JOURNAL OF WOMENS HEALTH Volume 18, Number 9, 2009 Mary Ann Liebert, Inc. DOI: 10.1089=jwh.2008.

1183

Original Article

Eating Disorders and Obstetric-Gynecologic Care

Meaghan A. Leddy, M.A., Candace Jones, Maria A. Morgan, Ph.D., and Jay Schulkin, Ph.D.

Abstract

Objective: Disordered eating can have consequences for gynecologic and obstetric patients and fetuses. Amenorrhea, infertility, hyperemesis gravidarum, and preterm birth have been linked to eating disorders (EDs). This study aimed to evaluate obstetrician-gynecologists ED-related knowledge, attitudes, and practices. Methods: Questionnaires were sent to 968 Fellows of the American College of Obstetricians and Gynecologists between November 2007 and March 2008. Data were analyzed separately for generalists (provide obstetric and gynecologic care) and gynecologists only (treat only gynecologic patients). Results: A majority of obstetrician-gynecologists assess body weight, exercise, body mass index, and dieting habits. Less than half assess ED history, body image concerns, weight-related cosmetic surgery, binging, and purging. Over half (54%) of generalists believed ED assessment falls within their purview. Most (90.8%) generalists agreed or strongly agreed that EDs can negatively impact pregnancy outcome. A majority rated residency training in diagnosing (88.5%) and treating (96.2%) EDs as barely adequate or less. Most knew low birth weight (91%) and postpartum depression (90%) are associated with maternal EDs, though over a third was unsure about several consequences. Some gender differences emerged; females screen for more ED indicators and are more likely to view ED assessment as within their role. Conclusions: Despite the consequences of EDs and the fact that most physicians agree EDs can negatively impact pregnancy, only about half view ED assessment as their responsibility. Only some weight- and diet-related topics are assessed, and there are gaps in knowledge of ED consequences. Obstetrician-gynecologists are not condent in their training regarding EDs. Improvement in knowledge and altering obstetrician-gynecologists view of their responsibilities may improve ED screening rates.

Introduction ating disorders (EDs) disproportionately affect females,1 often during their childbearing years. These psychological disordersanorexia nervosa, bulimia nervosa, and ED not otherwise speciedoften result in endocrinological and reproductive sequelae that are within the treatment domain of obstetrician-gynecologists.25 EDs have been associated with negative consequences in both gynecologic and obstetric patients. In non-pregnant patients, these associated risks include polycystic ovaries,68 infertility,9 and menstrual irregularities.1012 Even women with subclinical dieting patterns can be plagued by unexplained infertility and menstrual dysfunction. 13 There are also concerns that disordered eating in early adolescence can negatively impact the growth of the pelvis, which could later result in obstetric complications.14 Several maternal risks have been associated with EDs: hyperemesis gravidarum,1518 cesarean section,19,20 and post-

partum depression.17,19,21 Fetal risks include miscarriage,17,20,21 preterm delivery,2022 low Apgar scores,23 low birthweight,15,20,2224 small for gestational age,15,22,25 small head circumference,15 and neural tube defects.26 There are also concerns that excessive use of laxatives, diuretics, and appetite suppressants during pregnancy may have teratogenic effects.27 EDs have also been described as a possible factor in breech delivery.28 Negative consequences for both the mother and the fetus have been identied, though some of the evidence is inconclusive and there are null ndings.13,14,29,30 This has led to recommendations that obstetricians routinely screen for EDs and inquire carefully about histories and symptoms.19 Unfortunately, many women often try to disguise their symptoms and fail to disclose their disorder to their physicians,18,31 and most never seek mental health treatment.32 Despite the risks, Morgan33 found that only 20% of experienced gynecologists and obstetricians from teaching hospitals in Australia and the United Kingdom were condent in

Research Department, American College of Obstetricians and Gynecologists (ACOG), Washington, D.C.

