The Reciprocal Effects of Eating Disorders and the Postpartum Period: A Review of the Literature and Recommendations for Clinical Care

Impact of parenthood on eating pathology in young adults

OBJECTIVE

Few studies investigated parenthood as a predictor of eating pathology in young adulthood. We studied the association between parenthood, in the first year after becoming a parent and beyond, and eating pathology. Furthermore, we examined whether moving in together with a partner affected this association.

METHOD

This study used data of four measurement waves from TRAILS (Tracking Adolescents' Individual Lives Survey), a Dutch community cohort study (N = 2229) from preadolescence into young adulthood. The Eating Disorder Diagnostic Scale (EDDS), a measure to assess eating pathology, was assessed at ages 22, 26, and 29. Risk for eating disorder was assessed at age 19. Pregnant participants were excluded.

RESULTS

Parenthood was not associated with an increase of eating pathology in the first year after becoming a parent and beyond. Instead, parents were more likely to report being free from eating pathology symptoms compared to childless individuals (OR 2.07, 95% CI: 1.11-3.84). Among those who reported experiencing at least one eating problem, parenthood was not associated with the number of eating problems. Moving in together with a partner did not alter the association between parenthood and eating problems and neither did this association differ between males and females.

DISCUSSION

Parenthood in young adulthood was associated with a decreased risk of having eating pathology.

PUBLIC SIGNIFICANCE STATEMENT

In this longitudinal study among young adults, parenthood was not associated with the development of eating pathology.

Hyperemesis gravidarum and eating disorders before and after pregnancy: A register-based study

OBJECTIVE

Hyperemesis gravidarum (HG) is a severe form of excessive vomiting during pregnancy. The connection between psychiatric morbidity and HG has been debated, but only a few studies have focused on eating disorders (EDs). The objective of this study was to evaluate the association between HG and both pre-pregnancy and new post-pregnancy EDs.

METHODS

A register-based controlled study. HG diagnoses were retrieved from healthcare registers between 2005 and 2017. Women with HG in their first pregnancy resulting in delivery were chosen as cases (n = 4265; the HG group) and women with no HG as controls (n = 302,663; the non-HG group). The associations between EDs and HG were analyzed by binary logistic regression, adjusted with age, body mass index, smoking, socioeconomic status, and pre-pregnancy psychiatric diagnoses.

RESULTS

In the HG group, 1.6% and in the non-HG group, 0.2% had a pre-pregnancy ED. Women with ED were more likely to have HG in their first pregnancy compared with women with no history of EDs (adjusted odds ratio [AOR] 9.4, 95% CI 6.52-13.66, p < .0001). Moreover, 0.4% of the women in the HG group and 0.1% of the women in the non-HG group had a new ED diagnosis after pregnancy, and thus the women in the HG group were more likely to have an ED diagnosis after pregnancy (AOR I 3.5, 95% CI 1.71-7.15, p < .001, AOR II 2.7, 95% CI 1.30-5.69, p = .008).

DISCUSSION

We found a bidirectional association between ED and HG, suggesting a shared etiology or risk factors between these disorders. This finding emphasizes the importance of collaboration across various specialties when treating these patients.

PUBLIC SIGNIFICANCE

Our findings suggest a bidirectional association between HG and EDs before and after pregnancy. This finding provides essential information for healthcare professionals working with pregnant women. As both of these disorders are known to have far-reaching effects on the lives of both the mother and her offspring, our results help clinicians to target special attention and interventions to the patients suffering from these disorders.

Effect of maternal eating disorders on mother-infant quality of interaction, bonding and child temperament: A longitudinal study

AIMS

This study aims to investigate the effect of maternal eating disorders (ED) on mother-infant quality of interaction at 8 weeks and bonding and child temperament at 1 and 2 years postnatally. We also aimed to explore the relationship between maternal ED psychopathology, comorbid psychiatric difficulties, and both mother-infant quality of interaction and bonding in women with ED. Women were recruited to a prospective longitudinal study. By the time of giving birth, the sample consisted of 101 women of the initial 137 (73.7%). Overall, 62 women (ED = 36; HC = 26) participated in the 8-week assessment, 42 (ED = 20; HC = 22) at 1 year, and 78 (ED = 34; HC = 44) at 2 years. Mann-Whitney U Test was used to explore association between maternal ED and mother-infant quality of interaction and between maternal ED and bonding. Spearman correlations were used to explore associations between maternal ED psychopathology, comorbid psychiatric difficulties, and both mother-infant quality of interaction and bonding.

RESULTS

We found no differences between early mother-infant interaction and bonding in mothers with ED in comparison to HC. High levels of maternal ED psychopathology were correlated with high anxiety levels, higher negative affectivity, and lower extraversion in children of ED mothers both at 1 and 2 years. Furthermore, high levels of ED psychopathology were also associated with lower effortful control at 1 year.

CONCLUSIONS

Findings imply that maternal ED have an impact on child temperament. Future research should focus on resilience and on which protective factors might lead to positive outcomes. These factors can be then used as therapeutic and preventative targets.

