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Eating Disorders and Reproduction:
A Dangerous Combination
Eating disorders have numerous emotional, psychological, and physical consequences; despite this, many affected individuals refuse to admit that they have a problem. One of the more serious problems associated with eating disorders that may convince a young woman to seek treatment, is the negative effect disordered eating can have on fertility, pregnancy, and child rearing in general. In multiple studies anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified, have been associated with infertility, low maternal weight gain, low birth weight in infants, increased neonatal morbidity, and problems in infant feeding (Stewart, 1992). Women who are afflicted with an eating disorder at conception tend to experience a worsening in their symptoms as well as other psychological problems. In order to avoid harming herself and her infant, women with eating disorders should seek psychological treatment before attempting to become pregnant.
A literature review by Wade, Schneider, and Li (1996), used an array of female mammals to demonstrate the biological mechanisms behind the infertility of eating disordered women. In simple terms, when accessible energy is severely limited, animals preserve those activities necessary for survival (basic cellular functions, thermoregulation, etc.) and other less crucial functions, such as reproduction, are sacrificed for the time being. Fuel availability is thought to be detected by the caudal hindbrain and in the periphery; when a reduction in metabolic fuel is detected this information is relayed to the forebrain effector neurons that control GnRH secretion (a neurotransmitter used to regulate the ovulatory cycle) and reproductive behaviors. A reduction in energy due to excessive exercise or decreased food intake, can delay the onset of puberty, suppress ovulation, diminish lactational performance, and inhibit estrous and maternal behaviors. As long as the body remains undernourished or underweight, reproductive function will be diminished.
A study by Bates and Whitworth (1982), demonstrated that even small changes in body weight (loss of 5 or 10% of ideal body weight) are associated with slight alterations in the menstrual cycle and reproductive failure. Thirty-six women, twenty-six with unexplained infertility and ten with menstrual dysfunction, followed a dietary regimen to increase their weight to the predicted ideal. The majority of these women were within 15% of their ideal body weight, and only four met the criteria for anorexia nervosa. Results showed that once the women restored their body weight to within 5% of the ideal, 19 of the 26 infertile women conceived spontaneously, and 9 of 10 women with menstrual dysfunction resumed a regular cycle. These results indicate that the practice of weight control by caloric restriction may be a cause of unexplained infertility and menstrual disorders in otherwise healthy women.
When a reduction in reproductive function is seen in women who are only slightly underweight, it is evident that the consequences in women with anorexia nervosa will be extremely serious. In the largest study of its kind to date, 140 women with a former diagnosis of anorexia nervosa were followed-up on an average of 12.5 years later to determine reproductive outcome (Brinch, Isager, & Tolstrup, 1988). Fifty of the 140 women had given birth to 86 children; one-third of the expected fertility. The rate of prematurely born infants was twice the expected, and perinatal lethality was six times what would be expected in the general population. Although this study provides strong support for the fact that anorexic women have decreased reproductive functioning, the study did not distinguish woman in remission from those who continued to have a diagnosable eating disorder. This distinction seems important to establish the truly at-risk population and provide disordered women with motivation to seek treatment.
A more recent study using similar methods examined fertility and reproductive history in 66 women with a history of anorexia nervosa and 98 randomly selected community controls (Bulik et al., 1999). Interestingly, the two groups of women did not differ on rate of pregnancy, suggesting that the anorexic women did not experience fertility problems as has been shown in previous studies. However, women with a history of anorexia nervosa did have significantly more miscarriages and cesarean deliveries, and the infants of women with anorexia were significantly more likely to be born prematurely and at a low birth weight. Comparisons of women with active versus remitted anorexia nervosa showed no differences on any of these measures. These findings suggest that despite recovery, women with a history of anorexia nervosa have increased risk during pregnancy and delivery. Further studies are necessary to test the reliability of this finding, as much refuting evidence exists.
A study by Russell, Treasure, and Eisler (1998), indicates that even anorexic mothers who successfully bear children are not free from complications; there is a potential danger of anorexic mothers underfeeding their children, leading to shortness of stature, physical frailty, and psychological harm. Records from an eating disorders clinic were used to identify a series of eight anorexic mothers with twelve children, nine of whom had been food deprived. Plotting of the childrens heights and weights on charts of expected height by age and weight by age were used to determine the effects of food deprivation; the children were considered severely reduced if their height or weight fell below the tenth percentile. Results showed a severe reduction in weight-for-age in six children, and a severe reduction in height-for-age in eight children.
