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Prenatal and perinatal factors and risk of eating disorders

Published online by Cambridge University Press:  08 January 2020

Janne Tidselbak Larsen
National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
Cynthia M. Bulik
Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
Laura M. Thornton
Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Susanne Vinkel Koch
Mental Health Centre for Child and Adolescent Psychiatry, Copenhagen Region, Copenhagen, Denmark Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
Liselotte Petersen
National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
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Among the most disabling and fatal psychiatric illnesses, eating disorders (EDs) often manifest early in life, which encourages investigations into in utero and perinatal environmental risk factors. The objective of this study was to determine whether complications during pregnancy and birth and perinatal conditions are associated with later eating disorder risk in offspring and whether these associations are unique to EDs.


All individuals born in Denmark to Danish-born parents 1989–2010 were included in the study and followed from their 6th birthday until the end of 2016. Exposure to factors related to pregnancy, birth, and perinatal conditions was determined using national registers, as were hospital-based diagnoses of anorexia nervosa (AN), bulimia nervosa, and eating disorder not otherwise specified during follow-up. For comparison, diagnoses of depressive, anxiety, and obsessive-compulsive disorders were also included. Cox regression was used to compare hazards of psychiatric disorders in exposed and unexposed individuals.


1 167 043 individuals were included in the analysis. We found that similar to the comparison disorders, prematurity was associated with increased eating disorder risk. Conversely, patterns of increasing risks of EDs, especially in AN, with increasing parental ages differed from the more U-shaped patterns observed for depressive and anxiety disorders.


Our results suggest that pregnancy and early life are vulnerable developmental periods when exposures may influence offspring mental health, including eating disorder risk, later in life. The results suggest that some events pose more global transdiagnostic risk whereas other patterns, such as increasing parental ages, appear more specific to EDs.

