December 2018 Issue

CPE Monthly: Eating Disorders in Pregnancy
By Lindsay Stenovec, MS, RDN, CEDRD, CLEC
Today's Dietitian
Vol. 20, No. 12, P. 42

Suggested CDR Learning Codes: 3020, 4130, 4180, 5200
Suggested CED Performance Indicators: 8.1.4, 8.2.1, 12.2.1
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

According to epidemiologic studies, at least one in 20 women experiences some form of an eating disorder during pregnancy, with the highest risk for those who have a history of an eating disorder.1,2 A 2013 study found that 7.5% of women receiving their first routine ultrasound scan during pregnancy met the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria for an eating disorder in early pregnancy.3 Furthermore, a 2012 study by Broussard showed that 28% of subjects displayed disordered eating symptoms and psychological and behavioral traits associated with eating disorders during pregnancy, yet 93.3% of the women with disordered eating weren't identified by their medical practitioners.4 For the purposes of this article, the term "eating disorder" will be used when referring to a specific diagnosis or history of a diagnosis according to the DSM-IV and DSM-V criteria for eating disorders. The term "disordered eating" is used in reference to behaviors around food that are disordered but may not have been evaluated for or are not severe enough to reach a formal diagnosis.

Surprisingly, many studies show that eating disorder symptoms improve during pregnancy, or at least during the second trimester.4,5 This may be due to a combination of hormonal changes, a sense of responsibility and care for the developing fetus, a level of acceptance of the body's changes, and/or a perceived permission to eat and respond to the body's needs. This has led to the belief that pregnancy may be a time for women with eating disorders to learn healthful eating behaviors and discontinue those that may be harmful to themselves and their unborn children. However, some studies are conflicting, as they've shown that eating disorder symptoms worsen during pregnancy or pregnancy can lead to the onset of an eating disorder.6,7 Dietitians and medical professionals should remember that many women with eating disorders continue to experience high levels of associated symptoms during pregnancy, compared with women with no history of eating disorders, and these women often remain undiagnosed.6-8

Getting an accurate picture of the incidence of eating disorders during pregnancy is difficult for several reasons, including inconsistent criteria and measurements used to determine eating disorder symptoms; the severity, shame, and stigma often associated with eating disorder behaviors during pregnancy; and lack of medical practitioner insight.3 In addition, symptoms such as vomiting and decreased appetite due to nausea during pregnancy or the natural occurrence of gestational weight gain may mask eating disorder symptoms.3 Furthermore, culturally common body dissatisfaction and dieting behaviors may lead women to believe that their own concerns about disordered eating and body dissatisfaction are a normal part of the pregnancy experience and therefore are irrelevant to discuss in the short appointments with their medical practitioners.

Health care providers need tools and knowledge to effectively and sensitively screen for eating disorder symptoms around the gestational period and refer to the appropriate support persons when eating disorder symptoms are identified. RDs are likely to encounter women seeking care for nutrition advice and weight management before, during, and after pregnancy and therefore are in a prime position to screen for eating disorders and provide nutritional support and appropriate referrals for care and treatment.

This continuing education course identifies the incidence of eating disorders during pregnancy; examines signs, symptoms, risk factors, and nutritional deficiencies; and explores the RD's role in eating disorder treatment during pregnancy.

Risk Factors
A variety of biological, psychological, and sociocultural factors contribute to the onset and maintenance of eating disorders. For obvious reasons, having a distant or recent history of an eating disorder increases the risk of having an eating disorder during pregnancy.9 Additional risk factors that may indicate the need for further screening for disordered eating include family history of eating disorders, low BMI, previous infertility and/or menstrual inconsistencies; high concern about weight and shape; malnutrition; digestive issues; emotional and/or physical abuse; addiction to drugs or alcohol; sexual trauma; and an existing mental illness such as depression, anxiety, or obsessive compulsiveness.10,11

Since women with eating disorders may struggle with fertility, it's been suggested they may be more likely to seek infertility treatment, thus increasing the number of women who are pregnant and suffering from an eating disorder.12 However, while some women with eating disorders may struggle with infertility, pregnancy with an eating disorder is still possible. Women with amenorrhea and low body weight resulting from eating disorders often can conceive.13 There's accumulating evidence suggesting that anorexia nervosa (AN) and bulimia nervosa (BN) are associated with an increased risk of unplanned pregnancies and birth complications.3,13 One explanation is that women may assume that because they have amenorrhea they can't get pregnant and may choose not to use contraception. This could increase the risk of an unplanned pregnancy occurring upon the initial return of ovulation, before the first menstrual cycle. A woman also may ovulate despite experiencing amenorrhea.3,13