All eight mothers were offered treatment for themselves and their children; the majority resented the psychologists interference and only four children and three mothers were involved in an intensive whole family approach to treatment. Results indicated that the extent of the childs catch-up growth was associated with the extent to which both mother and child were successfully engaged in treatment. Despite its small sample size, this study denotes another concern with regard to anorexic mothers. Although these mothers were generally concerned for their children and had no intention of abusing them, the mothers concerns about body size and shape were passed onto their children. The mothers used a variety of different methods to ration their childs food intake in order to prevent their children from gaining weight. Further research using larger and more diverse populations will be necessary to determine the extent of the risk placed on the children of eating disordered mothers, and the degree to which these children develop eating disorders themselves.
The majority of research on eating disorders and reproduction has focused on anorexia nervosa or all diagnosable eating disorders; a study by Abraham (1996), sought to isolate the effects of bulimia nervosa on pregnancy. The reproductive and sexual histories of 43 women who had recovered or were recovering from bulimia were examined ten to fifteen years after first presenting for treatment. At follow-up 74% of the women were considered recovered, and 26% still had a diagnosable eating disorder, these two groups were compared to each other and to a group of 43 randomly selected controls, on a variety of measures using a semi-structured interview.
Overall, women with an active eating disorder experienced more problems with fertility, pregnancy, and childbirth. Eight of the forty-three women had been investigated for infertility; these women were more likely to have had an active eating disorder at the time of investigation. Women with a history of bulimia nervosa were significantly more likely than control subjects to have had unsuccessful pregnancies (miscarriage and ectopic pregnancy), and to be treated for postnatal depression. Subjects with an active eating disorder at the time of pregnancy were especially at risk for unsuccessful pregnancy and postpartum depression. The women in this study usually ceased or decreased the frequency of their eating disordered behaviors from the time they knew they were pregnant, although relapse was seen in the last stages of pregnancy, after pregnancy, and after ceasing breast feeding, in many women. This study suggests that women with both a history of bulimia and an active case of the disorder are at risk for complications during conception, pregnancy, and delivery. The present study only used women who had been treated for bulimia nervosa, an interesting comparison could be made in future studies between treated and untreated women.
Certain aspects of bulimia, particularly self-induced vomiting, major fluctuations in caloric intake, and depression, can lead to difficulties during pregnancy. An extreme case of such difficulties in a thirty-two year old woman who had been bulimic since the age of six, was reported by Ford and Dolan (1989). Between the ages of 17 and 25 the woman became pregnant seven times. Persistent binge eating and vomiting was associated with four miscarriages between three and five months gestation. Diminished symptoms in her fourth and seventh pregnancies were associated with successful births, and in her sixth pregnancy with a still birth at seven months gestation. Although this case can not be generalized to other eating disordered patients, it serves as an extreme example of the negative consequences of bulimic behavior.
A study comparing the pregnancies of women with active bulimia nervosa, active anorexia nervosa, and either disorder in remission, indicates that active bulimia nervosa may have the most negative effect on pregnancy and infant health (Stewart et al., 1987). Of 74 women previously treated for bulimia or anorexia, 15 had conceived 23 pregnancies at follow-up. Twenty of the 23 pregnancies proceeded to live births, and 18 of these births were performed vaginally. All the complications of pregnancy and delivery (spontaneous abortion, intra-uterine death, cesarean section) occurred in women who were ill at conception. Women in remission gained significantly more weight during pregnancy than women with restricting anorexia, and women with active bulimia gained even less. The average duration of gestation for term pregnancies was 37 weeks for women with bulimia, 38 weeks for women with anorexia, and 39 weeks for women in remission. In addition, women in remission had heavier babies and higher 5-minute Apgar scores, than women with anorexia and bulimia. With regard to postpartum depression, six of the eight patients in remission at conception remained well for at least one year postpartum. In contrast, all seven women who were ill at conception continued to be ill or had worsening of their eating disorder in the postpartum year. The findings of this study contradict the finding by Bulik (1999) that women with active and remitted eating disorders experience the same complications during pregnancy. Although the subjects in this study were not compared to a control group, women in remission were found to experience significantly less problems during pregnancy, birth, and the postpartum year, than women with an active eating disorder. Women with bulimia nervosa were especially at risk for low weight gain, premature birth, and complication during pregnancy and delivery.
