Eating disorders and motherhood

Yes, eating disorders are mental illnesses that affect food choices and lead to malnutrition and a constant state of alertness. Therefore, as an adaptive mechanism to this situation, our bodies go into conservation mode, avoiding expending what little energy they have and prioritizing processes essential for survival. Reproduction, while it may be important to the individual, is not essential.

Studies show that people with eating disorders take longer to conceive and experience more frequent miscarriages and unplanned pregnancies. It is also associated with an increased need for fertility treatments.

However, it is important to note that research also suggests that, with the right treatment, these effects are reversible.

Eating disorders in pregnancy

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Yes, having any eating disorder carries a higher risk of complications during pregnancy and for the normal development of the baby, such as:

• Intrauterine growth retardation.
• Premature births.
• Cesarean sections.
• Preeclampsia.
• Worst experience of the process.
• Increased anxiety.
• Higher likelihood of postpartum depression.

But it's also important to consider that pregnancy itself affects the course of our eating disorder . The changes inherent in pregnancy (increased energy needs, changes in appetite, nausea, vomiting, bodily changes, stress due to life changes, etc.) and the way this process is supported (concern about weight, normalization of pathological behaviors by society, prescription of diets, weight stigma, the presence of medical fatphobia) can negatively impact the eating disorder , as there is a greater risk of energy deficit, stress, excessive concern about health, or body dissatisfaction.

In many cases, pregnancy has been shown to lessen symptoms , likely due to the social acceptance of bodily changes and weight gain during this stage. In the postpartum period, this acceptance generally disappears, and the pressure to regain one's pre-pregnancy figure returns with renewed force. This, along with the stress and demands of raising a child, often exacerbates symptoms.

Generally, the menstrual cycle returns after a period of time has passed since the person regained and maintained their natural weight.

Your natural weight is the genetically determined weight range in which your body functions well, without restrictions or compensations, and with your brain feeling safe. This natural weight may not coincide with what is considered a normal body mass index (BMI). Some people experience amenorrhea even though they are not underweight, because, although their BMI is considered normal or high, they are below their natural weight range.

It's also important to know that the return of her menstrual cycle and the possibility of pregnancy don't mean your daughter has recovered. It means she's better, but not recovered. She may still be experiencing significant emotional distress. Continued support is necessary.

Implications of lack of menstruation in women with an eating disorder

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Yes, both restrictive disorders are associated with nutritional deficiencies, which can negatively affect fetal development and growth, as well as cause other unfavorable obstetric outcomes (preeclampsia, premature birth...).

ARFID, when food selection becomes a disorder

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First of all, I want to acknowledge that you're in the process of recovery and how positive it is that you can identify and express your fears. As you know, recovery is a difficult process that requires a lot of commitment and consistent effort to gradually release not only the restrictions themselves, but also the limiting beliefs and maladaptive behaviors. Looking at those fears, questioning them, and deciding what to do with them is also part of that journey.

I encourage you to keep working on this, and to surround yourself with specialized professionals who can support you in the process of accepting your body image and its changing nature, not only from a place of self-love and self-esteem, but also by questioning external voices, societal expectations, beauty standards, and fatphobia . Be critical of all those messages we receive from childhood that make us believe we should remain unchanged over time and constantly strive to maintain the lowest weight we once had, hide our tiredness, our stretch marks, disguise cellulite, our wrinkles, cover our pores, and dye our gray hair; in this case, we are urged to return to our former bodies, as if nothing had happened. Ultimately, it's about disguising ourselves and erasing any sign of life.

We must be critical of all those messages we receive from childhood that make us believe that we should remain unchanged over time and continually strive to maintain the weight we once had.

Socially, it seems that if you don't make any effort to hide your appearance, it's considered "neglecting yourself," "letting yourself go," or even a lack of self-love. I firmly believe it's illogical to think that fighting against our changing bodies is the prerequisite for loving ourselves. Our bodies aren't static; they change, and that's (or should be) desirable and natural.

Yes, body dissatisfaction itself is considered a risk factor for developing an eating disorder . I encourage you to ask yourself: Where does this dissatisfaction come from? Do you desire this specific body? Or do you desire what you think you'll gain with that body?

With this I want to show you that dissatisfaction and the desire for a certain body type have their logic in a culture that does not show body diversity , that praises thinness ("congratulations, you look great"), that punishes and makes fatness invisible, and demands that we remain unchanged over time ("Wow, you look fantastic, you can't tell you've been a mother").

