Pregnancy and Eating Disorders Among Cisgender Women

General Mental Health, Pregnancy, and Cisgender Women

One in five adults are impacted by mental health concerns in the United States. There is nearly a 12% discrepancy between prevalence of mental health concerns in men (40%) and women (51.7%; National Alliance on Mental Illness, 2023). This divergence begins as young as puberty, where the ratio of depression for females and males is 1:1 before puberty and increases to 2:1 after onset. Zender and Olshanky (2009, as cited in Nakamura, 2005) indicates the impact of estrogen and progesterone as leading factors of this change. 

According to the American Psychiatric Association (2017), depression, post-traumatic stress disorder, and eating disorders are the most common mental health concerns among women. Additionally, the National Institute of Health (2024) cites an increased vulnerability in mental health concerns in women during times of hormone change (e.g., during or after pregnancy, around the time of menstruation, and during menopause).

Mental health presentations in pregnant women, like anxiety and depression, have been associated with high-risk medical conditions in both the mother (e.g., preeclampsia) and the child (e.g., preterm birth; Rezaee & Framarzi, 2014). While body mass index (BMI) can be a misleading indicator of a person’s health status, a higher BMI was correlated with an increased risk of depression in pregnant women (Rezaee & Framarzi, 2014; Russell, 2024). Studies suggest those with a higher body weight may have internalized weight bias (IWB), which are the negative attitudes people hold regarding weight and size that are based on social stereotypes about one’s physical appearance. IWB is linked to increased depressive symptoms (Pearl et al., 2013) and has been associated with behavioral problems, such as eating disorders (Lee et al., 2019).   

Eating Disorders Among Pregnant Women

Pregnancy can be a sensitive time of life for women. Body and weight dissatisfaction may impact a person, even if there is no history of an eating disorder (Coker & Abraham, 2015). There is an increased attunement to negative self-perception, which can decrease self-esteem. There are more changes occurring in the body that have been happening since puberty, all while navigating societal expectations of thinness and motherhood (Sebastiani et al., 2020). The pressure of thinness is present before, during, and right after gestation, which has inspired the term “pregorexia” (Janas-Kozik et al., 2021). Tarchi and colleagues (2023) describe pregorexia as individuals engaging in eating disorder behaviors, like restriction or exercise, to counter the impact and changes that occur in pregnancy (i.e., changes in weight or body shape). Consequently, women enter a struggle between meeting the needs of their child while satisfying their eating disorder. Additionally, morning sickness can be triggering for individuals currently experiencing or in recovery from bulimia nervosa (McAdams, 2022). Fear of weight gain during pregnancy also may increase the risk of binge eating disorder (BED). During the first half of pregnancy, BED pathology is most associated with low social support, low partner satisfaction, and increased number of adverse life events (Knoph Berg et al., 2011).  “Intentional binge eating may occur as well, as the binge is intellectualized as eating for two” (M. Ortiz, personal communication, January 20, 2025). Binge eating is significantly understudied as a whole, especially within pregnant women. 

Eating Disorders Physiological Impact on Fertility, Conception, and Gestation

Eating disorders impact pregnancy prior to conception. Instances of amenorrhea and anovulation, the loss of menstrual period and loss of ovulatory egg release, are physical consequences associated with eating disorder pathology that have direct correlations to fertility (Letranchant et al., 2022). One study found that up to 48% of women seeking fertility assistance endorsed symptoms associated with disordered eating pathology (Hecht et al., 2021). A similar study found that 0.5-16.7% of women seeking fertility assistance also presented with current eating disorders. Of women who utilized pulsatile gonadotropin-releasing hormone as a fertility treatment, around 95% reported eating disorder pathology during their lifetime (Bailey-Straebler & Susser, 2023). Seeing as leptin impacts the hypothalamus, this is concurrent with the findings of reduced leptin levels in individuals with anorexia nervosa, a potential consequence of sustained restriction of nutrition and decrease in body fat (Letranchant et al., 2022). Nevertheless, it is important to note that merely energy expenditure alone, without the presence of body fat loss, can also mirror a similar effect on leptin and therefore impact fertility without weight changes; a phenomenon often associated with persistent strenuous exercise (Pinelli & Tagliabue, 2007). This urges providers to remember that a patient that engages in excessive workout regiments or long-duration exercises (e.g., marathons) may present with hormone-based fertility consequences independent of dietary intake or body changes. 

Individuals with diagnosed anorexia nervosa may have heard from professionals that their fertility is impacted or note to themself that their lack of a menses may impede their ability to get pregnant. Though this is sometimes the case, individuals with anorexia nervosa are also susceptible to unplanned conception due to fertility assumptions associated with their disorder (Micali et al., 2013). Many individuals with histories of eating disorder diagnoses reported unclear perceptions of their disorder’s impact on fertility. One study found that different individuals had an array of reactions to warnings relating to fertility from professionals, including feeling that this information was weaponized as a manipulation tactic for change, feeling unclear as to whether their chances of conception would be impacted, or feeling threatened that their fertility was certainly impeded by their actions (Holmes, 2018). This emphasizes the need for continued accessibility to education and overall increased awareness for providers to ensure proper communication of information to those undergoing eating disorder treatment.