1395

1396 their ability to diagnose an ED. This study also demonstrated that the greatest decits in knowledge were regarding endocrinological and gynecological sequelae, symptoms within the practice domain of obstetrician-gynecologists. Thus, it is of import, and this studys aim, to investigate the knowledge, attitudes, and practices of obstetrician-gynecologists practicing within the United States with regards to EDs. Methods Questionnaires were developed by the survey researchers of the Research Department of the American College of Obstetricians and Gynecologists (ACOG). Mailings were sent out between November 2007 and March 2008. Those who did not respond to the survey were sent up to three reminder mailings. Nine hundred and sixty-eight questionnaires were distributed throughout the United States, with at least one sent to every state of the United States except Alaska and Wyoming. Of these, 477 were sent to members of the Collaborative Ambulatory Research Network (CARN). Members of CARN are practicing obstetrician-gynecologists who have volunteered to complete ve to six surveys per year. The remaining 491 surveys were sent to non-CARN members who were randomly selected from ACOG membership. Questionnaires returned by May 16, 2008 were included in data analyses. The survey was comprised of 14 questions, with a total of 52 subquestions, and consisted of four sections: (1) physician and patient characteristics; (2) practices regarding screening, diagnosing, treating, and referring patients with EDs; (3) knowledge of the negative health effects of EDs on women and their offspring; and (4) beliefs and opinions regarding EDs and physician training to diagnose and treat EDs. Questions included yes=no check boxes, ve-point Likert-like scales, and open response. A survey on Down syndrome was included in the same mailing, and those results will be reported elsewhere. Statistical analysis Data were analyzed using a personal computer-based version of SPSS 15.0 (SPSS Inc., Chicago, IL). Descriptive and frequency data were computed for primary analysis. Because the proportion of women obstetrician-gynecologists has steadily increased over time, for instances where years in practice was used as a factor in the analysis we statistically controlled for gender. Means are provided with standard error of the mean in parentheses. Analyses were done using analysis of variance (ANOVA), chi-square, and McNemar tests. The McNemar test, which is for assessing the difference between two dependent samples when the variable of interest is dichotomous, was used when comparing generalists treatment of gynecologic patients with their treatment of obstetric patients on the same dichotomous measures. Signicance was evaluated at p < 0.05 (with condence intervals of 95%). Results Descriptives A total of 514 questionnaires were returned. Surveys from 10 respondents were judged invalid (physician retired, returned to sender, blank survey), resulting in a valid response rate of 53% (504=958). The response rates for similar studies performed by ACOGs Research Department were 4060%.3436 There were responding physicians from the

