Personalizing care for pregnant women with eating disorders
While anorexia nervosa is characterized by distorted body image and disturbed eating behaviors, the root cause is more complicated and may represent a lifelong challenge that is unique to each patient.
During pregnancy, treatment is based on when a person was diagnosed with the eating disorder and where they are in their recovery. Three main timeframes include:
1. Women who have successfully managed their eating disorder.
Wanting to have a baby can be an extra motivator for some women to put in the hard work to overcome their eating disorder. Women who have regained and maintained a stable weight, are eating regularly, and making sure they get enough nutrition often can focus on making sure that they continue to eat enough to support the pregnancy.
Drinking protein shakes can be quite beneficial – not to fully replace meals, but to provide some nutrients and offer satiety without the mental stimulus of eating more.
We’ll also want to monitor exercise. For some women who have faced eating disorders, it may be beneficial to reduce exercise to avoid triggers or unintentional weight loss.
2. Women diagnosed with an eating disorder while pregnant or trying to get pregnant.
Accepting you have an eating disorder can be difficult. Sometimes, it takes struggling to get pregnant or experiencing multiple miscarriages for the disorder to come to light.
For example, some women who have engaged in high-intensity exercise throughout their life may not be aware that these activities can contribute to infertility and early miscarriages. Learning that one may need to gain weight and reduce their exercise to achieve fertility is often a surprise, as the concept of weight gain leading to better health is rarely presented. Patients with an eating disorder can find it difficult to change entrenched behaviors, such as reducing exercise and increasing fat and calorie intake.
We meet these women where they are in the timeline of acceptance to start the journey toward recovery. This can include helping them physically prepare for a healthy pregnancy by optimizing nutrition or finding a balance of nutrition and behavioral health support.
Wanting a pregnancy can be a very strong motivation to change disordered eating. Typically, treatment starts with education about mental and physical wellness. Developing more insight about the situations, types of food, and times that make eating harder and easier is a top priority for women who are just starting to recognize their own disordered eating disorder as they become pregnant.
3. Women whose symptoms increase during pregnancy.
Common pregnancy issues such as fluctuating hormones, morning sickness, nutrition, hydration, or adjusting medications can become more complicated with an eating disorder.
Some patients with bulimia nervosa may start to recognize how physiological factors such as hunger and hydration exacerbate symptoms previously viewed as more psychological, such as binge-eating or vomiting. For example, many women with morning sickness find improvement with frequent small snacks – this strategy is also helpful for women with eating disorders.
Helping women find aspects of their health that they can control, such as drinking protein shakes when unable to eat meals or taking their medications, is an important part of this process. A dietitian with expertise in eating disorders can be very helpful by providing a meal plan as a guide.
A personalized approach tailored to the specific situation is required to care for and support women who struggle with particular aspects of their eating disorder during pregnancy.
Related reading: Inside the brain of someone with an eating disorder
"While issues related to your eating disorder may come up during pregnancy and can be challenging, by getting the support you need, you’ll be better equipped to ride them out without resorting to self-destructive habits. "
How eating disorders can affect fertility
Prolonged calorie reduction or excessive exercise can cause irregular or missed periods, and insufficient levels of certain vitamins and minerals can lead to increased difficulty in body functions, including conception.
But it’s a myth that a woman can’t get pregnant if she has an eating disorder. Generally, a woman needs at least 22% body fat to conceive and maintain a pregnancy. Ideally, we’d like to see a woman with an eating disorder maintain or exceed that level over time before trying to become pregnant. Doing so allows her body to build up the reserves necessary to keep herself and the baby as healthy as possible.
Be aware of triggers during pregnancy
Weight gain is one of the most obvious pregnancy-related triggers for eating disorders. Patients typically are weighed and measured countless times throughout pregnancy. Ask your provider not to tell you the numbers. And try to avoid looking at your medical records frequently, particularly if seeing your natural pregnancy weight increase might upset you.
Reminding yourself and your clinician to consider all weight gain as good during the pregnancy can be a necessity to maintain healthy eating behaviors.
Morning sickness can be especially difficult for women who have struggled with certain eating disorders. Vomiting can bring back memories of a past habit. If vomiting was a part of your eating disorder, you may have a weaker lower esophageal sphincter (LES), the bundle of muscles between the esophagus and stomach, making reflux more likely.
Gestational diabetes also can be a major trigger. We advise patients with eating disorders not to count calories or other numbers related to food. Guidelines created to manage gestational diabetes are often developed with an expectation of a larger body in both the patient and the fetus and may need modification for patients with eating disorders.
Talk with your doctor if you are concerned about specific situations. We can create a plan to avoid triggers when possible.
Taking medications during pregnancy
Many people with an eating disorder also struggle with depression and anxiety and are prescribed selective serotonin reuptake inhibitors (SSRIs) to help relieve symptoms. Most SSRIs are considered safe to take during pregnancy and not associated with birth defects.
Medications that have been associated with an increased risk of birth defects, such as certain seizure drugs, may need to be adjusted or paused during pregnancy. If you are thinking about getting pregnant or have just become pregnant, talk with your doctor about the best plan for you.
Related reading: Should I stop taking medication when I’m pregnant
Managing an eating disorder after delivery
Sleep disruption is common for new parents, and getting enough sleep is essential for good mental and physical health. If possible, ask a family member or friend to help take care of the baby while you get a few consecutive hours of sleep on a regular basis.
Breastfeeding requires adequate nutrition and hydration to be successful. Protein shakes continue to be helpful in getting adequate nutrition and calories. We also recommend carrying a water bottle in your diaper bag and drinking a glass every time you nurse to stay hydrated.
A few final tips
The best advice we can offer is to be honest with yourself and your doctors about your condition and ask for help when you need it:
- Lean on family and friends and accepts offers to help with meals, childcare, or housework.
- Keep seeing your therapist before and after pregnancy. They can support you through triggers and offer a listening ear if times get tough.
- See a dietitian to maintain or develop a healthy eating routine.
- Work towards eating a meal with other people.
“Normal eating” is sometimes hard to define in our society. In general, people with and at risk for eating disorders benefit from eating family-style meals with others. For people with eating disorders, family meals can provide social support, reduce decision-making about individual choices to eat or not eat, shifts focus from food to other topics, and promotes equity within the family as everyone eats the same foods at the same time.
While an eating disorder can create challenges during pregnancy, support and expert care are available.