When Pregnancy and Eating Disorders Mix

March 22, 2011— -- Melissa Henriquez grabbed her favorite Joe's jeans from her bedroom dresser. It was 7 a.m. and mid-July, but still dark outside. Kalamazoo, Mich., rests so close to the Central time zone divide that even though the city follows Eastern time, the sun does not.

She slid her legs into her jeans, but as she pulled them up around her waist, she stopped. The pants would not button. Melissa felt her unborn child starting to push its way across her waistline, interfering with all hopes of wearing tight-fitting designer denim.

Melissa hates fat. If it were any other time, Melissa would go for a long run to burn extra calories; she would only eat grilled chicken and vegetables for lunch. But, she folded the jeans and put them away, without remorse.

Melissa, who is 30, had never been pregnant before, though she'd always welcomed the thought of changing diapers and answering to Mommy one day. Now motherhood beckoned. Yet part of her squirmed when she thought about the weight gain.

Should I be eating for two people? 4,000 calories a day? How many meals are enough?

At the first doctor's visit last May, she was told not to dramatically change her diet; she would only need to eat between 200 and 500 calories more per day. Melissa vowed to accept the weight gain and emotional stress with it in order to have a healthy daughter.

But she neglected to tell her doctor about her eating disorder -- a situation all too common for women with the condition.

Eating Disorders, Pregnancy a Dangeours Mix

Pregnant women in general have a more exaggerated sensitivity to changes in their body shape, but for those suffering from an eating disorder, the heightened sensitivity can trigger life-threatening behaviors like starvation or purging. An eating disorder puts a pregnancy at high-risk if the mother does not nourish herself properly.

Just as a normal pregnant patient would battle pneumonia or flu, some professionals believe a pregnant woman with an eating disorder is sick. "It's an illness, disorder, disease and temporary psychosis," says Dr. Katy Aisenberg, a Massachusetts-based psychotherapist.

Some experts estimate that as many as one in 20 women suffer from an eating disorder while pregnant. But shame, secrecy and denial are inherent in eating-disorder patients, so the numbers do not account for those who are unwilling to describe symptoms to their obstetricians.

Visible symptoms can arise when the mother does not gain an adequate amount of weight (generally 25 to 35 pounds) or experiences hyperemesis, a severe form of morning sickness causing excessive vomiting and nausea. Pregnant mothers who purge can easily hide their behavior by blaming it on normal morning sickness or nausea.

Pregnant women with eating disorders are also prone to obstetric complications. Many have increased rates of difficult labor, like breech delivery, using forceps and Caesarian sections. Most commonly, when the mother acts on an eating disorder during pregnancy, a fetus will experience a low birth-weight, growth retardation and vitamin deficiencies, which can lead to more severe conditions.

Some pregnant women have two competing forces demanding medical attention: the baby and the eating disorder. Who or what demands priority of treatment can differ depending on whom you ask -- the obstetrician or the therapist.

For the obstetrician, the baby takes precedence over the mother's psychological state. Dr. Clarissa Bonanno, an obstetrician who deals with high-risk pregnancies at Columbia University, argues there is a weak correlation between the mother's weight gain and the baby's weight because the baby takes what it needs to grow, regardless of how much weight the mother gains.

Bonanno says eating disorders often go undetected during pregnancy because many patients don't tell and obstetricians don't receive special training on eating disorders in medical school. "We probably grossly under-diagnose it," she says.

Extreme Measures to Limit Weight

Years before she became pregnant Melissa struggled with her eating disorder. She recalled sitting in her car outside a gas station in Kalamazoo, tearing open candy wrappers. As soon as she took the first bite and felt it soften in her mouth, she spit out the intruder.

Chewing up the "bad" food and then spitting it out gave her the taste she craved, but not the satisfaction. From 2006 to 2009, she hid in her car, under her desk and even in an airport bathroom stall to spit out candy and cookies.

It had been over a year since Melissa chewed and spit, but watching the number on the scale increase during pregnancy while she ate and exercised the same startled her. At six months pregnant, she continued to focus on her growing unborn child though some days were a struggle.