Following conception, pregnancy with concurrent anorexia nervosa is viewed as a high-risk pregnancy due to potential complications such as anemia, inadequate fetal growth in utero, and lower birth weights (Pan et al., 2022). Though the behaviors associated with eating disorder pathology may also impact both woman and fetus, low maternal BMI alone carries significant risk alone (Micali, 2008). Attitudes associated with discovering pregnancy is also found to be altered in women endorsing eating disorder pathology as they are more likely to experience adverse or negative reactions (Easter et al., 2011). This may be associated with a lack of confidence in the ability to tolerate both the impending physical body changes and psychological identity changes. Though fear of weight gain or tolerating weight changes may be present pre-conception through postpartum periods of time, studies have shown that dissatisfaction associated with body changes peaks in the third trimester (Coker & Abraham, 2015). There was also found to be a positive correlation between history of an eating disorder presentation and the development of hyperemesis gravidarum, a diagnosis associated with extreme vomiting and nausea, illustrating that past eating disorder pathology can impact the prenatal period (Stewart & Stotland, 2002). These findings illustrate the presence of confusion among professionals and patients alike, as another study found no significant differences between pregnancies of individuals with and without a history of diagnosed anorexia nervosa if currently in remission (Chaer et al., 2020). Continued research is needed in this area due to small sample sizes and inconsistent findings.

Postpartum Experiences in Women with Eating Disorder Histories

Unfortunately, there is a notion in today’s society that women are supposed to bounce back after giving birth, meaning to return to their pre-conception body composition. This poses a risk for women both with and without histories of eating disorders. Women with pre-existing or current eating disorders may experience increased weight changes during the prenatal period and may also experience a more significant drop in BMI during the first to six months postpartum when compared to their non-diagnosed counterparts (Zerwas et al., 2014). Ability to adapt to postpartum adjustments may be limited by sustained eating disorder presentation in the postpartum period (Knoph et al., 2013). One study found that 27.8% of postpartum women showed indications for orthorexic qualities (Tayhan et al., 2023). Orthorexic tendencies should be considered warning signs or precursors of eating disorder presentation, specifically in the postpartum period. One study found that 50% of the individuals relapsed with their eating disorder postpartum, making it as prevalent as postpartum depression (Makino et al., 2020). Postpartum depression also has been shown to have a positive correlation with the presence of both bulimia nervosa and BED (Mazzeo et al., 2006). The Archives of Women’s Mental Health highlights the importance of having specialized services available and accessible due to the high prevalence rates of postpartum eating disorder pathology (Pettersson et al., 2016).

As for breastfeeding, eating disorder pathology may reduce breastfeeding confidence, duration, and continuation (Kapa et al., 2022). Pressure from professionals relating to breastfeeding was found to influence symptom presentation relating to both depression and eating disorders (Thompson et al., 2023). Healthcare providers may urge or recommend continuation of breastfeeding, creating a pressure that an eating disorder may attempt to neutralize. It is imperative to note that dissatisfaction with body weight and appearance postpartum alone influenced attitudes toward breastfeeding, not just the presence of eating disorder pathology (Kaß et al., 2021).

Pregnancy as a Protective Factor to Eating Disorder Histories

Pregnancy can also serve as a powerful protective factor for folks with eating disorders, with more than 50% of women who have a previous history of disordered eating find improvement or recovery during this time (Kimmel et al., 2016). Some women express appreciation for their pregnant body for two reasons: 1) weight gain can be attributed to pregnancy rather than getting fat and, 2) weight gain was in the context of something more important than their eating disorder (e.g., the well-being of their unborn child). However, women with eating disorders report the early months of pregnancy to be the most difficult, as weight gain has begun, but pregnancy is not yet observable and may have the preoccupation of appearing “fat” (Fogarty et al., 2018, p. 11). Alternatively, pregnancy allowed permission for weight gain and rigid food rules imposed by the eating disorder relaxed. Additionally, previously triggering areas of the body, such as the abdominal area, became “beautiful” (Fogarty et al., 2018, p. 11). 

Information for Obstetrics and Gynecology Providers for Pregnant Women with Eating Disorders

Lack of disclosure around eating disorders is common in medical and mental health settings. Non-disclosure in treatment was reported by more than 40% of participants in the eating disorder group in one study with shame being the mediating factor (Swan & Andrews, 2003). Disclosure could be impacted by other issues too, such as never being assessed (Fogarty et al., 2018). A full assessment on eating disorders is not necessary for every client, but screening questionnaires could better direct providers on who does need further intervention. 

Equip (2024), the leading evidence-based virtual eating disorder treatment program, suggests open-ended questions such as, “How do you feel about your weight?” or “What does a typical day of eating look like for you?” This gives space for a conversation around body, weight, shape, and size, as well as nutritional needs. The Eating Disorder Screen for Primary Care (ESP) is a quick, four question assessment about eating patterns, shame around eating, weight concerns, and family or personal history of an eating disorder. If clinically indicated, the Eating Disorder Examination Questionnaire (EDE-Q) and the Eating Attitudes Test (EAT-26) are widely used as a comprehensive assessment.

As previously discussed, people with eating disorders may not always be forthcoming about their pathology. When doing a physical exam, Equip (2024) recommends looking for swollen salivary glands, calluses on the knuckles, dental decay, lanugo hair, bradycardia, and changes in weight. Collaborative care with mental health professionals, dietitians, psychiatrists, and obstetrics is highly recommended when working with pregnant women with eating disorders. 

Training Opportunities on Eating Disorders and Pregnancy

• Eating Recovery Center offers providers the opportunity to view the recording from Dr. Crawford’s Pregnancy, Infertility, and Eating Disorders presentation by using code Prengancy&ED through the link found here. Another link will be sent via email to access the course in the Continuing Education portal. 
• Eating Recovery Center is also having a five-week training on eating disorders and infertility, pregnancy, pregnancy loss, post-partum, and raising children while in recovery. The training will start March 20, 2025 and will be held every Thursday. Access to their continuing education events can be found here. 
• The Institute of Psychiatry, Psychology & Neuroscience has a two-hour training video on eating disorders and pregnancy that can be accessed here. 
• Eating Disorders and Pregnancy website found here also has many resources for providers seeking additional information and training.