distinction absolute or clear-cut Laura and Marianne possess both acute feelings and a good understanding Elinor and Medora possess sense and a sensibility grounded in 'right and genuine feelings'. However, there is another connection Sense and Sensibility is the only Austen novel in which pregnancy receives more than a glancing reference. The fact that pregnancy should figure at all is perhaps not surprising in the context of contemporary ideas about the link between pregnancy and sensibility. Sense and Sensibility pairs a number of female characters, one of the most telling juxtapositions being that between Marianne and Mrs Palmer, whose stories run in counterpoint at one point in the novel. Mrs Palmer's narrative can be read in terms of the triumph of maternal insensibility. She is, in...

1913 micronutrients and postpartum depression 19131 Iron

Vitamin B12 is necessary for the maintenance of myelin, which insulates nerves and affects neurotransmission 79 . Although dietary B12 deficiencies are rare due to efficient recycling, strict vegetarians and individuals with decreased appetite anorexia should consider supplementing their diet. Neurological symptoms associated with deficiency include numbness and tingling, abnormalities in gait, memory loss, and disorientation. Vitamin B12 is found almost exclusively in animal products. Fortified cereal and grain products provide an alternative for those individuals who do not consume animal products. Although vitamin B12 is important to CNS functions, no associations have been reported for vitamin B12 and depression 90 or postpartum depression 88 .

The insanity of pregnancy

Preted some illnesses (such as anorexia) as forms of cultural protest.15 This has the advantage of situating disease in a specific social and cultural context, but risks overemphasis on disease as heroic resistance. In the case of the insanity of pregnancy, it is more accurate to see the illness as one that was jointly constructed by the medical profession and female patients, but that was differently inflected for these two groups. In this respect, the distinction Nancy Theriot makes between illness and disease is useful.16 Theriot suggests that illness can be defined as a behaviour pattern involving mental and physical symptoms, whereas disease is the definition given by physicians to the illness symptoms. In considering discussions of the insanity of pregnancy in medical texts, it is often helpful to distinguish between the reported symptoms (often given in the form of narrative case histories) and the disease classification.

3 Impact Of Pregnancy On Eatingdisorder Symptoms

Several studies have examined the effect of pregnancy on eating-disorder symptoms. In one of the few prospective studies to examine the impact and outcome of pregnancy, Blais et al. (6) interviewed 54 eating-disordered women before, during, and after pregnancy. Although pregnancy outcome was not related to any clinical variables, the live birth rate was 10 lower than the expected population rate. Eating-disorder symptoms were found to decrease from 3 mo prepregnancy to conception and from prepregnancy to 3 mo postpartum for both anorexic and bulimic patients (6). However, for women diagnosed with AN, symptom levels returned to prepregnancy levels within 6 mo following delivery. For women with a previous history ofBN who were not symptomatic at conception, there was no return of bulimic symptoms through 9 mo postpartum. Morgan and colleagues (7) reported similar findings in a study of94 women diagnosed with BN who, overall, improved throughout pregnancy. After delivery, however, 57 had...

Nutrition and Health

Deckelbaum, 2005 The Management of Eating Disorders and Obesity, Second Edition, edited by David J. Goldstein, 2005 Nutrition and Oral Medicine, edited by Riva Touger-Decker, David A. Sirois, and Connie C. Mobley, 2005 The Management of Eating Disorders and Obesity, edited by David J. Goldstein, 1999 Vitamin D Physiology, Molecular Biology, and Clinical Applications, edited by Michael F. Holick, 1999 Preventive Nutrition The Comprehensive Guide for Health Professionals, edited by Adrianne Bendich and Richard J. Deckelbaum, 1997


Primary problems lend themselves to investigation but sometimes no physical problems can be identified and a sizeable group of people have what is termed 'unexplained' infertility. Clearly, the psychological costs of such a diagnosis are high. Sometimes the causes of infertility can be directly due to other problems, illnesses or drug treatments. Sometimes you will have been directly informed of these risks, e.g. that a particular type of medication causes impotence. However, other problems may be hidden a previous history of anorexia nervosa can lead to fertility problems but if the eating problems were never recognised in the past,

Preconceptional Care

Preconceptional assessment of nutritional status should identify individuals who are underweight or overweight those with conditions such as bulimia, anorexia, pica, or hypervitaminosis and those with special dietary habits such as vegetarianism. Nutrition counseling may prove useful this may include information about dietary control of chronic diseases such as diabetes mellitus or phenylketonuria.

91 introduction

During periods of severe caloric deprivation, reproduction becomes a nonessential life function. For example, approximately half of all women of childbearing age experienced amenorrhea during the Dutch Winter Famine of 1944-1945 1 . Reproduction requires a nutritionally replete woman at conception and the availability of energy, macronutrients, and micronutrients throughout pregnancy (see Chap. 1, Nutrient Recommendations and Dietary Guidelines for Pregnant Women ). A supply of energy that is balanced to support eumenorrhea, implantation, and growth and development of the placenta and other maternal and fetal tissues is critical for optimal pregnancy outcomes. Anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS), and binge eating disorder (BED) represent conditions of energy, macronutrient, and micronutrient imbalances for individuals with such eating disorders. When occurring before, during, or after pregnancy, such a disorder may impact...

