When you’re consumed by an eating disorder, gaining weight can feel extremely scary and like the worst possible outcome. However, it’s often a non-negotiable aspect of healing your body and mind and is a necessary step on the way to living in full recovery.

Pregnancy is another scenario in which weight gain is essential, and this can be challenging for anyone living in a world where weight gain is considered inherently negative. For those in eating disorder recovery, however, this weight gain can be especially fraught. As an expecting mother living in recovery and an eating disorder dietitian, today I’ll share some truths about pregnancy weight gain in recovery, how weight stigma can impact your experience, and ways to deal with gaining weight during such a pivotal time in your life.

Pregnancy weight gain in eating disorder recovery

First, it’s important to note that having an active eating disorder has adverse consequences on pregnancy. A review of research from 2020 shows that having an active eating disorder while pregnant is related to anxiety and depression, as well as negative outcomes for mom and baby, including miscarriages and premature births. Another review from 2021 shows eating disorder symptoms during pregnancy can make both pregnancy and delivery more complicated. Eating disorders in pregnancy can also lead to breastfeeding issues, dehydration, and cardiac abnormalities.

Additionally, a 2023 study showed that pregnant mothers who were underweight before conception were at higher risk of delivering low-weight babies compared to those who were not underweight. “If a patient needs weight restoration prior to pregnancy, it’s recommended that they gain weight before getting pregnant,” says registered dietitian Melissa Bloom.

But regardless of whether weight gain is needed before pregnancy, it’s almost always essential during pregnancy, and this can be very difficult for people affected by eating disorders—even those in recovery. According to Equip lead dietitian Dani Castellano, RD, CEDS, there are several reasons why this can be so tough, including:

• body image distress that may come from weight gain
• increased energy needs
• nausea or vomiting that could be triggering for someone who has struggled with purging behaviors
• societal pressure to “bounce back” to a pre-pregnancy body after giving birth or to lose the weight via breastfeeding
• the way pregnant bodies are represented in media as thin bodies with perfectly round bumps
• the extra focus and commentary made about pregnant bodies

However, adequate weight gain is critical for the health of you and your baby. In a 2023 study, mothers who didn’t gain enough weight were more likely to birth low-weight babies compared to those who gained adequate weight. “Women who receive inadequate nutrition and gain inadequate weight give birth to low-weight infants, which is a risk factor for morbidity and mortality,” explains dietitian Amy Goldsmith RDN, LDN, who adds that pregnancy weight gain is essential for proper physical and emotional growth. “Infants of low birth weight have a hard time fighting infection, regulating body temperature, and have difficulty eating and potential damage to organs.”

Despite our diet culture’s toxic messaging that pregnant women shouldn’t gain “too much weight,” research indeed shows that not gaining enough is in fact the riskier outcome. In author Emily Oster’s science-based book Expecting Better, she cites four different studies highlighting the adverse side-effects of low-birth-weight babies, which include higher mortality rates, serious lung complications, higher diabetes risk, and lower cognitive skills.

Weight stigma and pregnancy weight gain

Weight stigma—or the bias against people because of body size—unfortunately infiltrates every corner of healthcare, including (and perhaps especially) prenatal care. Castellano says two clear ways it shows up are:

1) Being asked to gain less weight if you’re in a larger body

2) Waiting room chairs, medical equipment, and maternity and nursing products that aren’t size-inclusive

People in larger bodies are undoubtedly impacted the most by weight stigma, especially because standard pregnancy weight gain guidelines are unfortunately based on BMI. This is problematic because BMI is an unreliable measurement of health that was developed 200 years ago by a Belgian mathematician to quickly measure “obesity” (not overall health) in a mostly white and male population. If you live in a larger body and aren’t working with weight-inclusive providers, you’ll likely need to take extra steps to create healthy and safe boundaries that ensure you get the care you need and deserve throughout your pregnancy, and to protect your recovery.

Though weight stigma can be most damaging to pregnant women in larger bodies, those of all body sizes can be negatively impacted by fear-mongering messages about weight in pregnancy. In my experience, nearly every prenatal resource I read encourages gaining enough weight, but often comes with a caveat, like, “but don’t gain too much weight.” In fact, a 2020 study of pregnant and postpartum women showed nearly one in five felt judged, shamed, or guilty because of their weight in healthcare settings. Regardless of your body size, know that your body will gain adequate weight for your pregnancy when you regularly engage in health-promoting practices that feel realistic for you (many of which are likely a part of your recovery), like eating regular meals and snacks, eating a relative balance of nutrients, doing your best with sleep, and going to your prenatal visits.

