Obstetric and gynecologic problems associated with eating disorders

Analysis of the effects of eating and emotions on reproductive axis function in patients with functional hypothalamic amenorrhea

Objective: To investigate the effects of eating and emotions on reproductive axis function in patients with functional hypothalamic amenorrhea (FHA).

Methods: A retrospective cohort study was conducted to summarize the clinical and endocrine characteristics of 58 patients with FHA at initial diagnosis and to follow up the recovery of ovulation and spontaneous menstruation in the patients to investigate these biochemical indicators and their effects on recovery outcomes.

Results: Among patients with FHA, 13.8% (8/58) and 15.5% (9/58) had above moderately severe depressive and severe anxiety symptoms respectively, and 25.9% (15/58) were at high risk for eating disorders. 34.5% (20/58) were included assessed as having recovered. The non-recovered group had higher scores on the Patient Health Questionnaire (PHQ-9) (p = .022) and higher scores on the Eating Attitude Test-26 (EAT-26) (p = .03) as well as bulimia and food preoccupation (p = .041). Follicle diameter >5 mm at initial diagnosis was an independent factor influencing recovery of reproductive axis function (odds ratio = 7.532; 95% confidence interval, 1.321-42.930; p = .023).

Conculsions: Mood disorders and a certain risk of eating disorders were present in FHA.These, together with weight loss, endocrine and follicle size, could influence the outcome.

miRNA and leptin signaling in metabolic diseases and at extreme environments

The burden of growing concern about the dysregulation of metabolic processes arises due to complex interplay between environment and nutrition that has great impact on genetics and epigenetics of an individual. Thereby, any abnormality at the level of food intake regulating hormones may contribute to the development of metabolic diseases in any age group due to malnutrition, overweight, changing lifestyle, and exposure to extreme environments such as heat stress (HS), cold stress, or high altitude (HA). Hormones such as leptin, adiponectin, ghrelin, and cholecystokinin regulate appetite and satiety to maintain energy homeostasis. Leptin, an adipokine and a pleiotropic hormone, play major role in regulating the food intake, energy gain and energy expenditure. Using in silico approach, we have identified the major genes (LEP, LEPR, JAK2, STAT3, NPY, POMC, IRS1, SOCS3) that play crucial role in leptin signaling pathway. Further, eight miRNAs (hsa-miR-204-5p, hsa-miR-211-5p, hsa-miR-30, hsa-miR-3163, hsa-miR-33a-3p, hsa-miR-548, hsa-miR-561-3p, hsa-miR-7856-5p) from TargetScan 8.0 database were screened out that commonly target these genes. The role of these miRNAs should be explored as they might play vital role in regulating the appetite, energy metabolism, metabolic diseases (obesity, type 2 diabetes, cardiovascular diseases, inflammation), and to combat extreme environments. The miRNAs regulating leptin signaling and appetite may be useful for developing novel therapeutics for metabolic diseases.

Impact of parenthood on eating pathology in young adults

OBJECTIVE

Few studies investigated parenthood as a predictor of eating pathology in young adulthood. We studied the association between parenthood, in the first year after becoming a parent and beyond, and eating pathology. Furthermore, we examined whether moving in together with a partner affected this association.

METHOD

This study used data of four measurement waves from TRAILS (Tracking Adolescents' Individual Lives Survey), a Dutch community cohort study (N = 2229) from preadolescence into young adulthood. The Eating Disorder Diagnostic Scale (EDDS), a measure to assess eating pathology, was assessed at ages 22, 26, and 29. Risk for eating disorder was assessed at age 19. Pregnant participants were excluded.

RESULTS

Parenthood was not associated with an increase of eating pathology in the first year after becoming a parent and beyond. Instead, parents were more likely to report being free from eating pathology symptoms compared to childless individuals (OR 2.07, 95% CI: 1.11-3.84). Among those who reported experiencing at least one eating problem, parenthood was not associated with the number of eating problems. Moving in together with a partner did not alter the association between parenthood and eating problems and neither did this association differ between males and females.

DISCUSSION

Parenthood in young adulthood was associated with a decreased risk of having eating pathology.

PUBLIC SIGNIFICANCE STATEMENT

In this longitudinal study among young adults, parenthood was not associated with the development of eating pathology.

Management of eating disorders during pregnancy: A survey of Australian dietitians in clinical practice

BACKGROUND

Eating disorders (EDs) are estimated to affect 5.2%-7.5% of pregnant women, equating to 15,800-23,000 births in Australia annually. In pregnancy, an ED increases the risk of complications for both mother and child. Heightened motivation and increased utilisation of healthcare services during pregnancy present an opportunity to identify and commence ED treatment. Dietetic management of EDs differs from nutrition guidelines for pregnancy. This study aimed to assess current practice, confidence and training needs of dietitians to manage EDs in pregnancy.

METHODS

A cross-sectional survey of Australian dietitians with past year exposure to ED and/or antenatal fields was completed using Microsoft Forms between November 2022 and January 2023.

RESULTS

One hundred and seventeen responses were analysed. Confidence was less for assessment of a woman with an active ED in pregnancy than a pregnant woman with a history of an ED, pregnancy or an ED alone (p < 0.001). Greater than 5 years of experience as a dietitian, but without recent exposure to the patient population, was associated with increased confidence (p < 0.01). Almost half provided descriptions of treatments and interventions used to treat a pregnant woman with an ED, some of which conflict with ED or antenatal guidelines. Dietitians were more likely to weigh a person with an ED in pregnancy. Most respondents indicated further training (93%) and guidelines (98%) would be helpful.

CONCLUSION

This is the first investigation into the dietetic management of EDs in pregnancy, and it highlights a need for guidelines and training for dietitians.

Preconception weight suppression predicts eating disorder symptoms in pregnancy

OBJECTIVE

Disordered eating is common in pregnancy and associated with adverse health outcomes. Weight suppression (WS), the discrepancy between highest lifetime and current weight, is a robust predictor of loss of control (LOC) and binge eating and weight gain trajectories in clinical populations. This study explored the role of preconception WS as a predictor of disordered eating and weight gain in pregnancy.

METHOD

Pregnant individuals (n = 137) reported their highest, preconception, and current weights to calculate preconception WS, actual gestational weight gain (GWG), and deviations from recommended weight gain trajectories in pregnancy. Participants also completed the Prenatal Eating Behaviours Screening (PEBS) tool, a validated measure of disordered eating specifically in pregnancy.

RESULTS

Preconception WS was a significant predictor of PEBS total scores [F(5, 122) = 2.70, p = 0.02, R2 = 0.10] and significantly and positively correlated with individual item scores quantifying restrictive eating behaviours. Preconception WS was not predictive of deviations from recommended GWG trajectories or LOC or binge eating frequency and did not interact with pre-pregnancy body mass index or GWG to predict eating disorder symptom severity.

CONCLUSIONS

Preconception WS was predictive of disordered eating, and specifically restrictive eating behaviours in pregnancy, and should be assessed as part of screening for eating disorder risk in pregnant individuals.

Integrating behavioral interventions into a holistic approach to metabolic dysfunction-associated steatotic liver disease

INTRODUCTION

The therapeutic landscape of Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) is rapidly evolving with the FDA approval of resmetirom, the first authorized molecule to treat metabolic dysfunction-associated steatohepatitis. Clinical trials are investigating other promising molecules. However, this focus on pharmacotherapy may overshadow lifestyle interventions, which remain the cornerstone of MASLD management. A significant percentage of patients with MASLD struggle with an underlying eating disorder, often a precursor to obesity. The obesity pandemic, exacerbated by the increasing prevalence of binge eating, underscores the need for a psychological approach to address their common roots.

AREAS COVERED

We reviewed the current evidence on behavioral interventions for MASLD. Interventions such as self-monitoring, goal setting, and frequent counseling, have proven effective in achieving at least 5% weight loss. Cognitive behavioral therapy is the first-line treatment for eating disorders and has shown efficacy in treating binge eating and obesity. Further research is needed to establish the optimal behavioral therapy for MASLD, focusing on enhancing compliance and achieving sustained weight loss through diet and physical exercise.

EXPERT OPINION

The treatment of MASLD should not rely solely on pharmacotherapy targeting a single-organ manifestation. Instead, we must consider behavioral interventions, emphasizing the pivotal role of a holistic approach to this multifaceted disorder. [Figure: see text].