The Reproductive Impact of Eating Disorders in Adolescents

Eating disorders are common, chronic illnesses that frequently arise during adolescence. Because of the impact on nutrition, individuals with eating disorders have significant health consequences, including effects on reproductive health. Adolescent women with eating disorders frequently have menstrual irregularities, though the causes of these abnormalities are complex and vary depending on the type of eating disorder. Teens with eating disorders may have changes in current and future fertility, and eating disorders during pregnancy can have medical and psychologic impacts for both mother and child. Though not well researched, eating disorders in men can affect reproductive health and potentially impact fertility. Lastly, eating disorders in adolescents can have significantly deleterious, irreversible effects on bone health.

Eating disorders, pregnancy and the postnatal period: a review of the recent literature

PURPOSE OF REVIEW

Eating disorders (ED) are severe psychiatric disorders that affect women in reproductive age. The purpose of this review is to provide an up-to-date overview of the impact of maternal ED on pregnancy and the postnatal period. The clinical implications for identification and management of maternal ED are also discussed.

RECENT FINDINGS

In the last 2 years, 15 articles focused on the impact of maternal ED in pregnancy and postpartum. Findings from this review indicate that around 15% of pregnant women are likely to have had an ED at some point in their lifetime, and about 5% have an ED in pregnancy. Although ED symptoms tend to decrease during pregnancy, remission is often only temporary with symptoms typically resurfacing in the postnatal period. Women with ED are prone to psychiatric comorbidities such as depression and anxiety during the perinatal period, with up to a third of women with ED reporting postnatal depression in clinical studies and prevalence ranging between 40% and 66% in general population samples. Furthermore, recent findings continue to highlight that current and prior history of maternal ED are associated with a heightened risk of adverse pregnancy and birth outcomes, most notably preterm birth and adverse birth weight outcomes.

SUMMARY

These findings continue to emphasise the clinical importance of early identification and response to maternal ED to mitigate potentially adverse maternal and infant outcomes.

Disordered eating measures validated in pregnancy samples: a systematic review

Although disordered eating in pregnancy has been linked to numerous negative consequences, there is currently no published instrument specifically devised to identify or measure such symptoms in pregnancy. As such, this study systematically reviewed the literature to evaluate the performance of general measures of disordered eating in pregnancy samples. A systematic search of the following electronic databases was undertaken from inception to April 2019: Scopus, Medline, PsycINFO, Embase, ProQuest Dissertations and Theses, and the Cumulative Index to Nursing and Allied Health Literature. From 1724 citations, eight publications met the inclusion criteria and were included in the review. Most of the included studies (6/8) were of reasonable quality. Overall, three self-report inventories (EDE-Q, EDI-2, and DEBS) and one semi-structured clinical interview (EDE) had some form of psychometric information available. Most studies reported reliability, with only two reporting validity. No studies assessed screening accuracy. Other than the EDE-Q, which had preliminary evidence to suggest possible utility in pregnancy, the findings of this review revealed little to no evidence to support the use of general measures of disordered eating in pregnancy. A strong need for research exploring the validity of existing measures in pregnancy samples, including the EDE-Q, was also evident.

Predicting the change in perinatal disordered eating symptoms: An examination of psychosocial factors

Disordered eating symptoms remain a largely unidentified and unsupported area in perinatal healthcare, particularly as they pertain to women without diagnosed eating disorders. In an Australian prospective cohort study, women aged 18-48, completed questionnaires between: 18-24 weeks gestation (n = 249, T1), 30-32 weeks gestation (n = 151, T2) and 8-10 weeks postpartum (n = 124, T3), measuring disordered eating symptoms, psychosocial factors (attitudes to pregnancy or motherhood, self-compassion, relationship satisfaction and perinatal social support) and mental health factors (depressive or anxiety symptoms). Multilevel linear models examined predictive associations between psychosocial factors at T1 and the change in disordered eating symptoms from T1 to T2 and from T1 to T3, in addition to the moderating effects of pre-pregnancy BMI and pregnancy depressive or anxiety symptoms. Whilst restraint and shape concerns decreased from T1 to T2, restraint, shape and weight concerns increased from T1 to T3. Psychosocial factors at T1 were able to predict the change in some disordered eating symptoms. Moreover, when pre-pregnancy BMI or pregnancy depressive or anxiety symptoms were elevated, the impact of psychosocial factors on disordered eating increased. The findings of this study provide a more complex understanding of disordered eating across the perinatal period, with implications for future interventions and research design.

Disordered eating in the postpartum period: Role of psychological distress, body dissatisfaction, dysfunctional maternal beliefs and self-compassion

The present cross-sectional study tested the affect regulation model of disordered eating for women in the postpartum period, whereby disordered eating is used to cope with psychological distress. Two hundred and two women who had given birth in the last two years completed an online survey of self-report measures of study variables. Path analyses supported the primary hypothesis: negative affect mediated relationships between body dissatisfaction, dysfunctional maternal beliefs, negative components of self-compassion and disordered eating behaviours, particularly binge eating. Results suggest that negative affect plays a central role in postpartum disordered eating. Interventions to address maladaptive emotion regulation strategies, specifically targeting body image distress and self-critical maternal thoughts may improve eating behaviours for this population.

