• I have an eating disorder, but I want to have a family someday. Will I be able to have babies?

Because dieting, excessive exercise, stress, and low weight negatively impact a woman's endocrine (hormone) system, you may have trouble conceiving a baby and carrying it to term. The closer to normal your weight is, and the healthier your diet, the better your chances of a successful pregnancy. If you are underweight or overweight, and if you do not eat a wide variety of healthy foods, you and your baby may have problems.

A recent study in Denmark suggests that even eight years after successful ED treatment, the chances of having a high-risk pregnancy are the same as those for women who receive treatment immediately before they conceive. (Secher, et al. American Journal of Obstetrics and Gynecology, January 2004). It appears that a history of disordered eating may predict reproductive trouble even years after treatment and progress in recovery. In the U.S., about 20 percent of women patients who ask for help at fertility clinics have had an eating disorder.

• If I do manage to get pregnant before I'm recovered, could I hurt my baby by being eating disordered?

You might. Women with eating disorders have higher rates of miscarriage than do healthy, normal women. Also, your baby might be born prematurely, meaning that it would not weigh as much, or be as well developed, as babies who are born full term. Low birth weight babies are at risk of many medical problems, some of them life threatening.

An article in the January 2002 New England Journal of Medicine reports that premature babies have neurological and developmental problems well into early adulthood, and possibly longer. Some of the problems include lower IQs, learning disabilities, and cerebral palsy. Additional problems include increased chances of infant death and failure to thrive in the first year following birth. Even if low birth weight babies seem to be healthy, they may not reach full expected adult stature, remaining small and short throughout their lives.

Babies born to women with active eating disorders seem to be at higher risk of birth defects than those born to asymptomatic mothers. In particular, major handicaps such as blindness and mental retardation are common in those who survive.

• I know this sounds selfish, but could I hurt myself by trying to have a baby before I am recovered?

You are wise to think ahead. If you become pregnant now, you could seriously deplete your own body. The baby will take nourishment from you, and if you don't replenish your own reserves, you could find yourself struggling with the depression and exhaustion associated with malnutrition. You would also have to deal with the physical and emotional demands of pregnancy. You might find yourself overwhelmed and feeling out of control.

In addition, according to an article in the September 2001 American Journal of Psychiatry, pregnant women with active eating disorders or a history of eating disorders are at increased risk of delivery by caesarean section and postpartum depression, which makes taking care of themselves and their infants difficult to impossible.

• Are there any specific medical problems I might have trouble with?

Your teeth and bones might become weak and fragile because the baby's need for calcium takes priority over yours. If you don't replenish calcium with dairy products and other sources, you could find yourself with stress fractures and broken bones in later years. Once calcium is gone from your bones, it is difficult, if not impossible, to replace it.

Pregnancy can exacerbate other problems related to the eating disorder such as potentially fatal liver, kidney and cardiac damage. A woman who is eating disordered, pregnant, and diabetic is at especially high risk for serious problems. All pregnant women should receive prenatal care. Those who have one or more of the above complicating factors should consult with a physician as soon as they think they might be pregnant. To increase their own, and the baby's, chances of life and health, they should follow recommendations scrupulously.

• That's pretty scary, but I'm more concerned about my baby than I am about myself. Assuming it was born healthy, would it be OK from then on?

Maybe. There is evidence suggesting that babies born to eating disordered mothers may be retarded or slow to develop. Physically they may be smaller, weaker, and slower growing than other children their age. Intellectually they may lag behind peers and classmates. Emotionally they may remain infantile and dependent. They also may not develop effective social skills and successful relationships with other people.

At this point no one knows how many of the child's developmental difficulties are due to the medical consequences of an eating disorder and how many are the result of being parented by someone who is emotionally troubled and overconcerned about food and weight.

• This is scary stuff. I wish I had never started this stupid eating disorder. I may as well have all the bad news. What else could go wrong if I try to have a baby?

You could become depressed and frantic because of weight gain during pregnancy. You might feel so out of control of your life and body that you would try to hurt yourself or the unborn baby. You might worry and feel guilty about the damage you could be causing the baby.

