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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). Anthropometric Data

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.

Table 9.4

Screening for an Eating Disorder During Pregnancy Body weight

  1. What is your current weight? Current height?
  2. What is your usual weight?
  3. What was your highest weight as an adult?
  4. What was your lowest weight as an adult?
  5. Have you had any changes in weight in the last month?
  6. Does your weight fluctuate very often? If yes, by how much and how often?
  7. How much weight do you think that you will gain during this pregnancy?
  8. How much weight do you want to gain during this pregnancy?
  9. Do you think that your body shape will change during this pregnancy? 10. What do you think about any body shape changes?

Weight control tactics

Have you previously (or are you currently):

  1. Gone on (On) a diet to lose weight?
  2. Fasted (Fasting) for more than or equal to eight hours (other than during sleep)?
  3. Made yourself vomit (Vomiting frequently)?
  4. Used (Using) laxatives? If yes, how often?
  5. Used (Using) diuretics? If yes, how often?
  6. Eaten (Eating) very large amounts of food in a short period of time? If yes, how often?
  7. Restricted (Restricting) the amount of food or beverages that you consume(d)? If yes, how often?
  8. Eaten (Eating) in private or in secret?
  9. Avoided (Avoiding) certain types of food?
  10. Engaged (Engaging) in exercise? If yes, what type, frequency, duration, and intensity? Dietary intake
  11. How frequently do you eat foods and drink beverages?
  12. Do you ever skip meals?
  13. Do you have any food allergies?
  14. Do you have any food cravings?
  15. Do you have any food aversions?
  16. Have you had morning sickness?
  17. Do you drink fluids in place of solid foods or meals?
  18. Do you take any vitamin and/or mineral supplements?
  19. Do you take any other supplements such as herbal products?
  20. Do you use sugar substitutes or fat substitutes?

General health

  1. Were your menstrual cycles regular prior to this pregnancy?
  2. Have you experienced constipation or diarrhea?
  3. Have you experienced heartburn?
  4. Do you feel "stressed" or anxious?
  5. Do you think that you are "retaining fluid"?
  6. Have you felt weak or light-headed?
  7. Are you experiencing frequent urination?
  8. Are you taking any over-the-counter or prescription medications?
  9. Do you plan to breastfeed your infant?
  10. How does this pregnancy compare to your previous pregnancy (pregnancies)?

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 Data

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. Clinical Data

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 [68] may also be useful when evaluating the full clinical picture and relate to the functional and behavioral aspects of AN or BN. Dietary Intake Data

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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