Journal of Psychosomatic Res

Eating disorders symptoms in pregnancy: A longitudinal study of women

with recent and past eating disorders and obesity

Nadia Micali4, Janet Treasure, Emily Simonoff

King’s College London, Institute of Psychiatry, Department of Child and Adolescent Psychiatry, London, United Kingdom

Received 31 October 2006; received in revised form 22 March 2007; accepted 1 May 2007

Abstract

Objective: To determine the impact of pregnancy on eating

disorders (ED) symptoms using data from a large prospective,

community-based cohort study. Methods: Women (12,254) were

classified according to whether they had a recent or past history

of ED, were obese before pregnancy, or constituted part of the

general population control group. We evaluated self-induced

vomiting (SIV), laxative use, exercise behavior, and appraisals

about weight gain during pregnancy, as well as dieting, and

shape and weight concern before and during pregnancy. Results:

Women with a recent episode of ED dieted, used laxatives,

reported SIV, and exercised more than other groups during

pregnancy. They were also more likely to report ED cognitions

0022-3999/07/$ – see front matter D 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.jpsychores.2007.05.003

4 Corresponding author. Child and Adolescent Psychiatry, Box PO85,

Institute of Psychiatry, De Crespigny Park, SE5 8AF London, United

Kingdom. Tel.: +44 0207 848 0468; fax: +44 0207 708 5800.

E-mail address: N.Micali@iop.kcl.ac.uk (N. Micali).

in pregnancy and their weight and shape concern scores

remained high during pregnancy. Women with past ED were

also more likely than controls to have some ED behaviors and/

or concerns about weight gain during pregnancy. Conclusions:

Women with a recent ED continued to have some ED symptoms

in pregnancy, albeit fewer compared to before pregnancy.

Although at a lower level, women with a past history of ED

also had ED symptoms in pregnancy. Screening for ED

symptoms during pregnancy may provide a useful opportunity

for engagement in treatment and to reduce behaviors that might

be detrimental to the foetus.

D 2007 Elsevier Inc. All rights reserved.

Keywords: Eating disorders; Pregnancy; Obesity; ALSPAC

Introduction

Eating disorders (ED) affect about 5–7% of women of

child-bearing age. Previous studies have tried to clarify the

impact of pregnancy on ED symptoms; however, this

largely remains unclear. Two different hypotheses have

been postulated and have resulted from previous literature.

The first is that eating behaviors (and associated symptoms

if relevant) will improve during the early part of the

pregnancy because of concern for the well-being of the

foetus. The second is that the weight gain during pregnancy

may exacerbate or rekindle latent weight and shape

concerns which may lead to a relapse of the ED in the

post-partum period.

In general, previous studies have shown a decrease in

ED symptoms between the first and third trimester of

pregnancy in women with an active ED at conception (in

particular bulimia nervosa—BN) [1–3]. One study on 15

women with ED, however, reported a worsening or

continuation of symptoms in pregnancy in women with

either anorexia nervosa (AN) or BN who were symptomatic

at conception [4].

Three recent longitudinal studies followed up women

treated for ED. One investigated women who had received

treatment for AN (26 pregnancies) and BN (56 pregnan-

cies), some of whom had an active ED at conception [5] and

found that in the majority of cases bulimic symptoms

improved during pregnancy and for a period of time after

the birth. However, some ED behaviors did not change

significantly, i.e., self-induced vomiting (SIV), overconcern

earch 63 (2007) 297–303

N. Micali et al. / Journal of Psychosomatic Research 63 (2007) 297–303298

with body image, compulsive exercise, and restrictive

eating. ED symptoms did not decrease during pregnancy

in women with AN. The other two studies followed up

women who had received treatment for BN and investigated

the changes in bulimic symptoms during pregnancy. In one,

although bingeing and purging improved during pregnancy,

the number of women completely abstinent from these

behaviors did not change with pregnancy and body

dissatisfaction worsened during pregnancy [6]. The second

reported a nonsignificant decrease in ED symptomatology

in the year of childbirth, with a trend towards lower levels of

symptomatology [7].

Most studies in the literature are difficult to interpret as

they rely on small samples, with heterogeneous, poorly

described cases, and often use retrospective outcome

measures or reports of ED symptomatology. There are

many unanswered questions: there is little information on

pregnancy outcomes in women with AN and it is uncertain

what the outcomes are for women with a past vs. a recent

history of ED. Moreover, only one study has compared

women with ED to control subjects.