Nutritional and exercise interventions to improve conception in women suffering from obesity and distinct nosological entities

Infertility among women, particularly those living with obesity, presents a multifaceted challenge with implications for reproductive health worldwide. Lifestyle interventions, mainly focusing on weight loss, have emerged as promising strategies to improve fertility outcomes in this population. This review aims to explore the effectiveness of various lifestyle interventions, encompassing dietary modifications and exercise regimens, in enhancing fertility outcomes among women with obesity and associated conditions such as polycystic ovary syndrome, congenital adrenal hyperplasia, type 2 diabetes mellitus, premenopause, hypothyroidism and eating disorders. Methodology of study search encompass a broad spectrum, ranging from interventions targeting weight management through slow or rapid weight loss to dietary approaches emphasizing whole food groups, specific nutrients, and dietary patterns like low-carbohydrate or ketogenic diets, as well as the Mediterranean diet. By synthesizing existing findings and recommendations, this review contributes to the understanding of lifestyle interventions in addressing infertility, with an emphasis on the population of women of reproductive age with excess weight and known or unknown infertility issues, while promoting their integration into clinical practice to optimize reproductive health and overall well-being.

A clinical trial protocol of a single-session self-guided acceptance-based online intervention targeting food cravings as predictors of disordered eating in pregnant people

BACKGROUND

Pregnancy is a time of heightened risk for disordered eating behaviors, which are linked to adverse health outcomes in gestation, delivery, and the postpartum. These adverse outcomes may be partially mediated by greater rates of deviation from recommended weight gain trajectories, especially in those who engage in binge and loss of control (LOC) eating. Food cravings are powerful and highly modifiable triggers of binge and LOC eating in non-pregnant populations with preliminary evidence linking cravings to disordered eating behaviors in pregnancy as well. Acceptance-based approaches have been shown to be feasible and effective in reducing the adverse impact of cravings on behavior.

PURPOSE

To test the feasibility, acceptability, and preliminary efficacy of a single-session, self-guided, acceptance-based online workshop targeting food cravings as predictors of binge and LOC eating in pregnancy.

METHODS

We will conduct a pilot randomized controlled trial of a single-session, self-guided online acceptance-based workshop targeting food cravings in pregnancy. Pregnant individuals in the second trimester (n ≥ 74) endorsing current food cravings will be randomly assigned to the intervention or an untreated control group. The intervention group will participate in a one-hour workshop that imparts skills grounded in Acceptance and Commitment Therapy, including acceptance, defusion, and present-moment awareness. Both groups will complete comprehensive self-report assessments of primary outcomes and hypothesized mediators and moderators of intervention efficacy at baseline, one-month follow-up, and at full-term.

CONCLUSION

Results will inform integration of acceptance-based skills targeting food cravings into routine prenatal care to prevent adverse outcomes associated with disordered eating behaviors in pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT06129461; registered on November 10, 2023.

Assessment of eating disorders and depression in postpartum women

OBJECTIVE

To determine the prevalence of eating disorders and orthorexia in postpartum women and examine the relationship with postpartum depression.

STUDY DESIGN

Included in this study were 227 postpartum women. The Eating Attitude Test-26 (EAT-26) was used to determine the risk of eating disorders in the women, followed by the Orthorexia 11 Scale (ORTO-11) to identify orthorexia, and the Edinburgh Postpartum Depression Scale (EPDS) to identify postpartum depression.

RESULTS

63 of the women (27.8%) exhibited an orthorexic tendency, which was also related to eating disorders and postpartum depression. Each one-point increase in the EAT-26 score led to a decrease of 0.32 points in the ORTO-11 score. Similarly, each one-point increase in the EPDS score caused a reduction of 0.18 points in the ORTO-11 score. The ORTO-11 score increased by 0.26 points per each live birth.

CONCLUSION

An obsessive focus on healthful nutrition may result in the impairment of health and numerous adverse psychological and physiological outcomes in the future. Healthy eating habits should be maintained to improve the quality of life without causing an obsession with healthy eating.

The causal relationship of female infertility and psychiatric disorders in the European population: a bidirectional two-sample Mendelian randomization study

BACKGROUND

Infertility affects many couples globally, causing physical, emotional, and financial burdens. While observational studies suggest a link between psychiatric disorders and female infertility, causal relationships remain uncertain. Mendelian randomization analysis, using genome-wide association studies data, minimizes confounding factors and reverse causation, providing valuable insights into causal associations.

METHODS

We conducted Mendelian randomization analysis to explore the potential causal relationship between female infertility and psychiatric disorders. Genome-wide association studies summary data for female infertility (112,105 individuals of European ancestry, comprising 11,442 cases and 100,663 controls), depression (807,553 individuals of European ancestry, comprising 246,363 cases and 561,190 controls), anxiety (21,763 individuals of European ancestry, comprising 7,016 cases and 14,745 controls), bipolar disorder (51,710 individuals of European ancestry, comprising 20,352 cases and 31,358 controls), and eating disorders (72,517 individuals of European ancestry, comprising 16,992 cases and 55,525 controls) were utilized. Instrumental variables were selected based on significant single nucleotide polymorphisms associated with each phenotype. We assessed instrumental variable strength, examined confounding factors, and employed inverse variance weighting, weighted median, and MR-Egger approaches for analysis.

RESULTS

Our analysis included 85 single nucleotide polymorphisms for female infertility and 62 single nucleotide polymorphisms for psychiatric disorders. Results suggest a potential causal relationship between depression and female infertility, with both inverse variance weighting and weighted median methods showing increased infertility risk in depressed patients. Evidence is weak regarding bipolar disorder not increasing female infertility risk. We found no evidence supporting causal links between anxiety, eating disorders, and female infertility. Similarly, no causal relationship was found between female infertility and psychiatric disorders in the opposite direction. Sensitivity analyses and tests for heterogeneity and polymorphism supported result robustness.

CONCLUSIONS

This analysis provides evidence for a potential causal relationship between depression and female infertility. Addressing depression in infertile women may improve fertility outcomes. Further research is needed to explore underlying mechanisms and potential interventions for improving fertility outcomes in women with psychiatric disorders.

"It is more isolating to patients if you aren't familiar with the resources": a pilot test of a clinician sensitivity training on eating disorders in pregnancy

It is more isolating to patients if you aren't familiar with the resources: A pilot test of a clinician sensitivity training on eating disorders in pregnancy.(IRB Number: 1909705198).Background Pregnant women with a history of eating disorders (EDs) or active EDs have greater maternal and child health complications. They are also unlikely to disclose their history with an ED to their clinician, few of which are confident in their knowledge to provide appropriate care for patients who present with EDs. This study's goal was to evaluate changes to knowledge, behavior, and attitudes for health professionals who were part of a sensitivity training (to provide information of and awareness, address potential clinician biases, and offer strategies for more patient-centered care with de-stigmatizing language) about eating disorders and pregnancy compared with those who received a reference document.Methods Our pilot study compared responses of health professionals before and after this sensitivity training (N = 54) with a group who were provided a clinician reference document about the same topic (N = 61).Results Mann-Whitney Wilcoxon tests showed significant differences between the sensitivity training and reference document groups, with the sensitivity training resulting in increases to participants' perception of ED's relevance to overall treatment (p = 0.018), comfort in providing resources (p < 0.0001), frequency of ability to introduce strategies (p = 0.001), and interest in additional strategies/recommendations in treating patients with eating disorders (p = 0.009). Thematic analysis of the open-ended responses indicated four major themes: Resources and support, Treatment, Additional training, and Clinician Strategies. Discussion Results indicated that the sensitivity training improved training outcomes compared to the reference document group. Qualitative responses from both groups indicated four themes that can help inform ED-centered care. This study provides context for future directions for continuing education courses as well as clinical training recommendations for treating pregnant patients with EDs.

The effects of weight loss-related amenorrhea on women's health and the therapeutic approaches: a narrative review

Background and Objective

Weight loss-related amenorrhea is defined as the reversible functional inhibition of the hypothalamic-pituitary-ovarian (HPO) axis associated with weight loss or low body weight, which occurs mostly in adolescents and women of reproductive age. The specific pathological mechanisms of this disease have not yet been elucidated, and the optimal evidence-based guidelines for its clinical assessment and management are limited. This review summarizes its adverse effects on female health, and the individualized, emerging, and multidisciplinary therapeutic approaches used to treat it.

Methods

We searched the PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) databases for Chinese and English literature on functional hypothalamic amenorrhea (FHA), and retrieved original articles (on basic and clinical research) and reviews published up to December 2022.

Key Content and Findings

We reviewed the findings on the unfavorable effects of weight loss-related amenorrhea with a focus on reproduction, the skeletal and cardiovascular system, other endocrine effects, and mental health. Lifestyle changes and hormonal replacement have been shown to alleviate the underlying causes and lead to the recovery of menstruation. However, the efficacy of treatments is affected by many factors, such as psychological stress and heterogeneity.

Conclusions

Weight loss-related amenorrhea, which is an important type of FHA, is manifested by anovulation and hypoestrogenism, and has both short- and long-term adverse effects on women's overall health. It is difficult to alleviate its underlying causes. Individualized treatments need to be optimized and emerging or multidisciplinary therapeutic approaches need to be explored that aim to recover normal menstruation and ovulation, eliminate the undesirable effects of prolonged hypoestrogenism and alleviate psychological disorders.

