Navigating the path to parenthood with an eating disorder, or in its aftermath

SINGAPORE — She had anorexia in her younger days, to the point that she stopped menstruating and suffered severe hair loss and imbalances in electrolytes.

By the time Debbie (not her real name) began trying for a baby with her husband at the age of 26, she had recovered for “a number of years” after seeking professional help.

But she struggled to conceive for two years and had to turn to in vitro fertilisation.

Debbie was elated when the procedure was successful, but found it challenging to deal with the changes in her body during pregnancy.

“Feeling ‘out of control’ affected me more than the actual idea of gaining weight. My tummy had always been part of my body I hated the most, so it was hard seeing the baby bump get bigger,” said the healthcare worker, who is now is her 30s.

“I tried not to think or talk about it much as I feared that others would judge me for being selfish for focusing on ‘unimportant things’ instead of the baby inside of me. I had to keep reminding myself that eating disorder is an insidious disease that was trying to capitalise on pregnancy to rear its ugly head,” added Debbie, who is now a mother of two toddlers. Her second child was conceived naturally.

Besides dealing with the significant changes in shape, weight and hormones, some pregnant women find themselves grappling with, or recovering from, eating disorders, while others develop or experience a relapse of an eating disorder.

Although more people are seeking help for eating disorders, the topic remains taboo among those trying to start a family.

There are no official statistics on pregnant women with eating disorders here, but the eating disorders clinic at the Singapore General Hospital (SGH)  — which manages around 170 to 200 patients annually — sees two to five such cases a year. They are usually patients who conceive during their recovery and continue to follow up at the clinic, said Dr Alakananda Gudi, a consultant at the department of psychiatry at SGH.

Dr Kim Lian Rolles-Abraham, principal clinical psychologist specialising in eating disorders at the Better Life Psychological Medicine Clinic, has seen around 10 patients who have trouble conceiving or struggle to manage their eating disorders during pregnancy in the last six years.

Most are in their 20s and 30s.

Experts believe the occurrence is likely to be under-reported due to the stigma involved.

“Those struggling with the disorder may not reveal their conditions to their obstetricians,” said Dr Rolles-Abraham.

“Of all the people (with eating disorders), the community may stigmatise this group of adult women the most,” said Dr Abishek Mathew Abraham, a consultant psychiatrist at Better Life Psychological Medicine Clinic.

“(Others) may think, ‘It’s important to eat when you’re pregnant, so why can’t you just eat?’ or say things like ‘Why can’t you just think for your baby?’ Comments like this can be very condemning and add more guilt to the person who is already struggling with an eating disorder,” said Dr Abishek Abraham.

Fertility issues are among the long-term effects linked to eating disorders and can affect both men and women. For instance, women with anorexia tend to suffer from absent  or irregular menses while men may have reduced testosterone levels, which lowers sex drive, said Dr Gudi.

Eating disorders may also result in diabetes, increased stress, polycystic ovaries, anxiety, depression and psychosis, all of which might impair fertility, she said. 

About four in five patients with an eating disorder might suffer from fertility issues, based on worldwide literature, said Dr Gudi.

According to a study published in the BJOG: An International Journal of Obstetrics and Gynaecology in 2011, a higher proportion of women (39.5 per cent) with a history of eating disorder took longer than six months to conceive, compared to the general population (25 per cent).

The same study also found that women with eating disorders were more likely than others (6 per cent versus 2.7 per cent) to have received treatment or help to conceive their current pregnancy.

DOES MY BABY BUMP MAKE ME LOOK FAT?

If and when pregnancy happens, other challenges await. Women in the throes of an eating disorder are most at risk of complications.

“Pregnancy is a phase in a woman’s life when there are maximal bodily changes in terms of shape and weight, along with changes in female hormones that might affect the woman psychologically too. If the woman is still struggling with an eating disorder, she may find pregnancy overwhelming, not to mention the various pregnancy complications associated with eating disorder,” said Dr Gudi.

Underweight patients may suffer pregnancy or birth complications such as stillbirth, miscarriage, premature labour or have severely underweight babies. Binge eating is associated with maternal diabetes and high blood pressure, said Dr Gudi.

Even those who think they have their eating disorders under control may find them resurfacing during pregnancy, said Dr Rolles-Abraham. She has seen a couple of older mums in their 40s who develop eating disorders after pregnancy.

“Going to the obstetrician’s clinic requires a weigh-in at every appointment. The focus on weight, seeing their numbers (on the scale) go up, not being able to fit into their usual clothes, innocent comments from friends and relatives, and their doctors on what to eat and what not to eat, for instance, can be very triggering. Old behaviours can recur because of these triggers,” said Dr Rolles-Abraham.

The experts said it is important for women with eating disorders to recover physically and mentally even before trying for a baby.

During pregnancy and post-delivery, they should be closely monitored and treated by eating disorders specialists and their obstetrician. This is particularly important for pregnant mums who may require medications as part of their psychiatric treatment.

Medications are used for certain eating disorders like binge-eating disorder and to manage other co-morbid conditions like depression, obsessive compulsive disorder and anxiety, said Dr Abishek Abraham.

“The obstetrician will have to work very closely with the psychiatrist to choose when to give or adjust certain medications. For example, in the first trimester, when the organs (of the foetus) are forming, they may choose to avoid medications,” he said.

“There is also a need to balance the minor risks of taking medications versus not giving medications at all. For example, if the mum is not even eating properly, taking care of her basic hygiene, going for checkups because she is severely depressed, that will also damage the unborn baby.”

While some patients do not want their obstetricians to know about their eating disorder, the safest thing to do is to be upfront about it to circumvent innocent comments that may trigger a relapse, said Dr Rolles-Abraham.

“They can also get the right help they need, such as a dietitian who can advise on nutrition,’ she said.

Finally, loved ones must recognise that individuals with eating disorders “cannot help themselves”, said the experts. 

“If they could, they would stop. But they can’t. An eating disorder is not a matter of choice, whether one is pregnant or not,” said Dr Rolles-Abraham.

Public forum: It Takes A Village for Eating Disorders Recovery

Learn more about eating disorders and the recovery journey at a public forum organised by Singapore General Hospital’s Eating Disorders programme. The team will also launch the book, Treating Eating Disorders: The SGH Experience, at the event on March 2 (Saturday). Free registration here.