981 Assessment

Clinicians may pose several questions to their patients to identify preexisting or newly developed AN or BN (Table 9.4). Once such screening suggests the coexistence of pregnancy and an eating disorder, medical nutrition therapy (MNT) can be applied. As part of MNT, a full nutritional assessment involves systematic collection and evaluation of anthropomet-ric, biochemical, clinical, and dietary intake data. In addition, functional and behavioral status may be evaluated based on responses to screening questions (Table 9.4). An easily obtained parameter of adequate dietary intake and fetal growth is maternal body weight. Body weight should be measured at each prenatal visit, recognizing that this assessment may make a woman with AN or BN uncomfortable. Some women may even refuse to have body weight measured. In those women who may increase eating disorder behaviors with body weight gain 46, 48, 50 , nondisclosure of weight changes may be appropriate. Alternatively, in women who relax...

Alicias story

Alicia who was in hospital for treatment of her anorexia told me that she longed to be pregnant again as it was the only time she had ever eaten freely. She was able to imagine that everything she ate went directly into the baby and therefore she would not have gained any weight by the end of the pregnancy. Despite this she ate very little during the pregnancy and was very 'frail'after the birth of her baby and found caring for him an enormous struggle. Her husband had to take an extended leave from work to care for both of them.


Women with active AN or BN during pregnancy are at high risk for adverse outcomes. Ideally, treatment of the AN or BN should occur prior to conception. If not feasible, screening for and assessment of eating disorders during prenatal visits is critical. If an eating disorder is detected, then interdisciplinary care is vital to address all medical issues of the mother and developing fetus. Nutrition requirements of both the mother and fetus must be addressed, and eating patterns and behaviors that optimize a consistent and appropriate stream of nutrients to mother and fetus are key components of care. Treatment of the woman with AN or BN during pregnancy should not end at delivery, but rather, must continue into the postpartum period and beyond.

Katrinas story

Bulimia and other eating problems are often seen as 'teenage problems' but very many women continue to struggle with eating problems throughout their adult life. Katrina came to see me for help with bulimia. She had never sought help before but she was expecting her third child and finding it difficult to control the problems in the way that she had in the previous pregnancies. Katrina had two teenage sons who both excelled in sport. Her husband was out every night with the boys, taking them to various clubs, training and events. Katrina said that although she was enormously proud of them and of the efforts of her husband, she felt 'left out'and increasingly uninvolved in their lives. She had a very demanding jo b which she said had helped her to control her bingeing in the day but in the evenings, alone at home, she was regularly bingeing and vomiting. The pregnancy had been something of a surprise but both Katrina and her husband had felt it would be 'good'for her to have another...

Additional resources

Katz MG, Vollenhoven B (2000) The reproductive endocrine consequences of anorexia nervosa. Br J Obstet Gynaecol 107 707-713 Mitchell-Gieleghem A, Mittelstaedt ME, Bulik CM (2002) Eating disorders and childbearing concealment and consequences. Birth 29 182-191 Spear BA, Myers ES (2001) Position of the American Dietetic Association nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS). J Am Diet Assoc 101 810-819 Anorexia Nervosa and Related Eating Disorders, Inc. National Association of Anorexia Nervosa and Associated Disorders National Eating Disorders Association

1241 Macronutrients

HIV infection increases energy needs due to an increase in REE, as previously stated. This increased REE coupled with HIV-related infections and complications, such as anorexia, place HIV-infected pregnant women at greater nutritional risk than the uninfected woman 23, 24 . Current energy recommendations for HIV-infected pregnant and lactating women are an increase of 10 over baseline energy needs during the asymptomatic phase and an increase of 20-30 over baseline energy needs during the symptomatic phase 25 . Early symptomatic HIV infection is defined as the stage of viral infection caused by HIV when symptoms have begun, but before the development of AIDS. Symptoms may include but are not limited to mouth disorders (oral hairy leukoplakia, oral thrush, gingivitis), prolonged diarrhea, swollen lymph glands, prolonged fever, malaise, weight loss, bacterial pneumonia, joint pain, and recurrent herpes zoster. In addition, the World Health Organization (WHO) recommends an intake of an...

Debra L Franko

Eating disorders are most often diagnosed during the childbearing years. Pregnancy and postpartum issues for women with eating disorders are discussed with regard to symptoms, complications, course of pregnancy, delivery, breast-feeding, and postpartum depression (PPD). Research findings indicate that women with eating disorders during pregnancy may be at risk for a variety of pregnancy and obstetric complications. Moreover, there appears to be an association between eating-disorder symptoms and low birthweight as well as premature delivery. PPD is higher in women with eating disorders, and feeding issues have been documented. Assessment and treatment guidelines are presented to assist health care providers in caring for pregnant patients with eating disorders. Key Words Pregnancy eating disorders complications maternal weight gain low birthweight premature delivery breast-feeding postpartum depression.

81 First Trimester

The first trimester is quite difficult for a number of reasons. Weight gain often begins to occur before the patient has made her pregnancy known to others she is likely to experience anxiety that her weight gain will be attributed by others to being out of control and getting fat. Consider that many women with eating disorders have spent a substantial part oftheir adolescent and young adult lives trying to control their weight and now, early on in pregnancy, weight is increasing at a substantial rate. In addition, controlling one's appetite is often a primary goal for women with eating disorders (36), and in pregnancy it is normative and essential for a woman's appetite to be greater than usual. Furthermore, there is a substantial increase in fatigue during the first 3 mo ofpregnancy. For the eating-disordered woman who often ignores or denies her own needs, this increase in hunger and fatigue can be terrifying and lead to feelings of being out of control. These negative affective...

82 Second Trimester

The second trimester is one of relative calm, and women generally report this as the easiest 3 mo of the pregnancy. If the eating-disordered patient continues in psychotherapy, which is recommended, this period can serve as a time to examine a number ofpsychological issues that may emerge when the pregnant patient is feeling more energetic and capable of doing some exploratory work in therapy. she received as a child, which may have been experienced as inadequate or conflict-ridden. In this context, the patient with an eating disorder may struggle to determine how not to replicate that experience with her own child. This can be a time of tremendous growth and learning and offers a psychotherapist and other providers the opportunity for modeling and teaching of appropriate and warm parenting behaviors. Issues related to identity are often prominent for the eating-disordered patient and may emerge during this period of pregnancy. It is during this trimester that the pregnancy often...

83 Third Trimester

Body image issues, although present throughout pregnancy, tend to be especially problematic during this time. The eating-disordered patient is generally not able to accurately estimate her body size, even when she is thin or of normal weight. Her perception of her pregnant body is likely to be even more distorted. In seeing herself as bigger than she really is, her tendency may be to revert to minimizing her intake to keep herself from getting larger. The patient's increased weight in pregnancy may bring back memories of her pubescent weight gain, which may have been when her eating disorder started. Feelings of self-loathing, fears of spiraling out ofcontrol, and memories ofbeing teased may all be brought up as painful reminders of an earlier time. The patient's response may be to gain control in the only way she has learned how, by restricting or compensating for whatever food she takes into her body.

9 Helpful Strategies

Together with exploring or supporting these issues with the patient, there are several more pragmatic strategies that the clinician can use to help the patient through this often difficult 9 mo. Involvement with the spouse or partner is very important. It is well known that many women will choose not to tell their spouse about the eating disorder (37). During pregnancy, however, it is perhaps more important than ever before that the woman with an eating disorder makes her partner aware of her struggles with food and that the partner be enlisted for support. This may be the time for couples therapy, either with the woman's primary therapist or with someone new who is knowledgeable about eating disorders. Support will be needed not only during pregnancy, but also thereafter, in dealing with postpartum issues and caring for a newborn. In one of the prospective studies discussed earlier, the factor most strongly associated with positive pregnancy outcome was marital status (6). The...

10 Postpartum Issues

The period after delivery is most often experienced as stressful as well as joyful for most new mothers. For the patient with an eating disorder, the added stresses of her symptoms, pregnancy weight gain, and new feeding demands may pose particular challenges in the postpartum period. One issue of great concern is PPD (40). The prevalence of clinical depression in the postpartum period in the general population is estimated to be approx 12 (41). Franko et al. (22) reported more than three times that rate (35 ), an elevation that is consistent with the findings of earlier studies (7,17). In this prospective study a higher frequency of PPD was found in the group of women who were symptomatic with eating-disorder symptoms during pregnancy (22). Nearly half of the symptomatic group reported PPD, which may have been a function of previous affective disorder and or the physiological and psychological stresses of having an active eating disorder during pregnancy. Similarly, Morgan et al. (7)...

11 Conclusion

Consistent with the recommendations ofothers (7,12,17), close observation throughout pregnancy by obstetric and mental health providers is vital for patients with active eating disorders. Given the accumulating evidence of serious potential risk in patients with a history of or a current eating disorder, it is suggested that health care professionals routinely screen and assess for eating disorders in women and inquire carefully when a pregnant woman has a history of an eating disorder. The proposed treatment guidelines may provide assistance to both mental health and obstetric health care providers in optimizing maternal and fetal outcome.


Altitude-specific disorders that affect both pregnant and nonpregnant persons are acute mountain sickness (AMS), high-altitude pulmonary edema (HAPE), and chronic mountain sickness (CMS). AMS is characterized by symptoms including headache, insomnia, dyspnea, anorexia, and fatigue, which develop during the first 24 hours at altitude (18). Persons with HAPE, a potentially fatal disorder, present with tachypnea, tachycardia, frothy pink sputum, and may be obtunded or unconscious (19). CMS is characterized by severe headaches and confusion after a prolonged exposure to high altitude.