IVF-induced pregnancy and early motherhood among women with a history of severe eating disorders

Background

There is a higher prevalence of eating disorders among women seeking in vitro fertilization (IVF). Women with a history of eating disorders may be particularly vulnerable to eating disorder relapse during IVF, pregnancy, and early motherhood. The experience of these women during this process has hardly been studied scientifically, despite its high clinical relevance. The overall aim of this study is to describe how women with a history of eating disorders experience the process of becoming a mother through IVF, pregnancy, and the postpartum period.

Methods

We recruited women with a history of severe anorexia nervosa who had undergone IVF (n = 7) at public family health centers in Norway. Semi-openly, the participants were interviewed extensively first during pregnancy, and then 6 months after birth. The 14 narratives were analyzed using interpretative phenomenological analyses (IPA). All participants were required to complete the Eating Disorder Examination Questionnaire (EDE-Q) and were diagnosed (DSM-5) by using the Eating Disorder Examination (EDE), during both pregnancy and postpartum.

Results

All participants experienced a relapse of an eating disorder during IVF. They perceived IVF, pregnancy, and early motherhood to be overwhelming, confusing, a source of severe loss of control, and a source of body alienation. There were four core phenomena that were reported that were strikingly similar across all participants: "anxiousness and fear," "shame and guilt," "sexual maladjustment," and "non-disclosure of eating problems." These phenomena persisted continuously throughout IVF, pregnancy, and motherhood.

Conclusion

Women with a history of severe eating disorders are highly susceptible to relapse when undergoing IVF, pregnancy, and early motherhood. The process of IVF is experienced as extremely demanding and provoking. There is evidence that eating problems, purging, over-exercising, anxiousness and fear, shame and guilt, sexual maladjustment, and non-disclosure of eating problems continue throughout IVF, pregnancy, and the early years of motherhood. Therefore, it is necessary for healthcare workers providing services to women undergoing IVF to be attentive and intervene when they suspect a history of eating disorders.

Body Image Dissatisfaction, Breastfeeding Experiences, and Self-Efficacy in Postpartum Women with and Without Eating Disorder Symptoms

BACKGROUND

Women during the postpartum period undergo significant changes which affect body image, eating behaviors, and, potentially, breastfeeding. There is limited research about relationships among these variables, particularly related to breastfeeding experiences and self-efficacy.

RESEARCH AIMS

To determine: (1) the associations between eating disorder symptoms and body image, breastfeeding self-efficacy, and breastfeeding experiences; and (2) the differences in body image, breastfeeding self-efficacy, breastfeeding experiences, and breastfeeding status of postpartum women with and without clinically significant eating disorder symptoms.

METHODS

A secondary data analysis using a 2-group correlational, cross-sectional online survey design was used. Participants with infants 2-6 months old who had breastfed their infant at least once (N = 204) were recruited nationally to complete a cross-sectional survey assessing breastfeeding and postpartum physical and mental health using validated measures. Linear and logistic regression evaluated differences between participants with and without eating disorder symptoms regarding their body image, breastfeeding experience and self-efficacy, and breastfeeding status (continued vs. discontinued) at 2 months postpartum.

RESULTS

Clinical eating disorder symptoms were reported by 9.8% (n = 20). Participants with clinical eating disorder symptoms reported lower appearance evaluations (B = -0.53, 95% CI [-0.93, -0.14]) and body image satisfaction (B = -0.55, 95% CI [-0.87, -0.23]); reduced odds of breastfeeding at 2 months postpartum (AOR = 0.15, 95% CI [0.04, 0.56]); and lower breastfeeding self-efficacy (B = -7.70, 95% CI [-14.82, -0.58] relative to participants without clinical symptoms. No differences between groups were observed for breastfeeding experiences.

CONCLUSIONS

Participants with clinically significant eating disorder symptoms are at risk for early breastfeeding discontinuation and lower breastfeeding self-efficacy. Our findings have implications for future research and clinical care practices, including screening for body image concerns and eating disorder symptoms and supporting breastfeeding self-efficacy.

Fat–fat-free index in body mass assessment in young people

The study aimed to personalize the classification of body weight using the fat–fat-free (FFF) index with the percentage of body fat and to develop classification standards for the FFF index for men aged 18–25 years. Moreover, 1,642 adolescents (1,200 ♀) were examined. Using body composition analyzers, weight was determined, as well as overall and segmental body composition. Based on the obtained values for fat mass and fat-free tissue mass, an overall FFF index was calculated. According to the BMI classification, 9% of ♀ and 6% of ♂ are underweight, 29% of ♀ and 13% of ♂ are overweight, and 5% of the subjects are obese. Women and men classified in the same group according to BMI differed statistically significantly in terms of body weight, FM%, and FFM. In contrast to BMI and FM%, the FFF used takes into account the ratio of fat mass to fat-free tissue and muscle tissue mass. The proposed classification of FFF was made taking into account the differences that arise with sexual development and physiological changes occurring in ontogeny. Assessment of body mass using the FFF index should be used as part of preventive screening for the early diagnosis and prevention of overweight and thus many chronic diseases for which overweight or obesity is a risk factor.

Understanding the Effects of Disordered Eating on Fertility and Fertility Outcomes

Disordered eating and subthreshold eating disorders can affect fertility. A negative cumulative energy balance that occurs through inadequate nutrition and excessive exercise is often found in individuals engaging in disordered eating behaviors; these disruptions can affect the normal functioning of the hypothalamic-pituitary-gonadal axis and, thus, fertility. Appropriate screening; assessment; and medical, nutritional, and psychosocial interventions are needed to successfully treat these individuals. Educating nurses about the impact of disordered eating on fertility status will enable those who work with clients of reproductive age to better recognize signs and symptoms of disordered eating and to ultimately provide better care. This article addresses how to appropriately recognize and treat individuals presenting with infertility and disordered eating symptomatology.

Menstrual disorders in adolescents and young adults with eating disorders

Although amenorrhea is no longer a specific criterion required to make the diagnosis of anorexia nervosa (AN), the relationship between restrictive eating and menstrual status remains important in the diagnosis, treatment, and consequences for patients with eating disorders. Clinicians should understand the relationship between menstrual irregularities and malnutrition due to eating disorders, as it may be possible to intervene sooner if the diagnosis is made earlier. Treatment of AN (in those who are underweight) and atypical AN (in those who are not underweight) is aimed at cessation of restrictive thoughts and behaviors, restoration of appropriate nutrition and weight, and normal functioning of the body. While eating disorder thoughts and behaviors are helped by both therapy and nutrition, regular functioning of the body, including regular menstruation, is linked to both appropriate nutrition and weight. Patients who are not underweight based on their body mass index (BMI) may still have oligo/amenorrhea due to their caloric restriction; thus any patient who has irregular menses should have a detailed dietary evaluation as part of their workup. Timely diagnosis and treatment of patients with eating disorders and amenorrhea is important due to the impact on bone mass accrual for adolescents who have prolonged amenorrhea. Menstrual abnormalities may also be seen in patients with bulimia nervosa (BN).

Increased risk of somatic diseases following anorexia nervosa in a controlled nationwide cohort study

OBJECTIVE

To assess the risk of somatic diseases in connection with anorexia nervosa (AN).

METHOD

This matched cohort study was based on Danish registries of all patients born 1961-2008 with a first-time diagnosis of AN in 1994-2018 at age 8-32 and matched controls without an eating disorder. For 13 somatic disease categories, time from inclusion date to time of first somatic diagnosis, accounting for censoring, was studied by use of time-stratified Cox models.

RESULTS

A total of 9985 AN patients born 1961-2008 and 49,351 controls were followed for a median (interquartile range) of 9.0 (4.4-15.7) years. During the first 2 years after entry there was a 60% higher hazard for any somatic disease among patients with AN than among controls, while the ratio from three to 11 years was reduced to 1.18. Regardless of age at diagnosis, the hazard among patients and controls were no different at approximately a decade after diagnosis of AN and the cumulative risk for patients for 12 of 13 disease categories was always higher or no less that for controls. For all disease categories, the hazard ratio (HR) was higher when close to entry. For most disease categories, age at diagnosis of AN did not modify the effect.

DISCUSSION

While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls. Large HRs were seen in the early years after diagnosis during which patients require extensive medical interventions.

PUBLIC SIGNIFICANCE

Based on Danish registries, a large sample of almost 10,000 patients with AN born 1961-2008 and almost 50,000 matched controls were followed for a median of 9 years. While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls.

Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review

Anorexia nervosa is a potentially severe, chronic, and relapsing mental disorder that is more common in women and girls during the reproductive years (usually defined as those aged 12-51 years). It is associated with suicide and mortality linked with the physical consequences of starvation. Although anorexia nervosa is a disorder of low prevalence, and even lower prevalence in pregnancy, it is associated with substantial risks for the mother and infant when under-recognised and undermanaged. Despite the complexity and risk of managing anorexia nervosa in pregnancy, few studies are available to guide care. We conducted a systematic review, identifying only eight studies that addressed the management of anorexia nervosa in pregnancy. These studies were case studies or case reports examining narrow aspects of management. Subsequently, we conducted a state-of-the-art review across research in relevant disciplines and areas of expertise for managing anorexia nervosa in pregnancy and synthesised the findings into recommendations and principles for multidisciplinary management of anorexia nervosa in pregnancy. These recommendations included a focus on the specialist mental health, obstetric, medical, and nutritional care required to ensure optimal outcomes for women and their infants. Despite the complexity and risks, a gap exists in the comprehensive guidelines and recommendations for managing anorexia nervosa in pregnancy. This Review provides multidisciplinary recommendations for clinical care in this area. Managing anorexia nervosa in pregnancy is an area of clinical care that requires a multidisciplinary approach and includes those experienced in managing high-risk pregnancies.

Binge eating disorder

Binge eating disorder (BED) is characterized by regular binge eating episodes during which individuals ingest comparably large amounts of food and experience loss of control over their eating behaviour. The worldwide prevalence of BED for the years 2018-2020 is estimated to be 0.6-1.8% in adult women and 0.3-0.7% in adult men. BED is commonly associated with obesity and with somatic and mental health comorbidities. People with BED experience considerable burden and impairments in quality of life, and, at the same time, BED often goes undetected and untreated. The aetiology of BED is complex, including genetic and environmental factors as well as neuroendocrinological and neurobiological contributions. Neurobiological findings highlight impairments in reward processing, inhibitory control and emotion regulation in people with BED, and these neurobiological domains are targets for emerging treatment approaches. Psychotherapy is the first-line treatment for BED. Recognition and research on BED has increased since its inclusion into DSM-5; however, continuing efforts are needed to understand underlying mechanisms of BED and to improve prevention and treatment outcomes for this disorder. These efforts should also include screening, identification and implementation of evidence-based interventions in routine clinical practice settings such as primary care and mental health outpatient clinics.

Pregnancy outcomes in women with active anorexia nervosa: a systematic review

BACKGROUND

It is a common misconception that women with active anorexia nervosa (AN) are less likely to conceive. Pregnancies in women with AN are considered high risk. The purpose of this systematic review was to explore pregnancy complications in women with active AN, including maternal, fetal, and neonatal complications.

METHODS

The authors conducted a systematic review in accordance with PRISMA statement guidelines with stringent selection criteria to include studies on patients with active AN during pregnancy.

RESULTS

There were 21 studies included in our review. Anaemia, caesarean section, concurrent recreational substance use, intrauterine growth restriction, preterm birth, small-for-gestation (SGA) birth, and low birth weight were the most reported pregnancy complications in women with active AN, while the rates of gestational diabetes and postpartum haemorrhage were lower.

DISCUSSION

Women with active AN have a different profile of pregnancy complications comparing to malnourished women and women in starvation. We recommend early discussion with women diagnosed with AN regarding their fertility and pregnancy complications. We recommend clinicians to aim to improve physical and psychological symptoms of AN as well as correction of any nutritional deficiency ideally prior to conception. Management of pregnancies in women with active AN requires regular monitoring, active involvement of obstetricians and psychiatrist. Paediatric follow-up postpartum is recommended to ensure adequate feeding, wellbeing and general health of the infants. Psychiatric follow-up is recommended for mothers due to risk of worsening symptoms of AN during perinatal period.

Prevalence and phenotype of eating disorders in assisted reproduction: a systematic review

Background

Eating disorders (EDs) are common conditions that mainly affect women of reproductive age and have a major impact on fertility. Our systematic review focuses on the prevalence of EDs in patients in the process of assisted reproductive technique (ART) and describes the phenotypes of EDs identified.

Methods

Our systematic review is based on the PRISMA criteria. Articles were collected using the Medline/Pubmed, Web Of Science and Cochrane databases. The articles chosen had to mention the prevalence of ED in infertile patients undergoing ART and be cohort or case–control studies assessing the prevalence of ED during fertility treatment.

Main findings

Fifteen articles were included in this review. The prevalence of active ED varied between 0.13 and 44% depending on the types considered in each study. The main phenotypes described were EDNOS (eating disorder not otherwise specified) and binge eating disorders (BED) occurring in women with a normal body mass index (BMI) and a history of ED. Mainly subthreshold forms with cognitive distortions were described.

Conclusion

This review highlights a 6 times higher prevalence of EDs in infertile patients undergoing fertility treatment compared to regular pregnant women. However, diagnosing these conditions is complex. As a result, it is essential that professionals in contact with this population are alert to symptoms consistent with these conditions in order to refer them to specialized psychiatric care.

Eating disorders are frequent pathologies that primarily affect women of childbearing age. Numerous articles reveal an increased risk for the mother and the child in case of an active disorder during pregnancy.

We conducted a systematic review to determine the prevalence and phenotypes of eating disorders in infertile subjects undergoing fertility treatment.

The results of the fifteen articles included show a prevalence six times higher than in pregnant women in the general population. Subjects with eating disorders have normal body mass indexes. The active forms are mainly characterized by episodes of binge eating disorders or other unspecified forms. Studies also describe incomplete forms characterized by the presence of dysfunctional thoughts around shape and weight without associated compensatory behavior.

Professionals working in the field of reproductive medicine and providing fertility treatment have a major role to play in identifying and referring these subjects at risk to specialized care.

Early detection of eating disorders: a scoping review

PURPOSE

Early detection of eating disorders (EDs) could improve their prognosis, decrease morbidity and mortality, and prevent the risk of evolution towards a chronic form and somatic, psychiatric and psychosocial complications. The objective of this review was to examine the current scientific data concerning the early detection of EDs, which is one of the facets of secondary prevention.

METHOD

A scoping literature review was carried out following the PRISMA-ScR criteria, including all articles on ED detection published up to 2021 on PUBMED and PSYCINFO.

RESULTS

43 articles were included. Anorexia nervosa and bulimia nervosa were the most widely studied disorders. The articles focused on professionals from the medical field (GPs, psychiatrists, gynaecologists, gastroenterologists and residents), from the paramedical field, from education and sport, and from the general population. The assessments conducted with the professionals receiving interventions aiming to improve detection demonstrated their efficacy. Interventions for ED detection in the general population and at school seemed less efficacious.

CONCLUSION

The results highlighted some lines of action to be implemented. They pointed towards improving initial and continuing education for professional carers; e-learning could be an interesting solution for continuing education. Improving training with specific instructors, school personnel and sports professionals is also one of the solutions for a better detection of EDs. Specific recommendations could be published for fitness centre professionals to help them to deal with clients suspected of having an ED. Among secondary school students and in the general population, a better dissemination of mental health literacy and the development of mental health first aid programs could help improve early detection.

LEVEL OF EVIDENCE

Level I: Evidence obtained from systematic reviews.

Eating disorders in sport. Update and proposal for an integrated approach

Eating disorders are a group of conditions which have a huge impact on the health and performance of athletes. The aetiology of eating disorders is multifactorial, being influenced by genetic and environmental factors, but also involving psychological factors and factors specific to the practising of sport. Eating disorders are highly prevalent in sport, particularly in disciplines involving endurance, those that have weight-categories or those where low weight is a competitive advantage and aesthetics are important. Athletes with eating disorders need to be assessed and receive early, comprehensive treatment. Close monitoring of nutritional status is vital, especially with female athletes. Prevention is crucial and plays an invaluable role in this type of disorder, but represents a significant challenge for all professionals who look after athletes. Priority needs to be given to implementing structured nutrition training programmes for the athlete and their entourage to help prevent eating disorders.

Analysis of Neurodevelopmental Disorders in Offspring of Mothers With Eating Disorders in Sweden

IMPORTANCE

Despite indices of impaired neurodevelopment in children of mothers with eating disorders, it remains unclear whether these children are at increased risk of developing neuropsychiatric diseases.

OBJECTIVE

To evaluate the association between maternal eating disorders, whether preexisting or ongoing during pregnancy, and offspring neuropsychiatric disease risk.

DESIGN, SETTING AND PARTICIPANTS

This population-based prospective cohort study used the Swedish Medical Birth Registry and identified singleton births registered between from January 1, 1990, and December 31, 2012. Children of exposed mothers with eating disorders were matched with comparator children of mothers without diagnoses of eating disorders. To adjust for unmeasured shared familial factors, a cluster of exposed children with full maternal cousin comparators was identified. Follow-up was completed on December 31, 2017. Data were analyzed from August 31, 2020, to April 30, 2021.