You might underfeed your child to make her thin, or, you might overfeed her to show the world that you are a nurturing parent. Power struggles over food and eating often plague families where someone has an eating disorder. You could continue that pattern with your child.

Research suggests that mom's dieting and low weight can create problems for the fetus, who may slow its metabolism to conserve energy. As with adults, this adjustment can lead to obesity, heart disease, and diabetes later in life. Mom's dieting can also shunt scarce nutrients to the fetal brain, short changing organs like the liver.

On the other hand, when a fetus is overnourished (mom eats too much and is overweight), it may be at risk for adult obesity and breast cancer. Elevated blood sugar can retard growth of the placenta as well. Our best advice: eat healthy, well balanced meals and maintain a healthy normal weight for several months before you conceive and throughout the duration of your pregnancy. For more guidelines, see "The Best Start in Life" by David Barker. It's available through amazon.com in the U.K.

• This gets worse and worse, but I have a lot of love in my heart. I think I would be a good mother. The eating disorder wouldn't be that important if I had a child.

Motherhood is stressful. If you are not strong in your recovery, you will be tempted to fall back on the starving and stuffing coping behaviors that are so familiar to you. Ideally, as you begin raising a family, you will already have learned, and will have had practice using, other more healthy and effective behaviors when you feel overwhelmed.

Also, eating disordered women make poor role models. Your influence could lead your daughters to their own eating disorders and your sons to believe that the most important thing about women is their weight.

• I really want a baby, and I think having one would give me the motivation I need to recover. I think I would enjoy being pregnant even though handling the weight gain would be scary. What can I do to give myself and my child the best possible chance of success?

Some women with eating disorders welcome pregnancy as a vacation from weight worries. They believe they are doing something important by having a baby and are able to set aside their fear of fat in service to the health of the child. Others fall into black depression and intolerable anxiety when their bellies begin to swell. Most fall somewhere between these two extremes.

If you think you are pregnant, or if you want to become pregnant, tell your physician as soon as possible. Cooperate with prenatal care to increase the chances that your baby will be born healthy. Also, this would be a good time to check with a counselor who can help you manage your doubts, fears, and worries as you proceed through pregnancy. A couple of classes on pregnancy, childbirth, and child development after birth can give you reassuring information about what to expect. You can learn parenting skills, but role modeling comes from your sense of yourself. Acquire the former and improve the latter. You have our best wishes.

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One last thought: We now have evidence that what, and how much, a mother eats during pregnancy can influence a child's physiology and metabolism after birth, perhaps setting the stage for metabolic and hormonal problems that can lead to medical and psychological problems in the child's later life. For example, undernourished pregnant moms often produce underweight, premature babies. Those infants experience a 35% higher rate of coronary death in later life and a sixfold increase in the risk of diabetes and impaired sugar metabolism than do children of mothers who received adequate nutrition while they were pregnant. Related problems include faulty insulin sensitivity, diabetes, high blood pressure, high triglyceride levels, and too little "good" cholesterol. Maternal malnutrition can also lead to impaired liver development in the child and problems with blood clotting that can lead to heart attack and stroke in adult life. (Reported by Jane Brody in the New York Times. October 1996)

Studies also indicate that undernourished moms give birth to children at increased risk of major affective disorders (depression, manic-depression; uni-polar, bi-polar disease) when they reach adolescence and adulthood. Apparently healthy fetal development of brain and nervous system requires specific nutrients, and enough of them, that may not be provided by weight loss or weight management diets.

New research indicates that pregnant women need extra energy intake (calories and nutrition) over and above their requirements when they are not pregnant. According to Nancy Butte, Ph.D., USDA Children's Nutrition Research Center, Baylor College of Medicine, "Extra dietary energy is required during pregnancy to make up for the energy deposited in maternal and fetal tissues and the rise in energy expenditure attributable to increased basal metabolism and to changes in the energy cost of physical activity." Women with eating disorders should consider this fact before they become pregnant and decide if they can handle the increased nutrition requirements of a healthy pregnancy. (Reported in the May 2004 issue of the American Journal of Clinical Nutrition)