“You want me to gain how much weight?! My body looks disgusting…I will never lose the weight…People will judge me and think I’m worthless…I feel so alone….” Not uncommon to hear from a person struggling with an eating disorder, these comments offer a glimpse into the inner turmoil these individuals are experiencing from both their eating disorder and now, the news of a looming pregnancy.

Eating disorders (ED) are characterized by psychological and emotional disturbances surrounding food, weight, and body image that lead to abnormal eating patterns. ((nationaleatingdisorders.com)) Since eating disorders affect primarily women, and tend to peak during childbearing years, it is not surprising that experts estimate that 1 in 20 women suffer from an ED while pregnant. ((http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/)) ((http://www.eating-disorder.com/Eating-Treatment/Eating-Disorders/eatingdisorders_pregnancy.htm)).

As you can imagine, eating disorders may severely complicate the pregnancy and delivery for expectant mothers.

To start, there are several associated medical complications for the baby. Babies may be at risk of premature birth, low birth weights for age, respiratory distress, fetal tachycardia, cleft palate, low Apgar scores, and feeding difficulties. Negative long-term effects associated with low birth weight and premature delivery have been seen in children as old as 14 years of age.

As for the mother, a myriad of medical complications, nutritional deficiencies, and psychological and/or emotional complications may arise during and after these forty weeks of gestation. Expectant mothers with ED are at higher risk of delivery by cesarean section, miscarriage, postpartum depression, preterm delivery, lower maternal weight gain, and breech deliveries. Other medical complications may include dehydration, electrolyte imbalances and associated cardiac abnormalities, gestational diabetes, preeclampsia, hyperemesis, and malnutrition.

Mothers with ED are often at risk of both macro and micronutrient deficiencies, which as you can imagine, directly impact the fetus. Specifically, women with ED have demonstrated lower intake of meat, vegetarian dietary patterns, as well as higher caffeine consumption during pregnancy. High caffeine consumption is linked to impaired fetal and skeletal growth and a vegetarian lifestyle may put the mother at risk of nutrient deficiencies such as low vitamin D, iron, and B12. ((http://my.clevelandclinic.org/healthy_living/pregnancy/hic_nutrition_during_pregnancy_for_vegetarians.aspx)).

As for the emotional complexities associated with ED and pregnancy, it is not surprising that ED groups compared to control groups have been shown to demonstrate more negative feelings upon discovering their pregnancy. 10 Other common psychological stressors include fear of food, weight gain, and rapid body changes. Adaptation to a new mothering role may prove difficult as well, especially for women with histories of broken family relationships throughout childhood.

So, the question at hand is how does an expectant mother with an eating disorder engage in appropriate nutritional and emotional self-care while preserving the health of her fetus? Here are five basic tips:

1. Gain the appropriate amount of weight It is important that you talk to your obstetrician and dietitian regarding the amount of additional weight needed to sustain your pregnancy. The average amount of weight gain is between 25-35 pounds but this number varies according to mom’s baseline weight and weight history. It may be beneficial to be weighed backwards by your clinical team (aka “blind weights” only) so as to minimize ED thoughts and urges to engage in ED behaviors. DO NOT DIET or try to lose weight during pregnancy!

2. Variety, variety, variety! Focus on eating a variety of foods to provide adequate nutrition for both mom and baby. Specifically, it is important to eat enough fiber (whole-grain pastas/cereals, brown rice, and whole fruits/vegetables) to promote colon health and relieve constipation for mom. Sufficient protein intake is also important (nuts, peanut butter, legumes, soy, quinoa, tofu, poultry, fish, eggs, dairy, and meat) to support fetal growth.

3. Talk to your dietitian about specific dietary recommendations Micronutrients important for pregnancies include folic acid/folate, iron, and calcium. Pregnant women need 600 micrograms of folic acid each day to reduce risk of neural tube defects at birth. Excellent sources of folate include lentils, spinach, broccoli, and beans. You will also need 27 milligrams of iron daily. Stock up on dark leafy greens, beans, fortified cereals, and animal proteins. As an added bonus for enhanced absorption, pair your source of iron with vitamin C-rich foods. Lastly, calcium is needed for the baby’s skeletal, muscular, and neural growth. The recommendation is 1000 milligrams daily, so make sure to buy low-fat milk, yogurt, cheese, or calcium-fortified juices. And don’t forget to take your prenatal vitamins regularly! Lastly, avoid alcohol during pregnancy, as this has been linked to premature delivery and low birth weights.

