Identifying Eating Disorders in Pregnant Women
Most ob/gyns are sensitive about looking for eating disorders when women consult them for problems with their period, says Ann Honebrink, M.D., associate professor of clinical obstetrics and gynecology at the University of Pennsylvania Perelman School of Medicine. "But because one of the main side effects we see in women with eating disorders can be infertility," she says, "I don't think we are as sensitive to the problem once a woman is pregnant."
Only half of physicians surveyed by the American College of Obstetricians and Gynecologists screen for eating disorders and 86 percent said they had "barely adequate" training to diagnose and care for them. "I think we are less likely to look for something we don't know how to treat," Dr. Honebrink says, although she says that OBs are getting better about giving general weight-management advice and nutritional information to pregnant women.
If doctors don't bring up the issue of disordered eating, women are unlikely to, says Athena Kourtis, M.D., senior service fellow with the Division of Reproductive Health at the Centers for Disease Control and Prevention in Atlanta. Like Coggins, they may not understand how dangerous it can be. Or they may recognize the danger but stay quiet anyway. "Women are ashamed and secretive about having these problems and probably aren't forthcoming about them," Dr. Kourtis says.
It's little wonder that a patient already uncomfortable in her body wouldn't feel like discussing her eating habits with someone who isn't comfortable hearing about them. "There is still so much prejudice and stereotyping," Bulik says. "We have had patients whose OBs have gotten angry at them for 'choosing' to continue to 'practice' their eating disorder during pregnancy. Well, I have never heard of an OB getting angry at a mom for continuing to 'practice' her diabetes." Bulik suggests that every OB office should keep a list of psychologists, dietitians and psychiatrists who can treat an eating disorder, "to decrease concerns about being uncomfortable when they detect one."
The clinic Coggins went to refers women with past or current eating disorders to a nutritionist and encourages them to seek psychological counseling, says a nurse practitioner involved in Coggins's prenatal care. Coggins didn't bring up her history: She says she thought she didn't have to because she had been a patient there since she was 15. The nurse practitioner adds that because Coggins came into pregnancy with health issues, including anxiety and mitro-valve prolapse, that "her weight went under the radar."
More: The Mommy Diet
When Coggins went into labor, her dilation stalled at 4 centimeters, and she ended up requiring an emergency C-section—a complication that has been linked to bulimia and obesity. "She might have gotten by with a vaginal delivery without so much weight gain," the nurse practitioner says.
Luckily, Coggins's son, Jackson, was healthy. But her disordered thinking continued.
She helped fight the urge to throw up by breast feeding: "It felt like purging and gave me the sense that I was burning more calories, like I was getting rid of something," she says. Some women even breast-feed or pump only to shed calories, sometimes after the baby is weaned.
This so-called pump purging "is something we have just started to notice," Bulik says. It can be unhealthy for the mom if she starts to deplete her nutrients—for instance, if she is also purging food. And it's disordered because, Bulik says, "psychologically, it's twisting the function of lactation from something essential for life—feeding a child—to something that is part of the disorder—purging."
Jackson is now 2 1/2 years old, and Coggins weighs 27 pounds more than she did pre-pregnancy. She wants to trim down, but her disordered eating makes it impossible. She tends to skip both breakfast and lunch, then "eat everything in sight" around midafternoon. "I was miserable about my weight when I was pregnant, and I still am," she says. "I convinced myself that I could look the same as I did before I was pregnant, no matter what I ate. Now I worry I will never lose all this weight."
Kathy is in a happier place. She managed to stave off bulimia and gave birth a week past her due date to a boy weighing more than 9 pounds. "I'm proud of myself even though I fought with my eating disorder during my entire pregnancy," she says. "I knew I couldn't vomit because I didn't want that negative energy to go through the baby."
And yet, only two days after she stopped breast feeding, she purged. "I was more consumed with worries about my son and whether or not he would get good nutrition from formula and if he would sleep through the night than I was about coping with my eating disorder," she says. A couple of visits to her psychologist at Park Nicollet helped her reconnect with her more "rational voice."
It also reminded her to reach out. "The most helpful moment in my early treatment was when my parents came to a therapy session with my psychologist, and we figured out ways they could help me," she says. When she relapsed after her pregnancy, her husband was an anchor. "On bad days, I'd call him and say, 'I want to throw up' or 'I don't want to eat,' and he'd remind me that it's my eating disorder talking," she says. "I had all the skills I needed. I just needed to say out loud my disordered thoughts to a supportive person. Once I was able to make my rational voice stronger and louder, the symptoms went away."
Two years later, Kathy has come full circle and is pregnant again. But the second time around, she hasn't felt the same urge to purge. Heartened by her successful first pregnancy, she says, "I barely remember the tendency I had to binge, purge and restrict my food. I finally learned how to eat right and to feel at peace with my body as it is. Life is so much better when my eating disorder voice is quiet."