Systematic Review of Literature on Eating Disorders During Pregnancy-Risk and Consequences for Mother and Child

Background: Eating disorders (ED) are a diagnostic category that includes several nosological units such as anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). This category most often concerns women, while the peak incidence falls on the reproductive age. Therefore the issue of ED during pregnancy is an interesting topic. Due to the creation of unrealistic ideal of "desired," slim figure both by the mass media and social media even during and right after gestation, more and more pregnant women introduce behaviours aimed at maintaining the "perfect" appearance. However in some cases it may have serious consequences for the health of both mother and child leading to the creation of the term "pregorexia" by the media to describe this issue. Aim: The aim of this paper was to conduct a systematic review of the literature dealing with eating disorders in pregnant women, with particular emphasis on pregorexia. Method: A systematic review of literature published within the last 5 years (2016-2021) in English or Polish and available through MEDLINE / PubMed, Google Scholar and Cochrane Library databases was conducted based on the previously assumed inclusion and exclusion criteria. Results: Initially, 634 publications were obtained during the review, of which 55 papers were selected in the course of the title analysis. After further evaluation of abstracts, 28 papers were qualified for full text analysis. Ultimately, 10 papers were selected for the final analysis. Conclusions: The issue of ED in pregnant women is a broad topic covering a heterogeneous group of women-both those with a previous history and those with the onset during pregnancy. The occurrence of ED symptoms during this period is associated with a high likelihood of negative consequences for both the mother and the child. The course of pregnancies and deliveries in these patients is more complicated. Therefore, it seems reasonable to develop a multidisciplinary screening strategy and standards of management and supervision over this group of patients.

Interventions to Empower Adults with Eating Disorders and Their Partners around the Transition to Parenthood

The transition to parenthood is perceived as a stressful life event, when parents experience an immense change of their psychological focus and a reorientation of roles and responsibilities in the family system. This process may be even more challenging in the presence of a parental eating disorder history. This paper reviews the impact of parental eating disorders on the parents, the couple relationship, and their child during the perinatal period. A parental eating disorder is associated with more negative expectations of parental efficacy as well as specific difficulties in couple communication over the child's feeding, shape, and weight. Providers who better understand the effects of an eating disorder on parental functioning can more effectively intervene early on. We also present couple- or parent-based, empirically supported interventions for adults with eating disorders and their partners in the prenatal and postnatal periods: Uniting Couples in the treatment of Anorexia Nervosa (UCAN) and Uniting couples In the Treatment of Eating disorders (UNITE) both enhance recovery from the eating disorder through a couple-based intervention; the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) incorporates the support of partners, when appropriate; Parent-Based Prevention (PBP) focuses on improving parental functioning and reducing risk of negative parental and child outcomes. Finally, we discuss the clinical implications of addressing parental eating disorders and encourage more research on these families.

An application of psychosocial frameworks for eating disorder risk during the postpartum period: A review and future directions

The postpartum period may be a particular window of vulnerability for eating disorder symptoms given changes to body shape and weight that women experience. However, no quantitative studies have identified risk factors for postpartum eating disorder symptoms, and current psychosocial frameworks of risk may be missing key elements unique to this period. This manuscript reviews existing quantitative and qualitative literature regarding the developmental trajectory of eating disorder symptoms during the perinatal period and proposes an application of three psychosocial models of eating disorder risk (objectification theory, the tripartite influence model of body image and eating disturbances, and social comparison theory) to the postpartum period. Drawing on quantitative and qualitative literature, this paper identifies novel postpartum-specific factors that should be included for consideration in psychosocial models (e.g., self-oriented body comparison and pressure to achieve a prepregnancy weight and shape). This review is the first to theorize potential postpartum-specific risk factors for postpartum eating disorder symptoms. Prior models of eating disorder risk omit key psychosocial factors that are unique to the postpartum period. Other limitations of prior research relate to measurement and methodology. This critical window of vulnerability has been largely ignored in the quantitative literature and necessitates further research.

Disordered eating from pregnancy to the postpartum period: The role of psychosocial and mental health factors

The postpartum period has been identified as high-risk period for the increase of disordered eating. This study examined the psychosocial factors-attitudes to motherhood, self-compassion and relationship satisfaction- and mental health factors-depressive and anxiety symptoms-associated with this increase. One hundred and fourteen women completed online questionnaires about their eating behaviours between: 18-24 weeks gestation (T1), 30-32 weeks gestation (T2) and 8-10 weeks postpartum (T3). A cluster analysis examined the change of disordered eating from T2 to T3. Multinomial logistic regressions examined which demographic, psychosocial and mental health factors were associated with disordered eating cluster groups, as individual factors and as a combined model of predictors at T1, T2 and T3. Four cluster groups were identified: 'lower disordered eating', 'increasing risk', 'sub-clinical' and 'clinical'. All psychosocial and mental health predictors were individually associated with a risk group, when compared to the lower disordered eating group. However, when combined, only multiparity and higher depressive symptoms were associated with the sub-clinical group. Multiparity, higher pre-pregnancy body mass index and lower self-compassion were associated with the increasing risk group. This study introduces self-compassion as a psychosocial factor worthy of further investigation and application in the field of perinatal disordered eating, with promising avenues for antenatal intervention.

