Pregnancy is the eating disorder trigger that no one ever

Julie Speers* was desperate for a distraction. She had just told her parents she was pregnant and needed to forget about her dad’s unenthusiastic reaction. The only diversion she had the energy for was binging on Netflix and licorice with her boyfriend. She plunked herself on the couch, zoned out and ate Twizzler after Twizzler.

When she realized she had mindlessly consumed the whole package, she felt a familiar anxiety rise up. She rushed to the bathroom, hunched over the ceramic bowl, emptied her stomach and felt an instant sense of relief. It wasn’t morning sickness; Speers felt she needed to undo what she had done and regain control over her body. This wasn’t the first time she had forced herself to throw up during pregnancy, and it wouldn’t be the last.

Eating disorders affect about five to eight percent of pregnant women. For those with a history of these illnesses, there is a high risk of relapse during the prenatal and postpartum periods, which can lead to harmful behaviours such as restricting food, overexercising, binging and purging. All the attention on eating well during pregnancy and gaining the right amount of weight while being weighed and measured at prenatal appointments can be a trigger for women who have challenging relationships with food and their bodies. Instagram pictures of women sporting six-packs while six months pregnant and showing off tight stomachs weeks after birth don’t help matters either.

“A lot of the psychological underpinnings of eating disorders relate to control and negative body image,” says Simone Vigod, a psychiatrist and principal investigator for the Reproductive Life Stages Program at Women’s College Hospital in Toronto. “During pregnancy, your body is changing in a way that’s not necessarily in your control. For somebody who already struggles with body image difficulties, even if they’ve achieved a healthy weight, pregnancy can be really complicated psychologically.”

Among the deadliest of mental illnesses, eating disorders are more common than many doctors even realize. A study of 54 postpartum women published in the Journal of Midwifery & Women’s Health found that nearly 28 percent had psychological and behavioural traits associated with eating disorders, but only one woman’s medical records listed a history of eating disorders. Many women end up suffering on their own.

Speers’s long battle with bulimia started when she was 24. She had gained 80 pounds after undergoing gallbladder surgery, broke up with her boyfriend of a decade and moved back into her parents’ home, which was volatile due to her father’s alcoholism. Speers became compulsively compelled to purge. She didn’t feel like she had control over her body or her life, but bulimia helped her feel like she was in the driver’s seat.

After three years of vomiting after every meal, she still couldn’t admit that she had an eating disorder, but it was obvious to those close to her. Her right hand was often red, burned by stomach acid when she gagged herself, and her once-curvy figure was reduced to a boyish frame. When one of her university professors acknowledged that she was unwell, she felt angry and ashamed but finally confided in her doctor.

Speers received treatment at an outpatient clinic for three years and was hospitalized on a few occasions when her weight dipped dangerously low. Slowly, her episodes of bulimia became less frequent. When she and her boyfriend decided to start a family about a year after she completed treatment, though, she was still throwing up a few times a week. Still, she was confident that it was the right decision. If anything could compel her to be healthy, she thought, it would be a developing baby that she needed to nourish.

But it wasn’t that simple.

After she threw up, the wave of relief would pass and Speers would be overcome with shame and fear. She would think of the doctors who repeatedly told her that she could tear her esophagus and bleed out on the bathroom floor. Speers was terrified that her eating disorder would eventually kill her, and the thought of her baby growing up motherless was unfathomable.

“It was the guilt that finally got me to stop,” says Speers, who is now a mom to a healthy one-year-old girl. “I felt that if I was throwing up, I was doing something bad to my baby. As I felt more responsible, throwing up started to hurt physically. I felt like that was my brain telling my body, ‘Hey, you’re not doing something right.’ I wasn’t getting the same emotional relief.”

It became easier to abstain from purging throughout her second and third trimesters when she started showing and feeling her baby move. “After a while, it didn’t matter what I needed,” she says. “The baby came first.” 

Getting help

“Having a baby is one of the most stressful times in a woman’s life, yet we pressure women into believing that it’s the most euphoric,” says Deborah Berlin-Romalis, executive director of Sheena’s Place, an eating disorders support centre in Toronto. “Women are often afraid to say ‘I have anxiety’ or ‘I have depression,’ let alone ‘I have a history with an eating disorder and it has actually come back.’ It’s something that tends to go quietly underground.”