This study sought to examine the presence in pregnancy

of ED behaviors, as well as levels of shape and weight

concern in women with a recent episode of ED, women with

a past history of ED, and obese and nonobese controls. Our

secondary aim was to compare the risk of occurrence of ED

behaviors and cognitions in pregnancy amongst subgroups

of women with different ED. In order to do so we used data

from a well-characterized longitudinal cohort (the Avon

Longitudinal Study of Parents and Children—ALSPAC).

The inclusion of an obese control group aimed to determine

whether the effect of pregnancy on eating behaviors and

weight and shape concerns is specific to eating disordered

women or shared by women at high risk for weight and

shape concern (obese women). We hypothesized that

women with a recent episode of ED would be more likely

to report ED behaviors in pregnancy compared to other

groups; and that obese women would have lower rates of

ED behaviors. We also hypothesized that women with

recent and past ED and obese women would report similar

levels of weight and shape concern and abnormal cognitions

about weight gain in pregnancy. We also hypothesized that

amongst women with ED, women with recent AN or BN

would be more likely to report ED symptoms and cognitions

compared to women with past AN or BN.

Methods

Participants and procedures

The ALSPAC is a longitudinal, prospective study of

women and pregnancy [8]. All pregnant women living in

the geographical area of Avon, United Kingdom, who were

expected to deliver their baby between 1st April 1991 and

31st December 1992 were recruited. The sample has been

shown to be representative of the British population. Data

were obtained on 14,472 women via postal questionnaires.

At 12 weeks of pregnancy women were asked if they had

any recent occurrence or past history of psychiatric

problems, including depression, schizophrenia, alcohol

abuse, AN, BN or any other disorder. They also reported

their pre-pregnancy weight and height. Women were

excluded from the current study if they had not answered

this questionnaire (n=2019).

We included 12,252 women in the current study.

Amongst women who reported a history of ED 57 reported

a recent episode of ED (6 AN, 51 BN). Three hundred and

ninety-five (395) women had a past history of ED (167 of

AN, 158 of BN, 70 both AN and BN). These groups were

compared to obese women (n=618) [i.e., women who had a

body mass index (BMI) N30 kg/m2 before pregnancy] and

general population nonobese controls (n=11,184).

Measures

Socio-demographic data were obtained during preg-

nancy; BMI was calculated as pre-pregnant weight/height2.

18 weeks of pregnancy: Women were asked about SIV

and laxative use for weight loss at any time before

pregnancy and during pregnancy. At 18 weeks, women

were also asked how much exercise they engaged in per

week during pregnancy. They were given a list of exercise

activities, i.e., jogging, aerobics, squash, tennis, swimming,

weight training, cycling, etc., and were asked how many

hours per week they engaged in that type of exercise

during the first 18 weeks of pregnancy. These data were

categorized to have an index of bhigh exerciseQ. Women

who engaged in more than 1 h per day of moderate–hard

exercise (jogging, aerobics, squash, tennis, swimming,

weight training, cycling) during pregnancy were classified

as bhigh exercisersQ.Selected items from two subscales of the Eating

Disorder Examination questionnaire (EDE-Q) [9] were

administered to all women relating to the 3 months before

pregnancy and the previous 4 weeks. Five items from the

bweight concernQ and five items from the bshape concernQsubscales were used. Good reliability of these shortened

subscales has been shown [10]. Mean scores for each

subscale were calculated. The weight and shape concern

scales were analysed separately. Differences between mean

pregnancy and mean pre-pregnancy EDE-Q scores were

calculated to determine score changes. These bchangescoresQ were compared across groups.

32 weeks of pregnancy (third trimester): Women were

asked the following questions: bHave you had a strong

desire to lose weight this pregnancy?Q, bHave you felt a loss

of control over eating this pregnancy?Q, bDo you feel you

put on too much weight this pregnancy?Q, bHave you been

on a diet to slim this pregnancy?Q, bHave you ever been on a

diet to slim before this pregnancy?Q. All items were

dichotomous (Yes/No).

N. Micali et al. / Journal of Psychosomatic Research 63 (2007) 297–303 299

Statistical analysis

Women with a recent episode of ED were compared to

women with past ED, obese and nonobese controls. Group

comparisons used parametric (one-way analysis of var-

iance–ANOVA) and nonparametric tests as appropriate,

after testing for normality. Bivariate linear regression

models tested for predictors of continuous outcomes. Binary

logistic regression models were used for binary outcomes.