Eating Disorders in Pregnant and Breastfeeding Women: A Systematic Review

Background: Pregnancy is a stage associated with various biopsychosocial changes. These changes, along with concerns about keeping an adequate weight, can modulate an individual's risk for psychological disorders, especially eating disorders (EDs). The aim of this review was to investigate the prevalence, associated risks, and consequences of eating disorders in pregnancy and in breastfeeding mothers. Materials and Methods: A systematic review was carried out following the PRISMA guidelines in the scientific databases: PubMed, Web of Science, Scopus, and PsycINFO. Search terms related to EDs, pregnancy, and breastfeeding were used. The evaluation of the methodological quality of the studies was carried out using different scales; CASP (Checklist for Cohort Study), NICE (Methodology Checklist for Cohort Study), ARHQ (Methodology Checklist for Cross-Sectional), and NOS (Newcastle-Ottawa Scale for Cohort). Results: From 2920 studies, 16 were selected to study EDs in pregnant women and 2 studies in nursing mothers. Most of the studies used questionnaires and scales as tools for the diagnosis of EDs. Binge eating, anxiety, and depression were the most common comorbidities of EDs, accompanied in most cases by excessive concern about weight gain. The consequences of EDs are diverse. The prevalence of EDs in this population is estimated to be 1 out of 20. Conclusions: Eating disorders are related to anxiety and depression and have negative consequences for both mothers and fetuses (cesarean, miscarriages, premature births). More research on the field to determine the risk factors for EDs in the population of pregnant and lactating women is needed.

Eating Disorders During Gestation: Implications for Mother's Health, Fetal Outcomes, and Epigenetic Changes

Introduction: Eating disorders (EDs) have increased globally in women of childbearing age, related to the concern for body shape promoted in industrialized countries. Pregnancy may exacerbate a previous ED or conversely may be a chance for improving eating patterns due to the mother's concern for the unborn baby. EDs may impact pregnancy evolution and increase the risk of adverse outcomes such as miscarriage, preterm delivery, poor fetal growth, or malformations, but the knowledge on this topic is limited. Methods: We performed a systematic review of studies on humans in order to clarify the mechanisms underpinning the adverse pregnancy outcomes in patients with EDs. Results: Although unfavorable fetal development could be multifactorial, maternal malnutrition, altered hormonal pathways, low pre-pregnancy body mass index, and poor gestational weight gain, combined with maternal psychopathology and stress, may impair the evolution of pregnancy. Environmental factors such as malnutrition or substance of abuse may also induce epigenetic changes in the fetal epigenome, which mark lifelong health concerns in offspring. Conclusions: The precocious detection of dysfunctional eating behaviors in the pre-pregnancy period and an early multidisciplinary approach comprised of nutritional support, psychotherapeutic techniques, and the use of psychotropics if necessary, would prevent lifelong morbidity for both mother and fetus. Further prospective studies with large sample sizes are needed in order to design a structured intervention during every stage of pregnancy and in the postpartum period.

Randomized controlled trial of the Circle of Security-Intensive intervention for mothers with postpartum depression: maternal unresolved attachment moderates changes in sensitivity

Postpartum depression is related to inadequately sensitive caregiving, putting infants at risk for insecure attachment. Therefore, promoting sensitive maternal caregiving and secure child attachment is particularly important in postpartum depressed mothers and their infants. In this randomized-controlled-trial, we evaluated the efficacy of the Circle of Security-Intensive (COS-I)-intervention in supporting maternal sensitivity and mother-infant-attachment compared to treatment-as-usual (TAU) with unresolved-maternal attachment as a moderator of treatment effect. Eligible mothers with infants (N=72) 4-9 months-old were randomly assigned to treatment (n=36 dyads). Infant attachment was rated at follow-up (child age 16-18 months) (Strange-Situation-procedure). Maternal sensitivity was measured at baseline and follow-up (Mini-Maternal-Behavior-Q-sort). Maternal-unresolved-attachment was assessed at baseline (Adult-Attachment-Interview). We found no significant differences between treatments in infant attachment nor changes in mothers' sensitivity. However, in COS-I, unresolved-mothers exhibited significantly more change in sensitivity than non-unresolved-mothers, whereas in TAU, the opposite was true. These findings may help to optimize clinical use of COS-I.

Israeli and British women's wellbeing and eating behaviours in pregnancy and postpartum

OBJECTIVES

The study had two main objectives: (a) track changes in self-esteem, eating behaviours and body satisfaction from early pregnancy to 24 months postpartum and (b) to compare changes by context (Israel vs. UK) and maternal body mass index (BMI).

