I read the books, I listened to the podcasts, I even attended a series of classes specifically designed for first-time parents. While all of that helped me wrap my head around first trimester nausea, nursery must-haves, and what to expect as someone who is expecting, none of it prepared me for the challenges of navigating pregnancy with an eating disorder history.

I’ve written extensively about my fertility and eating disorder journeys, but one thing I haven’t explored in writing is the absolute make-or-break impact a healthcare provider can have in supporting eating disorder patients through pregnancy. While I was lucky to have a firm grip on recovery prior to becoming pregnant, I was highly aware of the potential eating disorder triggers that come with pregnancy—and the words and actions of every provider I saw left a meaningful mark on my experience.

From discussions of “normal” weight gain to recommendations around food and exercise, healthcare providers have innumerable opportunities to impact how pregnant people feel about their growing bodies. And for those in recovery (or actively dealing with an eating disorder), they play a pivotal role in helping protect both mother and baby from disordered habits. Here’s what every healthcare provider should know about supporting their pregnant patients with an eating disorder history.

Why all providers should have an education in eating disorders

While it may seem like all medical professionals would be well-versed in illnesses that are as common as eating disorders—which affect about 9% of the U.S. population, or 28.8 million Americans in their lifetime—that’s not actually the case. “Eating disorders are often not covered in-depth during medical school or OB/GYN training,” says reproductive endocrinologist Dr. Aimee Eyvazzadeh, MD, MPH. “Most medical curricula focus on the physiological aspects of pregnancy, often neglecting the psychological and behavioral components, including eating disorders.”

According to Equip family nurse practitioner Sarah Curran, FNP-C, many patients with eating disorders report feeling dismissed or invalidated by medical providers, including OB/GYNs, and that may be due to a lack of education and training. “While they are experts in their field, they simply do not hold the knowledge or have the bandwidth to adequately and holistically support pregnant patients with an eating disorder history through pregnancy and beyond,” Curran says. “Many OBs have received minimal training on conditions such as hypothalamic amenorrhea or RED-S, which can be consequences of underfueling and over-exercising, and will jump to quick fixes like hormonal birth control rather than addressing the root cause.”

While eating disorders are unequivocally defined as brain disorders, they have serious physical implications and consequences that can affect, among other things, pregnancy. “Given that eating disorders can significantly impact both maternal and fetal health, it's crucial for providers to have a comprehensive understanding of how to identify, manage, and support pregnant patients with an eating disorder,” Eyvazzadeh says. “Providing eating disorder-specific education helps healthcare providers recognize the unique challenges these patients face, tailor their care plans accordingly, and improve outcomes for both the mother and the baby.”

Why pregnancy can be challenging for patients with an eating disorder history

There’s no doubt that pregnancy can be challenging for any birthing person, but for those who have dealt with an eating disorder, the experience can be particularly difficult and even triggering.

“It’s easy to assume that weight gain is the only major trigger for those with an eating disorder history during pregnancy, but there is so much more at play, creating the perfect storm for relapse of behaviors,” Curran says. “Pregnancy is a time of rapid change, lack of predictability, as well as lack of control. It is well known that those struggling with eating disorders often carry personality traits in line with ‘type A,’ meaning they may hold perfectionistic tendencies, and struggle with change or lack of control.”

Of course, weight gain is one of the major triggers that patients with an eating disorder history have to contend with during pregnancy. Weight changes in general can be difficult for those who have dealt with an eating disorder, but to make matters worse, many of the country’s leading organizations on pregnancy wellness continue to rely on outdated measures of how much weight pregnant people “should” gain. “The American College of Obstetricians and Gynecologists (ACOG) and the American Pregnancy Association recommend strict weight gain guidelines based on BMI, which is a deeply flawed measurement of health, and fails to consider individual nutrition history or health status,” Curran says.

This is all exacerbated by the inescapable force of diet culture, which places unattainable expectations and pressures on pregnant people. “Diet culture is incredibly pervasive in the pregnancy world,” Curran says. “From pregnancy apps with daily messages, community forums online, or even resources provided by well-meaning medical providers, the overarching message unfortunately remains ‘gain weight, but not too much’ and ‘be sure to stay active.’” While those messages are fueled by good intentions, they can push those prone to eating disorders onto a slippery slope of harmful behaviors.

Aside from the rapid and often unpredictable changes in body shape and size, Eyvazzadeh says pregnancy can also be triggering for patients with an eating disorder for several other reasons:

• Loss of control: “Patients with eating disorders may struggle with the lack of control over their bodies and eating habits, as pregnancy requires a different approach to nutrition and self-care,” Eyvazzadeh says.
• Hormonal fluctuations: “Hormonal changes during pregnancy can exacerbate mood disorders, anxiety, and depression, which are often comorbid with eating disorders,” Eyvazzadeh says.
• Focus on food and nutrition: “The increased emphasis on dietary intake and nutritional monitoring during pregnancy can trigger obsessive behaviors or lead to relapse in those recovering from restrictive or binge-purge eating patterns,” Eyvazzadeh says.

Another often overlooked obstacle for many birthing people is “morning sickness;” a common symptom I personally found can occur at any time of day. “Eighty percent of women will deal with some form of nausea during pregnancy, which can make eating enough a challenge,” Curran says. She goes on to explain that even if you’re eating less for non-disordered reasons—i.e., out of a desire to avoid nausea rather than any eating disorder impulses—undereating can trigger pathways in the brain that lead to further restriction and other disordered behaviors.