How to cope with pregnancy weight gain while in recovery

Here are several strategies to help you navigate gaining weight in your pregnancy while keeping your recovery intact:

Set boundaries with your providers.

At my first prenatal visit with my midwife, I told her about my eating disorder history and explained that I would prefer blind weights (i.e., not seeing my weight on the scale) throughout my pregnancy, and only discussing my weight if I’m not gaining enough to support a healthy pregnancy. Now, toward the end of my pregnancy, I’ve obviously and thankfully gained weight, and we haven’t talked about it since our initial discussion. Personally, not concerning myself with a number that once controlled my life and that I feel is unimportant for me to know—even during pregnancy—feels mentally and emotionally supportive. Although I’m not entirely sure how I would respond to regular open weights for nine months, I’d prefer to protect myself from the potential of feeling more anxiety than I already do growing a human.

Of course, my approach is only one route you can take in your pregnancy. Consider what approach to weighing (blind, open, or less often) feels safest and most supportive of your recovery and go from there. “Have an upfront conversation with your provider about how weight gain will be monitored so you know what to expect and can advocate for your needs at whatever level feels comfortable for you,” Castellano advises.

Stay connected to (or reconnect with) your team.

If you’re still working with an eating disorder treatment team, continue accepting their support and leaning on them when body changes feel difficult. If it’s been a while since you were in treatment, now is a good time to check back in with your therapist or dietitian (or both) for extra support during a vulnerable time. Your therapist can help you navigate hard emotions around weight gain, and your dietitian can help you stay on track nutritionally and eat to support adequate weight gain and optimal health for you and baby.

If you’re years into recovery and feeling confident in your ability to handle weight gain, it’s a good idea to at least have an eating disorder provider in your back pocket in case the road gets rocky. “Accept that weight gain may trigger past thoughts and feelings that could affect nutrition intake, and be open to start working with a provider who understands both pregnancy needs and eating disorders,” Goldsmith suggests. “This provider can help with education as well as set challenges and hold you accountable as you move through the pregnancy.”

Decode negative body thoughts.

Sometimes, negative body thoughts aren’t about your body at all. In my practice, my clients often have worsening body image when they’re feeling harder emotions or going through significant life changes. When they realize their bodies have become the scapegoat for all their difficult emotions, they’re able to be kinder towards their bodies and deal directly with how they’re feeling. Pregnancy can feel overwhelming and bring a myriad of emotions—both pleasant and unpleasant. So, check in with yourself when negative body thoughts increase and see if there’s a deeper layer of emotion that needs to be addressed. From there, identify what you need emotionally and circle back to coping skills that have helped you endure hard feelings and transitions in your past. One of my go-to coping skills is self-compassion, which includes mindfulness, common humanity, and self-kindness.

Use body image tools.

To help befriend or at least be neutral towards your body during pregnancy, try reframing negative thoughts about weight gain. “When you have a negative thought about your body, practice shifting the focus to the positives of your body being able to carry a baby and how weight gain supports this process,” Castellano suggests. If positivity feels hard to access, work towards viewing your body and your growing belly as neutrally as possible, starting by writing down each body part and how it functions daily. Revisit your list whenever you start to notice thoughts going south. If it feels right, you may eventually start to extend gratitude (mentally or in writing) towards your body and all that it’s doing to support you and your baby. Additionally, consider unfollowing any social media accounts that worsen your body image and following ones that foster a healthy one during pregnancy, including @plussizebirth, @jessiemundell, and @fertility.prenatal.dietitian. You might also want to consider taking Equip’s free, self-paced body image program, Explore: Freeform.

Define and get rooted in your values.

Crystalize your core values for this pregnancy and think about how gaining weight helps you align with them. For example, one of my values is safety for me and my baby, and adequate weight gain is a key factor in cultivating such safety. Another one is holistic health, which includes staying the course of my eating disorder recovery—which, in turn, involves eating intuitively during and after pregnancy and trusting that my body knows what to do, especially with my weight.

So, try writing out your highest values for this time in your life and be sure to include how weight gain will help support them. When the going gets tough, validate your feelings first and apply self-compassion (it’s okay to feel uncomfortable with a drastically changing body, and many women do). Then, revisit your values and remember: growing and birthing a healthy human always requires sufficient weight gain.