BACKGROUND

High maternal BMI is associated with negative body image and restrained eating, which are experienced differently across cultures.

METHODS

156 pregnant women were recruited from Israel and the UK. Seventy-three women were followed up every six months from early postpartum and until 24 months following birth. Women completed questionnaires assessing self-esteem (RSEQ), body image (BIS/BIDQ) and eating behaviours (DEBQ) and self-reported weights and heights so that BMI could be calculated.

RESULTS

Women with higher BMI had higher levels of self-esteem and were less satisfied with their body. Healthy-weight women were more likely to lose all of their retained pregnancy weight compared to overweight and obese women. Self-esteem, body image and eating behaviours remained stable from pregnancy until 24 months postpartum. No significant differences were found for any measure by context.

CONCLUSION

BMI was the strongest predictor of self-esteem and body dissatisfaction and a higher BMI predicted less weight loss postpartum.

Consensus on the assessment of disordered eating in pregnancy: an international Delphi study

This study aimed to assess and develop consensus on the assessment of disordered eating in pregnancy. A three-round modified Delphi approach was used. Participants were international clinicians and researchers (N = 26) with extensive knowledge on and/or clinical experience with eating disorders, particularly in relation to pregnancy and/or women's health. Clear consensus among the panel, defined as 75% agreement, was reached regarding the assessment of disordered eating in pregnancy, in addition to potential assessment methods. Antenatal assessment of disordered eating was perceived to be crucial and ideally occur in a routine manner. Despite agreement that various assessment methods would be relevant in assessing disordered eating in pregnancy, psychometrically sound brief screening instruments were perceived to be most feasible for practitioners and women accessing antenatal care; however, these instruments must be pregnancy-specific and delivered in an authentic and caring manner to be beneficial.

The influence of psychological factors on postpartum weight retention 12 months post-birth

Background During the first postpartum year 20% of women retain excessive weight from pregnancy (postpartum weight retention; PPWR), which predicts long-term overweight/obesity. Objective The aim of this study was to explore the associations between psychological factors (depression, anxiety and stress symptoms and body attitudes) in late gestation and at 12-months postpartum with PPWR one-year post-birth. Methods Pregnant women (N = 176) completed questionnaires in early-mid pregnancy (Time 1; mean (SD) = 16.97 (1.35) weeks), late pregnancy (Time 2; mean (SD) = 33.33 (2.05) weeks), and one year postpartum (Time 3; mean (SD) = 53.12 (3.34) weeks). Women provided demographic characteristics, height and pre-pregnancy weight at Time 1. At Times 2 and 3, weight, depressive, anxiety and stress symptoms and body attitudes (salience of weight and shape, attractiveness, feeling fat, and strength and fitness) were assessed in addition to physiological, socio-contextual and lifestyle factors. Gestational weight gain and PPWR were calculated. Hierarchical linear regression models were conducted to explore variance in 12-month PPWR. Results Overall, models explained 26-39% variance in PPWR. Gestational weight gain in late pregnancy and low attractiveness at 12 months postpartum were the only variables associated significantly with 12-month PPWR. Conclusion While psychological factors did not appear to be important direct contributors to PPWR at 12 months, the overall contribution of all variables suggests that such factors may be implicated in a small and incremental way. Exploration of the interactions between variables will help unpack potential mechanisms of the development of PPWR at 12 months post-birth.

Maternal mental health symptoms are positively related to emotional and restrained eating attitudes in a statewide sample of mothers participating in a supplemental nutrition program for women, infants and young children

Postpartum, low-income mothers are at risk for mental health symptoms and obesity, and disordered eating attitudes may be associated with both mental health and obesity in this vulnerable population. The study objective is to determine whether higher levels of mental health symptoms are associated with increased odds of emotional and restrained eating attitudes in this sample of Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants. Data on 711 mothers of infants <13 months from a statewide sample of Maryland WIC participants were collected via telephone survey. Maternal mental health symptoms were measured on continuous scales for depression (PRIME-MD), stress (Perceived Stress Scale) and anxiety (Spielberger State-Trait Anxiety Inventory). Emotional and restrained eating attitudes were measured with questions adapted from the Dutch Eating Behavior Questionnaire. Multivariate logistic regression analysis was used. Obesity [body mass index (BMI) ≥ 30] was explored as a moderating variable. Mothers reporting higher levels of depression symptoms [odds ratio (OR) = 3.93, 95%CI: 2.71-5.69], anxiety symptoms (OR = 1.96, 95%CI: 1.47-2.65), stress symptoms (OR = 2.09, 95%CI: 1.67-2.61) and high overall mental health symptomatology (OR = 3.51, 95%CI: 2.43-5.3) had increased odds of emotional eating attitudes. There were significant associations between symptoms of depression (OR = 1.59, 95% CI: 1.12-2.25) and increased odds of restrained eating attitudes. Obesity did not moderate the association. Mothers with mental health symptoms are at risk for disordered eating attitudes, which may increase risk of poor diet. These findings underscore the need for greater focus on addressing maternal mental health status and eating attitudes in the postpartum period.

Antenatal and postnatal psychopathology among women with current and past eating disorders: longitudinal patterns

This study aims to investigate longitudinal patterns of psychopathology during the antenatal and postnatal periods among women with current (C-ED) and past (P-ED) eating disorders. Women were recruited to a prospective longitudinal study: C-ED (n = 31), P-ED (n = 29) and healthy control (HC; n = 57). Anxiety, depression and ED symptoms were measured at four time points: first/second trimester, third trimester, 8 weeks and 6 months postpartum. Linear mixed effects models were used to test for group differences. Women with C-ED and P-ED, in all diagnostic categories, had significantly higher levels of psychopathology at all time points. ED symptoms decreased in the C-ED group, compared with an overall increase in the other two groups but subsequently increased after pregnancy. Overall, depression and state and trait anxiety scores decreased in the C-ED group compared with the HC group throughout the antenatal and postnatal periods. High levels of psychopathology are common throughout the antenatal and postnatal periods among women with current and past ED, and despite some overall reductions, symptoms remain clinically significant. © 2014 The Authors. European Eating Disorders Review published by John Wiley & Sons, Ltd.

Gestational and postpartum weight change patterns in mothers with eating disorders

BACKGROUND

Although pregnancy can be associated with adaptive changes in weight and eating behaviour for women with eating disorders, less is known about whether these changes are maintained in the postpartum period. We used a longitudinal design to examine gestational and postpartum weight trajectories in mothers with and without eating disorders in the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health.

METHODS

Fifty-six women reported anorexia nervosa (AN), 636 bulimia nervosa, 3327 binge eating disorder and 69 eating disorder not otherwise specified, purging type. The referent group included 61,233 mothers with no eating disorder. We used a mixed effects model to predict weight change over time by eating disorder subtype.

RESULTS

Mothers with AN, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified had greater increases in body mass index (BMI) during pregnancy and greater decreases in BMI over the first 6 months postpartum. Women with AN shifted from the underweight BMI range before pregnancy to the normal weight range at 36 months postpartum

CONCLUSIONS

Patterns of maternal weight gain and retention during the perinatal period vary across eating disorder subtype and warrant clinical attention.

Reproductive issues in anorexia nervosa

Despite a high prevalence of menstrual irregularities, women with anorexia nervosa are becoming pregnant. The physical and psychological demands of pregnancy and motherhood can represent an immense challenge for women already struggling with the medical and psychological stress of an eating disorder. This article summarizes key issues related to reproduction in women with anorexia nervosa, highlighting the importance of preconception counseling, adequate gestational weight gain, and sufficient pre- and post-natal nutrition. Postpartum issues including eating disorder symptom relapse, weight loss, breastfeeding, and risk of perinatal depression and anxiety are also discussed.

NURTURE: development and pilot testing of a novel parenting intervention for mothers with histories of an eating disorder

OBJECTIVE

To describe the treatment development and pilot testing of a group parenting intervention, NURTURE (Networking, Uniting, and Reaching out To Upgrade Relationships and Eating), for mothers with histories of eating disorders.

METHOD

Based on focus group findings, extant research, and expert opinion, NURTURE was designed to be delivered weekly over 16 (1.5 h) sessions via an interactive web conferencing forum. It comprises four modules: (1) laying the foundation, (2) general parenting skills, (3) eating and feeding, and (4) breaking the cycle of risk. Pilot testing was conducted with three groups of 3-6 mothers (N = 13) who had children ages 0-3 years to determine feasibility (e.g., retention), acceptability (e.g., feedback questionnaire responses), and preliminary efficacy. Maternal satisfaction with NURTURE and changes in mother-child feeding relationship measures, maternal feeding style, maternal self-efficacy, and maternal psychopathology (eating disorder, depression, and anxiety symptoms) across three time points (baseline, post-treatment, 6-month follow-up) were examined. All outcomes were exploratory.

RESULTS

The intervention was well tolerated with a 100% retention rate. Feedback from mothers was generally positive and indicated that the groups provided an engaging, supportive experience to participants. We observed changes suggestive of improvement in self-reported maternal self-efficacy and competence with parenting. There were no notable changes in measures of maternal feeding style or psychopathology.

DISCUSSION

NURTURE is a feasible, acceptable, and potentially valuable intervention for mothers with eating disorder histories. Results of this pilot will inform a larger randomized-controlled intervention to determine efficacy and impact on child outcomes.

Childbearing and mortality among women with anorexia nervosa

OBJECTIVE

To assess the association between childbearing and mortality from anorexia nervosa (AN).

METHOD

A total of 5,251 females, from a population-based Swedish registry, admitted with an AN diagnosis during the period 1973-2003 were included. Standardized mortality ratios (SMR) were estimated and hazard ratios (HR) were calculated using Cox regression.

