Eating Disorders, Pregnancy, and the Postpartum Period: Findings from the Norwegian Mother and Child Cohort Study (MoBa)

Breastfeeding and pumping as maladaptive weight control behaviors

It is well recognized by the general public that breastfeeding expends calories. In our clinical practice, a number of postpartum women with a history of or a current eating disorder (ED) report using breastfeeding and/or pumping breast milk to influence their body shape and weight. This appears to be either a form of weight control behavior or, in some cases, a compensation for perceived overeating or binge eating. Breastfeeding and pumping have not generally been identified as maladaptive weight control behaviors, nor have they been a subject of research to date. We suggest that this practice should be investigated to determine how common it is, its potential role in maintaining EDs or contributing to relapse in the postpartum period, and to better understand other potential harms it may cause to both the mother and infant/child. PUBLIC SIGNIFICANCE: Breastfeeding and pumping may be used as maladaptive methods of weight control by women with EDs. This behavior is under-recognized in clinical practice and has received little research attention. We argue that maladaptive breastfeeding and pumping warrant further investigation, as the behaviors may play an important role in maintaining an ED or in contributing to relapse during the postpartum period and may also indirectly harm the infant/child.

Body Image Dissatisfaction, Breastfeeding Experiences, and Self-Efficacy in Postpartum Women with and Without Eating Disorder Symptoms

BACKGROUND

Women during the postpartum period undergo significant changes which affect body image, eating behaviors, and, potentially, breastfeeding. There is limited research about relationships among these variables, particularly related to breastfeeding experiences and self-efficacy.

RESEARCH AIMS

To determine: (1) the associations between eating disorder symptoms and body image, breastfeeding self-efficacy, and breastfeeding experiences; and (2) the differences in body image, breastfeeding self-efficacy, breastfeeding experiences, and breastfeeding status of postpartum women with and without clinically significant eating disorder symptoms.

METHODS

A secondary data analysis using a 2-group correlational, cross-sectional online survey design was used. Participants with infants 2-6 months old who had breastfed their infant at least once (N = 204) were recruited nationally to complete a cross-sectional survey assessing breastfeeding and postpartum physical and mental health using validated measures. Linear and logistic regression evaluated differences between participants with and without eating disorder symptoms regarding their body image, breastfeeding experience and self-efficacy, and breastfeeding status (continued vs. discontinued) at 2 months postpartum.

RESULTS

Clinical eating disorder symptoms were reported by 9.8% (n = 20). Participants with clinical eating disorder symptoms reported lower appearance evaluations (B = -0.53, 95% CI [-0.93, -0.14]) and body image satisfaction (B = -0.55, 95% CI [-0.87, -0.23]); reduced odds of breastfeeding at 2 months postpartum (AOR = 0.15, 95% CI [0.04, 0.56]); and lower breastfeeding self-efficacy (B = -7.70, 95% CI [-14.82, -0.58] relative to participants without clinical symptoms. No differences between groups were observed for breastfeeding experiences.

CONCLUSIONS

Participants with clinically significant eating disorder symptoms are at risk for early breastfeeding discontinuation and lower breastfeeding self-efficacy. Our findings have implications for future research and clinical care practices, including screening for body image concerns and eating disorder symptoms and supporting breastfeeding self-efficacy.

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.

Is there a relationship between breastfeeding status and life style changes, eating behaviors, attitudes, and orthorexia nervosa tendencies of mothers? A web-based study

AIMS

It was aimed to compare the breastfeeding status and healthy life style changes, eating behaviors, attitudes, and orthorectic tendencies of mothers.

METHODS

All volunteered mothers who have a child between the ages of 0 and 2 were included in this cross-sectional study. Five hundred fourteen individuals were included. Five parted questionnaire and "ORTO-11" test and "Eating Attitude Test" were used.

RESULTS

A statistically significant relationship was found between breastfeeding status and working status and professions of mothers. Mothers who did not breastfeed, skipped main meal more frequently, and smoking and occasional alcohol consumption was higher. The mean score of the participants on the ORTO-11 scale was 25.09 ± 4.80, EAT-40 scale mean score was 18.80 ± 10.42. High-risk in eating attitudes was found in 12.0% of all participants. It was observed that mothers who did not breastfeed were mostly in high-risk group in terms of eating attitude.

CONCLUSION

Mothers who did not breastfeed were mostly in high-risk group in terms of eating attitude compared with breastfeeding mothers. It is of great importance that healthcare professionals organize trainings for increasing the general level of knowledge of mothers and provide healthy living and breastfeeding counseling.

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.

Course, risk factors, and adverse outcomes of disordered eating in pregnancy

OBJECTIVE

Although eating disorders in pregnancy have been studied extensively, little research attention has been given to disordered eating. The objectives of the present study were to determine the prevalence and levels of disordered eating in the perinatal period, and to identify risk factors and adverse outcomes of disordered eating during pregnancy.

METHOD

A prospective longitudinal design with a quantitative approach was adopted. A consecutive sample of 1,470 Chinese pregnant women from hospitals in Hong Kong was assessed using standardized instruments at five time points from the first trimester to 6 months postpartum.

