When I became pregnant, I’d been in recovery from anorexia for five years. Upon learning the news, my primary emotions were joy and disbelief. It worked! This is happening! I'm going to have a baby! But in the days after, as the news settled in, I felt a stubborn worry worm its way into my mind: What did this mean for my body? I’d stopped the near-constant body checking that had been a hallmark of my illness, but I still registered how my body looked. I still caught my reflection in windows, still—however unconsciously—assessed my silhouette. What would happen when that silhouette began to do the one thing my now-dormant eating disorder was so terrified of: grow?
Pregnancy is almost universally thought of as a precious, special time, one in which a pregnant person watches in awe as their body does miraculous things. New curves form, old ones disappear, foreign movement can be sensed deep inside the body; from nothing, a tiny human grows. But for those affected by an eating disorder, pregnancy can also be fraught. An eating disorder doesn’t simply disappear when a person becomes pregnant, and for those in recovery, pregnancy can cause old thoughts and behaviors to resurface.
Indeed, the relationship between pregnancy and eating disorders is a complex one. The good news is that there's a lot that pregnant people can do to protect themselves and their recovery through these eventful nine months and beyond.
How common are eating disorders in pregnancy?
A pregnant person has so much going on—ultrasounds and blood tests, growth scans and vital signs, heart rates and genetic screenings, the life-changing experience of preparing for parenthood and a growing family—that it’s understandable for both healthcare providers and society at large to overlook the fact that they may also be dealing with an eating disorder. But according to at least one published paper, “eating disorders are more common than previously thought in pregnancy.”
That particular study found that during pregnancy, 7.5% of women met diagnostic criteria for an eating disorder, compared to a pre-pregnancy rate of 9.2%. The most common eating disorder symptom reported was binge eating, with 8.8% of women engaging in binges, and 2.3% engaging in compensatory behaviors, like restricting or overexercising. Another study found that for women who have eating disorders before becoming pregnant, disordered eating often persists into their pregnancy and the postpartum period. Other research paints a different picture, however, showing pregnancy as a time of relief from eating disorder symptoms, which can perhaps explain why the rate of eating disorders among pregnant women is lower than the baseline prevalence. (It's important to note that not all pregnant people are women, but many studies, including the ones cited here, use a female population.)
If and how an eating disorder shows up during pregnancy depends on a variety of factors, including the type of eating disorder (pregnancy seems to be a particularly high risk time for binge eating disorder, for instance) and whether a person was in recovery or not when they became pregnant (those in recovery may be vulnerable to a relapse, while those actively engaging with their eating disorder may experience a reprieve). But as with all things related to mental health, how pregnancy affects someone’s eating disorder will be unique to each person.
In my case, I was lucky: as my body expanded, my joy and awe did the same alongside it, and there was simply no room for body distress or eating disorder thoughts. Unfortunately, this isn’t the case for everyone.
Pregnancy brings specific challenges for those with eating disorders
When you’re pregnant, certain parts of your life—and your body—change, and for many people, these changes can be a wake-up call for a latent eating disorder. Some of the most challenging aspects of pregnancy include:
Getting weighed is a standard part of all prenatal appointments. For those in recovery, this can be jarring: many people with a history of an eating disorder have long ago thrown out their scales and make a point of not knowing their weight. With prenatal monitoring, this careful avoidance flies out the window.
“Even with my care team knowing my past of an eating disorder, they would still bring up the parameters of how much weight gain was ‘allowed’ to happen during pregnancy,” says Equip dietitian Stephanie Kile, RD. “That worry and focus on weight at each appointment tells a pregnant woman that she needs to fit in this box or something is wrong, and she must do whatever she can to stay in this box. During my first pregnancy, I approached every appointment with a bit of dread that I was going to be told I was gaining too much weight.”
Equip therapist Ashley Isenhower, AMFT, points out that this focus on weight has a disproportionate effect on those who begin pregnancy at a higher weight. “Doctors want your weight at every appointment. You’re only supposed to gain a certain amount of weight, and that number is drastically smaller for people in larger bodies,” she says. “If you’re above a certain BMI, like I was, you’re automatically considered a ‘high-risk pregnancy.’”
Equip’s Director of Clinical Training Urmi Patel, PsyD, explains that pregnancy can complicate an eating disorder, as the pregnant person may experience increased anxiety about weight gain due to their changing body. Indeed, eating disorders often go hand-in-hand with body image concerns, and so the rapid bodily changes associated with pregnancy (“Your body changes SO FAST,” emphasizes Isenhower) can be distressing.
Research also bears this out, showing that those with a history of an eating disorder may experience increasing anxiety around weight and shape as their body changes throughout pregnancy. As one research paper put it, “being pregnant is a vulnerable period for women with a history of eating disorders. A central issue in eating disorders is searching for control of one’s body and food preferences. Pregnancy implies being increasingly out of control of this.”