EXPOSURES

Maternal eating disorder diagnosis.

MAIN OUTCOMES AND MEASURES

All children were followed up from 1 year of age for autism spectrum disorder (ASD) and from 3 years of age for attention-deficit/hyperactivity disorder (ADHD). The relative risk of ASD and ADHD was assessed among exposed children, stratified by eating disorder subtype and ongoing vs previous disease, adjusted for potential confounders, including parental socioeconomic status and comorbidities.

RESULTS

Among the 52 878 children included in the analysis, maternal eating disorder exposure (n = 8813) was associated with an increased risk of ADHD (hazard ratio [HR] for anorexia nervosa, 1.42 [95% CI, 1.23-1.63]; HR for bulimia nervosa, 1.91 [95% CI, 1.43-2.54]; and HR for unspecified eating disorder, 2.00 [95% CI, 1.72-2.32]) and ASD (HR for anorexia nervosa, 2.04 [95% CI, 1.58-2.63]; HR for bulimia nervosa, 2.70 [95% CI, 1.68-4.32]; and HR for unspecified eating disorder, 1.95 [95% CI, 1.49-2.54]). After adjustment for parental confounders, the risk of ADHD remained significantly increased, whereas the risk of ASD in children to mothers with bulimia nervosa was no longer significant. Ongoing anorexia nervosa was associated with a significantly higher risk of ADHD (HR, 2.52 [95% CI, 1.86-3.42]) and ASD (HR, 3.98 [95% CI, 2.49-6.27]) compared with previous disease (HRs, 1.26 [95% CI, 1.06-1.48] and 1.81 [95% CI, 1.38-2.38], respectively). Results based on the family cluster were similar to those of the main analysis for maternal exposure to anorexia nervosa and bulimia nervosa.

CONCLUSIONS AND RELEVANCE

These findings suggest that children born to mothers with eating disorders, in particular disorders that were active during pregnancy, were at increased risk of developing ADHD and ASD. The association could not be fully explained by parental psychiatric comorbidities, and among children of mothers with anorexia nervosa and bulimia nervosa, it could not be explained by unmeasured familial confounding.

Development and validation across trimester of the Prenatal Eating Behaviors Screening tool

Rapid screening tools are useful for identifying at-risk patients and referring them for further assessment and treatment, but none exist that consider the unique medical needs of pregnant women with eating disorders (EDs). There is a need for a rapid, sensitive, and specific screening tool that can be used to identify a potential ED in pregnancy. We started with a set of 25 questions, developed from our qualitative work along with other ED screening tools, and tested on a development (n = 190) and validation sample (n = 167). Statistical analysis included factor analysis and logistic regressions with ROC curves. Development and validation samples were combined for trimester analysis (n = 357). Refining the tool to 12 items demonstrated strong internal reliability (development alpha = 0.95, validation alpha = 0.91). With correlated errors, questions demonstrated acceptable CFA fit (development: GFI: 0.91, RMSEA: 0.10, NNFI: 0.95; validation: GFI: 0.85, RMSEA: 0.14, NNFI: 0.86). Similar fits were seen by trimester: first trimester n = 127, GFI: 0.89, RMSEA: 0.12, NNFI: 0.94; second trimester n = 150, GFI: 0.83, RMSEA: 0.14, NNFI: 0.88; third trimester n = 80, GFI: 0.99, NNFI: 0.99. Validation against current ED diagnosis demonstrated acceptable sensitivity and specificity using a cutoff of 39 (development sensitivity = 80.7%, specificity = 79.7%, OR = 16.42, 95% CI: 7.51, 35.88; validation sensitivity = 69.2%, specificity = 86.5%, OR: 17.43, 95% CI: 6.46, 47.01). Findings suggest the PEBS tool can reliably and sensitively detect EDs across pregnancy trimesters with 12 questions. A further implication of this work is to reduce health and mental health treatment disparities through this standard and rapid screening measure to ensure early identification and treatment.

The first 20 weeks of pregnancy is a high-risk period for eating disorder relapse

OBJECTIVE

Eating disorders (ED) are associated with adverse pregnancy outcome and pregnancy is associated with both relapse and remission of ED. Knowledge is lacking on the risk of ED relapse during pregnancy and the postpartum period for women in stable remission. This study examined the occurrence of perinatal ED relapse as well as obstetric and postpartum outcome in women with at least a 6-month ED remission before pregnancy.

METHOD

A total of 122 women in stable remission before pregnancy were included in a prospective longitudinal study. Changes in ED symptoms based on the Eating Disorder Examination were systematically evaluated at each antenatal visit and in the postpartum period.

RESULTS

A total of 30 (25%) women relapsed. Twenty women relapsed within the first 20 weeks of pregnancy and eight in the early weeks postpartum. Severe postpartum depression symptoms (33%) were frequent in women with ED relapse; hyperemesis gravidarum (30%) was frequently present independent of the woman's relapse status.

DISCUSSION

To prevent relapse of ED and possible consequences, attention to relapse in women in stable remission is especially important in early pregnancy and in the postpartum period.

Eating disorders, pregnancy and the postnatal period: a review of the recent literature

PURPOSE OF REVIEW

Eating disorders (ED) are severe psychiatric disorders that affect women in reproductive age. The purpose of this review is to provide an up-to-date overview of the impact of maternal ED on pregnancy and the postnatal period. The clinical implications for identification and management of maternal ED are also discussed.

RECENT FINDINGS

In the last 2 years, 15 articles focused on the impact of maternal ED in pregnancy and postpartum. Findings from this review indicate that around 15% of pregnant women are likely to have had an ED at some point in their lifetime, and about 5% have an ED in pregnancy. Although ED symptoms tend to decrease during pregnancy, remission is often only temporary with symptoms typically resurfacing in the postnatal period. Women with ED are prone to psychiatric comorbidities such as depression and anxiety during the perinatal period, with up to a third of women with ED reporting postnatal depression in clinical studies and prevalence ranging between 40% and 66% in general population samples. Furthermore, recent findings continue to highlight that current and prior history of maternal ED are associated with a heightened risk of adverse pregnancy and birth outcomes, most notably preterm birth and adverse birth weight outcomes.

SUMMARY

These findings continue to emphasise the clinical importance of early identification and response to maternal ED to mitigate potentially adverse maternal and infant outcomes.

The development and initial validation of the Health and Reproductive Survey (HeRS)

Background:

Due to the diversity in profiles associated with the female reproductive cycle and their potential physiological and psychological effects, monitoring the reproductive status of exercising females is important from a practical and research perspective. Moreover, as physical activity can influence menstrual function, the effects of physical activity energy expenditure on reproductive function should also be considered.

Aim:

The aim of this study was to develop and establish initial face and content validity of the Health and Reproductive Survey (HeRS) for physically active females, which is a retrospective assessment of menstrual function from menarche (first menstruation) to menopause (cessation of menstruation).

Methods:

Face validity was evaluated qualitatively, and the initial content validity was established through a principal component analysis. The face validity process was completed by 26 females aged 19–67 years and the content validity was established through a survey sent to a convenience sample of 392 females, of which 230 females (57.9% and aged 18–49 years) completed the survey.

Results:

The revisions made following the face validation improved the understanding, flow, and coherence of the survey. The principal component analysis indicated that, at a minimum, the survey measures these constructs: menstrual cessation and associated moderators, athletic participation and performance levels (as associated with menstruation change and the menstrual cycle), age and menstrual cessation, hormonal contraception (“birth control”), and menarche and associated moderators.

Conclusion:

The Health and Reproductive Survey (HeRS) is a partially validated tool that can be used by researchers to characterize the menstrual status of physically active females relative to their physical activity status.

Menstrual Disorders Related to Eating Disorders

Eating disorders (ED) are associated with multiple physical complications that strongly affect the physical health of these young and fragile patients and can also cause significant mortality, the highest among psychiatric pathologies. Among the various organic complications, albeit still little known, the gynecological implications, up to infertility, are very widespread. Among adolescent and adult patients, gynecological symptoms can be very widespread and range from menstrual irregularities to amenorrhea, from vaginitis to ovarian polycystosis, up to complications during the gestational phase and postpartum, in addition to the possible consequences on the unborn child. Among the most frequent and significant gynecological disorders in women with ED, there are menstrual irregularities that may occur with oligomenorrhea or even amenorrhea. , Although no longer part of the DSM-5 diagnostic criteria for defining anorexia nervosa (AN), this symptom must be considered a very relevant event in the overall evaluation of young women and adolescents with eating disorders. Functional hypothalamic amenorrhea in ED patients is related to psychological distress, excessive exercise, disordered eating, or a combination of these factors, which results in suppression of the hypothalamic-pituitary-ovarian axis, and consequently, hypoestrogenism. This paper has the objective to summarize the causes and the mechanism underlying menstrual disorders and provide a better understanding of the correlation between the reproductive system and the mechanisms that regulate food intake and eating habits. In addition, early recognition of risk factors for eating disorders for gynecological implications can help put more accurate assessments of patients to prevent potentially fatal complications. The importance of the involvement of specialist gynecologists in the multidisciplinary team that has to follow patients with eating disorders is also discussed.

