At some point in their lives, most people have heard that they should “eat healthy.” This means different things to different people. For some, it means eating less junk food and more nutrient-rich foods; for others, it could mean making dietary changes to reduce sodium intake or to eat foods that help lower levels of bad cholesterol. Regardless of your medical history, healthy eating is something everyone is encouraged to do, and is especially important for women who are pregnant or breastfeeding. However, women with eating disorders who are also pregnant or breastfeeding can face additional challenges. This can include not only what to eat, but how much to eat and how often they should be eating.

A few years ago, I received a call from a woman name “Alice”. She called MotherToBaby because she was taking medication for high blood pressure, and wanted to know if it would affect her pregnancy. After some discussion, she told me her blood pressure was high because she was quickly gaining a lot of weight from binge eating. She said she had been binge eating for a long time and did not know how to stop. She was worried about how this would affect not only her health, but also that of her baby. When I asked what her healthcare provider suggested, she told me she was too afraid to talk to her midwife about it.

What is an eating disorder?
An eating disorder is a psychological disorder that results in serious disturbances of eating behavior. There are several different eating disorders. Some of the common ones include anorexia nervosa, bulimia nervosa, binge eating disorder, and pica. Each disorder has its own symptoms and effects.

• Anorexia nervosa –severely restricting the amount of food eaten, resulting in very low body weight. 0.9% of American women suffer from anorexia in their lifetime.1
• Bulimia nervosa – binge eating (eating large amounts of food in a short time and feeling loss of control over eating) and then purging (vomiting, not eating, over-exercising, misusing laxatives or diuretics). 1.5% of American women suffer from bulimia nervosa in their lifetime.
• Binge-eating disorder- binge eating without purging. 2.8% of American adults suffer from binge eating disorder in their lifetime.
• Pica – a craving for and eating of substances without any nutritional value (such as ice, clay, paper, or dirt) for at least one month. The amount of women affected by pica is unknown but it much more common in pregnant women than in non-pregnant women; it is also more common in developing countries than in the US.

Eating disorders can be difficult to identify in general and especially during and after pregnancy. The stigma surrounding eating disorders can make it hard for women to admit there is a problem. In addition, health professionals may not have the right training to identify eating disorders.

Can eating disorders affect my pregnancy?
A healthy, well-balanced diet during pregnancy is important for a baby to grow and develop as it should. It can also help to minimize some pregnancy symptoms such as nausea and constipation. Certain eating-disorder behaviors can cause issues for the pregnant woman and/or for her pregnancy, and may require hospitalization or other specialized care. For example:

• Not eating and/or calorie restricting can cause low energy and nutritional deficiencies in the mother and low birth weight for the baby.
• Vomiting can cause dehydration, electrolyte imbalances, sore throat, stomach pain, tooth damage, gum disease and ruptured esophagus in the mother.
• Using laxatives/diuretics can cause dehydration, electrolyte imbalances, laxative dependency and organ damage in the mother.
• Over-exercising can lead to fatigue, muscle pain/soreness, dehydration and overheating in the mother.
• Binge eating can lead to excessive weight gain, gestational diabetes, high blood pressure (and other complications) in the mother, and large birth weight for the baby.
• Eating of non-food substances (pica) can interfere with nutrient absorption, and may contain toxic or parasitic substances that could be harmful to mom or baby.
• Mental health issues, such as depression or anxiety, go hand in hand with eating disorders. According to the American College of Obstetricians and Gynecologists (ACOG), “depression during pregnancy has been linked to premature birth, problems with growth of the fetus, having a low birth weight baby, and complications after birth.”

What about breastfeeding?
Getting sufficient “high quality” calories is important for all moms. When a woman is breastfeeding, her body needs energy to make enough milk for the baby. Women who do not get enough calories may have trouble making milk. Regarding pica, non-food items may contain something potentially harmful to the baby, such as lead.

Studies have suggested that women who have an eating disorder and breastfeed may be more likely to stop breastfeeding within the first 6 months. However, it is possible for women with eating disorders to successfully breastfeed their babies, even if they are taking medications. The key is finding support, which you can get from healthcare providers (doctors, nurses, lactation consultants), family, friends, and support groups (online, over-the-phone, and in person).

What you can do.
If you have been diagnosed with an eating disorder, or think you may have one, talk with your healthcare provider. You are not alone. There are resources available to help you and your baby be as healthy as you can be.

All pregnant and breastfeeding women should focus on taking in the correct amount of calories, which can be different for each person. Talk to your healthcare provider to determine what is ideal for you. Plus, there are many resources available to help educate women about good food choices. The United States Department of Agriculture (USDA) has a website that can help moms and moms-to-be make healthy eating choices: https://www.choosemyplate.gov/moms-pregnancy-breastfeeding. There is also information on which foods/drinks to limit/avoid, the appropriate amount of weight to gain, and the recommended amount of exercise. https://www.niddk.nih.gov/health-information/weight-management/health-tips-pregnant-women.

So what happened with Alice? She called several times throughout her pregnancy and while breastfeeding. After our first conversation, she told her midwife everything. Alice did develop gestational diabetes, but under the care of her midwife, nutritionist and counselor, she was able to stop gaining weight and get her blood sugar and blood pressure under control. She gave birth to a healthy baby, and continued to work with her team during breastfeeding. She thanked me for suggesting she ask for help, and said she was closer to finding something we all are looking for – balance.

Chris Stallman is a certified genetic counselor based in Tucson, Arizona and proud mother of three. She currently works for The University of Arizona as a Teratogen Information Specialist at MotherToBaby Arizona, formerly known as the Arizona Pregnancy Riskline. Her counseling experience includes prenatal and cardiac genetics. She has also served as MotherToBaby’s Education Committee Co-chair.

About MotherToBaby
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References:
Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), 348–358.

Bye, A., Shawe, J., Bick, D., Easter, A., Kash-Macdonald, M., & Micali, N. (2018). Barriers to identifying eating disorders in pregnancy and in the postnatal period: a qualitative approach. BMC Pregnancy and Childbirth, 18, 114. http://doi.org/10.1186/s12884-018-1745-x

Dos Santos AM, Guerra Benute GR, Oliveira dos Santos N, Yamamoto Nomura RM, Souza de Lucia MC, Vieira Francisco RP. Presence of eating disorders and its relationship to anxiety and depression in pregnant women. Midwifery. Midwifery. 2017 Aug;51:12-15.

Women’s Health Care Physicians. (2012, July). Retrieved July 9, 2018, from https://www.acog.org/Patients/FAQs/Depression#affect

Torgersen L1, Ystrom E, Haugen M, Meltzer HM, Von Holle A, Berg CK, Reichborn-Kjennerud T, Bulik CM. (2010). Breastfeeding practice in mothers with eating disorders. Matern Child Nutr. 2010 Jul 1;6(3):243-52. https://www.ncbi.nlm.nih.gov/pubmed/20929496

Eating Disorders. (n.d.). Retrieved July 9, 2018, from https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml

Healthy Pregnant or Postpartum Women. (2015, June 04). Retrieved July 9, 2018, from https://www.cdc.gov/physicalactivity/basics/pregnancy/index.htm

Stanford Children’s Health. (n.d.). Retrieved July 9, 2018, from http://www.stanfordchildrens.org/en/topic/default?id=nutrition-during-pregnancy-85-P01227

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