LEDDY ET AL. District of Columbia and from every state of the United States except Alaska, Montana, and Wyoming. Respondents mean age (49.4 0.4 years) closely matched that of non-respondents (49.3 0.5 years). Females were marginally more likely to respond than males (56% of females [246 of 439] responded vs. 50% of males [258 of 519; w2 3.817; p 0.051]). CARN members were signicantly more likely to respond than non-CARN members (61% of CARN [288 of 471] responded vs. 44% of non-CARN [216 of 487; w2 27.083; p < 0.001]). A larger proportion of CARN members than nonCARN practice both obstetrics and gynecology as compared to practicing only gynecology (w2 (1) 11.561; p < 0.005). Of 504 respondents, 46 do not provide routine care for gynecologic or obstetric patients and they were not included in further analyses. Of the remaining 458 respondents, 79% (n 361) treat gynecologic and obstetric patients. This group is called generalists. The majority of these (n 348; 96%) reported a primary medical specialty of general obstetrics and gynecology. Twenty-one percent (n 97) of respondents do not see obstetric patients; this is the Gyn-only group. Of these, most (70%) indicated a primary medical specialty of gynecology-only, followed by general obstetrics-gynecology (12%), urogynecology (7%), and reproductive endocrinology (7%). For physician characteristics, see Table 1. There were few differences between CARN members and non-CARN members on non-demographic variables. In the generalist group, CARN members were more likely to say that they were unsure if cesarean section is associated with an ED in pregnancy (w2 (2) 8.783, p < 0.05). In the gyn-only group, non-CARN members were more likely to assess their gynecologic patients for concern about their body image (w2 (1) 4.445, p < 0.05). Because these differences were few and minor, we collapsed the data across membership group. There were also few differences between generalist and gynonly respondents. As such, we report the responses for the generalists, and only report the data for gyn-only practitioners where the two groups differed. Practices We were interested in ascertaining the ED patterns that obstetrician-gynecologists see in their practices. Half (50.2%) of generalists who were in practice 5 years ago (n 421) indicated that the proportion of patients they see with EDs has remained the same over the past 5 years, 15.3% indicated it has increased, 8.0% said that they have seen it decrease, and 26.5% did not know. Those in the gyn-only group were more likely than generalists to indicate that the proportion of patients they see with an ED has increased (29% vs. 17%) and less likely to say they do not know (18% vs. 25%; w2 (3) 8.686, p < 0.05). Female generalists, independent of years in practice, were more likely to indicate that they have seen a decrease than male generalists (12.8% vs. 5.5%; w2 (2) 6.883, p < 0.05). We asked physicians which ED-related topics they assessed in routine gynecologic and in routine obstetric care (Table 2). Female practitioners, independent of years in practice, were more likely than males to assess gynecologic (females, 88.2%; males, 67.3%; w2 (1) 28.665, p < 0.001) and obstetric (females, 69.7%; males, 58.0%; w2 (1) 6.187, p < 0.01) patients exercise habits. There are certain factors that indicate an ED may be present; we asked physicians how likely they are to screen for an ED in

EATING DISORDERS AND OBSTETRIC-GYNECOLOGIC CARE Table 1. Physician Characteristics Generalists, n 361 Gender Males Females CARN Non-CARN Age in years, mean (SEM) Males Females Years in practice, mean (SEM) Practice location Suburban Urban, non-inner city Urban, inner city Mid-sized town (10,00050,000 residents) Rural Other Military Practice type Ob=gyn partnership=group Solo practice Multi-specialty University full-time faculty and practice Other Consider self Mostly primary care provider Mostly specialist Both primary care provider and specialist Patient ethnicity, mean % of patients (SEM) Non-Hispanic white African-American Hispanic Asian=Pacic Islander Native American 48.50% 51.50% 61.5% 38.5% 47.81 (0.50) 52.56 (0.67) 43.34 (0.58) 15.83 (0.502) 37.6% 24.0% 13.9% 13.4% 9.2% 1.1% 0.8% 52.10% 17.50% 12.70% 8.60% 9.10% 3.30% 46.40% 50.30% 58.58% 15.31% 17.28% 5.91% 1.40% (1.28) (0.84) (1.01) (0.51) (0.361) Gynecologists only, n 97 55.7% 44.3% 42.3% 57.7% 53.84 (0.99) 57.09 (1.36) 49.74 (1.19) 21.29 (1.01) 31.6% 33.7% 17.9% 11.6% 3.2% 2.0% 0.0% 36.5% 31.2% 8.3% 12.5% 11.5% 1.1% 61.7% 37.2% 70.40% 11.86% 12.00% 4.22% 0.51% (2.08) (1.16) (1.54) (0.86) (0.12)

1397

Total 50.00% 50.00% 57.8% 42.2% 49.09 (0.46) 53.63 (0.61) 44.55 (0.55) 16.99 (0.461) 36.3% 26.0% 14.8% 13.0% 7.9% 0.7% 1.3% 48.8% 20.4% 11.8% 9.4% 9.60% 2.9% 49.6% 47.5% 60.99% (1.13) 14.6% (0.71) 16.2% (0.87) 5.57% (0.44) 1.22% (0.29)

a variety of scenarios (Table 3). Female practitioners, independent of the number of years in practice, were more likely to say they screen for an ED in all but two situations: if the patient comes in for an initial obstetric visit and if the patient has a high BMI.