During pregnancy, a certain amount of permission is given to change, to gain weight ("eat calmly, you'll have time to lose it later"), but after childbirth this permission disappears and we are again urged "to recover", to erase any sign that shows that we have been mothers.

If you're experiencing this discomfort and fear developing an eating disorder, it's very likely that your life choices are already heavily influenced by this dissatisfaction. I recommend you seek help now . The sooner we address this, the better.

During pregnancy we are given some permission to gain weight, but after childbirth we are again urged to erase any sign that shows that we have been mothers.

Likewise, as I said, it would be good if we reflected on beauty ideals and how they function as a control mechanism . And instead of wasting energy, time, money, and risking our health to fit into socially constructed molds, we should invest our efforts in breaking them.
As activist Magda Piñeyro says: "Living in the desire to be someone else, in the perpetual possibility of inhabiting another body, means that you don't inhabit this one you have, this one you are."

Pressure to conform to beauty standards can trigger eating problems

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How you prepare for this stage will depend largely on your own process, what phase you are in, your level of awareness of the disorder, your level of commitment, what symptoms you have, what your triggers are... The general answer would be to become aware of your process and also commit to taking action .

• Share your situation with the professionals supporting you during your pregnancy so they can tailor their care to your specific needs. Surround yourself with a team of specialized professionals who can help you throughout your process, including nutritional rehabilitation and working through and confronting your fears by reprogramming thought patterns associated with the disorder and identifying self-deceptions.
• Don't forget emotional support . Pregnancy and parenting are very stressful situations in which we can experience a loss of control. It's crucial that you develop new, healthy coping mechanisms for managing emotions and discomfort, and avoid dysfunctional behaviors.
• Keep in mind that it's very easy to experience energy depletion during this stage. Your demands during pregnancy and postpartum will increase, so you should increase your intake and not restrict yourself physically or mentally . Rest, and always move with pleasure and self-compassion, not as punishment.
• Share your process with close friends and family , build a support network, learn from real stories, and be careful with the content you consume on social media.
  

First, regarding the ability to lactate , focusing on the physical aspect—that is, the functioning of the mammary gland— lactation is possible . However, milk production may be reduced due to underdeveloped breast tissue in women who have lost their menstrual cycle (hypothalamic amenorrhea) or experienced significant menstrual irregularities during puberty. The composition of the milk has also been affected in cases of severe malnutrition.

On the other hand, regarding the suitability of breastfeeding , we must bear in mind that this process will involve a great expenditure of energy , besides the fact that it can be a significant source of stress, often due to a lack of family and social support, and difficulties that may arise. To find the answer, you have to be honest with yourself and weigh your desire against the risks and benefits.

If you decide to breastfeed, prioritize rest, delegate tasks, and make things easy for yourself . It's crucial to eat without restrictions. Keep in mind that energy needs increase significantly. People who have previously been malnourished may experience episodes of hyperphagia (binge eating) or intense mental hunger. Acknowledge this; it's an adaptive mechanism. Your body, which has been malnourished, wants to ensure it won't go hungry. If you're in an advanced stage of the disorder, the brain's reward circuits for hunger and satiety may be disrupted. In this case, you should eat according to a nutritional guideline, but always understand it as a minimum. If your body asks for more, give it more.

This is very common in women with a history of eating disorders. The concern for their children's healthy eating often reawakens that hypervigilance about food, bringing back the rigidity, the food Tetris-like mentality, the obsession with recipes, the stress... I encourage you to seek help to work through your fears and improve your relationship with food.

For a healthy diet, we must focus not only on what we eat, but also on how we eat it. Our diet should be flexible and sufficient, taking into account nutritional needs, but also the pleasure and social value of food.

Fear, when it's not pathological, has a protective function (it's what makes us turn around to check that we've put out the fire). In this case, it's probably prompting you to evaluate your own relationship with food , to work on improving it, and to prevent further harm.

It has been observed that rigid dietary practices in parents, as well as categorizing foods as good and bad, demonizing the latter, can lead to disordered eating behaviors.

Remember that for a healthy diet to be effective , it's not just what we eat that matters, but how we eat it . A flexible diet that takes into account our nutritional needs, hunger, satiety, pleasure, social interaction, and so on.

Many women already know they have or have had an eating disorder, but often, out of fear or shame of being judged, they don't talk about it. So the first step would be to make the consultation a safe, judgment-free space and include it in the data collection by asking about it directly.

