Perinatal Disordered Eating and Body Image Distress
Written by guest writer Emily Van Eck, MS, RDN
Pregnancy and postpartum are extraordinary times, but can also present a plethora of physical and emotional challenges. For someone with a history of disordered eating or an eating disorder, body size changes, identity shifts and general digestive discomfort can all feel overwhelming, intensified, and generally scary.
This article is a guide for anyone pregnant or postpartum, or considering pregnancy, who has a history - now or in the past - of any of these things.
Eating Disorders During Pregnancy
To start with, please note that anyone with an eating disorder history at any time in their life is at risk of heightened, reignited, or novel eating disorder thoughts and behaviors during pregnancy and postpartum, especially if they have never received support or treatment.
Take yourself seriously and be careful not to fall into the trap of believing you’re “not sick enough” for support, no matter your body size. During pregnancy, eating disorder behaviors can be exacerbated, can shift, or can go temporarily dormant.
Binge Eating Disorder (BED)
Pregnancy is a particularly vulnerable time for women with binge eating disorder (BED) or who are at risk of BED. Bulimia nervosa can shift into binge eating disorder during pregnancy, where you stop purging but continue binge eating.
Anxiety and depression, low self-esteem, low life satisfaction, poor social support, and traumatic life events including sexual abuse are some of the factors strongly associated with BED being triggered during pregnancy or at any time.
Women with BED are more likely to have large babies, especially if they have a lot of body image distress and feel very worried about weight gain during pregnancy. I’ll talk more about what to do about this below.
Anorexia Nervosa & Bulimia Nervosa
Women who have anorexia, are severely restricting their intake, or with bulimia during pregnancy may not get the nutrients they need and are at higher risk of preterm birth, miscarriage, and have higher rates of cesarean.
Because pregnancy is one of the only times when weight gain and extra eating are “acceptable” in our restraint-obsessed culture, many women experience a reprieve from eating disorder behaviors like food restriction, body image distress, purging, and anxiety about food and their bodies. This is especially common with anorexia and bulimia.
This makes sense to me! What a relief. I’m finally allowed to eat what I want - it’s good for my baby. I can let myself gain weight.
Unfortunately, though, these same women often experience an upswing or worsening of their eating disorder postpartum, so by no means is this reprieve a sign that things are “ok”.
OSFED, ARFID, and other Eating Disorders
Other specified feeding or eating disorder (OSFED), is a diagnosis given to someone with significant disordered eating and/or body image distress, who just happens to not fit neatly into one of the other eating disorder diagnoses.
ARFID, avoidant restrictive food intake disorder, is often described as “extreme picky eating” but can also look like disinterest in eating. Foods can be very fearful, not because of body image fears, but because of a fear of choking texture, or other physical aspects of the food.
The Impact of Societal Pressures On Eating Disorders During Pregnancy
The relentless scrutiny of women's bodies and our cultural obsession with thinness is certainly to blame for eating disorder exacerbation during pregnancy and postpartum. Even if someone has recovered from an eating disorder, the pressure to “be good at pregnancy” can reignite old thought patterns.
Groups who are at risk of an eating disorder during pregnancy are those with:
Years of chronic dieting and/or restrictive eating
Severe body image stress
Anxiety & depression
Obsessive-compulsive disorder
History of addiction
Fertility and/or period issues
Unplanned pregnancy
Shame Fuels Lack of Disclosure
Even though eating disorders and body dissatisfaction are pervasive, these are still very taboo topics to discuss. If you’re afraid to gain weight, you could blame yourself for this.
I’m supposed to feel euphoric about gaining weight! What’s wrong with me?!
And this is understandable.
Purging, restricting, binging, being terrified to gain weight, obsessing about the minutiae of your diet - can be difficult and shameful to report. This is the case even if you aren’t pregnant - part of the reason why so many people with eating disorders are never diagnosed.
Many fear judgment or misunderstandings from healthcare providers, especially during pregnancy. This stigma contributes to underdiagnosis and inadequate treatment. But trust me - if your provider does not listen to you - it is their fault. Find a new doctor.