Poor nutrition and eating disorders are one of the most common causes of unexplained infertility. Despite this fact, many doctors fail to recognize the problem and may prescribe treatments such as induced ovulation that put an eating disordered mother and her infant at risk. A study of 66 consecutive infertility clinic patients found that 16.7% of these women suffered from an eating disorder (Stewart et al., 1990). Of patients with amenorrhea, 58% had eating disorders. None of these women had divulged their problem to the infertility clinic gynecologist. In order to reduce the morbidity of both mother and infant, all women with infertility should be screened for eating disorders; women with eating disorders should be treated for this before infertility investigations and treatments are pursued.
Forty-one pregnant women in whom ovulation had been induced, and 1212 in whom ovulation was spontaneous were studied to determine the outcome of pregnancy in underweight women after spontaneous and induced ovulation. Thirteen of the women who had undergone induced ovulation were underweight; these women had five times the risk of giving birth to a baby who was small for gestational age as the normal weight women who had been induced, and ten times the risk of normal weight women with spontaneous ovulation. Women who begin pregnancy undernourished and continue to have inadequate dietary intake are at a considerable disadvantage. A lack of spontaneous ovulation caused by low maternal weight before pregnancy indicates an increased risk of giving birth to a low birth weight infant. For this reason, the most suitable treatment for infertility caused by weight related amenorrhea, is dietary improvement rather than induced ovulation.
Eating disorders, poor nutrition, and low body weight, have multiple negative effects on fertility, pregnancy, and offspring. Anorexia nervosa and bulimia nervosa especially can cause infertility, low maternal weight gain, low infant birth weight, spontaneous abortion, problems in breast feeding, and other complications. To protect her own health and that of her infant, a woman with an eating disorder should seek treatment and wait till she has reached an acceptable body weight and level of nutrition, before attempting to become pregnant. Several studies indicate that disordered eating in adolescence can negatively effect reproduction years down the line, for this reason, a woman who plans on having children should maintain proper nutrition not only during pregnancy, but throughout her life.
Abraham, S., (1998). Sexuality and reproduction in bulimia nervosa pateints over 10 years, Journal of Psychosomatic Research , 44(3-4): 491-502.
Bates, G., Bates, S., & Whitworth, N., (1982). Reproductive failure in women who practice weight control, Fertility and Sterility, 37(3): 373-379.
Brinch, M., Isager, T., & Tolstrup, K., (1988). Anorexia nervosa and motherhood: reproduction pattern and mothering behavior of 50 women, Acta Psychiatrica Scandinavica, 77(5): 611-617.
Bulik, C., Sullivan, P., Fear, J., Pickering, A., Dawn, A., & McCullin, M., (1999). Fertility and reproduction in women with anorexia nervosa: a controlled study, Journal of Clinical Psychiatry, 60(2): 130-135.
Ford,M., & Dolan, B., (1989). Bulimia associated with repeated spontaneous abortion, International Journal of Eating Disorders, 8(2): 243-245.
Russell, G., Treasure, J, & Eisler, L., (1998). Mothers with anorexia nervosa who underfeed their children: their recognition and management, Psychological Medicine, 28(1): 93-108.
Spuy, Z., Steer, P., McCusker, M., Steele, S., & Jacobs, H., (1988). Outcome of pregnancy in underweight women after spontaneous and induced ovulation, British Medical Journal, 296: 962-965.
Stewart, D., Robinson, E., Goldbloom, D., & Wright, C., (1990). Infertility and eating disorders, American Journal of Obstetrics and Gynecology, 163(4): 1196-1199.
Stewart, D., Raskin, J., Garfinkel, P., MacDonald, O., & Robinson, G., (1987). Anorexia nervosa, bulimia, and pregnancy, American Journal of Obstetrics and Gynecology, 157: 1194-1198.
Stewart, D., (1992). Reproductive functions in eating disorders, Annals of Medicine, 24(4): 287-291.
Wade, G., Schneider, J., & Li, H., (1996). Control of fertility by metabolic cues, American Journal of Physiology, 270(1): E1-19.
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