Anorexia Nervosa and Low Infant Birthweight 1

Association Between Maternal Anorexia
Nervosa and Low Infant Birthweight
Brenna Alvarez
Cal Poly, San Luis Obispo

Department of Food Science & Nutrition
FSN 310, Section 01, Maternal & Child Nutrition
Professor Hughes

Anorexia Nervosa and Low Infant Birthweight 2
Association Between Maternal Anorexia Nervosa
And Low Infant Birthweight
High levels of body image distortion produced by today’s society and beauty standards
have taken a heavy toll on young women’s health. Some women will resort to starving
themselves due to their distorted body image, which can lead to an eating disorder called
anorexia nervosa. Anorexia nervosa is a serious and life threatening eating disorder depicted by
fear of gaining weight and extremely low food consumption. Eating disorders are prevalent in
many women of childbearing age. One in twenty women deal with a maternal eating disorder
during pregnancy (Linna, et al. 2014). These women fear weight gain and greatly desire to
maintain a thin body. They accomplish this through restrictive eating, excessive exercise, and
sometimes even laxative abuse to lose weight. This behavior in turn produces detrimental
consequences associated with the health and development of the fetus. Pregnancy requires
women to be physically and emotionally strong, and those with anorexia nervosa (AN) tend to
struggle with the fact that their body is going to change during pregnancy. This may cause them
to continue to restrict their calorie intake and unintentionally harm their fetus. Maternal AN is
strongly associated with low infant birthweight due to common risk factors involving low prepregnancy body mass index (BMI) and nutrient deficiencies.
Low pre-pregnancy BMI in women who struggle with AN or who have had a history of
AN can lead to low infant birthweight. They may also face other serious complications during
their pregnancy and delivery. These serious complications are linked with low pre-pregnancy
BMI. Adverse outcomes include premature births, low birth weight infants, and miscarriages. A
study published in 2007 in the British Journal of Psychiatry called the Avon Longitudinal Study
of Parents and Children (ALSPAC) focuses on specific perinatal outcomes affected by a history

Anorexia Nervosa and Low Infant Birthweight 3
of eating disorders. Previous studies only looked at the harmful effect that eating disorders and
their symptoms have on pregnancy, but this study focused on other possible mediators of effect
including pre-pregnancy BMI. It was more in depth by taking into account the role of other
covariates that also lead to adverse perinatal outcomes in women with a history of AN, thus
resulting in stronger data. At twelve weeks gestation, a majority white British women were asked
if they had any past AN, bulimia nervosa, or other psychiatric disorders through a series of postal
questionnaires. Data collected from the ALSPAC study indicate women with a history of AN
have significantly lower pre-pregnancy BMI compared to the other groups. The data also showed
the mean infant birth weights for women who had AN were significantly lower. From the results,
the ALSPAC study concluded low maternal weight pre-pregnancy or at delivery has the greatest
impact on birth weight (Micali, et al. 2007).
Other studies have also found that low pre-pregnancy weight in anorexic women is a
main cause of low birthweight babies. A study published in 2014 in the American Journal of
Obstetrics & Gynecology titled “Pregnancy, Obstetric, and Perinatal Health Outcomes in Eating
Disorders” tried to identify the prevalence of low infant birthweight and SGA (small for
gestational age) babies in women with eating disorders compared to an unexposed group of
individuals. In previous studies, the subjects included women who have or previously had AN,
but there was no information collected on whether they had been treated which can lead to
inconclusive evidence. This study focuses on women with an eating disorder who were treated at
a hospital during the years of 1995-2010. They hypothesized that women with maternal AN have
a higher risk of perinatal complications, including low infant birthweight, related to
malnourishment (Linna, et al. 2014).

Anorexia Nervosa and Low Infant Birthweight 4
Community-based information on perinatal health complications was obtained for
singleton births among four groups: AN, bulimia nervosa, binge eating disorder, and unexposed
women. All groups were screened for low infant birthweight and SGA, including other health
complications immediately before or after birth. The data was adjusted by maternal age, parity,
and marital status. The results showed women with anorexia were more likely to be divorced,
develop anemia, have slow fetal growth, have the shortest first stage of labor, have the lowest
gestational age, have an increased risk of premature birth, and have lower birthweight babies
compared to unexposed women. According to the study, “low prepregnancy BMI and small
weight gain have been associated extensively with infant low birthweight… [because] AN is
associated with restrictive eating, elevated levels of stress, and low bodyweight” (Linna, 2014).
Any woman who is pregnant, whether they are anorexic or not, will deal with stress, have
increased body image disparities, and be emotionally and physically exhausted. Anorexia during
pregnancy can make these symptoms ten times worse. (Linna, et al. 2014).
In the systematic review of literature “Low Birth Weight in the Offspring of Women With
Anorexia Nervosa” published in Epidemiologic Reviews in 2014, fourteen different studies on
maternal anorexia and infant birthweight were assessed. The study calculated the accuracy of the
hypothesis that babies born to AN women weigh less than babies born to unexposed women of
healthy weight. The protocol they developed included a search procedure, inclusion and
exclusion criteria, and a data analysis strategy. A random-effects model and confidence intervals
were used to plot and analyze data. Around three hundred studies were identified and the
fourteen studies selected compared the mean birth weights of babies born to anorexic women
with the weight of babies born to women without anorexia. The studies were completed between
1987 and 2012. Of the fourteen studies selected, only nine studied the relationship between