RESULTS

Nulliparous women had a sixfold higher mortality due to natural causes and ninefold higher mortality due to unnatural causes compared to the general population. Parous women had higher mortality compared to the general population only due to unnatural causes. Suicide was the most common cause of death. Childbearing was associated with a 65% lower mortality. One hundred forty four women out of 1,941 parous women were hospitalized perinatally for any psychiatric disorder (7.4%).

DISCUSSION

Childbearing is associated with lower mortality among women with AN.

An exploratory analysis of associations between eating disordered symptoms, perceived weight changes, and oral contraceptive discontinuation among young minority women

PURPOSE

To explore associations between eating-disordered (ED) symptoms, perceived oral contraceptive (OC)-related weight changes, and OC discontinuation among young minority women.

METHODS

We conducted a prospective substudy of a randomized controlled trial evaluating the impact of a pill pack supply (3 vs. 7 months) on OC continuation among young urban women presenting to a university-affiliated community-based family planning clinic for OC management. Participants (n = 354) were adolescent (n = 173) and young adult (n = 181) women aged 13-24 years, predominantly underinsured and largely Hispanic (92%). We conducted a structured baseline interview that included an ED screening instrument. At the 6-month follow-up, we conducted a telephone interview to determine OC continuation and dimensions of perceived OC-related weight changes during the study period.

RESULTS

At baseline, 24% of the subjects fulfilled the moderate/severe ED symptom screen criteria (n = 60). By 6 months, 57% of the subjects (n = 200) reported weight changes and 62% (n = 218) had discontinued OC use. Unadjusted discontinuation rates were similar across age- and ED symptom groups. In multivariate analysis, both ED symptoms (odds ratio = .49, 95% confidence interval = .25-.96, p = .04) and perceived weight changes (odds ratio = .60, 95% confidence interval = .38-.94, p = .03) were negatively associated with OC continuation.

CONCLUSIONS

ED symptoms and perceived weight changes were associated with an increased likelihood of OC discontinuation among these young women. Reproductive health practitioners should consider psychological symptoms when managing OC.

Insatisfação corporal, prática de dietas e comportamentos de risco para transtornos alimentares em mães residentes em Santos

OBJETIVO: Avaliar a insatisfação corporal, a prática de dietas e os comportamentos de risco para transtornos alimentares em uma amostra de mães residentes no município de Santos. MÉTODOS: Foi realizado um estudo transversal, de base populacional, com 453 mães de filhos com até 10 anos de idade. As mães responderam ao Teste de Atitudes Alimentares (EAT-26), à Escala de Figuras de Stunkard e a uma questão sobre a prática atual de dietas. RESULTADOS: Das mães, 29,9% apresentaram escore positivo para os comportamentos de risco para transtornos alimentares e 21,8% estavam fazendo dieta para emagrecer no momento da entrevista. No tocante à imagem corporal, 17,5% das mães estavam satisfeitas com o seu tamanho corporal, 71,5% gostariam de diminuir seu tamanho corporal e 11,0% gostariam de aumentá-lo. Os comportamentos de risco para transtornos alimentares foram mais frequentes nas mães insatisfeitas com seus tamanhos corporais (p < 0,0001). CONCLUSÃO: A maioria das mães investigadas estava insatisfeita com os seus tamanhos corporais. A frequência de mães que praticavam dietas ou tinham comportamentos de risco para transtornos alimentares foi similar ou superior aos demais estudos nacionais, conduzidos, em sua maioria, com populações consideradas de risco, como meninas adolescentes e jovens universitárias.

Eating disorders and trauma history in women with perinatal depression

OBJECTIVE

Although the prevalence of perinatal depression (depression occurring during pregnancy and postpartum) is 10%, little is known about psychiatric comorbidity in these women. We examined the prevalence of comorbid eating disorders (ED) and trauma history in women with perinatal depression.

METHODS

A research questionnaire was administered to 158 consecutive patients seen in a perinatal psychiatry clinic during pregnancy (n=99) or postpartum (n=59). Measures included Structured Clinical Interview for DSM (SCID) IV-based questions for lifetime eating psychopathology and assessments of comorbid psychiatric illness including the State/Trait Anxiety Inventory (STAI), Patient Health Questionnaire (PHQ-9), Edinburgh Postnatal Depression Scale (EPDS), and Trauma Inventory.

RESULTS

In this cohort, 37.1% reported a putative lifetime ED history; 10.1% reported anorexia nervosa (AN), 10.1% reported bulimia nervosa (BN), 10.1% reported ED not otherwise specified-purging subtype (EDNOS-P), and 7.0% reported binge eating disorder (BED). Women with BN reported more severe depression (EPDS score, 19.1, standard deviation [SD 4.3], p=0.02; PHQ-severity 14.5, SD 7.4, p=0.02) than the referent group of women with perinatal depression and no ED history (EPDS 13.3, SD=6.1; PHQ 9.0, SD=6.2). Women with AN were more likely to report sexual trauma history than the referent group (62.5% vs. 29.3%, p<0.05), and those with BN were more likely report physical (50.0%, p<0.05) and sexual (66.7%, p<0.05) trauma histories.