"I blame myself for everything I went through," Henriquez says. "My disorder was a mind set, but I knew I needed to change how I thought about things in order to have a baby."

Melissa had a pleasant childhood growing up in Vernon, N.J., as the oldest child of three. Her red hair and heavier build distinguished her from her peers. Her parents would joke that she was born hungry, since she always had food on her mind. As a kid, Melissa ate what she wanted with no regard for counting calories or measuring portion sizes.

She listened to her body by gauging hunger and fullness. Her biggest concern about the food on her plate was how it tasted.

"I sometimes feel as if Melissa thought she had to perform more, or perform better, to make sure she was still recognized," says her mother, Sue Marion.

When she met her soon-to-be husband, Luis, during her senior year in college, Melissa was the heaviest she had ever been at 5 feet 5 inches tall and weighed slightly over 175 pounds. She was grateful Luis appreciated curvaceous women.

But in 2004 Melissa started to change the way she thought about her body. She joined Weight Watchers and began to lose a pound or more a week until she had lost 35 pounds by Christmas that year. She was ecstatic and proud of her weight loss; her hourglass figure had evened out, making her broad shoulders, tiny waist and hips follow a more symmetrical line.

By 2006 she had married and moved to Kalamazoo, Mich. But the stress of moving to a new city, a new marriage and a new job heightened Melissa's anxiety. She felt her Weight Watchers program was no longer providing enough control.

She gradually became obsessive about keeping off additional pounds. She shunned all food but her Weight Watchers portions. She worked out twice a day and missed going out with her friends if it meant losing time at the gym. When Luis surprised her for a weekend getaway one Friday morning, she cried hysterically and refused to go because she had not had a chance to go to the gym that day.

Melissa's mom remembers how obsessed Melissa became about dieting, which made her visits home very stressful. "She would announce to us all that she was only going to take a few bites of a sandwich because then she could enjoy her dessert later," recalls Sue.

Eating Disorder: No One Definition

Eating disorders are characterized by abnormal behaviors that prevent people from having a healthy relationship with food. The types of disorders reach far beyond the commonly known conditions like anorexia nervosa, when someone starves and depletes the body of necessary nutrition; bulimia nervosa, or bingeing and purging; and binge-eating disorder which refers to people who eat thousands of calories at one time.

Outsiders often assume people with eating disorders have a choice whether to eat properly. But experts say eating disorders disrupt logic and cause cognitive distortions or abnormal thinking patterns. For example, "all-or-nothing thinking" is a cognitive distortion, which sometimes leads disordered eaters to think, "if I gain weight, I will be a worthless person." When a fetus enters the equation, the impaired thinking prevents mothers from rationalizing what they need to do for the health of their unborn child.

For someone like Melissa, disordered eating helps classify the extreme behaviors and psychological side effects of a weight-loss obsession, without excessive starvation, purging or obesity. Even though Melissa does not have anorexia, bulimia, or binge-eating disorder, her particular kind of uncategorized disorder still presents a serious problem. For women like Melissa, pregnancy can either push them further into the disease, or offer them a nine-month respite.

At the Melrose Institute in St. Louis Park, Minn., Dr. Paula Deakins, a specialist for pregnant women with eating disorders, says they will give preferential treatment to their pregnant patients who are actively engaged in an eating disorder. "We put them in the hospital a lot more quickly than we would with a regular patient," Deakins says.

But she cannot force treatment on her patients and worries about the struggling women who refuse to come forward. "The message we need to get to the public is that it is the obstetrician who needs to send them to us," Deakins says.

According to Deakins, 60 to 70 percent of eating-disorder patients experience remission during pregnancy. While the actual pregnancy can aggravate an eating disorder, the postpartum period can compound its intensity.

A woman's body is already stressed after giving birth. Extreme starvation worsens the situation, making it impossible for a new mother to feed her child when lactation stops because of dehydration and malnutrition.

Pregnant women need certain nutrients, but readjusting the diet of an eating-disorder patient to consume those nutrients can be problematic.