Anorexia Nervosa and Low Infant Birthweight 5
anorexia and infant birth weight without including other eating disorders. All studies showed a
positive relationship between maternal anorexia and low birth weight. After analyzing the data in
each study, only nine were included in the meta-analysis because they were the only studies that
compared exposed groups with active AN to truly unexposed groups (Solmi, et al. 2014).
Systematic reviews of literature like this one with large population-based samples help to
increase our knowledge of the associations between maternal anorexia and low birth weight.
Knowledge of eating disorders and their affect on pregnancy has enhanced within the past ten
years. This review includes the first meta-analysis conducted on this field of study between
anorexia and its harmful affects on pregnancy. Because of this, it can be of helpful use for future
studies on this topic. Each study that was reviewed proved the hypothesis that the risk of
delivering babies of low birth weight is more prevalent in mothers with AN. This review is
successful because the studies were performed on community-based samples, and this reduces
bias. In addition it could be a great source to help educate the community of the adverse
pregnancy complications associated with maternal anorexia and to help prevent AN mothers with
low BMI from having low birth weight babies. The findings suggest that low BMI in women
with past or active anorexia is a risk factor for low infant birth weights, which supports the claim
that maternal AN is associated with low infant birth weight (Solmi, et al. 2014).
Self-imposed restrictive diets in women with AN result in poor nutritional status which is
another risk factor for low infant birthweight. Anorexic women tend to starve themselves due to
their weight obsession, and this can lead to nutritional deficiencies. Having low nutritional stores
during pregnancy can potentially harm the fetus because fetal development depends on the
nutritional intake of the mother. Anorexia’s course of illness and complications with pregnancy
are described in a review titled “Anorexia Nervosa: Definition, Epidemiology, and Cycle of

Anorexia Nervosa and Low Infant Birthweight 6
Risk” published in the International Journal of Eating Disorders in 2005. The published paper
reviews multiple studies that focus on the patterns, causes, and effects of AN. It also highlights
the adverse obstetric outcomes associated with AN. The reviewed studies indicate the prevalence
of low BMI among anorexic women and their tendency for being nutritionally deficient. The
researchers predicted low BMI was caused by the mother’s food restriction, obsessive weight
control, and the psychiatric maintenance of their “comfort zone” with body weight. Low BMI
makes them more susceptible to having nutritional deficiencies that lead to low birthweight
babies. Anorexic women with low BMI may have decreased plasma volume that in turn reduces
the transfer of nutrients from mother to fetus. Deficiencies found from these studies include
vitamin C, vitamin A and folate. Proper weight gain before pregnancy is vital in order to
increase pre-pregnancy BMI and nutritional stores for the baby to receive enough nutrients for
healthy development and proper weight gain (Bulik, et al. 2005).
Low pre-pregnancy BMI and nutrient deficiencies in pregnant women with AN are
strongly associated with the birth of underweight babies. Although it is common for women with
anorexia to have lower chances in getting pregnant, it is still possible and the consequences can
be life threatening. If the mother does not try to gain a healthy amount of weight and ensure
adequate nutritional intake, the risk for having a low birthweight baby increases. Babies of low
birthweight have an increased risk for developing AN or another chronic disease later on in life
and an increased mortality rate during their first year of life. Because AN is also a psychological
disorder, psychological treatment is just as important as physical treatment. Counseling may be
necessary in order to produce a healthier state of mind. It is important for anorexic women to
improve the health of both their mind and body before they get pregnant. Once this has been
accomplished, they can then be ready to invest time caring for both themselves and their baby.

Anorexia Nervosa and Low Infant Birthweight 7
Bulik, C., Reba, L., Siega-Riz, A., Kjennerud, T. (2005). Anorexia Nervosa: Definition,
Epidemiology, and Cycle of Risk. International Journal of Eating Disorders, 37: S2-S9.
doi: 10.1002/eat.20107
Linna M., Raevuori, A., Haukka, J., Suvisaari, J., Suokas, J., & Gissler, M. (2014). Pregnancy,
Obstetric, and Perinatal Health Outcomes in Eating Disorders. American Journal of
Obstetrics and Gynecology, 211: 392.e1-392.e8. doi: 10.1016/j.ajog.2014.03.067
Micali, N., Simonoff, E., & Treasure, J. (2007). Risk of major adverse perinatal outcomes in
women with eating disorders. British Journal of Psychiatry, 190: 255-259. doi:
Solmi, F., Hannah, S., Stahl, D., Treasure, J., & Micali, N. (2014). Low Birth Weight in the
Offspring of Women With Anorexia Nervosa. Epidemiologic Reviews, 36: 49-56. doi: