Eating disorders in pregnancy and breastfeeding / chestfeeding

Updated: Feb 10


Pregnancy / expecting a baby & Eating Disorders (EDs)


When you get pregnant, an active eating disorder (ED) doesn’t just go away. Some are able to put it on a shelf while they carry a child and perhaps even recover, some are able to reduce symptoms, and others simply can’t disengage.


Those that are able to “shelf” the ED during pregnancy often find urges to use their ED resurface postpartum when a major life transition, lack of sleep, hormonal shifts, relationship issues and isolation may render them more vulnerable to relapse.

When you get pregnant, an active eating disorder doesn’t just go away

Recommendations

  • Because an obstetrician or midwife is a new practitioner in your circle: tell them about your history of, or current struggles with food and/or body image. This historical information may cue them to check in with you about your ED as they provide the bulk of your primary care. It may even be worth directly asking them to check in with you about ED urges, or symptoms throughout you or your partner's pregnancy (or adoption/surrogacy), as well as at your postpartum contact.

  • Ask your primary healthcare practitioner to refer you to a reproductive psychiatrist if one is available in your area, or perhaps request a consult remotely if you aren’t proximal to one.

  • If you ever went to structured treatment (groups, individual psychotherapy, or inpatient treatment) or are currently in treatment bring out those resources that were the most helpful, review them and keep the handy. Try to recall what your best alternative coping mechanisms were and how you managed urges.

  • Work with a registered dietician (RD) with experience with EDs, they can help keep you on track and help you optimize your intake in a sensitive, informed way.

  • If you’re comfortable, tell your partner, a close friend, a family member or a support person what some warning “signs" are that would let them know you are slipping into dangerous territory. These signs could cue them to provide additional support and help keep you accountable.

Warning signs might be things like: “cleanses”, isolating, buying a lot of a particular food, avoiding a specific food group, not participating in mealtimes, big amounts of food missing from the cabinets or fridge suddenly, rigorous food tracking, over-exercising etc.


Let your support person know how you would like them to support you if they do worry that you’re slipping. Would you like them to not make a huge deal out of it and simply ask, by using a code-word/phrase like “You ok? Wave Crashing?!”. Would you like them to sit down with you and work out some strategies? Would you like them to support you to book an appointment with your primary healthcare provider? Or would you like their help in signing up for a support group?

  • Work with a therapist, a body image self-help book or journal independently about what body changes you’re excited for, scared of, and ways that you can cope with these changes. Note down some affirmations that you might use to accept your changing body. Affirmations don't have to be cheesy. It could be something like "I'm temporarily changing to accommodate something so exciting." Anticipatory work can help to almost pre-populate your mind with positive affirmations to combat automatic negative thoughts.

  • Anticipatory work, such as working on a relapse plan in advance of slips can allow you to return to non-disordered eating sooner after acting on ED urges. Having a plan noted down helps you res-stabilize sooner after a symptom as you've already predicted it and planned a course of action to keep yourself safe. Consider working on this with your therapist (if you have one), a support person or a peer-support group.

  • Ask your family members and friends to not comment on your body at all, even if they think it might be a positive comment. Communicate that there are ways of discussing your pregnancy, ways of checking in with you and celebrating you that don’t have anything to do with your changing form.


Those not carrying the baby, but expecting

Those who aren’t carrying the baby can also find themselves vulnerable to ED urges before and after baby is born.


Those parents awaiting surrogacy and adoption are at an increased risk for ED urges and symptoms because of the stress, cost and energy it takes to manage fertility issues, adoption and arranging surrogacy.


Partners to pregnant folx aren’t immune either. The stress of an upcoming life change, self-esteem related concerns around capacity to parent, the financial stress of expecting a child, etc. can also render someone more vulnerable to ED triggers and urges. These folx should also communicate with their primary healthcare provider about their current ED (or history of one) and encourage that practitioner to check in with them at multiple points of their journey of creating a family.