A majority (81.1%) of respondents do not treat EDs. If an obstetrician-gynecologist believes a patient has an ED, there are several possible courses of action (Table 4). Female physicians were more likely than males to say they refer gynecologic (M-W U 13,483.5; p < 0.01) and obstetric (M-W

Table 2. Percent of Respondents Who Assess Various Eating Disorder (ED)-Related Topics during Routine Gynecologic Care Percentage who assess ED Generalists Topic assessed Body weight Exercise routine Body Mass Index (BMI)* Dieting habits* ED history* Concern with body image Cosmetic surgery related to weight* Food binging Food purging In OB patients 98.6 80.2 52.9 61.0 42.6 27.9 16.7 9.2 8.1 In Gyn patients 96.9 78.8 65.2 50.4 34.6 29.5 27.9 9.5 8.4 Gynecologists only In Gyn patients 94.7 73.7 62.1 60.0 37.9 33.7 27.4 7.4 7.4

*p < 0.001. Generalists were compared in their assessment of various topics during obstetric and gynecologic care.

1398

LEDDY ET AL. Table 3. How Often Physicians Screen for an Eating Disorder in Different Scenarios Always (%) Often (%) 35.6 28.7 39.0 38.4 42.1 38.1 32.6 31.8 25.4 21.9 16.9 11.7 Sometimes (%) 8.1 21.9 19.8 20.6 20.2 25.5 28.1 33.1 26.0 31.2 41.7 39.5 Rarely (%) 2.8 11.8 6.7 7.8 7.9 7.8 9.8 12.3 26.3 27.8 26.1 35.2 Never (%) 1.4 4.3 1.9 1.7 2.8 2.2 3.4 3.6 8.1 6.9 6.7 7.5

Has a history of eating disorders* Has electrolyte imbalances* Has amenorrhea (and is not pregnant)*** Is reluctant to gain weight*** Has a low Body Mass Index (BMI)*** Has inadequate weight gain during pregnancy* Is averse to being weighed** Is infertile* Has a high BMI Comes in for an initial obstetric visit Is 1524 years old and comes in for a routine gynecologic exam* Is older than 24 and comes in for a routine gynecologic exam*

52.1 33.3 32.6 31.5 27.0 26.4 26.1 19.2 14.2 12.2 8.6 6.1

*p < 0.05. **p < 0.01. ***p < 0.001. Female physicians are more likely to screen for an ED in these cases, independent of years in practice.

U 13,713.5; p < 0.01) patients to a therapist, independent of number of years in practice. Generalists were more likely than gyn-onlys to say they monitor their patients weight if they suspect an ED (M-W U 12,862.5, p < 0.01). Beliefs The majority of generalists (54%) disagree or strongly disagree that assessment of the presence of an ED falls outside the routine practices of an ob=gyn. Females were more likely to disagree than males (M-W U 12,534.5; p < 0.001), independent of number of years in practice. Respondents who view themselves as both primary care providers and specialists more strongly disagree that assessment of EDs as outside their purview than do those who consider them solely specialists (M-W U 17,509.0; p < 0.001). Just under threequarters (71.7%) of respondents agree or strongly agree that the treatment of an ED falls outside the routine practices of an ob=gyn. Male physicians, independent of years in practice, were less likely than females to agree (66% vs. 77%) that the treatment of disordered eating falls outside their role (M-W U 13,759.0; p < 0.01). Physicians who view themselves as primary care providers and specialists more strongly disagree that treatment of EDs is outside their role than those who view themselves solely as a specialist (M-W U 20,154.0, p 0.001). Most (90.8%) generalists agreed or strongly agreed that EDs can have signicant negative effects on pregnancy outcome. Such agreement was negatively correlated with agreement that assessment of the presence of an ED falls outside the routine practices of an ob=gyn physician (Spearmans