Unfortunately, many well-intentioned healthcare providers simply aren’t educated about eating disorders. And during pregnancy, when the focus is so squarely on other issues—the baby’s health, the mother’s lab results, monitoring symptoms and vitals—providers may be even less inclined to consider if or how an eating disorder might be at play, and adjust their treatment accordingly.
“I'm fresh out of graduate school and I don't remember learning much about pregnancy or postpartum mental health at all, let alone the intersection of pregnancy/postpartum and disordered eating,” says Isenhower.
Kile worries that when providers are uneducated about what to say and not say about weight, bodies, and food, it could do lasting damage to vulnerable people. If providers speak about these topics in an uninformed way, she says, “That opens the door wide for an eating disorder to slip right in among all the falsehood of being ‘healthy’ for pregnancy.”
Comments from others
The unfortunate reality is that most people think it’s fair game to comment on pregnant bodies, even people who would never comment on someone’s body if they weren’t pregnant. Regardless of the content of that commentary (“You look like you’re about to pop!” or “Oh my gosh, you’re so small, I can’t believe you’re six months pregnant!), simply having your body remarked upon can be triggering for someone who has struggled with an eating disorder.
“You’re inevitably met with conversations about weight, and comments about your body—how big or small your bump is, or how it compares to someone else’s who is as far along as you,” says Kim Packebush, UX researcher at Equip.
A fixation on diet
While many people in eating disorder recovery have reached a place where food doesn’t take up too much of their brain space, pregnancy can once again thrust food, nutrition, and dietary concerns into the spotlight. “You’re inundated with information about what foods are best for fertility, what foods are unsafe, what foods provide the best nourishment for your body and baby,” says Packebush. “While this is all well and good, as someone recovering from food rules and restrictions, it felt like a step backward. Those hunger cues I fought so hard to regain were thrown out the window, either because of morning sickness in the first trimester or competing stomach and intestinal space in the third.”
Pregnancy also brings hormonal upheaval, which can have a wide range of different effects—both bad and good—when it comes to eating disorder symptoms. Binge eating and body dissatisfaction have a positive association with levels of progesterone, one of the hormones that steadily rises throughout pregnancy, making pregnant people particularly vulnerable to new-onset binge eating disorder or a relapse. In fact, community studies have found that higher progesterone concentrations are associated with binge eating, and that reproductive hormones like progesterone and estrogen account for 24% of the variance in binge eating in women diagnosed with bulimia.
For all of the above reasons, pregnancy is considered a high-risk time for relapse in people with a history of an eating disorder. In one study of women in remission from anorexia or bulimia, 67% of participants experienced a relapse during pregnancy, while in another study of people with a previous eating disorder, 23 of 24 participants reported a worsening of their symptoms or full-blown relapse during pregnancy. Both of these studies are quite small, and they don’t mean that relapse is inevitable, but they do highlight the unique risk of this time period.
But pregnancy can also provide relief from eating disorder symptoms
On the other hand, pregnancy can be a time of eating disorder relief for some people, especially those with active eating disorders or more recent eating disorder history. Research shows that for the majority of women struggling with anorexia or bulimia, pregnancy leads to positive, adaptive changes in their behavior, and while some women may continue to have eating disorder symptoms, those symptoms tend to be less frequent and less acute. Large-scale reports have placed eating disorder remission rates anywhere between 29-78% during pregnancy.
There are a few potential reasons for this. Again, hormones may be involved, but this time it’s the power of estradiol, the particular form of estrogen produced during pregnancy. Eating disorder symptoms and estradiol appear to have an inverse relationship, so as estradiol increases, eating disorder symptoms decrease. And since estradiol levels rise throughout pregnancy—with a particularly sharp increase after the first trimester—many people with eating disorders see their symptoms improve. Most of the research into this has been around anorexia and bulimia, with one study finding that symptoms decreased progressively through each trimester, and 75% of women showed no symptoms at all by their third trimester.
Patel also points out that for some pregnant people, their eating disorder may improve because of their own concern about the harmful effect it could have on an unborn baby. And for many, simply witnessing what one’s body can do may be transformative for eating disorder recovery.
“Being pregnant for the first time allowed my relationship with my body to become the best it has ever been,” Kile says. “There is something about developing life and watching your body house that life that helped me understand the power my body has. With each pregnancy, my body grew and became new each time. I allowed myself to give my body grace, the nourishment it deserves, and the time to heal.”
Eating disorders in the postpartum period
Unfortunately, the postpartum period can be a particularly hard time for those affected by eating disorders, even people who experienced some relief during their pregnancy. Research shows that while eating disorder symptoms like restriction, purging, and weight concerns all tend to diminish during pregnancy, this effect is short-lived. After giving birth, those symptoms return to baseline levels for most women, with only a small minority experiencing lasting psychological benefit.