The Postpartum Period


Many feel the pressure to shape-shift back to their pre-pregnancy body quickly postpartum. The culture of weight loss after baby is rampant and predatory. It’s hard to spend time on any social media platform or YouTube without being exposed to endless content about it. Breastfeeding/chestfeeding government messaging even encourages breast/chestfeeding by using "losing weight faster" as one of the reasons to breast/chestfeed.

Most of the people that relapse in the postpartum period (80%) relapse because of wanting to shed the weight gained during pregnancy. Those with eating disorders/a history of one have lower breastfeeding/chestfeeding rates. This may be because the time and energy dedicated to weight-loss may interfere with the time and energy required to breast/chestfeed. This could also be for many other reasons.


50% percent of those engaging in their ED postpartum will meet criteria for postpartum-depression. People who had an eating disorder but aren’t engaging in those behaviours have a 29% chance of postpartum depression.

Some challenges those with eating disorders may have with breastfeeding/ chestfeeding



HISTORY OF ED + ALSO APPLIES TO THOSE WHO ARE CURRENTLY SYMPTOMATIC :

  • Those who had anorexia nervosa during their pubescent phase may not have had sufficient fat pads during puberty, when their breast/chest ducts were developing. Some might find that they have insufficient glandular tissue as adults.

  • May have a harder time reading or registering infant hunger/fullness cues as they don't come naturally to many people with EDs. This can easily be learned, but based on research is noted.

  • Anxiety about how much infant is taking in / if baby is getting enough. With breast/chestfeeding one isn't able to measure their infant’s intake (unless expressing their human milk) which can cause anxiety in those who like to measure their own intake.


CURRENTLY ENGAGING IN ED BEHAVIORS:

N.B. Not all folx engaging in ED behaviours will show these behavioural or physiological affects of ED symptoms

  • Delayed lactogenesis II (delayed milk “coming in” after colostrum phase).

  • Some people with bulimia and/or anorexia nervosa, have hypothalamic dysfunction. What does this mean? The gland that controls hormone release may be slightly impaired, thus affecting milk production or let-down for some.

  • Bulimia can cause reduced absorption of necessary nutrients for making human milk.

  • Those who binge and purge show a significant reduction of nocturnal prolactin levels. At night is when feeding parents typically get a big surge of prolactin, leading to higher milk transfer at night and early morning feeds.

  • Minimal bodily fat stores and insufficient food intake in those with active anorexia nervosa make it challenging for the body to access components necessary for the production of human milk.

Nutritional support if you are breast/chestfeeding with an eating disorder

  • Fish oils or other sources of Omega-3 fatty acids daily (get specific amounts from an RD or other healthcare provider).



  • 20% (approximately, no need to track cals unless medically indicated) of calorie intake should come from saturated (think meat and coconut oil) and unsaturated fats (think avocado, nuts).

  • Eat a variety of foods.

  • Try your best to not restrict water or liquids.

  • If you aren’t able to eat enough solid foods to meet your caloric needs integrate a nutritional supplement like Boost or Ensure into your diet.

  • Try your best to not cut out entire food groups from your diet unless medically indicated.

  • Continue to take your prenatal vitamin.

  • Consider taking a calcium supplement.

Breast/Chestfeeding as a therapeutic activity for those with active EDs or history of such


Carwell & Spatz (2011) suggest that for folx with a history of ED, breastfeeding/chestfeeding can be a way of associating positive activities and healthy practises to their bodies. Because those with ED (or history of one) often have low self-esteem, feeding their infants from their own body can really improve their self esteem. Providing human milk is a powerful thing one’s body can do for our children---directly nourishing another body can help someone feel efficacious!


Another benefit of breast/chestfeeding is the increased oxytocin and Cholecystokinin (CCK) swirling around during breast/ chestfeeding, positively affecting parent and child. Oxytocin and CCK lead to decreased cortisol rates and adrenocorticotropic hormone. This leads people to have less perceived stress when asked to report it postpartum.