RESULTS

The levels of disordered eating changed significantly across trimesters. Higher levels of disordered eating in pregnancy were significantly associated with higher levels of disordered eating at 6 weeks and 6 months postpartum, greater anxiety and depressive symptoms, lower 1-min Apgar scores, and abnormal birth weight.

DISCUSSION

The present study pointed to the need for more research and clinical attention to antenatal disordered eating given that it is associated with anxiety, depression, postpartum disordered eating and obstetric outcomes.

Prenatal and perinatal risk factors for eating disorders in women: A population cohort study

OBJECTIVE

The fetal programming model hypothesizes that developmental programming in utero and in early life induces adaptations that predetermine the adult phenotype. This study investigated whether prenatal/perinatal complications are associated with lifetime eating disorders in women.

METHOD

Participants included 46,373 adult women enrolled in the Norwegian Mother and Child Cohort Study (den norske Mor & barn-undersøkelsen [MoBa]). MoBa mothers and their mothers (MoBa grandmothers) were the focus of the current study. MoBa mothers with lifetime eating disorders were compared to a referent group.

RESULTS

MoBa mothers who weighed more at birth (birth weight, adjusted odds ratio [OR] = 1.14; 95% confidence interval [CI]: 1.10-1.19) or were born large-for-gestational-age (adjusted OR = 1.39; 95% CI: 1.27-1.52) were more likely to develop binge-eating disorder in later life. MoBa mothers who weighed less at birth were more likely to develop anorexia nervosa (birth weight, adjusted OR = 0.88; 95% CI: 0.81-0.95). Bulimia nervosa and purging disorder (PD) were not significantly predicted by the prenatal and perinatal factors examined.

DISCUSSION

Results of this study, which include the first known investigation of prenatal and perinatal factors in binge-eating disorder and PD, suggest that fetal programming may be relevant to the development of anorexia nervosa and binge-eating disorder. Future genetically informative research is needed to help disentangle whether these associations are a function of genetic influences or a true environmental fetal programming effect.

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 role of maternal anorexia nervosa and bulimia nervosa before and during pregnancy in early childhood wheezing: Findings from the NINFEA birth cohort study

OBJECTIVE

This study evaluates associations of maternal eating disorders (bulimia nervosa, anorexia nervosa, and purging behaviors) with infant wheezing and examines the effects of eating disorders on several wheezing determinants.

METHOD

We studied 5,150 singletons from the NINFEA birth cohort. Maternal bulimia nervosa and anorexia nervosa diagnoses were ascertained from the questionnaires completed in pregnancy and 6 months after delivery, and were analyzed as: ever diagnosis, only before pregnancy, and during pregnancy. Purging behaviors were assessed for 12 months before or during pregnancy. The associations with wheezing between 6 and 18 months of age were assessed in models adjusted for a priori selected confounders.

RESULTS

Children born to mothers with lifetime eating disorders were at an increased risk of developing wheezing (adjusted OR 1.68; [95% CI: 1.08, 2.60]), and this risk further increased when the disorders were active during pregnancy (2.52 [1.23, 5.19]). Increased risk of offspring wheezing was observed also for purging behaviors without history of eating disorder diagnosis (1.50 [1.10, 2.04]). The observed associations were not explained by comorbid depression and/or anxiety. Bulimia nervosa and/or anorexia nervosa during pregnancy were also associated with several risk factors for wheezing, including maternal smoking, adverse pregnancy outcomes, shorter breastfeeding duration, and day-care attendance.

DISCUSSION

The associations of maternal eating disorders with offspring wheezing suggest long-term adverse respiratory outcomes in children of mothers with eating disorders. A better understanding of mechanisms implicated is necessary to help reduce the respiratory disease burden in these children.

Signs and symptoms of disordered eating in pregnancy: a Delphi consensus study

BACKGROUND

This study aimed to establish consensus on the expression and distinction of disordered eating in pregnancy to improve awareness across various health professions and inform the development of a pregnancy-specific assessment instrument.

METHODS

A three-round modified Delphi method was used with two independent panels. International clinicians and researchers with extensive knowledge on and/or clinical experience with eating disorders formed the first panel and were recruited using structured selection criteria. Women who identified with a lived experience of disordered eating in pregnancy formed the second panel and were recruited via expressions of interest from study advertising on pregnancy forums and social media platforms. A systematic search of academic and grey literature produced 200 sources which were used to pre-populate the Round I questionnaire. Additional items were included in Round II based on panel feedback in Round I. Consensus was defined as 75% agreement on an item.

RESULTS

Of the 102 items presented to the 26 professional panel members and 15 consumer panel members, 75 reached consensus across both panels. Both panels clearly identified signs and symptoms of disordered eating in pregnancy and endorsed a number of clinical features practitioners should consider when delineating disordered eating symptomatically from normative pregnancy experiences.

CONCLUSION

A list of signs and symptoms in consensus was identified. The areas of collective agreement may be used to guide clinicians in clinical practice, aid the development of psychometric tools to detect/assess pregnancy-specific disordered eating, in addition to serving as starting point for the development of a core outcome set to measure disordered eating in pregnancy.