Screening and Symptoms
No standardized screening for eating disorders is available during pregnancy, and it's uncommon for a medical practitioner to screen pregnant patients for disordered eating symptoms.3,4,7,8 In the 2012 Broussard study, 27.8% of subjects were found to suffer from disordered eating or psychological and behavioral traits associated with eating disorders. As previously stated, of those subjects, 93.3% weren't screened and their health care providers didn't identify symptoms. These women didn't mention concerns regarding disordered eating during medical check-ups.4 Considering that 5% to 7.5% of pregnant women may suffer from eating disorders during pregnancy and close to 30% may meet criteria for psychological and behavioral traits associated with eating disorders, pregnant women should be properly screened for eating disorders and disordered eating by their OB/GYNs or midwives. Dietitians also need to be aware that it isn't standard practice for OB/GYNs to screen; therefore, it would be prudent for RDs to screen clients for eating disorders and disordered eating. RDs who specialize in fertility and perinatal/pediatric nutrition should obtain training on how to identify risks and symptoms of disordered eating so they may properly screen, support, and refer when appropriate.

Various validated diagnostic tools used in the current research include the Eating Disorder Diagnostic Scale, Structured Clinical Interview for Axis I DSM-IV-TR Disorders, Eating Disorder Examination Questionnaire (EDE-Q), Eating Attitudes Test, the SCOFF questionnaire, and the Eating Disorder Inventory-3.3,4,8,14 These tools are used to screen for symptoms such as fear of weight gain or becoming fat; compensatory behaviors such as laxative use, fasting, or self-induced vomiting; and binge eating with a loss of control. They're inexpensive and easy to include in paperwork that patients are asked to complete before an appointment. It's been suggested that a standardized tool be developed or chosen to increase screening in practice and improve research conducted on this population.3,14

While research tends to show that eating disorder symptoms decrease during pregnancy, there's evidence that symptoms of binge eating disorder (BED) increase during pregnancy. Most research assessing incidence of prepregnancy BED rates compared with BED rates during pregnancy shows either no significant change in incidence or an increase.1,3,15,16 BED is more likely than other eating disorders to have an initial onset during pregnancy.1,3 In addition, BED wasn't formally recognized as a diagnosis until the publication of the DSM-5 in 2013. Therefore, studies published before 2013 that show an increase in incidence of Eating Disorder Not Otherwise Specified during pregnancy likely included individuals with BED.1,3,15,16 Some studies show that women with BN are able to decrease or eliminate compensatory behaviors before pregnancy but transition to meeting criteria for BED during pregnancy.16 One study evaluating nutrient intake reported that almost 34% of women suffering from BN prepregnancy met criteria for BED during pregnancy.16 There were no data in that study about whether these women met criteria for BN postpartum; however, several studies suggest that the postpartum time, specifically around six months post delivery, is a risky time when women may relapse into bulimia and subsequent compensatory behaviors such as vomiting.16,17

Mental Health
In a study of twins conducted by Mazzeo and colleagues in 2006, 39% of women with AN and 59% with BN experienced depression during pregnancy.18 A later study found that 40% of pregnant women with eating disorders experienced a major depressive episode during the year of childbirth.8 The Nutrition and Stress in Pregnancy (NEST-p) study is an observational prospective study of pregnant women and their infants. NEST-p found that women who had eating disorder symptoms during pregnancy coupled with a history of depression experienced the highest degrees of depression and anxiety during pregnancy as compared with healthy pregnant women.8 In addition, women with eating disorders during pregnancy are significantly more likely to develop postpartum depression, with one study finding that 45.5% of mothers with active eating disorders report postpartum depression.19

Detection of mental disorders also is inadequate due, among other reasons, to medical professionals' lack of expertise and education about mental disorders. In 2016, the Journal of the American Medical Association released an update to the 2009 US Preventive Services Task Force Recommendation Statement that recommended all adults be screened for depression, specifically emphasizing pregnant and postpartum women.20 Considering the overlap of depression, anxiety, and eating disorders, and the task force's recent emphasis on mental health screening, this may be a prime opportunity to advocate for consistent eating disorder screening in addition to depression screening.

Nutrition-Related Concerns
Surprisingly, research shows few significant differences in nutritional intake between women with or without eating disorders during pregnancy, specifically for women with BN and BED.16 It's possible that small sample size, poor subject participation, and a somewhat common reduction in symptoms that occur during pregnancy make it difficult to identify specific nutritional deficiencies in women with eating disorders during pregnancy. Clinically speaking, RDs witness a wide range of nutritional intake and nutrient status in clients with eating disorders during pregnancy. Research on nutrition trends should serve as a starting point, but individual clients' intake and needs should guide MNT.