In fact, research shows that most pregnant women with active eating disorders don’t tell their maternity care providers, which may be due to fear of judgment, blame or intervention from child-services agencies. Symptoms can also be difficult to spot because women may appear healthy. As a result, eating disorders often go undetected and untreated during pregnancy.

Vigod urges pregnant women to tell their doctors and midwives about past or present eating disorders because early intervention is essential to ensuring positive outcomes. A study published in the American Journal of Obstetrics & Gynecology found that women with anorexia and bulimia have babies with low birth weights, which can lead to a host of complications, including heart disease, asthma, diabetes and sudden infant death syndrome. Anorexia is associated with very premature birth, stillbirth and neonatal death, and bulimia is linked to the need for resuscitation after birth and poor health. Women with a very low body weight are at risk of miscarriage and developing heart problems during pregnancy, while those with binge-eating disorders are more likely to have high blood pressure, larger babies and weight gain that can lead to gestational diabetes.

Women with anorexia are also more than twice as likely to have unintentional pregnancies, often because their body weight is so low that they stop getting periods and incorrectly assume that they can’t conceive. That’s what happened to Sonja Garrison*, who had been subsisting on a diet of black coffee, water and rice cakes—which she purged if she felt she ate too many—before deciding to get help. Just a short while down her road to recovery, she found out that she was expecting her third child. “That was absolutely my rock bottom,” she says. “I was the sickest I’d ever been in my life. I certainly didn’t think I could get pregnant.”

Garrison’s earliest childhood memories are of being teased by her younger brother for being chubby. She started restricting her food intake when she hit her teens. When she was 17, she narrowly escaped being sexually assaulted at a party and forced herself to throw up the next morning. From that moment on, purging became her primary coping mechanism. “If I was stressed out, I would feel really full,” she says. “Even if there was nothing in my stomach, throwing up would make me feel lighter and better.”

Garrison found she was able to let go of her food rituals when she was pregnant. “It was a relief for me for nine months to not have to worry about the little voice in my head telling me not to eat something,” she says, admitting that she still occasionally purged. But the babymoon would only last so long. Garrison’s stress peaked in 2010, when her kids were six and two, she was working full time and her eldest child had started grade one. “I felt like he was growing up too fast and I wasn’t doing enough for him as a mother,” she says. “I couldn’t cope.”

As Garrison dropped dress sizes, her family and coworkers became increasingly concerned. Eventually, she was too sick to go to work and her husband threatened to leave her. When she realized she could lose her kids, she sought help at an eating disorders clinic. She had been seeing a counsellor for several months when she learned she was pregnant.

Garrison was fast-tracked into a residential hospital treatment program in Vancouver, where she stayed for four months, and returned home to Victoria on weekends. It was hard to be away from her family, missing her son’s hockey games and her daughter’s new words, but the treatment may have saved her and her baby.

Garrison got pregnant again last year (with twins) and was symptom-free this time, but now the mom of five is now struggling again and is considering counselling. “I can’t exercise because I’m so busy and I feel like I don’t want to eat anymore,” she says. “I have a terrible body image right now. It’s so hard to push past it.”

Unfortunately, her scenario isn’t uncommon: Many women make it through pregnancy only to relapse after giving birth, when they have little control over their new lives as moms and are subsisting on minimal sleep. Newborns eat, sleep and blow out their diapers on their own schedule. New moms with a history of bulimia or binge-eating disorder are also three times as likely to develop postpartum depression, making their struggles with food that much harder to manage.

illustration of table setting with a smashed dinner plate. On the palt is an image of a pregnant woman looking up at the crack

Illustration: Gracia Lam

Understanding the causes

There’s no single cause for an eating disorder. Biological, behavioural, psychological, social and environmental factors can play a role. Studies on twins show that genetic factors account for about 40 to 60 percent of the risk of an eating disorder, and a study published in the American Journal of Psychiatry found that people with an immediate family member with anorexia are about 11 times as likely to develop the disease themselves.