When there's no prior history, things get complicated, since unfortunately many behaviors go unnoticed because they're normalized or even socially accepted . But a woman with anxiety and depression who presents with the following might raise suspicion:

• Overly concerned with health and constantly checking the nutritional information on products.
• Dietary rigidity: their companion, for example, explains that they systematically avoid certain foods (fear foods) or that they eat them in a certain way following very strict rules (food rules).
• The presence of binge eating.
• The obsession with movement.
• That refers to body dissatisfaction or intense fear of bodily changes.
• Emotional suffering.
• Isolation.
• Mood swings if you can't stick to your diet or activity plan.

It can also be noticeable when someone experiences sudden weight fluctuations or, conversely, doesn't gain weight, etc. But, as you'll see, I'm not referring to a specific weight or BMI, since these occur in all body types.

What are the main warning signs of eating disorders?

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As midwives, how we accompany and how we offer health advice will be crucial, since we are present during moments of great vulnerability such as adolescence, pregnancy, postpartum, and menopause.

Today, one of the most measured parameters, for example, in pregnancy consultations, is still weight (the initial weight, at each visit, the total weight gained) and the health advice we offer is often focused on controlling that weight so that it meets that little chart that we all know that establishes ideal weight gains according to the body mass index (BMI).

These practices are not based on quality scientific evidence. In fact, it has been shown that when attention is focused on weight, it worsens a person's physical and mental health . Comments such as, for example, "watch what you eat," "don't eat for two, you've already gained all the weight you were supposed to," or "congratulations, you haven't gained any weight since the last visit" are inappropriate comments that generate more obsession with food, feelings of inadequacy, shame, and guilt. For a person with an eating disorder, it's like adding fuel to the fire.

So we must set aside the scale and put the person at the center. We must ask questions, listen, and support them with empathy and respect , accepting body diversity and understanding that health is a much broader and more subjective concept, determined by various modifiable factors (diet, movement, rest, consumption of toxins, leisure, stress management, etc.) but also by others beyond our control (weight, race, age, access to healthcare, belonging to a socially oppressed group, etc.).

Much more than a problem with food

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Translating all of this into more concrete guidelines , they would be:

• Be aware that putting someone on a scale is an intervention that is not without risk. Assess the risk-benefit ratio and, if weighing is decided upon, offer a blind weighing.
• We must be mindful of how we give nutritional advice. We need to be aware that for a diet to be healthy, it's not just what we eat that matters, but how we eat it. It's important to have a flexible diet that takes into account nutritional needs, hunger, satiety, pleasure, the social aspect, and so on. It has been shown that rigid dietary approaches, as well as categorizing foods as good or bad, can lead to disordered eating habits. Remember, eating better will improve your health, even if your weight doesn't change.
• Include body diversity in consultation poster images and presentations to promote acceptance of body changes.

Yes, it has already been discussed how pregnancy and, above all, postpartum affect the person with an eating disorder, potentially worsening the disorder.

Ideally, we would work with a multidisciplinary team and closely support the person, adapting the recommendations and care to the stage of the disorder they are in.

Providing emotional support to these women will be key; we must try to avoid blaming and paternalistic treatment, and recognize and value their achievements.

If you're asking this question as a friend or family member of someone with an eating disorder, I would say that many times it can be as simple as showing yourself to be approachable, available, or directly asking how you can help, without judgment.

As professionals, we must individualize and focus care on the person in front of us, keeping in mind their wishes, their needs, and their circumstances.

Breastfeeding can be more harmful than beneficial if sufficient intake is not ensured, as it can activate and reinforce the symptoms of eating disorders.

Sometimes, if a woman is experiencing an energy deficit, exclusive breastfeeding, with all its benefits, can be more harmful than helpful if sufficient intake isn't ensured, as it can trigger and exacerbate the symptoms of the eating disorder. It's crucial to avoid falling back into an energy deficit . Explain to the woman that it's normal to feel hungrier and to honor that feeling. Episodes of extreme hunger or hyperphagia have been described, which is perfectly normal. It will be important to always respond to both physical and mental hunger.

Finally, it's worth noting that, as healthcare professionals, emphasizing the caloric expenditure of breastfeeding is anything but valuable. Studies already suggest that in women with eating disorders, breastfeeding can be a dysfunctional weight control mechanism—in other words, a compensatory behavior.