Although there's some evidence for remission of symptoms during pregnancy, women with anorexia continue to report concerns about body image, weight, and shape and display more disordered eating symptoms compared with their noneating disorder counterparts.21 Clinical signs of AN related to malnutrition include hypotension, bradycardia, dehydration, muscular atrophy, and low serum gonadotrophin and estrogen levels, signs that should continue to be assessed by a medical team throughout the pregnancy of a woman who may be at risk.21

A study conducted by Siega-Riz and colleagues compared food group and nutrient intake in pregnant women with vs without bulimia or BED.16 According to the authors, there were no previous prospective, population-based cohorts evaluating the impact that eating disorders have on nutritional intake during pregnancy.16 The results of this study found that women with BED before and during pregnancy had higher overall caloric, monounsaturated, and saturated fat intake. They had a lower intake of chicken items than that of women without BED, and they specifically consumed less juice and more candy and milk-based desserts. This group also had lower folate, potassium, and vitamin C intake compared with women without eating disorders. Women with onset of BED during pregnancy had significantly higher caloric and saturated fat intake compared with women without BED.16 In addition, women suffering from bulimia before and during pregnancy had a lower intake of sweetened beverages and high-fat meats compared with women without eating disorders. Women who experienced a decrease in BN symptoms during pregnancy consumed more fruit and less fat during their pregnancies compared with their prepregnancy intakes. All women in the study with eating disorders consumed slightly higher amounts of artificially sweetened beverages and those with BED had insufficient intake of potassium, folate, and vitamin C. It's important to note that this study was conducted in Norway, where folate fortification of grains is uncommon. The authors also note that the study didn't account for vitamin and mineral supplement intake.16

A different study established that supplement intake doesn't differ between women with or without eating disorders, with 90% or more of pregnant woman regularly consuming supplements such as prenatal vitamins, folic acid, vitamin D, and omega-3 fatty acids.22

Nutrients of concern for all women during pregnancy include iron, folic acid, vitamin D, choline, calcium, zinc, DHA omega-3 fatty acids, and vitamin B12.23 RDs should assess all pregnant women with eating disorders for each of these nutrients in addition to vitamin C and potassium intake via regular food recall and, in some cases, laboratory testing.16,24 A prenatal vitamin also should be encouraged.

About 0.1% to 0.5% of pregnancies result in hyperemesis gravidarum (HG), a condition marked by severe nausea and vomiting throughout pregnancy. It often results in dehydration, electrolyte imbalance, nutritional deficiencies, and weight loss of greater than 5% of prepregnancy body weight.25-27 Women who suffer from BN appear to have a higher risk of HG.28 However, a 2008 study by Torgersen and colleagues found no significant differences in incidence of HG between pregnant women with eating disorder not otherwise specified with purging (defined by the authors as purging in the absence of bingeing), and BN.29 This study did reveal that women with BN did have higher odds of pregnancy vomiting and nausea and women with eating disorders not otherwise specified with purging had higher odds of pregnancy vomiting than other women. No recent studies appear to have evaluated a mother's ability to distinguish between bulimia-related purging and pregnancy-related vomiting; however, an earlier study reporting that women can distinguish between the two occurrences was cited by Torgersen and colleagues.29 RDs trained in eating disorder treatment are likely to support patients in exploring this phenomenon and managing concerns that arise and collaborate with the patient's OB/GYN or midwife, as needed.

Maternal Weight Change and Weight Concern
A 2011 Norwegian study conducted by Siega-Riz and colleagues evaluated gestational weight gain in women with AN, BN, eating disorders not otherwise specified with purging, or BED, and those without eating disorder symptomology.30 Those with BN and BED had a greater risk than women without eating disorders of gaining more weight than is recommended in the Institute of Medicine (IOM) guidelines. Although it wasn't significant, women with AN were less likely than those without eating disorders to gain inadequately and more likely to gain more than the recommended amount of weight. The authors, however, note that a small sample size may be a possible factor in these findings.

Current IOM guidelines recommend an 11 to 20 lbs weight gain for women with a prepregnancy BMI greater than 30, 15 to 25 lbs for women with a BMI of 25 to 29.9, a 25 to 35 lbs weight gain for women with a BMI of 18.5 to 24.9, and 28 to 40 lbs for women with a BMI less than 18.5.31 While IOM guidelines are widely accepted in the health care field as a way to determine a healthy pregnancy, there are limitations to their use that are dangerous to ignore. Studies used to validate the guidelines are observational and don't reveal causal relationships; nor do they investigate the "predictive value of pregnancy weight gain as a screening tool."32 The recommended ranges were the only ranges validated and the research can't confirm whether other ranges might be superior to the current recommendations. Many women also are tasked with specific IOM weight gain pattern recommendations (ie, one pound per week); however, these patterns were based on only a few studies.32 Women with disordered eating and diagnosed eating disorders are particularly vulnerable to weight gain pattern recommendations, and worry of weight gain can impact their efforts to manage eating disorder behaviors.33,34 Finally, IOM guidelines are based on prepregnancy BMI, which is a poor indicator of individual health and wellness.35-38