"It's never just the calories with me," says Julie Mowery, a Registered Dietician at the Melrose Institute for 15 years. Nutrients are critical during pregnancy because the body is already comprised if the mother has been suffering from an eating disorder. Mowery encourages expecting mothers to have enough calcium, folate and protein.

One of the hardest obstacles for pregnant women with eating disorders, Mowery says, is ingesting enough fat. The fear of gaining weight leads pregnant women to cut fatty foods, but a developing fetus needs fatty acids.

Healthy pregnant women should gain an average of 25 pounds. Pregnant woman who intentionally restrict their food intake still gain an average of 15.8 pounds. Bulimic pregnant women gain an average of 5.7 pounds, and the average birth weight of their babies is 4.9 pounds.

Although excess is what the body and baby need, women with eating disorders cannot accept why they should eat more. "The eating disorder becomes their identity," says Dr. Jill Pollack, director of The Center of Study for Anorexia and Bulimia in New York City. "Food conquers all of this."

Seeking Support

Melissa found out she was pregnant on May 4, 2010. She was seven weeks along, and unprepared for the numerous rounds of tests she had to undergo. Her 10-week ultrasound found the baby had increased nuchal translucency, a symptom associated with Down syndrome. The doctors tested her DNA, chromosomes and everything they could to determine if something was wrong with the baby. During the first few weeks of testing, Melissa could not ward off emotional eating. She inhaled cheddar Chex Mix. She sucked the crystallized sugar off of jellied candy fruit slices, but threw away the rest.

The emotional eating lasted for six weeks while she stressed about her baby. Melissa wanted to treat her body gently with this new life inside it, so the disordered behaviors had to be restrained. She turned to her blog, "Tales of a (Recovering) Disordered Eater," for support.

When Melissa wrote her first blog post in the summer of 2008, it was for her eyes only. She logged the behaviors and feelings she had kept to herself. When she sent the blog link to her family, they were stunned. Especially her mother, Sue, who did not suspect a serious problem. Whenever her daughter visited, Sue had always made efforts to be complimentary "You look great! You're so thin!"

Sue had no idea that her praise was encouraging behaviors that made Melissa feel worse, despite her more svelte physique. "I was so saddened to know that she had been suffering so much, and alone," says Sue. "That is where the pain comes in for me, that as her parent, who is suppose to protect her from harm and see her through anything and everything, that she went through this pain all by herself and for so long."

After she shared the blog with her family, she opened the blog to a wider audience.

In the blog's introduction Melissa wrote that she wanted to have a healthier relationship with her body so she could hear the pitter-patter of little feet. But, on June 26, 2008, she admitted her qualms about pregnancy. "I'll be honest..." Melissa wrote, "I fear being pregnant. Getting 'fat,' and having to lose the weight all over again daunts me...the very notion that I'd deliberately put myself in a position to gain weight all over again is both scary and intimidating."

The Genes Behind Eating Disorders

The genes identified as chromosomes 1 and 10 increase the likelihood that a child will develop an eating disorder. A woman with a sister or mother who has anorexia is 12 times more likely to develop anorexia nervosa and four times more likely to develop bulimia nervosa. But extenuating factors and outside influences will determine whether the genes come to fruition.

When a mother has an unhealthy relationship with food, it is easier for the child to pick up the same habits. "Parents can deactivate an eating disorder or make it more apparent," says Dr. Aisenberg, who has witnessed the disastrous cycle: a child adopts the mother's anxiety and obsessive behaviors.

Anorexia can worsen during pregnancy and postpartum for many women. "Pregorexia" has become a popular way to describe pregnant women suffering with anorexia. It is not a clinical term, but does illustrate the devastating merger of pregnancy and anorexia.

For Kate Wicker, giving birth to her first child made it easier to cope with her eating disorder, but only after she had suffered with anorexia during her pregnancy. Raised in Snellville, Ga., Wicker developed anorexia and a purging disorder in college. While she was treated in college and gained more stability after she graduated, she struggled during her first pregnancy and felt a loss of control with her weight.

