Screening for Eating Disorders in Pregnancy: How Uniform Screening During a High-Risk Period Could Minimize Under-Recognition

Eating disorders are associated with adverse effects on maternal and fetal health. ^{6 –14} Though eating disorders (diagnostic criteria, Table 1) can present throughout the female life-course (clinical presentations, Table 2), pregnancy and the post-partum period are particularly high-risk times for relapse. Studies of pregnant women with a history of eating disorders demonstrate three periods of elevated risk: (1) the initial diagnosis of pregnancy, (2) early in the second trimester (coinciding with pregnancy “show”) and (3) the post-partum period. ^1,4,15 The first risk period coincides with the initial diagnosis of pregnancy. At this time, elevation in risk can be attributed to higher rates of unplanned pregnancy and pregnancy-related anxiety and depression in the eating disorder population. ^{16 –18} The most intensely negative feelings toward pregnancy have been demonstrated to occur around 18 weeks of gestation. ¹⁵ This period coincides with pregnancy show and the outgrowing of pre-partum clothing, milestones that signify a loss of control. ¹ The third period of elevated risk encompasses both the immediate post-partum period (0–6 weeks) and the cessation of breast-feeding, during which women have been shown to be at higher risk for anxiety and depression ^13,16,17 and return to patterns of disordered eating to cope. ¹⁹ Ensuring adequate emotional and mental health support during these periods, while critical for all women, is especially important for those with maladaptive coping mechanisms such as disordered eating.

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Table 1.

Diagnostic Criteria for the Major Eating Disorders

Eating disorder 3	Diagnostic criteria (DSM-IV-TR) 3	Possible signs 39,40
Anorexia nervosa  - Restrictive type  - Binge-eating/purging type	- Weight <85 percentile * with refusal to maintain minimally normal body weight - Intense fear of weight gain - Distorted perception of body size - Amenorrhea	Malnourishment, lanugal hair growth, muscle wasting, amenorrhea, inappropriate influence of weight/shape on self-worth
Bulimia nervosa †  - Purging type  - Non-purging type	- Recurrent episodes of binge eating - Recurrent compensatory behaviors:  - Purger: vomiting, laxatives, enemas  - Non-purger: starvation, intense exercise ‡ - Occurs ≥2× per week for 3 months	Parotid enlargement, poor dentition, knuckle calluses (“Russell's sign”), inappropriate influence of weight/shape on self-worth
EDNOS  - Night-eating disorder  - Binge-eating disorder  - Sleep-related eating disorder  - Purging disorder	Preoccupation with or angst related to food intake and aberrant eating in patient who does not meet diagnostic criteria for anorexia nervosa or bulimia nervosa.	Varies by disorder prototype

*

Distinguishes binge-eating/purging type from bulimia nervosa.

†

Note: ICD-10 diagnostic criteria does not differentiate subtypes of bulimia.

‡

Also surreptitious thyroxine, diabetics abstaining from insulin.

EDNOS, eating disorder not otherwise specified.

American Psychiatric Association, ³ Tyler I and Birmingham CL, ³⁹ UpToDate. ⁴⁰

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Table 2.

Clinical Presentations of Eating Disorders by Reproductive Status

Reproductive status	Potential presenting complaint
General 17 (non-pregnant)	- Reduced exercise tolerance or fatigue - Pre-menopausal low bone density - Constipation - Menstrual irregularities - History of miscarriage, pre-term or low birth weight deliveries
Pregnant 1	- Hyperemesis gravidarum after 20 weeks gestation - Signs of depression - Signs of dieting - Lack of weight gain

Zauderer CR, ¹ Andersen AE and Ryan GL. ¹⁷

However, there exists a paucity of research, particularly in the United States, evaluating how providers can best identify and intervene in cases of eating disorders in pregnancy. ^{20 –24} The presiding explanation for this is a mutual lack of recognition whereby patients are reluctant to admit symptoms and providers lack the time or training to broach this complex topic. ^{21 –24} Though primary care providers are becoming increasingly overworked, studies suggest the best hope to improve recognition may lie with them. In a recent poll, patients reported they expect primary care doctors, including obstetrician-gynecologists, to address their mental health. ^23,24

Adding complexity is the fact that risk profiling of eating disorders is highly inefficient: women of any age, weight, or ethnicity can be affected. Recent data identified a surprisingly high incidence of eating disorders in women over age 50 ²⁵ and demonstrated that unrecognized eating disorders are disproportionally higher in minorities. ²⁶ At the same time, research shows that patients are in fact responsive and amenable to provider questioning. Studies have shown decreased delay in seeking help when providers initiated symptom disclosure. ^27,28 These findings support a direct approach and refute the belief that only patients who volunteer information are open to change.

Providers routinely screen for domestic violence and depression in pregnant and post-partum women, but screening for eating disorders is only recommended in women with a documented history. ²⁹ And yet, research shows that practice fails to identify many cases. In a study of new mothers with no documented history of mental illness, over one-fourth admitted to disordered eating when directly asked. ²⁰ Among women receiving treatment for post-partum depression, one-third endorsed a history of eating disorders. ³⁰

We recommend uniform screening in pregnant women in the form of the SCOFF questionnaire, which can be administered verbally or in writing. As such, this questionnaire could be included on a pre-visit form in practices where providers are too busy for individual, verbal administration.

The SCOFF questionnaire:

1. Do you make yourself Sick (vomit) because you feel uncomfortably full?

2. Do you worry that you have lost Control over how much you eat?

3. Have you lost more than one stone (15 lbs) in a 3-month period?

4. Do you believe yourself to be Fat when others say you are too thin?

5. Would you say that Food dominates your life?

Each “yes” earns 1 point and a score of 2 or higher merits follow-up evaluation. ³¹ The SCOFF questionnaire has been validated to suggest probable eating disorder in adults ^32,33 and used in the screening of disordered eating in pregnant and post-partum women. ³⁴ The Eating Attitudes Test is also used for screening purposes but is less successful than questionnaires that combine both attitude and behavioral questions. ³⁵ Studies evaluating mental illness screening programs indicate providers could further maximize success by providing visible resources in waiting and exam rooms and employing nonjudgmental staff to provide prompts about mental health. ^{21,36 –39}

Eating disorders remain challenging from a public health and clinical standpoint. Yet, research suggests providers can improve recognition through uniform questioning. ⁴¹ Particularly in reproductive-age women, screening and creating a safe environment for disclosure should be an ongoing part of preconception, antenatal, and post-partum care.