The evidence for IOM pregnancy weight gain guidelines gets even weaker when evaluating BMI and correlates such as C-section or infant birth weight in the black population, a group underrepresented in eating disorder and pregnancy research.34 In fact, people of color and the lesbian, gay, bisexual, transgender, and queer/questioning population are grossly underrepresented in research about pregnancy and pregnancy with eating disorders. In addition, there's a lack of research that includes plus-size pregnant mothers without being weight biased, leaving them susceptible to stigmatizing and biased medical care. Dietitians are highly encouraged to seek education on social justice issues for underrepresented and oppressed populations and learn how the Health at Every Size paradigm impacts medical care.

It's critical that women's medical providers and RDs consider individual circumstances and weigh the pros and cons of discussing weight gain goals for patients with eating disorders during pregnancy. The evaluation of a healthy pregnancy needs to consider a range of physical and psychological factors that affect the individual woman and child's state of wellness.36,39 Some data on women's attitudes regarding weight gain and body satisfaction during pregnancy suggest that there's a decrease in weight concern and body dissatisfaction for many women without eating disorders during pregnancy as compared with their attitudes before pregnancy.9,33 However, for women with eating disorders, concern about gestational weight gain can remain high throughout pregnancy and has been found to be significantly greater than the worries of pregnant women without eating disorders.33

Furthermore, it's been suggested that concern about weight gain may be a predictor of higher maternal weight gain and higher birth weight of infants. Results from the Norwegian Mother Child Cohort Study (MoBa) on attitudes toward weight gain during pregnancy revealed that women with BED who were very worried about weight gain during pregnancy were more likely to experience greater gestational weight gain than were those who were not worried. In addition, women who did not have eating disorders but reported being very or somewhat worried about weight gain had a higher risk of having a large-for-gestational-age baby and higher gestational weight gain. When the data were controlled for prepregnancy weight, this trend continued to be significant.33

Finally, although significant differences didn't emerge, for the small group of women in the study with AN, worry was associated with lower birth-weight infants. These data highlight the significance of weight concerns and the fact that, regardless of diagnoses, the experience of worrying about weight gain is correlated with the weight of the baby and gestational weight gain of the mother. Dietitians working with all pregnant women, and especially those with eating disorders, should be mindful of the potential for increased stress and worry when discussing weight gain guidelines and avoid triggering feelings of deprivation, which are likely to backfire and potentially lead to overeating, bingeing, subsequent compensatory behaviors, and psychological distress.33

In another MoBa study from 2011, remission from BED during pregnancy was significantly more likely among women who perceived themselves as overweight before pregnancy and placed less emphasis on weight as a measure of self-worth.15 It should be noted that dietitians who use a weight-inclusive Health at Every Size philosophy and intuitive eating approach could be uniquely qualified to help pregnant mothers reduce their concern about weight gain, discuss the vast limitations of BMI as an indicator of health, put weight-gain guidelines into proper context, and refocus the mothers' attention to healthful behaviors to support healthy pregnancies.36,39-42

Impact on Maternal Health and Neonatal Growth and Development
Due to potential nutritional deficiencies and risky behaviors associated with women with eating disorders, there are concerns regarding the health of both mother and baby. In addition, there's evidence that an eating disorder can interfere with the adjustment to motherhood, breast-feeding, and child feeding.43

There's an increased risk of gestational diabetes in women with BN or a history of BN.9 Gestational diabetes is associated with increased risk of birth defects such as cleft lip and cardiac, central nervous system, limb, and renal abnormalities. The rapid and abnormal changes in blood glucose that occur with the binge-purge cycle may be related to this risk and may have a negative impact on the fetus.9,44 RDs and physicians, therefore, should check for hyperglycemia with an oral glucose tolerance test.45

Research shows that women with previous or active AN are more likely to have low-birthweight babies.9 Poor nutrition and low protein intake during pregnancy affects the hypothalamic-pituitary-axis, triggering a cascade that results in increased exposure to cortisol in utero. This is associated with low birth weight and can have a lasting impact on the infant's stress response as well as other physiological and psychological outcomes that are being further explored.46,47

There are higher rates of miscarriages in women who have AN and BN. There also are reported higher rates of C-section deliveries in women with AN. Infants of women with eating disorders have been reported to have greater likelihood of stillbirth, low birth weight, low Apgar scores, breech presentation, and cleft lip and palate.48

Research tends to reveal few findings on the impact of BED on neonatal outcomes. BED typically is associated with high gestational weight gain although not necessarily significantly different from gestational weight gain of mothers with BN.48,49 Compared with women without eating disorders, women with BED have been shown to be at higher risk of having large for gestational age babies, babies with higher birthweights, and C-sections. One study showed an increased risk of preterm delivery for women with BED compared with women with BN and AN. No significant differences were found for risk of preeclampsia or gestational diabetes in women with BED compared with women without eating disorders.48