Rho 0.19, p < 0.001), and negatively correlated with agreement that treatment of an ED falls outside the routine practices of an ob=gyn physician (r 0.12, p < 0.05). Agreement that EDs have negative effects on pregnancy was related to more frequently referring a pregnant patient to a therapist (Spearmans Rho 0.138, p < 0.01). It was also correlated with frequency of screening for an ED at an initial obstetric visit (Spearmans Rho 0.222, p < 0.001), and screening if there is inadequate weight gain in pregnancy (Spearmans Rho 0.166, p < 0.01). Believing that EDs have a negative impact on pregnancy outcome was also correlated with the number of ED-related topics assessed for during routine obstetric care (Spearmans Rho 0.21, p < 0.001). Physicians rated the training they received in residency regarding diagnosing an ED, with 0.3% believing their training was comprehensive, 11.2% viewing it as adequate, 34.0% as barely adequate, 27.8% as inadequate, and 26.7% as nonexistent. The same question was asked of their residency training in treating EDs, and 0.3% rated it as comprehensive, 3.6% as adequate, 20.5% as barely adequate, 39.8% as inadequate, and 35.9% as nonexistent. Females rated their training in diagnosing (M-W U 11,034.5, p < 0.001) and treating (M-W U 11,972.0, p < 0.01) an ED more highly than males, independent of number of years in practice. Knowledge Given that EDs can have negative maternal and fetal effects, we assessed physician knowledge of the potential adverse outcomes (Table 5). Most respondents knew that low birth weight (91%) and postpartum depression (90%) are as-

Table 4. How Often Physicians Follow Possible Courses of Action if They Believe a Patient Has an Eating Disorder Always (%) Refer a non-pregnant patient to a therapist Refer a pregnant patient to a therapist Counsel the patient yourself Monitor the patients weight 58.1 62.8 13.8 38.1 Often (%) 30.6 25.4 11.8 30.4 Sometimes (%) 7.9 7.6 25.6 15.4 Rarely (%) 2.6 2.8 31.2 8.9 Never (%) 0.8 1.4 17.6 7.2

EATING DISORDERS AND OBSTETRIC-GYNECOLOGIC CARE sociated with maternal EDs, though over a third was unsure whether several risks are associated. Conclusions EDs have been linked to pregnancy complications that often come to the attention of obstetrician-gynecologists. These complications can put both mothers and their offspring at risk. As such, it is crucial that physicians are able to accurately identify eating pathology and refer patients for treatment. Despite these risks and the fact that most (90.8%) physicians agree that EDs can have detrimental effects on pregnancy outcome, only about half of respondents agree that the assessment of the presence of an ED is within the routine practices of an obstetrician-gynecologist. It is unclear from this study exactly why some obstetrician-gynecologists view this clinical practice as outside of their role, though it seems to be related to whether physicians consider themselves primary care providers; physicians who view themselves as both a primary care provider and specialist are more likely to view the assessment and treatment of EDs to be within their professional purview than are those obstetrician-gynecologists who consider themselves primarily a specialist. This may indicate that screening for and treating EDs is, somewhat, considered to be a primary care issue. Encouraging all obstetrician-gynecologists to recognize the importance of this issue to women and fetal health may increase screening and provision of care for those who may be suffering from disordered eating. Physicians acknowledge the importance of some weightand diet-related topics in overall patient health. Body weight, exercise routine, dieting habits, and BMI are assessed by over half of respondents during routine obstetric and gynecologic care. However, the assessment of these topics may be used for determining general health, rather than discovering an ED. Other topics more closely linked to disordered eating, including concern with body image, are assessed by less than half of respondents during obstetric and gynecologic care. Bingeing and purging behaviors are also infrequently assessed. It is possible that physicians believe that a thorough physical examination or other types of assessment sufce, or are unaware that this is an easy route to determining the presence of an ED. It is important to note that less than half of physicians assess for ED history; given the high rates of ED relapse,3740 a past diagnosis can alert the obstetrician-gynecologist aware to the risk of current or future EDs and potential complications in pregnancy.