Eating disorders in sport. Update and proposal for an integrated approach

Eating disorders are a group of conditions which have a huge impact on the health and performance of athletes. The aetiology of eating disorders is multifactorial, being influenced by genetic and environmental factors, but also involving psychological factors and factors specific to the practising of sport. Eating disorders are highly prevalent in sport, particularly in disciplines involving endurance, those that have weight-categories or those where low weight is a competitive advantage and aesthetics are important. Athletes with eating disorders need to be assessed and receive early, comprehensive treatment. Close monitoring of nutritional status is vital, especially with female athletes. Prevention is crucial and plays an invaluable role in this type of disorder, but represents a significant challenge for all professionals who look after athletes. Priority needs to be given to implementing structured nutrition training programmes for the athlete and their entourage to help prevent eating disorders.

Eating Disorders in Children and Adolescents: A Practical Review and Update for Pediatric Gynecologists

Eating disorders (EDs) are common among female adolescents and young adults and can have serious and diverse health consequences. Pediatric gynecology providers have the opportunity to play a vital role in the recognition of EDs in this population. Early medical detection and referral for appropriate evidence-based treatment can lead to better health outcomes for youth. In this article we aim to increase the awareness of the pediatric gynecologist of typical and subtle presentations of EDs, provide guidance for screening, discuss common and serious medical complications, and review treatment considerations for gynecologic issues in patients with EDs.

Eating disorders are associated with adverse obstetric and perinatal outcomes: a systematic review

Objective:

To systematically review the literature focusing on obstetric and perinatal outcomes in women with previous or current eating disorders (EDs) and on the consequences of maternal EDs for the offspring.

Methods:

The study was performed following the systematic review and meta-analysis (PRISMA) statement. PubMed, SciELO, and Cochrane databases were searched for non-interventional studies published in English or Portuguese from January 1980 to December 2020. Risk of bias was assessed using the Methods guide for effectiveness and comparative effectiveness reviews (American Agency for Healthcare Research and Quality).

Results:

The search yielded 441 records, and 30 articles were included. The psychiatric outcome associated with EDs in women was mainly perinatal depression. The most prevalent obstetric outcomes observed in women with EDs were vomiting, hyperemesis, bleeding, and anemia. Most studies found maternal anorexia nervosa and bulimia nervosa to be associated with low birth weight and slow fetal growth. Women with binge EDs delivered children with increased birth weight. Of the 30 studies included, methodological quality was good in seven, fair in eight, and poor in 15 studies.

Conclusion:

A considerable body of evidence was reviewed to assess obstetric and perinatal outcomes in EDs. Acute and lifetime EDs, especially if severe, correlated with poor perinatal, obstetric, and neonatal outcomes. Obstetricians and general practitioners should be vigilant and screen for EDs during pregnancy.

Psychological aspects of infertility. A systematic review

Objective

Fertility may be defined as a capacity to conceive and produce offspring. Infertility is characterized by failure to establish a clinical pregnancy after 12 months of regular and unprotected sexual intercourse. Infertility concerns an estimated 8–12% of the global population, and is associated with factors including time of unwanted non-conception, age of female partner and number of diseases impacting fertility. Unexplained infertility is described as idiopathic. This study aimed to analyse and evaluate the influence of mental disorders, often considered as reasons for idiopathic infertility, on female and male fertility, including stress, depression, sleep and eating disorders, and addictions.

Methods

This systematic review comprised a search of MEDLINE, Cochrane and PubMed databases for relevant articles that were analysed by two independent reviewers.

Results

A total of 106 articles published between 1955–2019 were included. Mental disorders modify endocrine gland and immune system functioning at both the tissue and cellular level, and are negatively associated with female and male fertility.

Conclusion

Mental disorders may negatively impact female and male fertility. Further studies are required to explain the exact role and contribution of mental disorders to fertility.

Postpartum psychiatric disorders and subsequent live birth: a population-based cohort study in Denmark

STUDY QUESTION

Are women with a history of first-onset postpartum psychiatric disorders after their first liveborn delivery less likely to have a subsequent live birth?

SUMMARY ANSWER

Women with incident postpartum psychiatric disorders are less likely to go on to have further children.

WHAT IS KNOWN ALREADY

Women are particularly vulnerable to psychiatric disorders in the postpartum period. The potential effects of postpartum psychiatric disorders on the mother's future chances of live birth are so far under-researched.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study consisted of 414 571 women who had their first live birth during 1997-2015. We followed the women for a maximum of 19.5 years from the date of the first liveborn delivery until the next conception leading to a live birth, emigration, death, their 45th birthday or 30 June 2016, whichever occurred first.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Postpartum psychiatric disorders were defined as filling a prescription for psychotropic medications or hospital contact for psychiatric disorders for the first time within 6 months postpartum. The outcome of interest was time to the next conception leading to live birth after the first liveborn delivery. Records on the death of a child were obtained through the Danish Register of Causes of Death. Cox regression was used to estimate the hazard ratios (HRs), stratified by the survival status of the first child.

MAIN RESULTS AND THE ROLE OF CHANCE

Altogether, 4327 (1.0%) women experienced postpartum psychiatric disorders after their first liveborn delivery. The probability of having a subsequent live birth was 69.1% (95% CI: 67.4-70.7%) among women with, and 82.3% (95% CI: 82.1-82.4%) among those without, postpartum psychiatric disorders. Women with postpartum psychiatric disorders had a 33% reduction in the rate of having second live birth (HR = 0.67, 95% CI: 0.64-0.69), compared to women without postpartum psychiatric disorders. The association disappeared if the first child died (HR = 1.01, 95% CI: 0.85-1.20). If postpartum psychiatric disorders required hospitalisations, this was associated with a more pronounced reduction in live birth rate, irrespective of the survival status of the first child (HR = 0.54, 95% CI: 0.47-0.61 if the first child survived, and HR = 0.49, 95% CI: 0.23-1.04 if the first child died).

LIMITATIONS, REASONS FOR CAUTION

The use of population-based registers allows for the inclusion of a representative cohort with almost complete follow-up. The large sample size enables us to perform detailed analyses, accounting for the survival status of the child. However, we did not have accurate information on stillbirths and miscarriages, and only pregnancies that led to live birth were included.

WIDE IMPLICATIONS OF THE FINDINGS

Our study is the first study to investigate subsequent live birth after postpartum psychiatric disorders in a large representative population. The current study indicates that postpartum psychiatric disorders have a significant impact on subsequent live birth, as women experiencing these disorders have a decreased likelihood of having more children. However, the variations in subsequent live birth rate are influenced by both the severity of the disorders and the survival status of the first-born child, indicating that both personal choices and decreased fertility may have a role in the reduced subsequent live birth rate among women with postpartum psychiatric disorders.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Danish Council for Independent Research (DFF-5053-00156B), the European Union's Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement No. 837180, AUFF NOVA (AUFF-E 2016-9-25), iPSYCH, the Lundbeck Foundation Initiative for Integrative Psychiatric Research (R155-2014-1724), Niels Bohr Professorship Grant from the Danish National Research Foundation and the Stanley Medical Research Institute, the National Institute of Mental Health (NIMH) (R01MH104468) and Fabrikant Vilhelm Pedersen og Hustrus Legat. The authors do not declare any conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Is Ovarian Reserve Impacted in Anorexia Nervosa?

STUDY OBJECTIVES

Hypothalamic amenorrhea is common in adolescents and young adults (AYAs) with anorexia nervosa (AN), and ovarian reserve is not routinely assessed. AN increases rates of fertility problems, but how or when AN negatively influences future fertility is unclear. We sought to determine whether biomarkers of ovarian reserve were impacted in AYA with AN.

DESIGN

Cross-sectional study.

SETTING

Tertiary care center.

PARTICIPANTS

Females with AN and amenorrhea (n = 97) at the pre-intervention visit of a clinical trial, n = 19 females without an eating disorder or menstrual dysfunction.

MAIN OUTCOME MEASURES

Serum anti-Müllerian hormone (AMH) concentrations.