Treatment Recommendations
Not much literature is available that specifically focuses on nutritional treatment of eating disorders during pregnancy. However, RDs may combine expertise in eating disorder treatment with knowledge of prenatal nutrition and wellness. Appropriate treatment can't begin until there's proper screening and evaluation. Perinatal practitioners such as OB/GYNs or midwives should be trained in properly screening pregnant mothers and refer them to clinicians who specialize in eating disorders. Considering that the majority of eating disorders begin before age 25, when women typically are seeing OB/GYNs for regular care, OB/GYNs are in an ideal position to screen for eating disorders.50 RDs who specialize in eating disorders are encouraged to educate OB/GYN's on screening and options for referring to specialists.

Treatment of an eating disorder should be offered by a multidisciplinary team, often including, but not limited to, a therapist, RD, psychiatrist, and one or more physicians.24 As outlined in the Academy of Nutrition and Dietetics' practice paper on nutrition intervention in eating disorders, RDs should conduct a thorough evaluation of clients, giving them adequate time to tell their stories, and assessing for factors such as rigid eating patterns, caloric intake, dietary extremes, thoughts, beliefs, and rules about intake and severity and frequency of restriction, bingeing, and compensatory behaviors.24 When working with pregnant women, it's important to assess for weight and body concern, and feelings the mother may have about experiencing an eating disorder during pregnancy. RDs can help women who experience guilt and shame about their eating disorders by providing nonjudgmental support and guidance about how to best meet nutritional needs.

As previously discussed, when examining nutrient deficiencies commonly experienced by women with eating disorders, RDs should pay special attention to overall caloric intake and intake of total fat, iron, omega-3s, folate, and vitamin C due to the role these nutrients play in the development of the fetus and health of the mother.1,16,20,22 The priority should be to support the client with decreasing eating disorder behaviors such as restriction, binging, or purging. In addition to supplementing with a prenatal vitamin, supplemental omega-3 fatty acids should be considered for the health of mother and baby since the maternal supply will be depleted as the developing fetus uses omega-3 fatty acids. The International Society for the Study of Fatty Acids and Lipids recommends a minimum dosage of 300 mg of DHA per day during pregnancy and nursing.

The RD's role also should include assessing the severity of eating disorder behaviors and urges and knowing which treatment modalities may meet the mothers' individual needs. These methods may include various versions of meal planning support with special care taken to provide adequate structure while avoiding triggering restrictive behaviors. Counseling methods may include motivational interviewing, cognitive behavioral therapy, acceptance and commitment therapy, and dialectical behavioral therapy within the RD's scope of practice.24 In addition, since eating disorder symptoms may decrease during pregnancy, it may be an ideal time to use approaches such as intuitive eating and mindfulness to improve clients' relationships with food and try to prevent the return of symptoms often seen during the postpartum period.24,51 Regardless of the severity of the eating disorder, using intuitive eating and mindfulness techniques also will provide an opportunity to explore the origin of cravings, investigate appetite changes, and evaluate the impact of messages related to weight gain and nutrition on food intake and body image during pregnancy and postpartum.5

It's also crucial to continue care and support for the mother in the postpartum period and beyond. The postpartum period is a particularly risky time for relapse or onset of disordered eating—even more so than during pregnancy. In one study, women with previous eating disorders showed lower EDE-Q scores at the third trimester compared with healthy controls but showed a significant increase in EDE-Q scores at eight weeks and six months postpartum.8

Another study assessed body dissatisfaction during pregnancy and postpartum in a group of 506 women; data on such issues as appetite, overeating, mental health, and weight were collected. Data on eating disorder history or active symptoms weren't assessed. Overall, the study revealed that there was a significant increase in body dissatisfaction up to nine months postpartum. Furthermore, body dissatisfaction at nine months postpartum was associated with overeating or poor appetite, greater weight, decreased mental health, nonbreast-feeding status, and fewer immediate family relationships.52 It's unclear whether poor body satisfaction leads to these associated factors or vice versa. Additional research is needed to establish a cause and effect relationship.

