Anorexia nervosa is a potentially fatal—and often chronic—relapsing mental disorder that typically requires long-term multidisciplinary management.

In exclusive interviews with MDLinx, three prominent researchers in eating disorders discussed the current gaps in clinical guidance and practice regarding management of anorexia nervosa during pregnancy. These experts shared recommendations and tools that could close these gaps.

 

An under-recognized challenge

The complexities and potential severity of anorexia nervosa in pregnant people underscore the need for better guidance on the multidisciplinary care of this relatively rare patient population.

Research published in Lancet Psychiatry shows very few studies have addressed anorexia nervosa during pregnancy.

Galbally M, Himmerich H, Senaratne S, et al. Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review. Lancet Psychiatry. 2022;9(5):402–412.

Those that have are usually case studies or reports examining “narrow aspects of management,” according to the researchers.

 

In an MDLinx interview, lead author of the Lancet study Megan Galbally, MBBS, PhD, said that anorexia nervosa in pregnancy is often overlooked in clinical care due to a misconception that only women in remission can become pregnant.

“I have worked in perinatal mental health within tertiary maternity services for 20 years and previously only ever saw an occasional woman with current anorexia nervosa,” she commented, “whereas in the last 3 to 4 years, I have seen a steep increase in women presenting in pregnancy with very low body mass index and current anorexia nervosa requiring treatment in pregnancy.”

Ellen Astrachan-Fletcher, PhD, FAED, CEDS-S, the regional clinical director at Eating Recovery Center, explained that body mass index, which is often used to determine if someone with an eating disorder requires more treatment support, is not nearly as informative for determining treatment needs in pregnancy.

If someone is maintaining their weight while pregnant, it actually means they are losing weight.

“This under-recognition of anorexia nervosa in pregnancy can lead to worse outcomes for both the mother and the baby due to unrecognized and untreated symptoms,” she added.

 

Addressing gaps in guidelines

Galbally noted that there are currently no comprehensive guidelines for managing anorexia nervosa in pregnancy. Current recommendations for non-pregnant adults have significant gaps regarding managing the disease in pregnant individuals, she added.

“Recommendations developed for managing anorexia in non-pregnant adults require alterations and adaptations, as well as consideration of additional areas of care such as monitoring fetal growth and development, when managing anorexia nervosa in pregnancy,” Galbally explained.

To help guide clinical care, Galbally and colleagues conducted a review and synthesized available study findings into specific recommendations for multidisciplinary care of anorexia nervosa in pregnant people, focusing on mental health, obstetric, medical, and nutritional management.

There are considerable risks for women and their unborn children in managing moderate-to-severe anorexia nervosa in pregnancy.

“And while we have provided some recommendations," Galbally acknowledged, "it still requires considerable adaptation to individual presentations and circumstances.” This is best done with a maternity service that manages other high-risk pregnancies.”

Astrachan-Fletcher stated that there are also not enough clinicians who both specialize in the treatment of anorexia and understand the complex effects of pregnancy on the body, particularly when it’s been compromised by anorexia.

“Therefore, we do need guidelines established so that when a clinician is faced with this dilemma, they have resources to learn and understand how to identify and manage these complex patients safely and effectively,” she asserted.

Psychotherapy is an area needing more attention, too, according to Astrachan-Fletcher.

“People with anorexia nervosa are typically emotionally overcontrolled,” she explained. “When one is pregnant, anorexic, and overcontrolled, there can be an exacerbation of the fears and loneliness that keep people sick.” 

 

Dialectical behavior therapy

Galbally pointed to the potential value of radically open dialectical behavior therapy, which she described as “a relatively new treatment that teaches people how to be more open, flexible, and vulnerable so that they can develop true connection and end emotional loneliness.”

Similar to other available treatments, this approach is driven by a person’s values, especially those relating to connection.

“During pregnancy—a time when a person needs the most help and care, when a person can feel the most vulnerable—connection is imperative for better medical and psychological outcomes,” Galbally said. “During pregnancy and postpartum, the need for connection is more important than ever because, as we all know, ‘it takes a village,’ and often those with anorexia nervosa do not even have one connection.”

 

Screening challenges

Eating disorders are so diverse and multifaceted that clinicians may be challenged to even identify the symptoms. To help with diagnosis in pregnancy, a team of US researchers recently conducted a study which resulted in the development and validation of a rapid screening tool capable of identifying patients with eating disorders across pregnancy trimesters.

Claydon EA, Lilly CL, Ceglar JX, et al. Development and validation across trimester of the Prenatal Eating Behaviors Screening tool [published online ahead of print, 2022 May 2]. Arch Womens Ment Health. 2022;1–12.

 

Study investigator Elizabeth Claydon, PhD, MPH, MS, Assistant Professor at West Virginia University, explained the rationale for the study in her interview with MDLinx. She and her colleagues recognized that many clinicians don’t have the training needed to identify eating disorders in pregnancy.

“This is due more to the structures in place for training and limited amount of time to provide training in so many areas than from an interest in this subject,” she added.

Because of the under-recognition of anorexia nervosa in pregnancy, Claydon noted that many patients who could benefit from referrals eating disorder aren’t getting them.

Pregnancy provides a critical window for intervention where clinicians have an opportunity to improve not only maternal outcomes, but also pregnancy and child outcomes.

“We also know that there are epigenetic changes associated with eating disorders and pregnancy," she continued, "so the effects from a pregnancy could be seen throughout that child’s life."

 

New tools for identifying cases

Claydon said there are three tools currently available to identify eating disorders, but some aren't validated in pregnancy or don’t consider all types of eating disorders.

The 12-item measure developed by Claydon and her research team, dubbed the Prenatal Eating Behaviors Screening (PEBS) tool, demonstrated acceptable sensitivity and specificity in screening for an eating disorder during pregnancy. It takes only a few minutes to complete. A score above 39 indicates that the patient may have an eating disorder and should be referred for further assessment.

“Having a rapid screening tool was very important for us when developing this, because we wanted something that would not create additional clinical burden,” Claydon explained.

The tool can allow clinicians to screen for eating disorders quickly instead of relying on referral, which can only be done if the patient discloses eating disorder behavior. However, most individuals with eating disorders during pregnancy are unlikely to disclose these behaviors to providers.

The PEBS tool helps to fill this gap by providing clinicians with a tool to start that conversation and allow for a referral process.

“It also makes it less likely that misconceptions about eating disorders will play a role in whether someone receives a referral,” she added.

Claydon said that she and her team have developed clinician information booklets to educate clinicians about eating disorders in pregnancy, as well as to provide directions on using the PEBS tool. Over the next year, they will focus on disseminating these materials and creating a feasibility study to see how the tool works and is accepted by clinicians and patients.