Post hoc comparisons of odds ratios (OR) amongst groups

were performed. For each analysis, we checked for selective

attrition; none was found.

All analyses were performed using Stata (version 8 for

Windows; STATACorp, College Station, TX, USA) and

SPSS (version 12 for Windows; SPSS Inc., Chicago, IL,

USA). All statistical tests presented are two tailed. Statistical

significance was defined as a P value of less than .05.

Ethical approval

The study was approved by the Institute of Psy-

chiatry Ethics committee (Ref. 110/02) and the ALSPAC

Law and Ethics committee and the Local Research

ethics Committees.

Results

Socio-demographics

Women who were included in the current study were

compared on several socio-demographic variables. Age at

delivery differed for women with ED compared to controls,

as did BMI for women with recent ED. Obese women were

more likely to have had previous pregnancies compared to

nonobese controls; they were also less likely to be

employed. Women with recent or past ED were comparable

on parity, ethnicity, and employment status to nonobese

control women (see Table 1).

Table 1

Socio-demographic data

Recent ED

(57) (a)

Past ED

(395) (b)

Age at delivery, mean (S.D.)b 26.9 (4.9) 28.9 (4.8)

BMI pre-pregnancy, mean (S.D.)c 24.1 (5.9) 21.9 (3.2)

Parity (multiparous), % (OR, 95% CI) 49.1% (0.8, 0.5–1.3) 52.6% (0.9, 0.7

Ethnicity (white), % (OR, 95% CI) 98.1% (1.3, 0.2–9.2) 97.0% (0.8, 0.4

Employmentd, % (OR, 95% CI) 56.0% (1.3, 0.8–2.4) 46.6% (0.9, 0.7

*Pb.05; **Pb.01; ***Pb.001; based on ANOVA, binary logistic regression (ina Only comparisons showing statistically significant group differences are shb F(3, 12213)=4.7, P=.002.c F(3, 11356)=3280.1, Pb.001.d Percentage who are in full-time, part-time employment or full-time educati

Lifetime ED behaviors

Data on ED behaviors were available for 11,047 women.

As expected, all women with a recent or past history of ED

had significantly higher lifetime rates of laxative use and

SIV for weight loss compared to both control groups (see

Table 2).

ED behaviors during pregnancy

Women with a recent ED had a significantly higher

risk of using laxatives during the first 18 weeks of

pregnancy (OR=49.6, 16.1–152.5, Pb.001) compared to

normal-weight controls, obese controls (OR=50, 5.5–

496.5, Pb.001) and women with past ED (OR=11.1,

2.3–50.0, Pb.05). Women with a past history of ED had

significantly higher risk of laxatives use compared to

nonobese controls (OR=4.7, 1.4–16.2, P=.01). Both

women with a recent ED and with a past history of ED

had a significantly higher risk of self-inducing vomiting

during the first 18 weeks of pregnancy compared to

nonobese controls (respectively OR=51.9, 26.4–102.1,

Pb.001; OR=5.9, 3.3–10.5, Pb.001) and obese controls

(respectively OR=67.6, 18.4–248.2, Pb.001; OR=7.6, 2.2–

26.9, Pb.001). High exercise in pregnancy was more

common in women with a recent ED and women with

past ED compared to obese and nonobese controls.

Women with recent ED had comparable rates to women

with past ED (see Table 2).

Weight and dieting domains at 32 weeks

(third trimester of pregnancy)

Dieting for weight loss before pregnancy was highly

prevalent (N80%) amongst women with ED and obese

women and more common than amongst nonobese

controls (57%). The reported prevalence of dieting for

weight loss during pregnancy decreased dramatically

Obese

(681) (c)

Nonobese controls

(11,184 ) (d) Group comparisonsa

28.0 (4.8) 28.2 (4.8) abb**,d*

bNc**,d**

33.9 (3.8) 22.3 (2.7) aNb***,d***

bbd**

cNa***

b***,d***

–1.1) 64.8% (1.5, 1.3–1.8) 54.8% Ref cNa*,b***,d***

–1.4) 97.9% (1.1, 0.6–2.0) 97.6% Ref. a=b=c=d

–1.1) 40.7% (0.7, 0.6–0.8) 48.5% Ref cNa*,d***

italics).

own: (a) recent ED, (b) past ED, (c) obese controls, (d) nonobese controls.

on, training vs. unemployed, housewives or retired.