1399

Low rates of assessing these kinds of topics may result in missed opportunities to identify women struggling with disordered eating, and refer them for proper treatment. Other missed opportunities arise when physicians do not further investigate eating patterns in women with high BMI scores. This is concerning due to the fact that there are high rates of Binge Eating Disorder (BED) in overweight populations.41,42 This disorder may be missed due to the fact that this ED is not associated with the same sequelae as other EDs; for example, BED is not associated with the risks associated with vomiting or the use of laxatives and diuretics. These missed opportunities can result in negative health consequences for mother and baby, as well as greater nancial costs and longer hospital stays.43 Due to the possibility of these serious consequences, some have recommended a cooperative team approach, utilizing obstetricians, mental health professionals, and dietitians to treat pregnant women with suspected EDs.44 When compared with males, female obstetriciangynecologists screen for more indicators of EDs, and are more likely to disagree that assessing for EDs is outside of their role. This may be a result of more personal experience with these disorders, through friends, families, or themselves. Given that EDs disproportionately affect women, female physicians may be more aware of the negative impact these illnesses can have. Our results demonstrate that there are some gaps in the ED knowledge of obstetrician-gynecologists. Many physicians were aware of the more commonly known consequences, but were unfamiliar with less common outcomes. This may be due to the fact that evidence is inconclusive13,14,19,29 and that some research lacks control groups.17,19,23,28 Physicians who believe disordered eating can have negative effects on pregnancies are more likely to view assessment of the presence and treatment of an ED as within their role, and assess more ED-related topics during routine obstetric care. Increasing physicians knowledge and awareness of the detrimental consequences of EDs can improve their patients treatment, thus increasing the chances of having healthy pregnancies. Past studies33 have demonstrated that there are gaps in obstetrician-gynecologists knowledge of EDs and that they are not condent in their ability to diagnose eating pathology. This study conrmed those ndings; we found some uncertainty regarding ED symptomatology and its effects on obstetric care, and many rated their training in this realm as less than adequate. This has implications for the health of women and fetuses. In order to identify the presence of an ED early

Table 5. Physicians Responses to Whether Various Maternal (A) and Fetal=Neonatal (B) Risks Are Associated with an Eating Disorder (ED) during Pregnancy Yes, % A Miscarriage Breech delivery Hypertension B Still birth Preterm delivery Low Apgar scores 57.4 2.8 26.4 60.5 82.0 46.5 No, % 12.6 61.5 39.6 6.5 2.8 14.3 Unsure, % 30.0 35.7 34.0 33.0 15.2 39.4 Hyperemesis gravidarum Postpartum depression Cesarean delivery Low birth weight Intrauterine growth restriction Cleft palate Yes, % 80.3 89.6 24.5 91.2 86.4 15.4 No, % 6.2 1.7 38.5 1.2 2.2 26.6 Unsure, % 13.5 8.7 37.0 7.6 11.4 58.0

1400 on and allow the patient to obtain treatment prior to the onset of more serious sequelae, physicians must be made more aware of the risk factors for and consequences of eating pathology. There are some limitations to this study. Our inquiries regarding screening habits asked physicians about their assessment of patient dieting habits and concern with body image, which are not easily operationalized, and thus can be interpreted and assessed in a variety of ways. It may be unclear to respondents exactly what constitutes assessment of these topics, and it remains unclear how exactly they may do this. However, we have a large national sample with a response rate over 50%, indicating that these response patterns are likely representative of the profession as a whole. It seems that obstetrician-gynecologists are not fully incorporating assessment of eating pathology into routine care, though some topics (e.g., body weight) are routinely assessed. Obstetrician-gynecologists often act as primary care physicians for women over the life cycle. Given that patients tend to hide their ED symptoms,18,31 there is a potential missed opportunity to identify at-risk patients. As such, obstetriciangynecologists should be knowledgeable of these symptoms in order to be alerted to at-risk women. Future research may want to determine the change in the amount of screening physicians are performing in their practices to determine whether physicians have become more aware or likely to ask about EDs. Additionally, an emphasis should be placed on the importance of obstetrician-gynecologists in assessing the presence of EDs in order to change the potentially harmful view that this is not within the scope of their routine practice. Given that studies have found that past diagnoses of EDs can impact later fertility and pregnancy22 as well as overall wellbeing, ED-related topics should be regularly discussed with gynecologic and obstetric patients. Acknowledgments This study was supported by Maternal and Child Health Bureau (Title V, Social Security Act; grant R60-MC-05674), Health Resources and Services Administration, Department of Health and Human Services. Disclosure Statement No competing nancial interests exist. References
1. Hsu LG. The gender gap in eating disorders: why are the eating disorders more common among women? Clin Psychol Rev 1989;9:393407. 2. Chrousos GP, Torpy DJ, Gold PW. Interactions between the hypothalamic-pituitary-adrenal axis and the female reproductive system: clinical implications. Ann Intern Med 1998; 129:229240. 3. Warren MP, Voussoughian F, Geer EB, et al. Functional hypothalamic amenorrhea: hypoleptinemia and disordered eating. J Clin Endocrinol Metab 1999;84:873877. 4. Golden NH. Eating disorders in adolescence and their sequelae. Best Pract Res Clin Obstet Gynaecol 2003;17:5773. 5. Wolfe BE. Reproductive health in women with eating disorders. J Obstet Gynecol Neonatal Nurs 2005;34:255263.

LEDDY ET AL.
6. Morgan JF, McCluskey SE, Brunton JN, et al. Polycystic ovarian morphology and bulimia nervosa: a 9-year followup study. Fertil Steril 2002;77:928931. 7. Raphael FJ, Rodin DA, Peattle A, et al. Ovarian morphology and insulin sensitivity in women with bulimia nervosa. Clin Endocrinol 1995;43:451455. 8. Naessen S, Carlstrom K, Garoff L, et al. Polycystic ovary syndrome in bulimic womenan evaluation based on the new diagnostic criteria. Gynecol Endocrinol 2006;22:388394. 9. Stewart DE, Robinson E, Goldbloom DS, et al. Infertility and eating disorders. Am J Obstet Gynecol 1990;163:11961199. 10. Schweiger U, Pirke KM, Laessle RG, et al. Gonadotropin secretion in bulimia nervosa. J Clin Endocrinol Metab 1992; 74:11221127. 11. Gendall KA, Bulik CM, Joyce PR, et al. Menstrual cycle irregularity in bulimia nervosa: associated factors and changes with treatment. J Psychosom Res 2000;49:409415. 12. Crow SJ, Thuras P, Keel PK, et al. Long-term menstrual and reproductive function in patients with bulimia nervosa. Am J Psychiatry 2002;159:10481050. 13. Bates GW, Bates SR, Whiteworth NS. Reproductive failure in women who practice weight control. Fertil Steril 1982; 37:373378. 14. Ekeus C, Lindberg L, Lindblad F, et al. Birth outcomes and pregnancy complications in women with a history of anorexia nervosa. BJOG 2006;113:925929. 15. Kouba S, Hallstrom T, Lindholm C, et al. Pregnancy and neonatal outcomes in women with eating disorders. Obstet Gynecol 2005;105:255260. 16. Lingam R, McCluskey S. Eating disorders associated with hyperemesis gravidarum. J Psychosom Res 1996;40:231234. 17. Abraham S. Sexuality and reproduction in bulimia nervosa patients over 10 years. J Psychosom Res 1998;44:491502. 18. Stewart DE. Reproductive functions in eating disorders. Ann Med 1992;24:287291. 19. Franko DL, Blais MA, Becker AE, et al. Pregnancy complications and neonatal outcomes in women with eating disorders. Am J Psychiatry 2001;158:14611466. 20. Bulik CM, Sullivan PF, Fear JL, et al. Fertility and reproduction in women with anorexia nervosa: a controlled study. J Clin Psychiatry 1999;60:130137. 21. Morgan JF, Lacey JH, Chung E. Risk of postnatal depression, miscarriage and preterm birth in bulimia nervosa: retrospective controlled study. Psychosom Med 2006;68:487492. 22. Sollid CP, Wisborg K, Hjort J, et al. Eating disorder that was diagnosed before pregnancy and pregnancy outcome. Am J Obstet Gynecol 2004;190:206210. 23. Stewart DE, Raskin J, Garnkel PE, et al. Anorexia nervosa, bulimia, and pregnancy. Am J Obstet Gynecol 1987;157: 11941198. 24. Waugh E, Bulik CM. Offspring of women with eating disorders. Int J Eat Disord 1999;25:123133. 25. Conti J, Abraham S, Taylor A. Eating behavior and pregnancy outcome. J Psychosom Res 1998;44:465477. 26. Carmichael SL, Shaw GM, Schaffer DM, et al. Dieting behaviors and risk of neural tube defects. Am J Epidemiol 2003;158:11271131. 27. Fahy TA, Morrison JJ. The clinical signicance of eating disorders in obstetrics. Br J Obstet Gynaecol 1993;100:708710. 28. Lacey JH, Smith G. Bulimia nervosa. The impact of pregnancy on mother and baby. Br J Psychiatry 1987;150:777781. 29. Willis DC, Rand CS. Pregnancy in bulimic women. Obstet Gynecol 1988;71:708710.