How to support pregnant patients with an eating disorder history

“When caring for pregnant patients with a history of an eating disorder, it’s crucial for providers to adopt a holistic approach that integrates both medical and psychological support,” says Eyvazzadeh. “Pregnancy can be a transformative but challenging time, especially for those who have dealt with eating disorders.

While every patient and pregnancy is unique, there are some helpful, expert-approved guidelines for supporting pregnant patients with an eating disorder history:

1. Avoid unnecessary weight monitoring or offer “blind weighing.” “Honor a patient's right to refuse weights, or offer blind weights periodically if absolutely necessary,” Curran advises. Eyvazzadeh agrees that providers may not need to closely monitor every pregnant patient’s weight, but in cases where a scale measurement is deemed necessary, the patient can simply turn around or avoid looking at the number if they prefer. “This can reduce anxiety associated with weight gain and prevent triggering obsessive behaviors around weight,” she says. “Providers should focus on overall health and well-being rather than weight.”

2. Get to know the patient’s past and stay vigilant. “Understand the patient's full medical and psychiatric history, including eating disorder behaviors,” Curran says. “And screen frequently throughout pregnancy for relapse of symptoms or behaviors.” Eyvazzadeh says that signs of relapse may include frequent discussions about weight and body image, or food avoidance. She also advises that providers check in regularly on patients’ mental health.“Early intervention is key to preventing a full relapse,” she says.

3. Prepare patients for what’s to come. “It’s critical to educate patients early on in the pregnancy journey about what to expect with regards to body changes—physically, hormonally, mentally and emotionally,” Curran says. “It can also be beneficial to normalize the fact that pregnancy can be an equally beautiful, exciting, and challenging experience. All feelings that arise during pregnancy are valid."

4. Be mindful of diet culture messaging: “Avoid language that reinforces diet culture or stigmatizes certain foods,” Eyvazzadeh says. “Instead, encourage a balanced, inclusive approach to nutrition that focuses on nourishing the body for both the mother and baby. Remind patients that all foods can have a place in a healthy diet.”

5. Monitor mental health symptoms. ”Due to increased risk for depression and anxiety during pregnancy, it’s important to assess mental health frequently,” Curran says. “Educate patients on safe options for treatment including CBT, SSRIs, and alternative medicine options.”

6. Recommend an eating disorder-trained dietitian. “Refer patients to a dietician who specializes in eating disorders—and ideally prenatal nutrition—to ensure the patient is equipped with ongoing, compassionate support,” Curran says. Eyvazzadeh agrees, noting that a registered dietitian who is well-versed and experienced in the realm of eating disorders can help provide tailored nutritional guidance. “This collaboration ensures that the patient receives specialized support to meet the nutritional needs of pregnancy without triggering disordered eating patterns,” she says.

7. Create a safe, non-judgmental space: “Encourage open communication by creating a safe and supportive environment,” Eyvazzadeh says. “Let patients know that they can talk about their struggles with eating or body image without fear of judgment. This can help build trust and encourage honesty about any behaviors or feelings they may be experiencing.”

8. Acknowledge your gaps in knowledge or experience. “Own your limitations as a medical provider who may or may not have received adequate training in eating disorders, and refer out when applicable,” Curran says.

When to make a referral to an eating disorder specialist

Even the most well-intentioned and educated medical professionals need support in providing their patients with the most appropriate care. Here are some signs that a patient may be relapsing or require more support:

1. Down-trending weight or failure to gain adequate weight during pregnancy.
2. Report of increase in disordered behaviors such as purging, compulsive exercise, calorie counting, or body checking.
3. Changes in mood or behavior. “Increased irritability, depression, or anxiety may be signs of relapse or heightened distress related to the eating disorder,” Eyvazzadeh says.
4. Pregnancy complications that indicate potential inadequate nutrition, including intrauterine growth restriction (IUGR), often seen later in pregnancy.
5. Significant anxiety around weight gain or body changes. “This could manifest as excessive worry, avoidance of appointments where weight is measured, or repeated requests to discuss weight management,” Eyvazzadeh says.
6. Frequent conversations about caloric intake or “safe” foods. “This may indicate restrictive eating or obsession with dieting during pregnancy,” Eyvazzadeh says.
7. Physical signs of nutritional deficiency. “These may include hair loss, dental issues, or dizziness, which may indicate purging behaviors or inadequate nutritional intake,” Eyvazzadeh says.

It’s also crucial for providers to be on the lookout for these and other red flags after pregnancy. “As challenging as pregnancy can potentially be for those affected by eating disorders, it is imperative for providers to also be aware of the challenges that arise during the postpartum period,” Curran says. “New mothers are going through a major life transition and identity shift, and can often be blindsided by the ‘fourth trimester.’”

According to Curran, some potentially triggering factors during the postpartum period include:

• Sleep deprivation (which can exacerbate mood dysregulation)
• Increased risk for postpartum depression and anxiety
• Less time to prepare and eat adequate meals
• Breastfeeding struggles
• Body changes
• Diet culture messaging around “losing the baby weight”
• General lack of support from providers outside of the six-week postpartum check-up

“Providers should be proactive in their care, provide a supportive environment, and utilize a multidisciplinary approach to address the complex needs of these patients,” adds Eyvazzadeh. “Encouraging a focus on the health and well-being of both the mother and the developing baby, rather than solely on weight or appearance, can foster a more positive pregnancy experience.”

If you’re concerned that a patient of yours might be struggling with an eating disorder, we can partner with you to support them. Start a referral or reach out to learn more.