N. Micali et al. / Journal of Psychosomatic Research 63 (2007) 297–303300

(about four times lower) in all groups. Women with ED

(recent ED: OR=5.1, 2.1–11.9, Pb.001; past ED: OR=1.8,

1.1–3.1, Pb.05) and obese (OR=3.4, 2.5–4.8, Pb.001)

were more likely to diet in pregnancy than nonobese

controls. Women with recent ED had the highest preva-

lence of dieting, followed by obese women and women

with past ED (see Table 2).

At 32 weeks in pregnancy women with recent or past

ED were more likely to report a strong desire to lose

weight (respectively OR=6.1, 3.4–10.7, Pb.001; OR=1.6,

1.3–2.0, Pb.001), that they bfelt they had put on too

much weightQ (respectively OR=2.5, 1.3–4.8, Pb.01;

OR=1.4, 1.1–1.7, Pb.01), a loss of control over eating

(respectively OR=4.6, 2.5–8.6, Pb.001; OR=1.3, 1.1–1.6,

Pb.01), and a high concern about weight gain (respec-

tively OR=2.4, 1.2–4.7, Pb.01; OR=1.3, 1.0–1.6, Pb.05)

compared to nonobese controls. Obese women shared a

strong likelihood of bfeeling they had put on too much

weightQ with women with recent or past ED compared to

nonobese controls (62%, OR=1.2, 1.1–1.5, Pb.01) and a

strong desire to lose weight (OR=2.1, 1.7–2.5, Pb.001)

(Table 2). More women with recent ED had negative

cognitions about weight gain compared to women with

past ED and obese women.

Table 2

ED behaviors before (lifetime) and during pregnancy (18 weeks), dieting and weig

regression and pairwise comparisons

Recent ED

(57) (a)

Past ED

(395) (b)

Lifetime laxative use 42.9% (OR=20.6, 11.6–36.6) 35.1% (OR=14.8, 11.6–1

Lifetime SIV 59.2% (OR=35.8, 20.1–64.0) 49.0% (OR=23.7, 18.9–3

18 weeks

Pregnancy laxative

use (twice or more)

8.2% (OR=49.6, 16.1–152.5) 0.8% (OR=4.7, 1.4–16.2

Pregnancy SIV

(twice or more)

26.5% (OR=51.9, 26.4–102.1) 3.9% (OR=5.9, 3.3–10.5

High exercise

in pregnancy

32.7% (OR=1.8, 1.0–3.3) 31.2% (OR=1.7, 1.3–2.1

32 weeks

Dieting in pregnancy 11.3% (OR=5.1, 2.1–11.9) 4.4% (OR=1.8, 1.1–3.1)

Strong desire to

lose weight

63.5% (OR=6.1, 3.4–10.7) 31.4% (OR=1.6, 1.3–2.0

Put on too much

weight

76.9% (OR=2.5, 1.3–4.8) 64.9% (OR=1.4, 1.1–1.7

Loss of control

over eating

72.5% (OR=4.6, 2.5–8.6) 42.8% (OR=1.3, 1.1–1.6

Concern about

weight gain

78.8% (OR=2.4, 1.2–4.7) 66.1% (OR=1.3, 1.0–1.6

*Pb.05, **Pb.01, ***Pb.001.

Odds ratios are presented for comparisons between index groups and general popa Only comparisons showing statistically significant group differences are sh

EDE-Q scores in pregnancy

Complete weight concern data were available on 10,962

women. Mean weight concern scores pre-pregnancy and

during pregnancy were significantly higher for all ED groups

and obese women compared to nonobese controls (overall

F(3, 10986)=234.68, Pb.001 for pre-pregnancy scores; overall

F(3, 11091)=126.90, Pb.001 for pregnancy scores). Weight

concern scores decreased in pregnancy in all groups.

However, the change score over time was significantly

different in the recent ED group (b coefficient: �0.1,Pb.05) and the obese group (b coefficient: �0.2, Pb.001)only. These two groups changed in a comparable fashion

(Fig. 1) and differently from the other two groups.

Complete shape concern data were available on 10,955

women. Mean shape concern scores pre-pregnancy and

during pregnancy were higher for all groups (ED groups

and obese controls) compared to nonobese controls (overall

F(3, 10983)=231.52, Pb.001 for pre-pregnancy scores, overall

F(3, 11085)=65.43, Pb.001 for during pregnancy scores).

Shape concern scores decreased in pregnancy for obese

women and women with recent ED; the change score was

different for women with recent ED (b coefficient: �0.2,P=.003) and obese women (b coefficient: �0.3, Pb.001)

ht perception at 32 weeks: prevalence and odds ratios (OR), binary logistic

Obese controls

(618) (c)

Nonobese controls

(11,184) (d) Group comparisonsa

8.9) 4.8% (OR=1.4, 0.9–2.0) 3.5% aNc***,d***

bNc***,d***

0.0) 4.6% (OR=1.2, 0.8–1.8) 3.9% aNc***,d***

bNc***,d***

) 0.2% (OR=0.9, 0.1–7.4) 0.2% aNb*, c**,d***

bNd*

) 0.5% (OR=0.8, 0.2–2.4) 0.7% aNb***, c***,d***

bNc***,d***

) 19.7% (OR=0.9, 0.7–1.1) 21.2% aNc*,d*

bNc***,d***

8.0% (OR=3.4, 2.5–4.8) 2.5% aNb*,d***

cNb*,d***

bNd*

) 37.3% (OR=2.1, 1.7–2.5) 22.2% aNb***, c***,d***

bNd*** ,cNd***

) 62.0% (OR=1.2, 1.1–1.5) 56.9% aNc*,d**

bNd**, cNd**

) 33.8% (OR=0.9, 0.7–1.1) 36.1% aNb***, c***,d***

bNc**,d**

) 62.6% (OR=1.1, 0.9–1.3) 60.5% aNc**,d**

bNd*

ulation controls.

own: (a) recent ED, (b) past ED, (c) obese controls, (d) nonobese controls.

Fig. 1. Weight and shape concern pre-pregnancy and in pregnancy.

N. Micali et al. / Journal of Psychosomatic Research 63 (2007) 297–303 301

compared to women with past ED and nonobese controls.

Women with recent ED and obese women changed similarly,

but differently from women with past ED and nonobese

controls (see Fig. 1).

Table 3

ED behaviors and weight perception in pregnancy: sub-group comparisons of pr

Recent ANa

(6) (a)

Recent BN

(51) (b)

Past BN

(158) (c

18 weeks

Laxatives (twice or more)

in pregnancy

0 9.1% (OR=7.3, 1.3–41.6) 0.7% (

SIV (twice or more)

in pregnancy

0 29.5% (OR=62.0, 7.8–492.1) 4.9% (

High exercise in pregnancy 60% 29.5% (OR=0.7, 0.4–1.6) 22.2% (

32 weeks

Put on too much weight 80% 76.6% (OR=2.1, 1.0–4.4) 70.5% (

Strong desire to lose

weight

60% 63.8% (OR=4.2, 2.1–8.3) 36.2% (

Loss of control over eating 80% 71.7% (OR=3.5, 1.7–7.1) 48.3% (

Concern about

weight gain

80% 78.7% (OR=2.1, 1.0–4.6) 69.1% (

Dieting in pregnancy 0 12.5% (OR=4.0, 1.2–13.9) 4.0% (

*Pb.05; **Pb.01; ***Pb.001.

Odds ratios are presented for comparisons between all groups and women with pa This group was not compared to other groups, because of low power.b Only comparisons showing statistically significant group differences are sh

past AN.

ED subgroup analyses

We also performed a subgroup analysis to examine ED

behaviors and cognitions in pregnancy by comparing women

with a past history of AN (167), women with a past history of

BN (158), women with a past history of AN and BN (70), and

women with a recent episode of BN (51). Six (6) women in

our sample reported having had a recent episode of AN;

however, due to the small number and subsequent low power

to determine differences, this group was excluded from

subgroup analyses. Amongst women with a recent episode of

BN, 9% had used laxatives and 29.5% had SIV in the first 18

weeks of pregnancy; they were more likely to use both

compared to all other groups (OR=7.3, 1.3–41.6, Pb.05,

OR=62.0, 7.8–492.1, Pb.001 compared to women with past

AN).Womenwith past AN andBN also had high rates (9.5%)

of SIV (OR=15.6, 1.8–132.2, Pb.01). All groups had high

rates of high exercise in pregnancy. Most women across

groups felt that they had put on too much weight in

pregnancy, and rates were comparable. Women with recent

BN were more likely to report a strong desire to lose weight

(OR=4.2, 2.1–8.3, Pb.001) and loss of control over eating

(OR=3.5, 1.7–7.1, Pb.01) in pregnancy compared to all other

groups (see Table 3).

Discussion

This study focused on ED behaviors, dieting and

appraisals about weight and shape in pregnancy in women

with ED compared to obese and nonobese women in a

population-based prospective study.

evalence and odds ratios

)

Past AN and BN

(70) (d)

Past AN

(167) (e)

Group

comparisonsb

OR=0.5, 0.1–5.7) 0 1.3% bNc**,e*

OR=7.5, 0.9–62.2) 9.5% (OR=15.6, 1.8–132.2) 0.7% bN c***, d** ,

e*** dNe**

OR=0.5, 0.3–0.9) 41.5% (OR=1.3, 0.7–2.4) 35.3% cbe ** dNc**

OR=1.5, 0.9–2.5) 60.6% (OR=0.5–1.8) 61.2% b=c=d=e

OR=1.3, 0.8–2.2) 24.2% (OR=0.7, 0.4–1.5) 29.7% bN c***,

d***,e***

OR=1.3, 0.8–2.0) 31.8% (OR=0.6, 0.3–1.2) 42.2% bN c***,

e** cNd*

OR+1.3, 0.8–2.1) 64.6% (OR=1.0, 0.6–1.9) 63.7% b=c=d=e

OR=1.2, 0.3–4.0) 7.6% (OR=2.3, 0.6–8.3) 3.4% bN c*,e*

ast AN.

own: (a) recent AN, (b) recent BN, (c) past BN, (d) past AN and BN, (e)

N. Micali et al. / Journal of Psychosomatic Research 63 (2007) 297–303302

Recent ED

We found that, as hypothesized, over a quarter of women

with a recent ED purged during pregnancy (in particular,

women with recent BN reported high rates of purging

behaviors in the first trimester). About 10% of women with

recent ED also reported dieting for weight loss at 32 weeks,

and high rates of concern about weight gain during the third

trimester of pregnancy. In fact, their EDE-Q shape and

weight concerns, although decreased compared to pre-

pregnancy, remained above those of controls during

pregnancy. This finding is consistent with previous studies,

which have shown that most ED behaviors are present

although not common in pregnancy in women with active

ED [1,3,11]. In our study, laxative use was less common,

compared to SIV in pregnancy. This is in line with the

studies of Blais et al. [5] and Crow et al. [6], which showed

a decreased risk of laxative use in pregnancy, but some risk

of continuing to self-induce vomiting.

As expected women with recent ED had the highest rates

of dieting, of concerns about weight gain, and the highest

EDE-Q subscale scores in pregnancy. These findings

suggest that women with recent ED might benefit from

increased support and help during pregnancy aimed at

stopping or reducing their ED behaviors and cognitions.

Past ED

Compensatory behaviors (i.e., SIV, laxative use, and

excessive exercise) were present in women who had had an

ED in the past; nearly 10% of women with a past history of

ED had purged in the first 18 weeks of pregnancy. Although

lower than previous studies, this finding parallels those by

Mitchell et al. [12] that a high percentage of women with a

history of ED continued to vomit and 15% did so at least

once daily in pregnancy. Regarding weight perception in

pregnancy, these women had similar concerns to obese

women, although higher compared to nonobese controls.

As highlighted by previous studies [4,5], high levels

of some ED symptoms (i.e., high exercise and SIV) can

be present in pregnancy in women with a history of AN

(including those who also had BN in the past). Concerns

about weight gain (in particular a sense of loss of control

over eating) and high EDE-Q shape concern scores in

pregnancy were also very common in these women and

increased in pregnancy compared to pre-pregnancy. This

suggests that negative cognitions about weight gain might

be rekindled during pregnancy in this group. This is an

important group clinically, as these women might not be

linked to services and therefore less likely to have access

to specialist help. Perinatal services should be alerted to

the possibility of ED symptoms resurfacing in pregnant

women with a past ED history, especially given that

women are reluctant to admit to ED to their obstetricians

[2]. Research is needed to determine whether this is just

a temporary resurgence of symptoms with a spontaneous

remission in the post-partum or whether it may lead

to relapse.