EATING DISORDERS AND OBSTETRIC-GYNECOLOGIC CARE

30. Lemberg R, Phillips J. The impact of pregnancy on anorexia nervosa and bulimia. Int J Eat Disord 1989;8:285295. 31. Hollield J, Hobdy J. The course of pregnancy complicated by bulimia. Psychotherapy 1990;27:249255. 32. Powers PS, Santana CA. Eating disorders: a guide for the primary care physician. Prim Care 2002;29:8198. 33. Morgan JF. Eating disorders and gynecology: knowledge and attitudes among clinicians. Acta Obstet Gynecol Scand 1999;78:233239. 34. Coleman VH, Laube DW, Hale RW, et al. Obstetrician gynecologists and primary care: training during obstetrics gynecology residency and current practice patterns. Acad Med 2007;82:602607. 35. Power ML, Schulkin J, Rossouw JE. Evolving practice patterns and attitudes toward hormone therapy of obstetriciangynecologists. Menopause 2007;14:2028. 36. Morgan MA, Goldenberg RL, Schulkin J. Obstetrician gynecologists screening and management of preterm birth. Obstet Gynecol 2008;112:3541. 37. Keel PK, Mitchell JE, Miller KB, et al. Long-term outcome of bulimia nervosa. Arch Gen Psychiatry 1999;56:6369. 38. Pike KM. Long-term course of anorexia nervosa: response, relapse, remission, and recovery. Clin Psychol Rev 1998;18: 447475. 39. Morgan HG, Russell GF. Value of family background and clinical features as predictors of long-term outcome in an-

1401
orexia nervosa: four-year follow-up study of 41 patients. Psychol Med 1975;5:355371. Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 1015 years in a prospective study. Int J Eat Disord 1997;22:339360. de Zwaan M. Binge eating disorder and obesity. Int J Obes 2001;25:S51S55. Striegel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J Eat Disord 2003;34:S19S29. Paauw JD, Bierling S, Cook CR, et al. Hyperemesis gravidarum and fetal outcome. JPEN J Parenter Enteral Nutr 2005;29:9396. Franko DL, Spurrell EB. Detection and management of eating disorders during pregnancy. Obstet Gynecol 2000;95: 942946.

40.

41. 42. 43.

44.

Address correspondence to: Meaghan A. Leddy, M.A. Research Department ACOG 409 12th Street, SW Washington, DC 20024 E-mail: mleddy@acog.org