There are a lot of different factors that can make the postpartum period so tough. For one, there’s the inescapable influence of diet culture: while pregnant women are celebrated as their bodies grow and expand, as soon as the baby is born, they’re once again subject to society’s demand that they be as small as possible. “I will say that the postpartum period has been difficult due to ‘bounce back culture,’” says Isenhower. “I developed preeclampsia and was in the hospital for three weeks before giving birth to my son, then he spent two weeks in the NICU. All that trauma, and some days my biggest concern is, ‘Will I ever fit back into my jeans?’ I loved watching my body grow and expand—but now, there’s a little voice in my head who routinely reminds me that I no longer have ‘an excuse.’”
Then there are a panoply of physical, biological, and psychological reasons that the postpartum period is so risky for eating disorders. As one review put it, “the combination of psychological stressors of new motherhood and body image concerns intensified by the residual bodily changes of pregnancy may predispose women to have an exacerbation in eating disorder symptoms.” Studies have also found that women with eating disorder histories tend to both gain more weight during pregnancy and be more concerned about that weight gain while pregnant and postpartum—the combination of which can lead to disordered behaviors.
People with eating disorders are also at an increased risk of developing postpartum depression: in one study of women with eating disorders, a third of them experienced postpartum depression, compared to a rate of 3-12% in the general population. Dealing with a serious mood disorder like this adds to the psychological stress of being a new parent, and eating disorder behaviors may arise as a way to cope.
And hormones once again rear their head: remember that rise in estradiol we mentioned above, which contributes to a decrease in eating disorder behaviors during pregnancy? Postpartum, those levels plummet, and the opposite effect is felt. While high estradiol decreases eating disorder symptoms, low estradiol increases them—meaning that when a woman’s estrogen levels abruptly fall after she gives birth, she’s vulnerable to her old eating disorder patterns taking hold.
But again, these elevated risks are not life sentences, and many people with histories of eating disorders are able to remain in strong recovery through the postpartum period. “My postpartum body was new and scary, just as it had been during recovery, but I was able to look back and see the growth and development and the new life, and that helped me put it all into perspective,” says Kile.
How to protect your eating disorder recovery during pregnancy
The relationship between pregnancy and eating disorders is complex, multifaceted, and will play out differently for each person. But the reality is that this is a time of elevated risk for those with past or current eating disorders, as well as those who have never experienced an eating disorder but may be vulnerable to one. The good news is there are things you can do to emerge from pregnancy—and the postpartum period—feeling strong in your recovery and empowered to resist any eating disorder thoughts or behaviors that may arise.
Find the right provider
Both Packebush and Isenhower emphasize the importance of finding an OB who is knowledgeable about the HAES (Health at Every Size) approach and has a fat-positive or weight-neutral philosophy. “While it’s a privilege and dependent on several factors, try to find a doctor who is trauma-informed and weight-inclusive,” Packebush advises.
Communicate with your doctor
If you have a history of an eating disorder, it’s important to make that clear from the get-go. “At the very least, be upfront with your care team about your history and what are potential triggers for you,” says Packebush.
Communication can also help with the dreaded weigh-ins that happen at each prenatal visit. “You can still ask for a blind weight or not to be weighed at all, though some doctors will argue that there is a medical need to check weight—for example, a symptom of preeclampsia is rapid weight gain over a short period,” says Isenhower.
Use social media mindfully
Patel advises that those who feel vulnerable to eating disorders should limit or reduce their exposure to social media accounts that make them feel bad about their bodies, or that tend to prompt comparisons. It can be helpful to curate your social media and follow fat-positive birthing accounts (Isenhower recommends @theheavyweightmidwife).
Putting in place a robust support system at the beginning of pregnancy can help you stay on track when challenges come up. It’s important to build a support network that includes both loved ones and mental health professionals, a sentiment that Packebush backs up, emphasizing that “this is a really hard thing to tackle alone, and it's important to have someone who can be there and empathize.”
“If you’re already seeing a therapist, make sure this is an ongoing conversation so that when and if issues arise, you’ve got someone to hold you accountable. Talk, talk, talk about it,” Isenhower advises.
Establish good habits
Being intentional about your eating and exercise can go a long way toward keeping you on track throughout pregnancy. Patel says that it’s important to practice regular eating patterns—even during the first trimester, when you might be experiencing aversions or nausea—and incorporate physical activity in a mindful way. “Develop a list of joyful movement and activities to enjoy while pregnant or after birth,” recommends Patel. “This can help reduce the focus on exercising.”
For my part, I found prenatal workouts—which tend to be gentler and focused on how the body feels as it moves versus more external goals, like speed or number of reps—to be truly revelatory for my push-it-to-the-limit attitude around physical activity.
Watch your self-talk
“Body image concerns are unavoidable—the body is changing so rapidly that once you get used to one change, it changes again,” says Packebush. “It’s important to evaluate and analyze the things you say to yourself about yourself, and challenge if they’re neutral observations or stemming from a place of criticism.”
In this area in particular, Kile says, self-compassion goes a long way. “Your pregnancy and postpartum journey is yours alone. Don’t compare yourself to anyone,” she says. “Grace is going to be your best friend in this season of your life.”
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