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Ahrén, J. C., Chiesa, F., af Klinteberg, B., & Koupil, I. (2012). Psychosocial determinants and family background in anorexia nervosa – results from the Stockholm birth cohort study. International Journal of Eating Disorders, 45, 362369.CrossRefGoogle ScholarPubMed
Ahrén, J. C., Chiesa, F., Koupil, I., Magnusson, C., Dalman, C., & Goodman, A. (2013). We are family--parents, siblings, and eating disorders in a prospective total-population study of 250 000 Swedish males and females. International Journal of Eating Disorders, 46, 693700.CrossRefGoogle Scholar
Ahren-Moonga, J., Silverwood, R., Klinteberg, B. A., & Koupil, I. (2009). Association of higher parental and grandparental education and higher school grades with risk of hospitalization for eating disorders in females: The Uppsala birth cohort multigenerational study. American Journal of Epidemiology, 170, 566575.CrossRefGoogle ScholarPubMed
Anttila, V., Bulik-Sullivan, B., Finucane, H. K., Walters, R. K., Bras, J., Duncan, L., … Murray, R. (2018). Analysis of shared heritability in common disorders of the brain. Science, 360, eaap8757.Google ScholarPubMed
Arboleya, S., Sanchez, B., Solis, G., Fernandez, N., Suarez, M., Hernandez-Barranco, A. M., … Gueimonde, M. (2016). Impact of prematurity and perinatal antibiotics on the developing intestinal Microbiota: A functional inference study. International Journal of Molecular Sciences, 17, 649.CrossRefGoogle ScholarPubMed
Banks, W. A., Kastin, A. J., & Broadwell, R. D. (1995). Passage of cytokines across the blood-brain barrier. Neuroimmunomodulation, 2, 241248.CrossRefGoogle ScholarPubMed
Black, M. H., Sacks, D. A., Xiang, A. H., & Lawrence, J. M. (2013). The relative contribution of prepregnancy overweight and obesity, gestational weight gain, and IADPSG-defined gestational diabetes mellitus to fetal overgrowth. Diabetes Care, 36, 5662.CrossRefGoogle ScholarPubMed
Bliddal, M., Broe, A., Pottegard, A., Olsen, J., & Langhoff-Roos, J. (2018). The Danish medical birth register. European Journal of Epidemiology, 33, 2736.CrossRefGoogle ScholarPubMed
Bock, C., Bukh, J. D., Vinberg, M., Gether, U., & Kessing, L. V. (2009). Validity of the diagnosis of a single depressive episode in a case register. Clinical Practice and Epidemiology in Mental Health, 5, 4.CrossRefGoogle Scholar
Breithaupt, L., Köhler-Forsberg, O., Larsen, J. T., Benros, M. E., Thornton, L. M., Bulik, C. M., & Petersen, L. (2019). Association of exposure to infections in childhood with risk of eating disorders in adolescent girls. JAMA Psychiatry, 76, 800809.CrossRefGoogle Scholar
Bulik, C. M., Sullivan, P. F., & Kendler, K. S. (1998). Heritability of binge-eating and broadly defined bulimia nervosa. Biological Psychiatry, 44, 12101218.CrossRefGoogle ScholarPubMed
Bulik, C. M., Sullivan, P. F., Tozzi, F., Furberg, H., Lichtenstein, P., & Pedersen, N. L. (2006). Prevalence, heritability, and prospective risk factors for anorexia nervosa. Archives of General Psychiatry, 63, 305312.CrossRefGoogle ScholarPubMed
Bulik, C. M., Thornton, L. M., Root, T. L., Pisetsky, E. M., Lichtenstein, P., & Pedersen, N. L. (2010). Understanding the relation between anorexia nervosa and bulimia nervosa in a Swedish national twin sample. Biological Psychiatry, 67, 7177.CrossRefGoogle Scholar
Byrne, M., Agerbo, E., Bennedsen, B., Eaton, W. W., & Mortensen, P. B. (2007). Obstetric conditions and risk of first admission with schizophrenia: A Danish national register based study. Schizophrenia Research, 97, 5159.CrossRefGoogle ScholarPubMed
Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders: A meta-review. World Psychiatry, 13, 153160.CrossRefGoogle ScholarPubMed
Dellava, J. E., Thornton, L. M., Lichtenstein, P., Pedersen, N. L., & Bulik, C. M. (2011). Impact of broadening definitions of anorexia nervosa on sample characteristics. Journal of Psychiatric Research, 45, 691698.CrossRefGoogle ScholarPubMed
Deverman, B. E., & Patterson, P. H. (2009). Cytokines and CNS development. Neuron, 64, 6178.CrossRefGoogle ScholarPubMed
de Wolff, M. G., Backhausen, M. G., Iversen, M. L., Bendix, J. M., Rom, A. L., & Hegaard, H. K. (2019). Prevalence and predictors of maternal smoking prior to and during pregnancy in a regional Danish population: A cross-sectional study. Reproductive Health, 16, 82.CrossRefGoogle Scholar
Duncan, L., Yilmaz, Z., Gaspar, H., Walters, R., Goldstein, J., Anttila, V., … Bulik, C. M. (2017). Significant locus and metabolic genetic correlations revealed in genome-wide association study of anorexia nervosa. American Journal of Psychiatry, 174, 850858.CrossRefGoogle ScholarPubMed
Eaton, W. W., Mortensen, P. B., Thomsen, P. H., & Frydenberg, M. (2001). Obstetric complications and risk for severe psychopathology in childhood. Journal of Autism and Developmental Disorders, 31, 279285.CrossRefGoogle Scholar
Favaro, A., Tenconi, E., Ceschin, L., Zanetti, T., Bosello, R., & Santonastaso, P. (2011). In utero exposure to virus infections and the risk of developing anorexia nervosa. Psychological Medicine, 41, 21932199.CrossRefGoogle ScholarPubMed
Frans, E. M., Sandin, S., Reichenberg, A., Langstrom, N., Lichtenstein, P., McGrath, J. J., & Hultman, C. M. (2013). Autism risk across generations: A population-based study of advancing grandpaternal and paternal age. JAMA Psychiatry, 70, 516521.CrossRefGoogle ScholarPubMed
Goodman, A., Heshmati, A., & Koupil, I. (2014a). Family history of education predicts eating disorders across multiple generations among 2 million Swedish males and females. PloS One, 9, e106475.CrossRefGoogle Scholar
Goodman, A., Heshmati, A., Malki, N., & Koupil, I. (2014b). Associations between birth characteristics and eating disorders across the life course: Findings from 2 million males and females born in Sweden, 1975–1998. American Journal of Epidemiology, 179, 852863.CrossRefGoogle Scholar
Grimm, P. (2010). Social desirability bias. In Sheth, J. N. and Malhotra, N. (Eds.), Wiley international encyclopedia of marketing (Vol. 2). USA: John Wiley & Sons, Ltd.Google Scholar
Henderickx, J. G. E., Zwittink, R. D., van Lingen, R. A., Knol, J., & Belzer, C. (2019). The preterm gut microbiota: An inconspicuous challenge in nutritional neonatal care. Frontiers in cellular and infection microbiology, 9, 85.CrossRefGoogle ScholarPubMed
Hvelplund, C., Hansen, B. M., Koch, S. V., Andersson, M., & Skovgaard, A. M. (2016). Perinatal risk factors for feeding and eating disorders in children aged 0 to 3 years. Pediatrics, 137, e20152575.CrossRefGoogle ScholarPubMed
Jakobsen, K. D., Frederiksen, J. N., Hansen, T., Jansson, L. B., Parnas, J., & Werge, T. (2005). Reliability of clinical ICD-10 schizophrenia diagnoses. Nordic Journal of Psychiatry, 59, 209212.CrossRefGoogle ScholarPubMed
Javaras, K. N., Rickert, M. E., Thornton, L. M., Peat, C. M., Baker, J. H., Birgegard, A., … D'Onofrio, B. M. (2017). Paternal age at childbirth and eating disorders in offspring. Psychological Medicine, 47, 576584.CrossRefGoogle ScholarPubMed
Kipman, A., Gorwood, P., Mouren-Simeoni, M. C., & Ades, J. (1999). Genetic factors in anorexia nervosa. European Psychiatry, 14, 189198.CrossRefGoogle ScholarPubMed
Klump, K. L., Miller, K. B., Keel, P. K., McGue, M., & Iacono, W. G. (2001). Genetic and environmental influences on anorexia nervosa syndromes in a population-based twin sample. Psychological Medicine, 31, 737740.CrossRefGoogle Scholar
Köhler-Forsberg, O., Petersen, L., Gasse, C., Mortensen, P. B., Dalsgaard, S., Yolken, R. H., … Benros, M. E. (2018). A nationwide study in Denmark of the association between treated infections and the subsequent risk of treated mental disorders in children and adolescents. JAMA Psychiatry, 76, 271279.CrossRefGoogle Scholar
Kortegaard, L. S., Hoerder, K., Joergensen, J., Gillberg, C., & Kyvik, K. O. (2001). A preliminary population-based twin study of self-reported eating disorder. Psychological Medicine, 31, 361365.CrossRefGoogle ScholarPubMed
Krug, I., Taborelli, E., Sallis, H., Treasure, J., & Micali, N. (2013). A systematic review of obstetric complications as risk factors for eating disorder and a meta-analysis of delivery method and prematurity. Physiology & Behavior, 109, 5162.CrossRefGoogle Scholar
Lauritsen, M. B., Jorgensen, M., Madsen, K. M., Lemcke, S., Toft, S., Grove, J., … Thorsen, P. (2010). Validity of childhood autism in the Danish Psychiatric Central Register: Findings from a cohort sample born 1990–1999. Journal of Autism and Developmental Disorders, 40, 139148.CrossRefGoogle ScholarPubMed
Lupattelli, A., Spigset, O., Torgersen, L., Zerwas, S., Hatle, M., Reichborn-Kjennerud, T., … Nordeng, H. (2015). Medication Use before, during, and after pregnancy among women with eating disorders: A study from the Norwegian Mother and Child Cohort Study. PloS One, 10, e0133045.CrossRefGoogle ScholarPubMed
Lynge, E., Sandegaard, J. L., & Rebolj, M. (2011). The Danish national patient register. Scandinavian Journal of Public Health, 39, 3033.CrossRefGoogle ScholarPubMed
Malaspina, D., Harlap, S., Fennig, S., Heiman, D., Nahon, D., Feldman, D., & Susser, E. S. (2001). Advancing paternal age and the risk of schizophrenia. Archives of General Psychiatry, 58, 361367.CrossRefGoogle ScholarPubMed
Marsal, K., Persson, P. H., Larsen, T., Lilja, H., Selbing, A., & Sultan, B. (1996). Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatrica, 85, 843848.CrossRefGoogle ScholarPubMed
McGrath, J. J., Petersen, L., Agerbo, E., Mors, O., Mortensen, P. B., & Pedersen, C. B. (2014). A comprehensive assessment of parental age and psychiatric disorders. JAMA Psychiatry, 71, 301309.CrossRefGoogle ScholarPubMed
Monfils Gustafsson, W., Josefsson, A., Ekholm Selling, K., & Sydsjö, G. (2009). Preterm birth or foetal growth impairment and psychiatric hospitalization in adolescence and early adulthood in a Swedish population-based birth cohort. Acta Psychiatrica Scandinavica, 119, 5461.CrossRefGoogle ScholarPubMed
Mors, O., Perto, G. P., & Mortensen, P. B. (2011). The Danish psychiatric central research register. Scandinavian Journal of Public Health, 39, 5457.CrossRefGoogle ScholarPubMed
Nicholls, D., Statham, R., Costa, S., Micali, N., & Viner, R. M. (2016). Childhood risk factors for lifetime bulimic or compulsive eating by age 30 years in a British national birth cohort. Appetite, 105, 266273.CrossRefGoogle ScholarPubMed
Nosarti, C., Reichenberg, A., Murray, R. M., Cnattingius, S., Lambe, M. P., Yin, L., … Hultman, C. M. (2012). Preterm birth and psychiatric disorders in young adult life. Archives of General Psychiatry, 69, E1E8.CrossRefGoogle ScholarPubMed
O'Reilly, J. R., & Reynolds, R. M. (2013). The risk of maternal obesity to the long-term health of the offspring. Clinical Endocrinology, 78, 916.CrossRefGoogle ScholarPubMed
Packness, A., Halling, A., Simonsen, E., Waldorff, F. B., & Hastrup, L. H. (2019). Are perceived barriers to accessing mental healthcare associated with socioeconomic position among individuals with symptoms of depression? Questionnaire-results from the Lolland-Falster Health Study, a rural Danish population study. BMJ Open, 9, e023844.CrossRefGoogle ScholarPubMed
Packness, A., Waldorff, F. B., Christensen, R. D., Hastrup, L. H., Simonsen, E., Vestergaard, M., & Halling, A. (2017). Impact of socioeconomic position and distance on mental health care utilization: A nationwide Danish follow-up study. Social Psychiatry and Psychiatric Epidemiology, 52, 14051413.CrossRefGoogle ScholarPubMed
Pedersen, C. B. (2011). The danish civil registration system. Scandinavian Journal of Public Health, 39, 2225.CrossRefGoogle ScholarPubMed
Phung, T. K., Andersen, B. B., Hogh, P., Kessing, L. V., Mortensen, P. B., & Waldemar, G. (2007). Validity of dementia diagnoses in the Danish hospital registers. Dementia and Geriatric Cognitive Disorders, 24, 220228.CrossRefGoogle ScholarPubMed
Raevuori, A., Linna, M. S., & Keski-Rahkonen, A. (2014). Prenatal and perinatal factors in eating disorders: A descriptive review. International Journal of Eating Disorders, 47, 676685.CrossRefGoogle ScholarPubMed
Romero, R., Espinoza, J., Chaiworapongsa, T., & Kalache, K. (2002). Infection and prematurity and the role of preventive strategies. Seminars in Neonatology, 7, 259274.CrossRefGoogle ScholarPubMed
Saigal, S., & Doyle, L. W. (2008). An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet, 371, 261269.CrossRefGoogle Scholar
StataCorp (2017). Stata statistical software: Release 15. College Station, TX: StataCorp LLC.Google Scholar
Trace, S. E., Thornton, L. M., Baker, J. H., Root, T. L., Janson, L. E., Lichtenstein, P., … Bulik, C. M. (2013). A behavioral-genetic investigation of bulimia nervosa and its relationship with alcohol use disorder. Psychiatry Research, 208, 232237.CrossRefGoogle ScholarPubMed
Verma, I., Avasthi, K., & Berry, V. (2014). Urogenital infections as a risk factor for preterm labor: A hospital-based case-control study. Journal of Obstetrics and Gynaecology of India, 64, 274278.CrossRefGoogle ScholarPubMed
Wade, T. D., Bulik, C. M., Neale, M., & Kendler, K. S. (2000). Anorexia nervosa and major depression: Shared genetic and environmental risk factors. American Journal of Psychiatry, 157, 469471.CrossRefGoogle ScholarPubMed
Watson, H. J., Yilmaz, Z., Thornton, L. M., Hubel, C., Coleman, J. R. I., Gaspar, H. A., … Bulik, C. M. (2019). Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nature Genetics, 51, 12071214.CrossRefGoogle ScholarPubMed
Yilmaz, Z., Gottfredson, N. C., Zerwas, S. C., Bulik, C. M., & Micali, N. (2019). Developmental premorbid body mass index trajectories of adolescents with eating disorders in a longitudinal population cohort. Journal of the American Academy of Child and Adolescent Psychiatry, 58, 191199.CrossRefGoogle Scholar
Yilmaz, Z., Halvorsen, M., Bryois, J., Yu, D., Thornton, L. M., Zerwas, S., … Crowley, J. J. (2018). Examination of the shared genetic basis of anorexia nervosa and obsessive-compulsive disorder. Molecular Psychiatry. [Epub ahead of print].CrossRefGoogle ScholarPubMed
Zerwas, S., Larsen, J. T., Petersen, L., Thornton, L. M., Mortensen, P. B., & Bulik, C. M. (2015). The incidence of eating disorders in a Danish register study: Associations with suicide risk and mortality. Journal of Psychiatric Research, 65, 1622.CrossRefGoogle Scholar

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