I’ve gotten a few requests from folks to discuss key questions about eating disorders and child-bearing. I’ll use excerpts from a chapter I just wrote in Encyclopedia of Feeding and Eating Disorders for Springer Reference. I think the key questions are: do women with eating disorders seek more fertility help? What are pregnancy outcomes in women who have had an eating disorder? How does childbearing affect mortality rates in those with a history of anorexia nervosa (AN)? And finally, how does pregnancy itself affect eating disorders?

To get and stay pregnant, an immense number of things must “go right,” among them a reasonable nutritional status and adequate body weight for ovulation to occur. Even some modern day healthy bodies in women without eating disorders may simply be too underweight, from Mother Nature’s perspective, to conceive a baby. Purging, and the psychological stressors that drive purging, may also impede fertility. A large study showed that 16-20% of women attending fertility clinics had eating disorders. This is a way higher number than the population prevalence of eating disorders. Relative to women with no psychiatric disorder, women with bulimia nervosa in particular had more than double the rates of having undergone fertility treatment. Another study showed that 7.2% of eating disordered patients who had previously received residential treatment sought infertility treatment, compared with 4.5% of those without an eating disorder.

When patients have lost a lot of weight, or are quite underweight, they may experience difficulty swallowing. It might be that dry foods feel like they get stuck in your throat, or that you’ve naturally moved toward moister foods because they’re easier to get down. It might be that you’ve found yourself coughing after drinking liquids, or that food or liquid seems to “go down the wrong pipe” more often. This condition is known as dysphagia.

Dysphagia (pronounced dis-FAY-juh) refers to dysfunction in the swallowing muscles. Usually, when you swallow a bite of food, your mouth and throat muscles naturally guide the food down your esophagus and into your stomach, blocking off your airway briefly in the process so that food and bacteria don’t end up in your lungs. But in anorexia nervosa—restricting or purging subtype—those swallowing muscles get just as thin and weak as your other muscles, and they can’t do their job as well. Reflux, in which acid contents from the stomach flow up into the esophagus, can independently cause dysphagia, or can make dysphagia from an eating disorder worse. The risk is that when your swallowing muscles get weak, food, liquid, and even bacteria from your saliva may not actually end up in your stomach. 

Once again, I’m going to discuss a topic that can help you combat the “I’m Fine Syndrome” – a term we at the ACUTE Center for Eating Disorders use to explain when a patient is in denial about the severity of his or her eating disorder. The subject is temperature regulation, and this one isn’t about life-threatening medical complications so much as it is about knowing your body when you’re in your disorder so that you can use good objective evidence of body suffering with your wise mind in order to combat the mean lies and distortions that your eating disorder whispers to you.

When you’re not eating enough, your “cave girl brain” (the one responsible for controlling body processes and species survival) assumes that you must be in famine, so she sets to work doing everything in her power to keep you alive. She starts by slowing your metabolism way down and does this by turning down your inner furnace – aka: your body temperature.

Many people with eating disorders are in denial about the severity of their illness and believe that they are fine – something we at ACUTE term the “I’m fine” syndrome. Despite family, friends, and colleagues expressing their worry over food habits, withdrawal from previously enjoyed activities, and health issues, somehow the eating disorder makes people ignore the concerns of their loved ones. They think that because they can still engage in their normal, everyday activities including going to school, work, exercise, hobbies and social events, that there must be nothing wrong with them. Well my friends, this is absolutely not the case. 

In restricting disorders, blood tests are often normal because there isn’t any sort of electrolyte loss through purging. In addition to the already existing denial, these normal blood tests can further contribute to the “I’m fine” syndrome. Well-meaning primary care providers can unwittingly contribute to this issue by focusing too heavily on measurable data (i.e.: potassium levels) and not on the whole person…the person who is clearly NOT fine! 

Hypoglycemia is a medical term that refers to low blood glucose levels. In effect, a healthy body will metabolize what you eat and break down carbohydrates into sugars, which are absorbed into your bloodstream and form a key nutritional element – glucose -- needed by your cells. The brain in particular can only run on glucose -- not on protein or fat. In between eating, when you’ve fully metabolized your last meal, your liver synthesizes glucose for you and puts it into your bloodstream, so that you always have sufficient blood glucose levels to fulfill your body’s need. To go over all the ways blood sugar goes awry would take textbooks! But let’s talk about what can happen in anorexia nervosa.

With anorexia, the liver becomes depleted of the chemical building blocks needed to create glucose, as well as depleted of glycogen, which is key to maintaining a good blood sugar. That means between meals—and for people with eating disorders, those meals are often inadequate, calorie-poor, and imbalanced—your body may stop being able to sustain blood sugar. 

Many patients with eating disorders are highly intelligent and very emotionally intuitive...great traits, and ones often accompanied by a truly sensitive soul. Many of my patients glow a little too much when praised, and can withdraw like a closing sea anemone when criticized or corrected. I think of this sensitivity as the darker or more difficult side of a two-sided coin – the other side being incredibly bright and representative of a patient’s intelligence, work ethic, and thoughtfulness.

Frequently, folks who have this very bright/dark sided coin start experiencing belly pain, nausea, or other digestive issues very early in life – sometimes as early as elementary school. Although these symptoms feel very, very real, doctors keep telling them that they are “fine” - something they have been repetitively told their entire lives. This unexplained digestive discomfort/dysfunction is often diagnosed as Irritable Bowel Syndrome (IBS) or attributed to food allergies or symptom somatization. Regardless of what we choose to call it, it must be understood that the pain and discomfort arises from emotions being made physical – a prime example of the mind/body connection.

Cerebral atrophy — or what’s known as “starved brain” — is a common complication of anorexia nervosa and describes a loss of brain mass due to starvation. When a person does not get adequate nutrition regularly, starved brain will affect concentration, memory, cognitive flexibility, and fear responses, regardless of brain size. 

Many of our patients at the ACUTE Center for Eating Disorders — even while being high-functioning — realize about a week into nutritional rehabilitation that they do have some type of so-called brain fog. They realize their concentration was compromised, that they were driven by rigid rules and fears rather than having the ability to be spontaneous, creative, and flexible, and that their memory was worsened. 

We all know how hard it can be for a patient with an eating disorder to find the motivation to enter and stick with treatment. (Because I work in a hospital setting, I use the word “patient” rather than client.) Whether you suffer from an eating disorder yourself, are a loved one of someone who has one, or are a clinician, it’s clear that sustaining motivation is one of the greatest challenges.

So many of my patients—brilliant and articulate and sensitive and driven—hear a constant message from their eating disorder that they are “fine” (Aren’t they getting great grades? The star employee? Still able to complete their run?) and in fact should probably restrict more, purge more, go further.

It’s an exhausting and deafening message, and it’s incredibly hard to overcome. Since self-esteem often runs low at the same time, encouragement to “get treatment because you deserve something better” may not be motivating enough.

You may be someone with an eating disorder, a parent/partner/sibling/teacher/coach/grandparent of someone who has an eating disorder, or a clinician. You are all welcome to read on…everyone who has anything to do with eating disorders should understand why bone density loss and underweight are linked. I want you to understand the basic science behind the linkage, to grasp what’s at stake, and to use this scary example of objective body suffering to break through the syndrome of “I’m fine.”

So let’s start with some basics. During adolescence, 90% of your bone density is laid down…that’s the healthy, strong, resilient bone that has to carry you around the rest of your life, so it’s incredibly important. After age 20, the window to lay down this dense bone closes, and you will live in a balance of building up and breaking down bone until (if you’re a woman) menopause, at which point you’ll probably slowly start losing more bone density than you make because you no longer produce estrogen.