Body Image Issues are Normalized
It’s no secret that more than 70% of women are unhappy with their bodies, and 60% are actively trying to shrink them. If you reveal to your doctor that you have body image issues, they may not think anything of it! That’s so normal! ME TOO, honey. What’s new?
This is a serious problem.
If your thoughts about your body are distressing enough for you to reveal them to a doctor, you need to be taken seriously. The amount of shame and discomfort that so many people have about their bodies is usually just kept quiet, not discussed. And shame thrives in isolation.
Find someone that you can talk to first, a friend or partner. They can help you figure out what to say. There are many amazing eating disorder professionals in Austin and beyond who would love to support you.
Screening & Advocacy
Even though about the same percentage of women meet the criteria for an eating disorder during pregnancy (7%) as will be diagnosed with gestational diabetes (9%), screening rates are wildly different.
100% of women are screened for gestational diabetes and those diagnosed will be offered comprehensive care for their condition. On the other hand, only a tiny fraction (7%!!) of women who are experiencing an eating disorder during pregnancy are screened or asked about their disordered eating by their doctors. That means 93% of women who do have disordered eating are not even asked about it. Not okay!
Racial & Gender Disparities
While the eating disorder stereotype remains a thin, white, affluent, cis-gender female, the research strongly points to a much more diverse picture.
Black women are at higher risk of eating disorders, especially BED, compared with their white counterparts, but experience different triggers such as systemic stress, oppression, and trauma. Black women are also much less likely to access treatment - 8% vs 20% for white women.
Food insecurity is a major risk factor for eating disorders, especially bulimia and BED. Luckily, pregnancy is the one time a woman is most likely to receive healthcare visits, so ideally practitioners are trained and screening folks at clinics.
Trans and gender-diverse people have a higher risk of eating disorders than cis-gender people, likely due to added body dysphoria, and mental health challenges that gender diversity can trigger. If pregnancy occurs, body changes can be extremely complex.
Managing an Eating Disorder During Pregnancy
Pregnancy and postpartum are ideally times when gaining weight and eating more doesn’t feel too challenging. But for those with food & body image anxiety, this is not often the case and the expectation fuels fears and shame.
Weight Gain Confusion & Anti-Fat Bias
Let’s be clear: there is no one “right” way to gain weight during pregnancy. Often women who have reached the recommended amount of weight gain during pregnancy are told to stop gaining weight. This is especially true for women who have higher BMI to begin with.
This is not good advice. What are you supposed to do at the end of a pregnancy, with a baby growing so fast? Stop eating? Definitely not.
Even though some studies have indeed shown that higher weight gain during pregnancy is correlated with more cesarean births and other negative outcomes, dieting or reducing your calories to stay within these margins is a dangerous idea. Overly worrying about weight gain during pregnancy is associated with weight problems with the baby, regardless of the mom’s weight!
Weight gain recommendations are based on the outdated BMI scale, are not an exact science, and are based on just a few studies. They should be interpreted loosely and be individualized.
Jen McCellen from Plus Size Birth suggests (and I agree), that what’s more important than the amount of weight you gain is that you’re eating what you need to support your growing baby, and your weight will do what it does.
In other words: there is a wide range of normal and the number on the scale is a poor marker of health. What’s important is that you’re eating well, consistently, enough, and are working on any disordered eating habits if they exist.
My best advice to anyone very concerned about weight gain in pregnancy: see a HAES-aligned dietitian. You do not want to go on a diet or reduce your intake to manipulate your weight during pregnancy, but you can take a look at your eating habits and make sure they are balanced and healthy for your body.
Nutrition Needs: Make Sure You’re Eating Enough
Nourishing your body adequately is essential for having a healthy pregnancy and delivering a healthy baby. For folks with an eating disorder history, even if you’re fully recovered, this can be extra challenging. You have to eat more than usual and gain weight. It’s hard!
Nutrition is critical during fetal development, particularly micronutrients like vitamins B-2, B-6, and B-12, choline, betaine, and omega-3 fatty acids. Not getting adequate nutrition can lead to neural tube defects, low birth weight, and other complications for mom and baby.