Another study revealed that compared with healthy subjects, those with active eating disorders, and those with past eating disorders displayed increased weight and shape concerns at eight weeks and six months postpartum.8 Having an eating disorder postpartum can negatively affect child feeding, mother-baby attachment, and risk of postpartum mood disorders.53 Based on these data, it's recommended that eating disorder treatment with a multidisciplinary team continue into the postpartum period regardless of whether a mother experienced a decrease in symptoms during her pregnancy. In addition, RDs should extend child-feeding support to the mother to improve attachment, increase confidence, and ensure that the infant's nutritional needs are met.53

It appears that women with eating disorders are more likely to discontinue breast-feeding shortly after delivery. And it's important to note that a large percentage of women who suffer from eating disorders have been victims of sexual abuse and trauma.10 While many women who have suffered from sexual trauma go on to have positive breast-feeding experiences, that's not the case for all.54 A woman's choice to breast-feed is very personal, and perinatal practitioners, including RDs, should be encouraged to listen, support, provide education when requested, and help protect the feeding choice a mother makes.55

Vital Responsibilities
RDs must be vigilant and prepared to help women suffering from eating disorders. Due to OB/GYNs' lack of attention and screening for eating disorders during pregnancy, RDs may find themselves on the frontlines of treatment, identifying risk factors and symptoms, referring patients to receive diagnoses, and assisting in the compilation of multidisciplinary teams. The RD plays a critical role in preventing adverse outcomes for mothers and babies by supporting pregnant mothers with decreasing eating disorder behaviors, improving nutritional intake, managing worry about weight gain during pregnancy and weight loss postpartum, and improving the relationship with food. Moreover, steps should be taken to give mothers a strong foundation of support during this time of change, and nutritional care should continue well into the postpartum period.

— Lindsay Stenovec, MS, RDN, CEDRD, CLEC, is the founder of Intuitive Eating Moms Club, an online body-positive wellness membership for moms and moms-to-be, and the owner of Nutrition Instincts® — San Diego Nutrition Therapy, a group private practice specializing in eating disorders, intuitive eating, maternal wellness, and family feeding.

Learning Objectives
After completing this course, nutrition professionals will be better able to:
1. Compare incidence of anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified before, during, and after pregnancy.
2. Assess clients for signs, symptoms, and risk factors for eating disorders during pregnancy.
3. Evaluate patients with eating disorders for specific nutritional deficiencies and behaviors for which they may be at risk.
4. Arrange a multidisciplinary team of specialists for pregnant patients after eating disorders have been diagnosed.

CPE Monthly Examination
1. According to the 2012 study conducted by Broussard, what percentage of pregnant women with disordered eating wasn't identified by their medical practitioners?
a. 17.2%
b. 25.8%
c. 93.3%
d. 98.1%

2. The symptoms of which eating disorder have been shown to typically increase during pregnancy?
a. Anorexia nervosa (AN)
b. Binge eating disorder (BED)
c. Bulimia nervosa (BN)
d. Feeding disorder

3. Which of the following do 45.5% of women with active eating disorders during pregnancy experience postpartum?
a. Diabetes
b. High blood pressure
c. Postpartum depression
d. Hypoglycemia

4. What is a primary reason that eating disorders during pregnancy often go undetected?
a. Medical professionals routinely ask about them but patients lie about their symptoms.
b. Eating disorders go away during pregnancy.
c. OB/GYNs do not routinely screen for eating disorders.
d. The eating disorder screening tools used in offices are poor.

5. According to Mazzeo and colleagues, what percentage of women with BN experienced depression during pregnancy?
a. 25%
b. 38%
c. 59%
d. 72%

6. Some literature shows that women with BN before pregnancy can decrease or eliminate compensatory behaviors during pregnancy but transition to meeting criteria for which other eating disorder?
a. Orthorexia
b. BED
c. AN
d. BN

7. Women with BN before or during pregnancy are at increased risk of which condition that may be influenced by nutrition?
a. High blood pressure
b. Preeclampsia
c. Anemia
d. Gestational diabetes

8. What eating disorder has been shown to have lower intake of potassium, folate, and vitamin C during pregnancy?
a. AN
b. BN
c. AN with purging
d. BED

9. Poor nutrition and low protein intake impacts the hypothalamic-pituitary axis, triggering a cascade that results in the fetus receiving increased __________ in utero, having a lasting impact on birth weight and infant stress response.
a. Cortisol
b. Iron
c. Homocysteine
d. Carbon dioxide

10. The International Society for the Study of Fatty Acids and Lipids recommends what minimum dosage of DHA supplementation during pregnancy?
a. 200 mg DHA
b. 300 mg DHA
c. 400 mg DHA
d. 500 mg DHA

1. Bulik CM, Von Holle A, Hamer R, et al. Patterns of remission, continuation and incidence of broadly defined eating disorders during early pregnancy in the Norwegian Mother and Child Cohort Study (MoBa). Psychol Med. 2007;37(8):1109-1118.

2. Watson HJ, Torgersen L, Zerwas S, et al. Eating disorders, pregnancy, and the postpartum period: findings from the Norwegian Mother and Child Cohort Study (MoBa). Nor Epidemiol. 2014;24(1-2):51-62.

3. Easter A, Bye A, Taborelli E, et al. Recognising the symptoms: how common are eating disorders in pregnancy? Eur Eat Disord Rev. 2013;21(4):340-344.