RESULTS

AMH levels were higher in AYA with AN than unaffected adolescents (4.7 vs. 3.2 ng/mL; P = .03). Neither FSH nor inhibin B differed between groups. In 19.6% of participants with AN, AMH levels were elevated above the normal range (>6.78 ng/mL). These subjects had a longer disease duration than those with normal AMH levels (9 vs. 3 mos; P = .03); age or degree of malnutrition did not differ between AN subjects with normal or elevated AMH.

CONCLUSIONS

AMH levels appear to be normal or elevated in AYA with AN. Low AMH in a patient with AN should raise clinical concern regarding ovarian reserve, and should not be attributed to degree of malnutrition alone. Currently, AMH is not regularly assessed during routine AN clinical care. However, our findings suggest some clinical utility in identifying those patients with reduced ovarian reserve. Potential links between the hypothalamic amenorrhea suffered by patients with AN and PCOS should be explored.

Systematic Review of Literature on Eating Disorders During Pregnancy-Risk and Consequences for Mother and Child

Background: Eating disorders (ED) are a diagnostic category that includes several nosological units such as anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). This category most often concerns women, while the peak incidence falls on the reproductive age. Therefore the issue of ED during pregnancy is an interesting topic. Due to the creation of unrealistic ideal of "desired," slim figure both by the mass media and social media even during and right after gestation, more and more pregnant women introduce behaviours aimed at maintaining the "perfect" appearance. However in some cases it may have serious consequences for the health of both mother and child leading to the creation of the term "pregorexia" by the media to describe this issue. Aim: The aim of this paper was to conduct a systematic review of the literature dealing with eating disorders in pregnant women, with particular emphasis on pregorexia. Method: A systematic review of literature published within the last 5 years (2016-2021) in English or Polish and available through MEDLINE / PubMed, Google Scholar and Cochrane Library databases was conducted based on the previously assumed inclusion and exclusion criteria. Results: Initially, 634 publications were obtained during the review, of which 55 papers were selected in the course of the title analysis. After further evaluation of abstracts, 28 papers were qualified for full text analysis. Ultimately, 10 papers were selected for the final analysis. Conclusions: The issue of ED in pregnant women is a broad topic covering a heterogeneous group of women-both those with a previous history and those with the onset during pregnancy. The occurrence of ED symptoms during this period is associated with a high likelihood of negative consequences for both the mother and the child. The course of pregnancies and deliveries in these patients is more complicated. Therefore, it seems reasonable to develop a multidisciplinary screening strategy and standards of management and supervision over this group of patients.

Prospective Longitudinal Assessment of Linear Growth and Adult Height in Female Adolescents With Anorexia Nervosa

CONTEXT

Growth retardation is an established complication of anorexia nervosa (AN); however, findings concerning the adult height of AN patients are inconsistent.

OBJECTIVE

The objective of this work was to assess linear growth and adult height in female adolescents with AN.

DESIGN AND SETTING

A prospective observational study was conducted in a tertiary university hospital.

PARTICIPANTS

Participants included all 255 female adolescent AN patients hospitalized in the pediatric psychosomatic department between January 1, 2000 and May 31, 2015.

INTERVENTIONS

Height and weight were assessed at admission and during hospitalization. Patients were subsequently invited for measurement of adult height. Additional data collected included premorbid height data, menstrual history, skeletal age, pertinent laboratory studies, and parental heights.

MAIN OUTCOME MEASURE

The main outcome measure of this study was adult height.

RESULTS

Mean age at admission was 15.4 ± 1.75 years, mean body mass index (BMI) was 15.7 ± 1.8 kg/m2 (BMI SDS = -2.3 ± 1.45 kg/m2). Premorbid height SD scores (SDS) were not significantly different from those expected in normal adolescents (0.005 ± 0.96). However, height SDS at admission (-0.36 ± 0.99), discharge (-0.34 ± 0.96), and at adult height (-0.29 ± 0.95), were significantly (P < .001) lower than expected. Furthermore, adult height was significantly (P = .006) shorter compared to the midparental target height. Stepwise forward linear regression analysis identified age (r = 0.32, P = .002) and bone age (r = -0.29, P = .006) on admission, linear growth during hospitalization (r = 0.47, P < .001), and change in luteinizing hormone during hospitalization (r = -0.265, P = .021) as independent predictors of improvement in height SDS from the time of admission to adult height.

CONCLUSIONS

Whereas the premorbid height of female adolescent AN patients is normal, linear growth retardation is a prominent feature of their illness. Weight restoration is associated with catch-up growth, but complete catch-up is often not achieved.

Fertility and Reproduction after Recovery from Anorexia Nervosa: A Systematic Review and Meta-Analysis of Long-Term Follow-Up Studies

Reproductive health is compromised during anorexia nervosa (AN). However, it is still unclear whether this medical complication is reversible after recovery from AN. The purpose of this paper was to conduct a systematic review of the major reproductive health outcomes in females after recovery from AN. The review was conducted in adherence to preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. Data were collated using meta-analysis and a narrative approach. Of the 1186 articles retrieved, five studies met the inclusion criteria and were reviewed. These studies monitored weight-restored females who had recovered from AN for a follow-up period of between six and 18 years. Their narrative analysis revealed that appropriate treatment of AN leads to the normalization of reproductive function, especially in terms of fertility, pregnancy, and childbirth rates. The meta-analysis confirmed this finding, where the pooled odds of childbirth rates between the AN group and the general population was not statistically significant (OR = 0.75, 95% CI: 0.43–1.29, p = 0.41). We conclude that if patients undergo appropriate eating-disorder treatment and weight restoration, it appears to be unlikely that reproductive health is affected by AN. However, since this finding is derived from only a few studies, it requires replication and confirmation.

A neonate with intrauterine growth restriction and pseudo-Bartter syndrome due to severe maternal eating disorder: A case report

Maternal diet before and during pregnancy plays an important role for the developing fetus. Any eating disorder in this period can cause transient or/and permanent negative effects on the mother and her offspring.

Interventions to Empower Adults with Eating Disorders and Their Partners around the Transition to Parenthood

The transition to parenthood is perceived as a stressful life event, when parents experience an immense change of their psychological focus and a reorientation of roles and responsibilities in the family system. This process may be even more challenging in the presence of a parental eating disorder history. This paper reviews the impact of parental eating disorders on the parents, the couple relationship, and their child during the perinatal period. A parental eating disorder is associated with more negative expectations of parental efficacy as well as specific difficulties in couple communication over the child's feeding, shape, and weight. Providers who better understand the effects of an eating disorder on parental functioning can more effectively intervene early on. We also present couple- or parent-based, empirically supported interventions for adults with eating disorders and their partners in the prenatal and postnatal periods: Uniting Couples in the treatment of Anorexia Nervosa (UCAN) and Uniting couples In the Treatment of Eating disorders (UNITE) both enhance recovery from the eating disorder through a couple-based intervention; the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) incorporates the support of partners, when appropriate; Parent-Based Prevention (PBP) focuses on improving parental functioning and reducing risk of negative parental and child outcomes. Finally, we discuss the clinical implications of addressing parental eating disorders and encourage more research on these families.

Treatment of Eating Disorders in Adults Versus Adolescents: Similarities and Differences

FINDINGS

Although several individual psychotherapies for adults with eating disorders are empirically supported, with family-based treatment (FBT) being the leading recommended empiric treatment in adolescents, patients with eating disorders are still difficult to treat, and outcomes are often poor. In some countries, the clinical services for adolescents and adults are separate, and it is common for patients to receive treatments that differ in terms of both theory and content when they are switched from adolescent to adult services. Changes in the nature of treatment also often occur when patients move from less intensive types of care to more intensive treatment, and vice versa. These transitions may create a discontinuity in the care pathway and disorient patients and their significant others about the strategies and procedures used for addressing eating problems. However, the observation that younger and older patients essentially share the same eating-disorder psychopathology has led to evidence-based enhanced cognitive-behavioral therapy (CBT-E) being adapted for use in adolescents. Originally an evidence-based treatment for adults with eating disorders, CBT-E has yielded promising results in trials in cohorts of adolescent outpatients and inpatients, and is recommended as an alternative to FBT in adolescent patients.

IMPLICATIONS

With a unified treatment such as CBT-E, several issues that plague conventional eating-disorder services could be partially overcome, as patients can move seamlessly from adolescence to adulthood and through different levels of care, with no change in the nature of the treatment itself. Future randomized, controlled trials should compare FBT to CBT-E to better clarify the specific therapeutic needs of subgroups of adolescents and adult patients with eating disorders.

Predictors of Resumption of Menses in Anorexia Nervosa: A 4-Year Longitudinal Study

OBJECTIVE

Amenorrhea is a disabling medical consequence of anorexia nervosa (AN); therefore, resumption of menses (ROM) represents an important goal in the treatment for these patients. The aim of the present study was to evaluate possible clinical, psychopathological, and biological predictors of ROM, including age, body mass index (BMI), AN subtype, childhood abuse, duration of illness, general and eating disorder (ED)-specific psychopathology, and sex hormones.