Variation in reproductive outcomes of women with histories of bulimia nervosa, anorexia nervosa, or eating disorder not otherwise specified relative to the general population and closest-aged sisters

OBJECTIVE

This study seeks to examine the long-term reproductive consequences of eating disorders (ED), to assess variation in reproductive outcomes by ED type, and to examine reproductive differences between women with previous ED diagnosis and their discordant sisters.

METHOD

Using a sample of women with previous ED diagnosis generated by the Utah Population Database, this study compares the fecundity (parity) and age at first birth of women by ED subtype (bulimia nervosa [BN], anorexia nervosa [AN], and ED not otherwise specified [EDNOS]) (n = 1,579). We also employed general population match case-control, and discordant sibling pair analyses, to estimate the magnitude of association between EDs and reproductive outcomes.

RESULTS

Women previously diagnosed with AN or EDNOS experienced delayed first birth (HRR = 0.33, HRR = 0.34, respectively) and lower parity (IRR = 0.19, IRR = 0.22, respectively) relative to BN (p < .05), the general population (p < .05), and closest-aged sisters (p < .05). Women previously diagnosed with BN experienced more moderate reductions and delays to their reproduction, and had similar reproductive outcomes as their discordant sisters.

DISCUSSION

Clinicians should consider ED type and family fertility histories when addressing the long-term reproductive health needs of women with prior AN, BN, or EDNOS diagnosis. Women previously diagnosed with AN or EDNOS likely experience the greatest reductions and delays in reproduction across their lifespan. Reproductive health screenings may be especially critical for the wellbeing of women with a history of AN or EDNOS.

Prenatal exposure to gestational diabetes mellitus as an independent risk factor for long-term neuropsychiatric morbidity of the offspring

BACKGROUND

The reported rates of gestational diabetes mellitus are constantly escalating and little is known about long-term complications in the offspring. Evidence from the field of epigenetics strongly advocates the need for research on the neuropsychiatric complications in offspring prenatally exposed to gestational diabetes mellitus.

OBJECTIVE

We sought to assess whether in utero exposure to gestational diabetes mellitus increases the risk of long-term neuropsychiatric morbidity in the offspring.

STUDY DESIGN

A population-based cohort study compared the incidence of hospitalizations due to neuropsychiatric disease between singletons exposed and unexposed to gestational diabetes mellitus. Deliveries occurred in the years 1991 through 2014 in a regional tertiary medical center. Perinatal deaths, multiple gestations, mothers with pregestational diabetes or lack of prenatal care, and children with congenital malformations were excluded from the study. A multivariate generalized estimating equation logistic regression model analysis was used to control for confounders and for maternal clusters.

RESULTS

During the study period 231,271 deliveries met the inclusion criteria; 5.4% of the births were to mothers diagnosed with gestational diabetes mellitus (n = 12,642), of these 4.3% had gestational diabetes type A1 (n = 10,076) and 1.1% had gestational diabetes type A2 (n = 2566). During the follow-up period, a significant linear association was noted between the severity of the gestational diabetes (no gestational diabetes, gestational diabetes mellitus A1, gestational diabetes mellitus A2) and neuropsychiatric disease of the offspring (1.02% vs 1.36% vs 1.68%, respectively, P < .001). A Kaplan-Meier curve demonstrated that children born to women with gestational diabetes mellitus had higher cumulative incidence of neuropsychiatric morbidity. Using a generalized estimating equation multivariable logistic regression model, controlling for time-to-event, maternal age, gestational age at delivery, maternal obesity, maternal preeclampsia and fertility treatments, maternal gestational diabetes mellitus was found to be an independent risk factor for long-term neuropsychiatric disease of the offspring (gestational diabetes mellitus A1 [adjusted odds ratio, 1.83; 95% confidence interval, 1.53-2.19] and gestational diabetes mellitus A2 [adjusted odds ratio, 1.64; 95% confidence interval, 1.18-2.27]). Within the limits of our database, our findings also point to a possible association between in utero exposure to gestational diabetes mellitus and autistic spectrum disorder of the offspring (adjusted odds ratio, 4.44; 95% confidence interval, 1.55-12.69), which was found significant also after controlling for time-to-event, maternal age, gestational age at delivery, and offspring weight at birth.

CONCLUSION

Exposure to maternal gestational diabetes mellitus is an independent risk factor for long-term neuropsychiatric morbidity in the offspring.

Pandemic of Pregnant Obese Women: Is It Time to Re-Evaluate Antenatal Weight Loss?

The Obesity pandemic will afflict future generations without successful prevention, intervention and management. Attention to reducing obesity before, during and after pregnancy is essential for mothers and their offspring. Preconception weight loss is difficult given that many pregnancies are unplanned. Interventions aimed at limiting gestational weight gain have produced minimal maternal and infant outcomes. Therefore, increased research to develop evidence-based clinical practice is needed to adequately care for obese pregnant women especially during antenatal care. This review evaluates the current evidence of obesity interventions during pregnancy various including weight loss for safety and efficacy. Recommendations are provided with the end goal being a healthy pregnancy, optimal condition for breastfeeding and prevent the progression of obesity in future generations.