4. Be honest with your treatment team It is important to inform your entire treatment team (including your obstetrician) of the disorder in order for them to best serve you. Continued management of the disorder with mental health providers is recommended and it’s especially important to see a therapist/trauma specialist when experiencing increased depression, anxiety, or trauma flashbacks during (or after) the pregnancy.

5. Get connected! Lastly, find a doula, lactation consultant, or join a support group specifically for pregnant women with eating disorders. Cut back on activities and life commitments in order to engage in more frequent self-care activities, including spending time with your primary supports. ((http://www.eatright.org/Public/content.aspx?id=6808)) 12

This blog post is not intended to discourage the blessing and miracle that is pregnancy, but rather to instill a healthy level of fear and respect for the associated complications that may arise for women who become pregnant while battling an eating disorder. Rather than stereotyping, labeling, or stigmatizing, let us (both eating disorder professionals and the community at large) walk alongside these strong women and be a resource to them as they journey into what is possibly largely unfamiliar territory. To the expectant mothers with ED: You have been given a tremendous amount of responsibility and it starts now. Your health affects not just you, it affects your child. Take great pride in the care of another human life and remember that your hard work to sustain this pregnancy is, in fact, worth it. It is both my honor and privilege to be able to speak into this time of your life characterized by both inevitable hardship and joy. Remember that you are not alone, nor are you expected to do this alone. Stay connected to the loved ones around you. Cherish and nourish the life growing within you.

Lauren Buboltz MPH RD/LDN is a Clinical Dietitian at Carolina House in Raleigh, North Carolina. Lauren currently works with patients at the Partial Hospitalization and Intensive Outpatient levels of care. Lauren received her Masters of Public Health from the Nutrition Department at the Gillings School of Global Public Health at the University of North Carolina in Chapel Hill. She has been working with eating disorder populations since 2008 in private practice settings, as a study coordinator at the UNC Center of Excellence for Eating Disorders, and has experience both at the Renfrew Center as well as the South Island Eating Disorder Service in Christchurch, New Zealand where she worked on an inpatient unit. Lauren has also worked at Nutrition in Medicine to develop evidence-based clinical nutrition curriculum for practicing physicians.

1. nationaleatingdisorders.com

2. http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/

3. http://www.eating-disorder.com/Eating-Treatment/Eating-Disorders/eatingdisorders_pregnancy.htm

4. DC James, “Eating Disorders, Fertility, and Pregnancy: Relationships and Complications.” J Perinat Neonatal Nurs. 2001 Sep; 15 (2):36-48.

5. Stewart DE et al., “Anorexia Nervosa, Bulimia, and Pregnancy.” Am J Obstet Gynecol. 1987 Nov; 157 (5):1194-8.

6. Franko DL and Walton BE, “Pregnancy and Eating Disorders: a Review and Clinical Complications.” Int J Eat Disord. 1993 Jan; 13 (1):41-7.

7. Franko DL et al., “Pregnancy Complications and Neonatal Outcomes in Women with Eating Disorders.” Am J Psychiatry. 2001 Sep; 158(9):1461-6.

8. Bakker R et al., “Maternal caffeine intake from coffee and tea, fetal growth, and the risks of adverse birth outcomes: the Generation R Study.” Am J Clin Nutr. 2010 Jun; 91(6):1691-8.

9. http://my.clevelandclinic.org/healthy_living/pregnancy/hic_nutrition_during_pregnancy_for_vegetarians.aspx

10. Easter A et al., “Fertility and prenatal attitudes towards pregnancy in women with eating disorders: results from the Avon Longitudinal Study of Parents and Children.” BJOG. 2011 Nov; 118(12):1491-8.

11. http://www.eatright.org/Public/content.aspx?id=6808

Nykjaer C et al., “Maternal alcohol intake prior to and during pregnancy and risk of adverse birth outcomes: evidence from a British cohort.” J Epidemiol Community Health. 2014 Jun;68(6):542-9.