"When I was really sick and weighed myself four to five times a day," Wicker says, "I put so much energy into fighting my own flesh that I could have spent that time solving world hunger."

As a new mother, she gained a whole new respect for her body. Worrying about the health of her three young girls has helped her become more comfortable with food. Although she does not consider herself fully recovered, she is able to recognize her weaknesses and handle them. "It's like a pebble in your shoe," Wicker says about her eating disorder. "It's always there, but you get better at being able to walk with that pebble there and not letting it control everything."

Struggling With a Changing Self Image

As a public relations manager at an Internet advertising agency in Kalamazoo, Melissa normally wears trendy outfits to work. But lately she's been forced to turn her hip wardrobe into a maternity one. At least the maternity clothes are comfortable, and The Bella Band, a nylon and spandex belt attached to her pre-pregnancy pants, has helped her keep some of the clothes she likes (except the Joe's jeans) in her fashion rotation.

By four months in, some of her pre-pregnancy tops began accentuating her protruding stomach. "People can see now, that I'm pregnant," Melissa says, "I like that."

Still, Melissa's feet have become so sore that she cannot wear her beloved high heels or wedges. The added weight of the baby reshapes her body from head to toe. Even at her heaviest, she had a defined waist and fairly flat stomach. Now, the extra pounds have eliminated all the definition in her stomach.

"This is brand-new territory for me," she says, "it also means my clothes aren't fitting right and prepared for it as I was, that has been a bit difficult for me to grasp." Her chest has also grown, but the added cup-size is something Melissa would gladly hold on to after the pregnancy. "I have boobs!" she wrote on her blog recently. "For the first time in my adult life, I have a chest and some cleavage."

Melissa still keeps track of everything she eats. When she was following the Weight Watchers program, it was about tracking the number of points. Now that she is pregnant, she is trying to be more conscious of what nutrients she needs every day. She records everything at MyDailyPlate.com, which gives her the nutritional breakdown of foods in addition to the number of calories.

The pregnancy has bumped up the number of calories she allows herself, which gives her what she calls "cautious freedom" to indulge in once-forbidden foods.

"If I'm going to gain weight I might as well eat something that I enjoy rather than grilled chicken," Melissa says about savoring richer foods during pregnancy. But she still tries to stay around 1,800 to 2,000 calories per day while burning 300 to 400 calories with exercise, five days a week. Her calorie intake is lower compared with most pregnant women, but her doctor recommended staying in the normal range of calories since she was at a slightly higher pre-pregnancy weight.

Melissa's pregnancy has cut her time at the gym in half. Now, she spends 30 to 45 minutes doing low-impact pedaling on the elliptical or takes a walk, but Melissa does not have the same amount of energy she normally would. She needs naps in addition to at least seven hours of sleep per night, which are interrupted by her frequent trips to the bathroom.

On a recent cool, dusk evening, Melissa, clad in yoga pants and a T-shirt, was able to make it out for a run. She had barely jogged 100 yards from her house until she felt pressure around her abdomen. The bouncing baby was squeezing her bladder and she could not continue at the pace she wanted without having an accident. A year ago she would have pushed through the pain. She remembers the grueling workouts of intense sweating for hours, but now, she has to restrain herself. She forfeited her run and walked at a quick pace the rest of the way.

A New Start

Melissa gave birth to Maya on December 18, 2010 and they are both healthy and thriving. In addition to having a healthy baby, Melissa wants to be a good role model for Maya. "I would never want her to see me agonizing over food," Melissa says.

Melissa plans to use Weight Watchers again to lose her baby weight. She is not comfortable with keeping the extra weight on her body that she says she does not need. "I would not like it if I was left with this ginormous pouch," she says.

There is a risk that some of the disordered eating behaviors may return.

There will be reminders, triggers, things that signal her to chew and spit. But Melissa says she will fight. She has found joy inside a giant belly for the sake of her daughter. She has deflected panic when the scale reached more than 170 pounds.

Her sacrifices during pregnancy have shown she is capable of taming her disordered behaviors and at this point, she says, "I don't fear those things coming back."