CONCLUSIONS

ED histories were present in over one third of admissions to a perinatal psychiatry clinic. Women with BN reported more severe depression and histories of physical and sexual trauma. Screening for histories of eating psychopathology is important in women with perinatal depression.

Reproductive risk: its role in maternal mental health

For many women, pregnancy and childbirth are not without substantial risk in terms of new-onset, recurrent or existing mental disorder. This has consequences not only in terms of poor maternal mental health but also in terms of increased pregnancy- and delivery-related morbidity and can have a significant negative impact on the wellbeing of the fetus or neonate. New-onset disorders such as postnatal depression and puerperal psychosis have been recognised for some considerable time but it is also becoming apparent that, with the exception of anorexia nervosa, severe intellectual disability and possibly schizophrenia, conception rates among women with all types of mental disorder are the same as those in the general population. In high-income countries, the widespread use of atypical antipsychotics, most of which do not impair reproductive function, may lead to increased conception rates in women with schizophrenia. In addition, pregnancy and childbirth are multifactorial stressors which may render women with previous mental disorders vulnerable to a recurrence. Hence it is no surprise that studies in urban, low-income and ethnically diverse populations in the USA estimate that around a third of pregnant women are suffering from a mental disorder when substance misuse is included (e.g. Kim et al, 2006).

Predictors of mothers' postpartum body dissatisfaction

PURPOSE

To investigate changes in mothers' body dissatisfaction from delivery to 9 months postpartum, and the relationship of postpartum body dissatisfaction to weight, other health, and social characteristics.

METHODS

In this prospective longitudinal study, 506 mothers completed surveys at 0-1 and 9 months postpartum. Postpartum changes in body dissatisfaction and weight were evaluated by paired t-tests, and predictors of postpartum body dissatisfaction were identified by stepwise multiple regression analysis.

RESULTS

Mothers' body dissatisfaction increased significantly from 0-1 to 9 months postpartum (mean scores of 15.2 and 18.2, respectively, p < .001). Although women lost an average of 10.1 pounds (sd = 16.3) or 4.6 kg. (sd = 7.4) between 0-1 and 9 months postpartum (p < .001), their weight at 9 months postpartum remained an average of 5.4 pounds (sd = 15.6) or 2.5 kg (sd = 7.1) above their pre-pregnancy weights (p < .001). Body dissatisfaction at 9 months postpartum was associated with overeating or poor appetite, higher current weight, worse mental health (SF-36 Mental Health scale), race other than black, bottle-feeding (vs. breastfeeding), being single (vs. married), and having fewer children.

CONCLUSIONS

Mothers' body satisfaction worsened from 1 to 9 months postpartum, and 9-month body dissatisfaction was associated with eating/appetite abnormalities, greater weight, worse mental health, non-black race, non-breastfeeding status, and fewer immediate family relationships. Given these relationships, it is important to educate women about expected postpartum weight and body changes, and to find ways to enhance mothers' postpartum self-esteem and body satisfaction.

Eating disorders in the obstetric and gynecologic patient population

The eating disorders anorexia nervosa and bulimia nervosa and eating disorders not otherwise specified disproportionately affect women, have profound effects on the overall well-being of women and their children, and can have mortality rates as high as those found with major depression. These disorders may present to obstetrician-gynecologists (ob-gyns) clinically as menstrual dysfunction, low bone density, sexual dysfunction, miscarriage, preterm delivery, or low birth weight in offspring. Ninety percent of eating disorders develop before the age of 25 in otherwise healthy young women, a group that characteristically seeks the majority of their health care from ob-gyns. For all of these reasons, ob-gyns must have a greater awareness of these disorders and a lower index of suspicion for screening their patients than they currently do. Otherwise, they may miss life-threatening illness, treat characteristic amenorrhea inappropriately, or inadvertently intervene to help these women conceive, contributing to maternal and fetal risks. As providers of both primary and specialty care for women, ob-gyns have the opportunity to play a vital role in prevention and diagnosis of eating disorders and in the multidisciplinary management required to effectively manage these disorders.

Transtornos alimentares e gestação: uma revisão

OBJETIVO: Estudar o impacto dos transtornos alimentares nas funções reprodutivas, problemas na gestação e puerpério, e dificuldades com a alimentação dos filhos. MÉTODOS: Realizou-se revisão da literatura nos últimos 28 anos nos bancos de dados MedLine e Lilacs. Combinaram-se os descritores anorexia nervosa, bulimia nervosa, transtornos alimentares e gestação. RESULTADOS: Os estudos de revisão, estudos de caso e pesquisas realizadas com gestantes apontam uma associação entre TA e uma variedade de complicações na gestação, no parto, para o feto, com aumentado risco de morbidade perinatal, além de complicações na alimentação futura da criança. CONCLUSÕES: Observa-se uma maior necessidade de acompanhamento especializado, principalmente no pré-natal, em relação aos hábitos alimentares e preocupação com peso e forma corporais - especialmente nas mulheres que apresentam ganho ponderal inadequado, hiperêmese gravídica, picacismo, entre outros.