Tracing the Course of Eating Disorders in the Postpartum Period

The first large-scale study of eating disorders during the postpartum period reveals risk in a population with hidden eating disorders.

It is still not known if the changes in eating behavior during pregnancy persist into the postpartum period and beyond. In the first large-scale population-based study of eating disorders during the postpartum period, Cecilie Knoph and colleagues at the Norwegian Institute of Public Health and the University of North Carolina explored the course of anorexia nervosa (AN), bulimia nervosa (BN), eating disorders not otherwise specified, purging type (EDNOS-P), and binge eating disorder (BED). The authors used data from the Norwegian Mother and Child Cohort Study, a large, population-based, prospective pregnancy cohort; 77,807 patient records were used in the current study (Int J Eat Disord. 2013; 46:355).

A search for predictive factors

The authors were particularly interested in studying the courses of women with BED whose symptoms began during pregnancy, and to identify predictors of the course of women with diagnoses of BN and BED 18 and 36 months after the birth of their children. The researchers looked at body mass index (BMI, kg/m²) and weight retention, psychological distress and depression, partner satisfaction, and demographic data. The study participants completed questionnaires during pregnancy including items from the DSM-IV criteria for AN, BN, EDNOS-P, and BED diagnoses that were present before pregnancy. Additional questionnaires were completed at 18 and 36 months postpartum.

Three years postpartum, the proportion of women in remission was 59% for those with AN, 30% for those with BN, and 42% for those with BED. At this time, a substantial proportion of the women continued to have disordered eating, either as continuation, subthreshold or crossover behavior. Among those with onset of BED during pregnancy, 57% reported being in remission at the 3-year time point.

What factors predicted the postpartum course?

The presence of BN during pregnancy increased the risk approximately fourfold for continuation of BN at 18 and 36 months postpartum. Psychological distress at 6 and 35 months postpartum was positively associated with persistence of BN 36 month postpartum.  BMI before pregnancy and 6, 18, and 36 months after delivery was associated with a course of BED at 18 and 36 months; specifically, BMI at all time points was positively associated with continuation of BED. Another factor was pregnancy-related weight gain, which was positively associated with crossover from BED to BN at 18 months postpartum and negatively associated with continuation of BED at 36 months postpartum.

The authors also found that psychological distress at 6 months postpartum was negatively associated with remission of BED and positively associated with BED crossover at 18 months postpartum. Psychological distress at 18 months postpartum was positively associated with continuation and crossover of BED and negatively associated with remission of BED at 18 months. A satisfying partnership at 6 months postpartum was negatively associated with BED crossover at 18 months postpartum and positively associated with remission of BED at 18 months postpartum. Relationship satisfaction 36 months postpartum was negatively associated with continuation of BED at 36 months.

Although postpartum weight retention has been suspected of playing an important role in relapse of eating disorders during the postpartum period, this was not the case in this study. A strong association was identified between psychological distress and crossover from BED to BN.

Although some women experienced remission of their initial eating disorder symptoms during the postpartum period, a substantial proportion continued to have an eating disorder during the postpartum period.

Since many women do not disclose the fact that they have an eating disorder during pregnancy and postpartum, the authors stress that healthcare professionals working with pregnant women and new mothers should be trained to recognize eating disorder symptoms and behaviors. Intervening early may help interrupt the transgenerational cycle of risk hypothesized to be associated with eating disorders, say the authors.