METHODS

Fifty amenorrheic patients with AN were enrolled. Baseline clinical data and information on childhood abuse were collected. Questionnaires to evaluate general and ED-specific psychopathology were administered, and blood samples were drawn. All patients received treatment as usual and underwent regular follow-up visits for 4 years or until ROM. Time to ROM, BMI at last evaluation, and data regarding diagnostic crossover into bulimia nervosa were collected.

RESULTS

Twenty-nine (58.0%) patients recovered menses. Diagnostic crossover was associated with a higher probability of ROM (odds ratio = 10.3, p = .030). Time-to-event analysis showed that a shorter duration of illness (χ(1) = 11.00, p = .001), binge-eating/purging subtype (χ(1) = 7.01, p = .008), and history of childhood abuse (χ(1) = 4.03, p = .045) were associated with an earlier ROM. Furthermore, higher baseline ED-specific psychopathology was associated with a reduced likelihood for ROM, whereas higher general psychopathology and follicle-stimulating hormone levels predicted an earlier ROM (all, p < .050). Age, BMI, luteinizing hormone, and estrogen hematic levels had no predictive value with respect to ROM.

CONCLUSIONS

The present study provides data in support of an integrated model, emphasizing the importance of duration of illness, childhood abuse, and psychopathological characteristics of amenorrheic patients with AN in predicting ROM.

Hospitalization following eating disorder diagnosis: The buffering effect of marriage and childbearing events

Eating Disorders (ED) are defined as abnormal eating behaviors, stemming from an obsession with food, body weight, or body shape. EDs affect 10 million men and 20 million women in the US, with an estimated 15% lifetime prevalence among women. An ED diagnosis is often accompanied with a host of adverse physical and mental health outcomes, including a heightened risk for suicidality. Given the complex comorbidities associated with EDs, treatment occurs in inpatient and outpatient settings. This study used linked administrative and health records from the Utah Population Database to create a cohort of women n = 4183 and men n = 423 who had a known diagnosis of ED between 1995 and 2015. Cox proportional hazard regression was used to model ED-related hospitalization trajectories, including subsequent risk for suicidality/self-injurious behavior-related hospitalization. To better estimate the risk profiles associated with different health care utilization patterns, models explored how family-related life course events (childbirth, marriage transitions) and sociodemographic characteristics (race, sex, and median income at census-block) modify hospitalization trajectories following initial diagnosis. Results suggested that increased outpatient treatment was associated with reduced risk of initial ED-related hospitalization, but higher risk for subsequent ED-related hospital readmission. In addition, transition to marriage (i.e., getting married) was associated with reduced risk of ED-related and suicidality/self-injurious behavior-related hospitalizations (initial hospitalization and subsequent readmission). Increased number of children was only associated with reduced risk of initial ED-hospitalization, but not readmission. When assessing individuals' risk for ED-related hospitalizations, social and health services researchers should contextualize treatment trajectories within the individual's life experiences, particularly marital transitions, while simultaneously considering sociodemographic characteristics and utilization of outpatient care. Future research should further examine whether marriage represents an important turning point in the health trajectories of individuals with EDs.

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Childbearing reduces risk of initial eating disorder hospitalization.

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Marriage reduces risk of eating disorder hospitalization and readmission.

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Marriage reduces risk of suicidality hospitalization for persons with prior eating disorder.

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Higher outpatient treatment reduces risk of initial eating disorder hospitalization.

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Higher outpatient treatment increases risk of eating disorder hospital readmission.

The effectiveness of healthy lifestyle interventions on weight gain in overweight pregnant women: A cluster-randomized controlled trial

Aim

Interventions based on adopting a healthy lifestyle have been less successful. The aim of this study was to investigate the effectiveness of healthy lifestyle interventions on weight gain in overweight pregnant women.

Design

A cluster randomized controlled trial.

Methods

Health centres were selected by simple random sampling; then, 66 overweight pregnant women were enrolled by convenience sampling and divided into intervention and comparison groups. Intervention group received individual nutritional counselling and physical activity training. The data were collected in several stages with the demographic and obstetric questionnaire, maternal weight record, food frequency and international physical activity questionnaire.

Results

Pregnancy weight gain‐4.75(CI 95%: −4.02, −5.48) was significantly lower in the intervention group (p < .001). Comparing between groups with adjustment for baseline values indicated that there was a statistically significant difference in terms of total calorie 95.46 (CI 95%: −22.37, 213.30), carbohydrate 23.45 (CI 95%: 2.12, 44.78), protein −7.16 (CI 95%: −12.85, −1.47) and fat 8.82 (CI 95%: 2.21, 15.67) intake. Despite the higher level of physical activity in the intervention group, there was no statistically significant difference between the two groups.

Conclusion

Counselling interventions for healthy living during pregnancy can lead to controlling weight gain, improving dietary habits and increasing the physical activity in overweight pregnant women.

Medical Complications of Anorexia Nervosa

OBJECTIVE

The purpose of this study was to describe the medical complications of anorexia nervosa (AN) to enable a consult-liaison psychiatrist to be familiar with these complications when involved with the care of a hospitalized patient with AN.

METHODS

Comprehensive PubMed search of English language publications of adult patients with AN was carried out using keywords, phrases, and medical subject headings of anorexia nervosa-medical complications, cardiac, osteoporosis, gastrointestinal, hematological, and endocrine. The database search was restricted by time of publication of studies from 2005 to 2020.

RESULTS

Every organ system can be adversely affected by AN. Most are fully reversible with time and informed medical care. A multidisciplinary team is needed to optimally care for patients who are hospitalized as a result of the medical complications of their AN.

CONCLUSIONS

Consult-liaison psychiatrists are asked to help in the care of patients with AN who are admitted to a hospital because of a medical complication of their illness. Being familiar with these complications and their treatments will optimize their hospital stays and the care provided. In addition, involving other relevant ancillary services is an important care consideration.

Psychosocial factors, mental health symptoms, and disordered eating during pregnancy

OBJECTIVE

The impact of disordered eating extends beyond women with a diagnosed eating disorder. Scarce research to date has investigated disordered eating in a general perinatal population, including the complex interplay between psychosocial factors, mental health symptoms, and disordered eating at numerous pregnancy periods. Specifically, maternal attitudes and relationship satisfaction are psychosocial factors that have been identified as a gap in the literature.

METHOD

Pregnant women completed an online questionnaire between 18 and 24 weeks gestation (T1, n = 258) and again between 30 and 32 weeks gestation (T2, n = 159). Structural equation modeling was used to test an interrelated model of psychosocial factors-attitudes to pregnancy, attitudes to motherhood, and relationship satisfaction-and disordered eating, mediated by either depressive or anxiety symptoms. Invariance testing examined whether model weights differed between primiparous and multiparous women at each time point.

RESULTS

While at T1 and T2, there were significant direct associations between psychosocial factors and disordered eating, only at T2 were the associations between psychosocial factors and disordered eating mediated by depressive and anxiety symptoms. Furthermore, at T2, multiparous women were at greater risk of an association between maladaptive attitudes to pregnancy and motherhood, depressive symptoms, and disordered eating.

DISCUSSION

The present study highlights the need to investigate the relationships between psychosocial factors and disordered eating, while accounting for the unique antenatal needs of women during different pregnancy periods and across differing parity. The mediating effect of depressive and anxiety symptoms have implications for future research and clinical care.

The effect of underweight on female and male reproduction

Chronic energy deficiency can impair the hypothalamic-pituitary-gonadal (HPG) axis and lead to hypothalamic anovulation in underweight women. This review presents the syndromes related to underweight status that are associated with infertility, summarizes the underlying mechanisms, and reviews the available treatment options. Eating disorders, such as anorexia nervosa (AN), constitute the most common cause of infertility in underweight women, who, in addition, experience miscarriages, and sexual dysfunction. The relative energy deficiency in sports (RED-S; former terminology: athlete's triad) involves menstrual dysfunction due to low energy availability, which results in anovulation. Moreover, lipodystrophies, malnutrition, starvation, systematic illnesses (malignancies, endocrinopathies, infectious diseases, advanced chronic diseases, neurologic illnesses), and the utilization of drugs can cause excessive weight loss. They may result in fertility problems due to the loss of adipose tissue and the subsequent hormonal disturbances. Each of these conditions requires multidisciplinary management. Nutritional counseling should target the restoration of energy balance by increasing intake and reducing output. Medical treatment, recommended only for patients who did not respond to standard treatment, may include antipsychotics, antidepressants, or leptin administration. Finally, psychiatric treatment is considered an integral part of the standard treatment.