Major life changes and trauma can also play a significant role. Several studies have shown that people with eating disorders are much more likely to have experienced physical, emotional and sexual abuse. “People who have had trauma struggle with shame and guilt, lack of control and body dissatisfaction,” says Vigod. “An eating disorder can become an attempt to regain control or cope with intense emotions, and it takes on a life of its own.”

Arianne Tremblay developed anorexia when she was 13, soon after her family moved to Canada from Australia. Her parents were quick to get her help at an eating disorders clinic, where she improved with the support of psychiatrists and dietitians. After being in recovery for a few years, she graduated from high school and went travelling in Australia, where she was sexually assaulted. She relapsed, and this time it was much worse.

Tremblay was hospitalized twice and repeatedly told that she may never be able to have children due to the damage caused by the disease, but she didn’t care—she couldn’t fathom having a bulging belly, even after she recovered. However, her feelings changed when she got married, and she felt extremely lucky when she was able to conceive. Still, she struggled through pregnancy. “As soon as my body started to change, I became hyperaware of the loss of control,” she says.

Tremblay’s obstetrician saw her medical history in her file and discussed how she was coping at every check-up. When her doctor didn’t feel that she was gaining enough weight in the first trimester, Tremblay admitted that she felt herself slipping and wasn’t consuming the recommended extra calories. They agreed that she should see a psychiatrist, which she did every two weeks until she was 26 weeks along.

Tremblay’s psychiatrist helped her understand her control issues and how to manage them. They did exercises to help Tremblay cope with stress and feel comfortable with her body. Most importantly, the psychiatrist told her, “If you don’t take care of yourself, you may not get to carry this baby to term.”

Finding treatment

When a pregnant woman tells her doctor or midwife that she is struggling with an eating disorder, there are different courses of treatment. Depending on the severity of her disorder, she may be referred to a high-risk obstetrician, psychiatrist, psychologist, counsellor or dietitian, and sometimes medication may be prescribed. Both she and her baby are closely monitored during the prenatal and postpartum periods. Depending on where she lives, a private or public residential treatment program may be available. In rare and severe cases, a woman may be involuntarily admitted to the hospital under her province’s mental health act.

While Canada doesn’t have medical treatment programs tailored to pregnant women, support for new moms is becoming more available. In Toronto, Sheena’s Place offers a group counselling program called Mothers Living with ED, which is believed to be the only one of its kind in Canada. Women don’t need a referral or diagnosis to attend, and they can be at any stage of relapse or recovery. They gather to talk about issues that influence their eating disorders and what they’re struggling with on that day, but talk of how to get their pre-baby bodies back is strictly off-limits.

“What new mothers find [in the program] is release and acceptance,” says Berlin-Romalis. “A huge part of the struggle and suffering for people with eating disorders happens in isolation. We want women to feel comforted, supported and understood by knowing that there are other moms who are going through exactly what they are. When they come through the door, no one is judging them as a mother.”

Relapses with eating disorders are very common, but a recent study from Massachusetts General Hospital found that about two-thirds of women with anorexia or bulimia recover after treatment. However, the road to recovery is long: After nine years, less than one-third of those with anorexia had recovered; after 22 years, 63 percent were well. Recovery from bulimia happens faster, with about 68 percent in remission within a decade of seeking treatment.

Having children often changes the way women think about their bodies and their lives. Now that Tremblay is a mom, she is spending less time counting calories and more time playing with her daughter. “Having my daughter has lifted a heavy blanket off of me,” she says. “I can’t say that I’m carefree now—I am still very attuned to what I’m putting into my body and my exercise level, and I think I always will be. I’m just trying not to let it run my life because I don’t want to lose the things I’ve worked really hard for.”

Still, when Tremblay gets stressed, she starts bargaining with herself (eating one thing but skipping another), mentally tallying calories and pushing food around on her plate to make it look like she has eaten more. But with her daughter now at the table, she is trying to set a good example. If she feels herself slipping, she’ll practice the breathing exercises she learned from her psychiatrist and try to focus on the big picture: being healthy and happy for herself and her daughter.

“I can’t imagine seeing my daughter go through what I’ve gone through,” she says. “I know I will always have disordered eating thoughts in my head and that they will become stronger during times of stress, but I hope that I can use that knowledge and experience to help my daughter be confident, healthy and take care of herself.”

*Names have been changed.

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