Clinicians may pose several questions to their patients to identify preexisting or newly developed AN or BN (Table 9.4). Once such screening suggests the coexistence of pregnancy and an eating disorder, medical nutrition therapy (MNT) can be applied. As part of MNT, a full nutritional assessment involves systematic collection and evaluation of anthropomet-ric, biochemical, clinical, and dietary intake data. In addition, functional and behavioral status may be evaluated based on responses to screening questions (Table 9.4).
An easily obtained parameter of adequate dietary intake and fetal growth is maternal body weight. Body weight should be measured at each prenatal visit, recognizing that this assessment may make a woman with AN or BN uncomfortable. Some women may even refuse to have body weight measured. In those women who may increase eating disorder behaviors with body weight gain [46, 48, 50], nondisclosure of weight changes may be appropriate. Alternatively, in women who relax their eating disorder behaviors during pregnancy [45-47, 49, 55], discussion of weight changes may provide positive reinforcement of healthy behaviors. Inadequate [35, 36, 45, 46, 48] and excessive [46, 49, 50] weight gain must be tracked and compared to the recommended weight gain based on prepregnancy body mass index (BMI) (see Chap. 2) and any needed nutritional repletion in AN.
Weight control tactics
Body weight and weight gain may be affected by the patient's hydration status, glyco-gen stores (in AN), and changes in lean and fat mass. Body composition testing during pregnancy may be performed by bioelectrical impedance analysis but is significantly affected by hydration status. Skin fold and circumferential measurements will be affected by differential changes in maternal body fat deposition. Dual-energy X-ray absorptiometry should not be performed during pregnancy. Pitting edema may be a sign of BN.
Biochemical or laboratory values are generally normal in women with AN or BN. During semistarvation in AN, catabolic and compensatory mechanisms mobilize tissue stores, releasing nutrients to the serum pool. As a result, hypercarotenemia is often found in women with moderate to severe AN. Yet when serum concentrations of nutrients are low, severe AN is likely. At this point, several B vitamins, including B6 and B12, and minerals, such as zinc, will show signs of depletion. Dehydration in either AN or BN may falsely normalize or elevate several biochemical markers of nutritional status, such as serum albumin and iron. Thus, establishing normal hydration is important for accurate nutrition assessment. Vitamin and mineral supplement use is common in AN and BN and may mask nutrient deficiencies. Elevated blood lipids may be noted in the majority of women, due to liver and hypothalamic dysfunction in AN and inappropriate intake of dietary fats or lipids in AN or BN during binge eating.
Upon clinical assessment, signs and symptoms of AN or BN will be present (see Sect. 9.2 and Table 9.1). Bleeding gums or sensitive teeth may present as new symptoms or worsened conditions. Assessment instruments such as the Eating Disorders Examination  may also be useful when evaluating the full clinical picture and relate to the functional and behavioral aspects of AN or BN.
Methods designed to gather dietary intake information include dietary history, food frequency questionnaire, 24-h recall, and food diary or record. A variety of techniques for data collection, including written, computerized, and Web based have been used with validated instruments. Dietary intake data may be evaluated for energy, macronutrient, and micronutrient intakes; food patterns; food groups; and/or food variety. Comparison to established standards is important, as is comparison to the woman's previous intake. Such evaluation will identify foods, nutrients, and/or eating behaviors of concern as well as areas where improvements have been made.
Inquiry about eating behaviors may also uncover related issues such as food cravings or aversions, timing and triggers of intake, and fasting and ritualistic behaviors. These may be linked to dental problems, morning sickness, hyperemesis gravidarum, gastrointestinal symptoms, and mood changes during pregnancy.
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