It’s worth noting that issues with breast/chestfeeding without appropriate supports could aggravate mental illness. Getting supports for those with EDs or history of such, who have a goal of breast/chestfeeding, is extremely important as breast/chestfeeding has such therapeutic capacity when established with the right supports available.

General coping strategies: active EDs postpartum

  • Talk to your support person, primary healthcare provider. Ask for an immediate referral to individual counselling and or/ a psychiatrist for specialized support

  • Social services are available (in most public health units) that connect parents with active illness to childcare relief. Call your public health unit to enquire about being connected to this type of service. In Toronto one is called: Visiting Homemakers Association.

  • Review any previously learned materials related to delaying urges, preferred coping mechanisms etc.

  • Use harm reduction strategies if you are unable to stop engaging in ED symptoms such as: not purging after taking necessary medications, protecting electrolyte balance, drinking a nutritional supplement if you are not able to eat a meal, etc. Speak to your primary healthcare provider about specific harm-reduction strategies to keep you and your family safe.

  • If you feel faint or dizzy after purging and it doesn’t resolve go to the hospital or call emergency services. If your nutritional intake is so low that you feel weak/dizzy go to the hospital or call emergency services.

  • Consider having a friend or family member stay with you to support you and baby if your symptoms are getting quite active.

  • Get a regular EKG.

  • Work with a registered dietician (RD) with experience in supporting folx with EDs

  • If breast/chestfeeding is important to you and it's getting challenging invest in supports to help you reach your goals or explore them further. Call your local public health department and ask for help with breast/chestfeeding or hire an experienced lactation consultant

**Reminder: if your ED is causing you to lose your menstrual cycle this does not necessarily mean that you aren't ovulating. You can still get pregnant--it isn't likely but it isn't impossible. If this isn't your aim, use contraception.


Why healthcare practitioners need to screen folx for EDs at multiple points through their reproductive years & especially those expectant and postpartum parents


Somewhere around 1 million Canadians have an Eating Disorder and because many of those folx are in their reproductive years physicians, midwives, nurse practitioners, registered nurses, registered dieticians, etc. should regularly be screening for disordered eating.


1 million is not nothing and certainly reason enough for most practitioners to screen for it at all points of contact. You better believe some of those 1 million with EDs are expectant or new parents.

Under-resourced folx are disproportionately affected by EDs and require screening of EDs, especially when planning a family

Practitioners should be extra mindful with vulnerable populations to check in around disordered eating in times of higher stress, such as when trying to conceive, pregnancy, waiting for adoption and surrogacy and in the post-partum period


From the National EDs Association:

  • Females identified as lesbian, bisexual, or mostly heterosexual were about twice as likely to report binge-eating at least once per month in the last year

  • Black and Latinx LGBTTIQs have at least as high a prevalence of eating disorders as white LGBTTIQs.

  • Elevated rates of binge-eating and purging by vomiting or laxative abuse was found for people who identified as gay, lesbian, bisexual, or “mostly heterosexual” in comparison to their heterosexual peers.

  • Gay males are thought to only represent 5% of the total male population, but among males who have eating disorders, 42% identify as gay

These under-resourced populations are also under-researched.




References


“Canadian Eating Disorders Strategy: 2019 - 2029.” National Eating Disorder Information

Centre (NEDIC), EDAC-ATAC, EDFC, NEDIC and NIED, 2019.


Carwell, Micaela L. BSN, RN; Spatz, Diane L. PhD, RN-BC, FAAN Eating Disorders & Breastfeeding, MCN, The American Journal of Maternal/Child Nursing: March-April 2011 - Volume 36 - Issue 2 - p 112-117 doi: 10.1097/NMC.0b013e318205775c


“Eating Disorders in LGBTQ+ Populations.” National Eating Disorders Association, 21 Feb. 2018, www.nationaleatingdisorders.org/learn/general-information/lgbtq.