Do not restrict your food intake to gain as little weight as possible - that is not what you, your body, or your baby need. You need to eat when you’re hungry, even if that’s very often.
Chronic Dieting History
If you have lost and gained same 20, 30, or 50 pounds many times, or have tried all the diets - keto, paleo, low calorie, Noom, etc. you may be predisposed to develop disordered eating, binge eating, and “excess” weight gain during pregnancy.
Even though we still hear that weight loss will solve all your problems, it certainly will not. We know now that dieting does not work in the long run, and is more likely to cause weight regain or overshoot, worsened cardiovascular risk factors, binge eating, and increased body and food obsession and preoccupation.
But again, please don’t blame yourself for this. Our culture has created this dysfunction - not your lack of willpower.
Nausea and Appetite Confusion
Being pregnant, especially in the first trimester brings about nausea, loss of appetite, and maybe even vomiting, which are all common with eating disorders. Many symptoms of anorexia can look like pregnancy symptoms - fatigue, hypotension, and dehydration.
These symptoms can mask an eating disorder and confuse you or make you feel conflicted about how you should feel and what you should do. Make sure to report your symptoms to your doctor and be honest with yourself about how much you’re eating.
Gestational Diabetes Can Be Triggering
Women diagnosed with gestational diabetes are often told to be vigilant about their food and exercise habits. This can be extremely triggering for someone with an eating disorder history but is certainly not limited to those predisposed.
If you are experiencing lots of food and body anxiety with this diagnosis, take a deep breath. Remember that you don’t need to make dramatic changes to your diet, small tweaks are best. Your body is smart and it can guide you. And please, reach out to a dietitian to support you.
Postpartum Disordered Eating & Body Image
As I’ve mentioned, for some, pregnancy can be a reprieve from their eating disorder, but this reprieve doesn’t usually last long. During the postpartum period, most will experience an upswing of symptoms.
If you have a history of an eating disorder, it is smart to establish care with someone before or during your pregnancy, so you can have someone to call if troubling thoughts or behaviors pop up postpartum.
Unrealistic Body Expectations Postpartum
Many are overly preoccupied with losing weight quickly after childbirth and have unrealistic expectations for their bodies.
Once the baby is born, our society immediately expects you to lose weight and go back to your “pre-baby body”. That intense pressure can be overwhelming and is very unrealistic for many women.
If your eating disorder has lit up during pregnancy, once you have that baby, you could feel you don’t have a “reason” to have put on weight, so those disordered thoughts can come barrelling back in.
Remember, your body is not a machine. It takes many women much longer than a year, up to three years to recover from pregnancy. Our weight is not a math equation, so while some women will return to their weight, or near their weight before they had a baby, many will not. And that is okay.
Postpartum Depression & Anxiety
Women who have a current eating disorder or a history of an eating disorder are FOUR TIMES more likely to experience postpartum depression. That is a huge increase.
This study found that 40% of pregnant women with an eating disorder history experienced a major depressive episode during the year of childbirth. I’ll say it again, if you have an eating disorder history, report it to your care team.
Tips for Managing Eating Disorders During Pregnancy and Postpartum
Now that we’ve talked about all the things that cause eating disorders to flare up during pregnancy and what to be aware of in yourself, here are my tips for making sure you’re taking good care of yourself and your body.
Get a Care Team in Place
Eating disorders are not a matter of willpower or choice. They are mental health disorders that are displayed with food. There are deep issues that have triggered your eating disorder, and while this is often very emotionally taxing, you can recover.
Make sure you have people you can talk to and whom you feel safe talking to about your eating. It’s wise to have an eating disorder dietitian, doctor, and therapist on board who are supporting you during this time. If you are using other healthcare practitioners, it’s wise to choose HAES-aligned folks, and/or talk to them about your desire to not talk about food and your weight with them.
If accessing care is a challenge for you, as it is for so many, reach out to Project Heal.
Give Yourself Grace and Compassion
You are not a baby-making machine, but a real human who may be vulnerable to diet culture messages. Our society’s pressure on women to be perfect, thin, successful, and “good”, can be overwhelming.
Many people who develop eating disorders have experienced significant trauma. You deserve to get the care you need to recover and live a full, satisfying life. You deserve to enjoy eating and thrive.
Even if you are pregnant and restricting food, know that you deserve tons of love and self-compassion. You are doing your best, but perhaps now is a time you need help.
Eat Enough. If You’re Hungry, It’s for a Reason
You need a lot of nutrients (ie calories, carbs, fat, protein, etc) during pregnancy and postpartum. The “recommendation” that you don’t need extra calories during the first trimester and that you shouldn’t gain weight is wrong for many women. Many women are extremely hungry during this time. This is normal.
Morning sickness can last a while, and you may not be able to eat much during this time. Afterward, your body will be very eager for enough food and show you that with intense hunger. This is normal and a sign that your body is actually quite brilliant, trying to restore your nutrient stores and get enough nutrients to support your pregnancy.
Eat regularly. If big meals don’t sound good, and that would be normal, try and eat a little bit every few hours, even if you’re not hungry. It’s ok.
If you’re very concerned about eating enough or too much, reach out to a weight-neutral dietitian to help guide you.
Recognize That Body Image Issues May Come Up
If you have overcome disordered eating or are in recovery from an eating disorder, you are likely quite happy about your progress. And for good reason!
But becoming pregnant and gaining weight can trigger these distressing thoughts all over again, or at the very least cause you to have to accept your body over and over again as you gain weight throughout your pregnancy.
Keep in mind there is a wide range of “normal”.
Body image distress might not change as you become pregnant. This could still be very uncomfortable for you - and it’s ok. This does not mean you are a horrible person or are going to be a bad mother, just that you might need some support during your pregnancy.
Tune Out Weight and Calorie Numbers
Believe it or not, you don’t really need to know how many calories you’re eating, or how much you weigh. As long as you’re eating enough nourishing foods and watching your disordered eating, you’re probably doing okay.
That said, if you have struggled with anorexia, you might need to be on a meal plan to make sure you’re getting enough calories and nutrients. You might want to ditch the pregnancy apps if they give you too much information about food and your weight. Diet culture can easily be woven into these apps.
You can also speak up when it comes to being weighed. You can ask not to be weighed at every visit, or stand backward on the scale. I know this is challenging, but it is your right not to be weighed, so if you decide this is best for you, stand by it. You can tell them your dietitian said it was best. ;)
Check in about what information is helpful and what is too much for you. Eat Nourishing Foods, But Don’t Micromanage Your Diet
Despite what some pregnancy books might tell you, it’s okay not to eat “perfectly” during pregnancy. While I am all about good nutrition, optimizing your diet isn’t easy for everyone and can come with considerable stress.
The most important thing is that you’re eating ENOUGH - enough carbohydrates, enough protein, fat, B vitamins, and minerals. Keep taking your prenatal vitamins.
If you can tolerate it, eat fish with high omega-3 content like salmon and anchovies, nuts and seeds, whole grains, beans, and legumes, and get plenty of brightly colored fruits and vegetables. Eat protein with every meal, and remember that beans and whole grains have protein in them too! Oatmeal actually has 5g of protein per serving and is great for an upset belly.
Final Thoughts
The conversation about eating disorders is still very much in the shadows and not talked about openly enough. Women should not be as terrified of gaining weight as they are, but anti-fat bias and the way we police women's bodies keep us stuck in shame and perfectionism.
Doctors need to fit in routine screenings for eating disorders and find time to refer clients to mental health clinicians and dietitians when appropriate. If you’re struggling, reach out for support.
If you are a healthcare professional who sees women and is unsure how to talk about eating and body image, you can download this free guide - 7 Questions To Ask Clients About Food and Body Image.
Further reading:
Emily Van Eck, MS, RD is a registered dietitian who specializes in intuitive eating, eating disorders, body image, and women's reproductive health. She has a private practice based in Austin, Texas, and loves supporting women who are pregnant or trying to conceive.
When Emily is not eating, talking about food, or grocery shopping, you can find her at the honky tonk two-stepping, gardening, or cycling around Austin. You can learn more about her here - www.emilyvaneck.com