No previous studies have compared women with ED to

obese women. Our study suggests that weight gain during

pregnancy might trigger different cognitions in women who

have a history of ED and obese women. As hypothesized,

obese women had low rates of compensatory behaviors in

pregnancy. However, subjective dissatisfaction with weight

gain, desire to lose weight, and dieting in pregnancy were

more common in obese women than in nonobese controls.

Although EDE-Q shape and weight concern scores were

significantly higher in this group in pregnancy than in

nonobese controls, they decreased significantly in preg-

nancy compared to pre-pregnancy. This might suggest that

perhaps the well-being of the baby takes precedence over

these concerns in pregnancy in this group of women.

A number of methodological strengths and weaknesses

warrant mention. This is the first study to investigate ED

symptoms and behaviors in pregnancy in a large prospective

population sample with a sufficient number of cases with a

lifetime ED history and the opportunity to have obese and

nonobese weight comparison groups. The main weakness of

this study is that women were classified according to self-

report of a past or recent ED. It is possible that this

represents an underestimate of cases, given the tendency of

screening measures for ED in community samples to miss

cases. The self-reported lifetime ED behaviors and BMI pre-

pregnancy to an extent confirm the self-reported diagnosis.

Moreover, in a recent study, self-report of ED has been

shown to be comparable to longer and widely used ED

screening instruments for screening purposes in general

population studies [13].

Data on lifetime rates of laxative use and SIV for weight

loss and weight and shape concern were obtained contem-

poraneously to pregnancy data, possibly introducing a recall

bias. No data are available on the exact timing of the

occurrence of the ED, apart from self-reported timing of the

ED described as recent or past. It would have been

interesting to collect data on weight gain in pregnancy or

ED symptoms in the post-natal period, given that some

studies have shown that, although there is a symptom

reduction during pregnancy, ED symptoms will recur after

delivery [3,5,14].

In summary, our findings indicate that, although preg-

nancy might have the effect of improving ED symptoms in

women with a recent onset ED, ED symptoms and

cognitions remain elevated in this group of women. More-

over, women with a past history of ED do experience some

ED symptoms and cognitions during pregnancy. It remains

to be established how significant these are in terms of a

relapse of the ED or the effects on the foetus. In a study on

this same sample, we found that babies of women with a

history of AN were significantly smaller than babies of

controls [15].

Our study suggests that although the appraisal of weight

gain and desire to lose weight in obese women is higher

N. Micali et al. / Journal of Psychosomatic Research 63 (2007) 297–303 303

compared to nonobese women, these women have fewer

concerns compared to eating disordered women. Moreover,

weight and shape concern decline in pregnancy in this group

of women, although they still remain more similar in values

to ED women than nonobese controls, suggesting pregnancy

might have a similar effect on weight and shape concern in

obese women and ED women. It remains to be clarified

what the effects of the high weight and shape concerns

might be in this group, in particular as one study suggested

pregnancy is a risk factor for the development of binge-

eating disorder [16].

Our findings have important clinical implications.

Some researchers have reported that pregnancy might

be a good time to engage women with ED in treatment

[6] as they might be motivated to start changing their

eating behaviors. This could also prevent the recrudes-

cence of symptoms that has been reported to occur in the

post-partum period [1–3]. The recent National Institute of

Clinical Excellence (NICE) guidelines for EDs [17] have

suggested that pregnant women with an ED may need

more intensive prenatal care to ensure adequate prenatal

nutrition and foetal development. In view of our results,

women with a past history of ED should also receive

more intensive prenatal care as this may avoid detrimen-

tal outcomes to the foetus, as well as decrease post-

partum resurgence of ED symptoms. Further studies are

needed to clarify the longitudinal aspect of ED sympto-

matology in women with past and recent AN and BN in

the general population.

Acknowledgments

We are extremely grateful to all the families who took

part in this study, the midwives for their help in recruiting

them, and the whole ALSPAC team, which includes

interviewers, computer and laboratory technicians, clerical

workers, research scientists, volunteers, managers, recep-

tionists, and nurses. The UK Medical Research Council, the

Wellcome Trust, and the University of Bristol provide core

support for ALSPAC. This publication is the responsibility

of the authors. Nadia Micali will serve as guarantor for the

contents of this paper. This research was specifically funded

by the National Alliance for Schizophrenia and Depression

(NARSAD) and the Psychiatry Research Trust. We would

specifically like to thank Dr. Sam Leary for her help with the

data and Prof. Alan Stein for selecting the screening

questions for ED symptomatology that were included in

the questionnaires.

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