4. Broussard B. Psychological and behavioral traits associated with eating disorders and pregnancy: a pilot study. J Midwifery Womens Health. 2012;57(1):61-66.

5. Orloff NC, Hormes JM. Pickles and ice cream! Food cravings in pregnancy: hypotheses, preliminary evidence, and directions for future research. Front Psychol. 2014;5:1076.

6. Coker EL, Mitchell-Wong LA, Abraham SF. Is pregnancy a trigger for recovery from an eating disorder? Acta Obstet Gynecol Scand. 2013;92(12):1407-1413.

7. Linna MS, Raevuori A, Haukka J, Suvisaari JM, Suokas JT, Gissler M. Pregnancy, obstetric, and perinatal health outcomes in eating disorders. Am J Obstet Gynecol. 2014;211(4):392.e1-8.

8. Easter A, Solmi F, Bye A, et al. Antenatal and postnatal psychopathology among women with current and past eating disorders: longitudinal patterns. Eur Eat Disord Rev. 2015;23(1):19-27.

9. Micali N, Treasure J, Simonoff E. Eating disorders symptoms in pregnancy: a longitudinal study of women with recent and past eating disorders and obesity. J Psychosom Res. 2007;63(3):297-303.

10. Deep AL, Lilenfeld LR, Plotnicov KH, Pollice C, Kaye WH. Sexual abuse in eating disorder subtypes and control women: the role of comorbid substance dependence in bulimia nervosa. Int J Eat Disord. 1999;25(1):1-10.

11. Government of South Australia, Department of Health. Clinical guideline: South Australian perinatal practice guidelines — eating disorders and pregnancy.
. Published June 10, 2014.

12. Stewart DE, Erlick Robinson G. Eating disorders and reproduction. In: Stotland NL, Stewart DE, eds. Psychological Aspects of Women's Health Care: The Interface Between Psychiatry and Obstetrics and Gynecology. 2nd ed. Washington, D.C.: American Psychiatric Press; 2001:441-446.

13. Madsen IR, Hørder K, Støving RK. Remission of eating disorder during pregnancy: five cases and brief clinical review. J Psychosom Obstet Gynaecol. 2009;30(2):122-126.

14. Micali N. Management of eating disorders during pregnancy. Prog Neurol Psychiatry. 2010;14(2):24-26.

15. Knoph Berg C, Torgersen L, Von Holle A, Hamer RM, Bulik CM, Reichborn-Kjennerud T. Factors associated with binge eating disorder in pregnancy. Int J Eat Disord. 2011;44(2):124-133.

16. Siega-Riz AM, Haugen M, Meltzer HM, et al. Nutrient and food group intakes of women with and without bulimia nervosa and binge eating disorder during pregnancy. Am J Clin Nutr. 2008;87(5):1346-1355.

17. Carter FA, McIntosh VV, Joyce PR, Frampton CM, Bulik CM. Bulimia nervosa, childbirth, and psychopathology. J Psychosom Res. 2003;55(4):357-361.

18. Mazzeo SE, Slof-Op't Landt MC, Jones I, et al. Associations among postpartum depression, eating disorders, and perfectionism in a population-based sample of adult women. Int J Eat Disord. 2006;39(3):202-211.

19. Franko DL, Blais MA, Becker AE, et al. Pregnancy complications and neonatal outcomes in women with eating disorders. Am J Psychiatry. 2001;158(9):1461-1466.

20. Siu AL; US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.

21. Lowes H, Kopeika J, Micali N, Ash A. Anorexia nervosa in pregnancy. Obstet Gynaecol. 2012;14(3):179-187.

22. Dellava JE, Von Holle A, Torgersen L, et al. Dietary supplement use immediately before and during pregnancy in Norwegian women with eating disorders. Int J Eat Disord. 2011;44(4):325-332.

23. Procter SB, Campbell CG. Position of the Academy of Nutrition and Dietetics: nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014;114(7):1099-1103.

24. Ozier AD, Henry BW; American Dietetic Association. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236-1241.

25. Charlin V, Borghesi L, Hasbún J, Von Mülenbrock R, Moreno MI. Parenteral nutrition in hyperemesis gravidarum. Nutrition. 1993;9(1):29-32; discussion 68.

26. Bailit JL. Hyperemesis gravidarum: epidemiologic findings from a large cohort. Am J Obstet Gynecol. 2005;193(3 Pt 1):811-814.

27. Abell TL, Riely CA. Hyperemesis gravidarum. Gastroenterol Clin North Am. 1992;21(4):835-849.

28. Koubaa S, Hällström T, Lindholm C, Hirschberg AL. Pregnancy and neonatal outcomes in women with eating disorders. Obstet Gynecol. 2005;105(2):255-260.

29. Torgersen L, Von Holle A, Reichborn-Kjennerud T, et al. Nausea and vomiting of pregnancy in women with bulimia nervosa and eating disorders not otherwise specified. Int J Eat Disord. 2008;41(8):722-727.

30. Siega-Riz AM, Von Holle A, Haugen M, et al. Gestational weight gain of women with eating disorders in the Norwegian pregnancy cohort. Int J Eat Disord. 2011;44(5):428-434.

31. American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 548: weight gain during pregnancy. Obstet Gynecol. 2013;121(1):210-212.

32. Abrams B, Altman SL, Pickett KE. Pregnancy weight gain: still controversial. Am J Clin Nutr. 2000;71(5 Suppl):1233S-1241S.

33. Swann RA, Von Holle A, Torgersen L, Gendall K, Reichborn-Kjennerud T, Bulik CM. Attitudes toward weight gain during pregnancy: results from the Norwegian mother and child cohort study (MoBa). Int J Eat Disord. 2009;42(5):394-401.

34. Gillespie SL, Christian LM. Body mass index as a measure of obesity: racial differences in predictive value for health parameters during pregnancy. J Womens Health (Larchmt). 2016;25(12):1210-1218.

35. Romero-Corral A, Montori VM, Somers VK, et al. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet. 2006;368(9536):666-678.

36. Wildman RP, Muntner P, Reynolds K, et al. The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004). Arch Intern Med. 2008;168(15):1617-1624.

37. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861-1867.

38. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013;309(1):71-82.

39. Crow SJ, Agras WS, Crosby R, Halmi K, Mitchell JE. Eating disorder symptoms in pregnancy: a prospective study. Int J Eat Disord. 2008;41(3):277-279.

40. Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.

41. Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10:9.

42. Bacon L, Keim NL, Van Loan MD, et al. Evaluating a 'non-diet' wellness intervention for improvement of metabolic fitness, psychological well-being and eating and activity behaviors. Int J Obes Relat Metab Disord. 2002;26(6):854-865.

43. Knoph C, Von Holle A, Zerwas S, et al. Course and predictors of maternal eating disorders in the postpartum period. Int J Eat Disord. 2013;46(4):355-368.

44. Correa A, Gilboa SM, Besser LM, et al. Diabetes mellitus and birth defects. Am J Obstet Gynecol. 2008;199(3):237.e1-237.e9.

45. Yasuhara D, Kojima S, Naruo T, Inui A. Relationship between pretreatment laboratory-measured episodes of reactive hypoglycemia and short-term weight restoration in anorexia nervosa: a preliminary study. Psychoneuroendocrinology. 2006;31(4):452-458.

46. Seckl JR, Holmes MC. Mechanisms of disease: glucocorticoids, their placental metabolism and fetal 'programming' of adult pathophysiology. Nat Clin Pract Endocrinol Metab. 2007;3(6):479-488.

47. McTernan CL, Draper N, Nicholson H, et al. Reduced placental 11beta-hydroxysteroid dehydrogenase type 2 mRNA levels in human pregnancies complicated by intrauterine growth restriction: an analysis of possible mechanisms. J Clin Endocrinol Metab. 2001;86(10):4979-4983.

48. Bulik CM, Von Holle A, Siega-Riz AM, et al. Birth outcomes in women with eating disorders in the Norwegian Mother and Child cohort study (MoBa). Int J Eat Disord. 2009;42(1):9-18.

49. Nunes MA, Pinheiro AP, Camey SA, Schmidt MI. Binge eating during pregnancy and birth outcomes: a cohort study in a disadvantaged population in Brazil. Int J Eat Disord. 2012;45(7):827-831.

50. Andersen AE, Ryan GL. Eating disorders in the obstetric and gynecologic patient population. Obstet Gynecol. 2009;114(6):1353-1367.

51. Mitchell JE, King WC, Courcoulas A, et al. Eating behavior and eating disorders in adults before bariatric surgery. Int J Eat Disord. 2015;48(2):215-222.

52. Gjerdingen D, Fontaine P, Crow S, McGovern P, Center B, Miner M. Predictors of mothers' postpartum body dissatisfaction. Women Health. 2009;49(6):491-504.

53. Astrachan-Fletcher E, Veldhuis C, Lively N, Fowler C, Marcks B. The reciprocal effects of eating disorders and the postpartum period: a review of the literature and recommendations for clinical care. J Womens Health (Larchmt). 2008;17(2):227-239.

54. Sørbø MF, Lukasse M, Brantsæter AL, Grimstad H. Past and recent abuse is associated with early cessation of breast feeding: results from a large prospective cohort in Norway. BMJ Open. 2015;5(12):e009240.

55. Wood K, Van Esterik P. Infant feeding experiences of women who were sexually abused in childhood. Can Fam Physician. 2010;56(4):e136-e141.