Halwes M, Battle C. Body dissatisfaction and disordered eating in the perinatal period: a narrative review. HPHR. 2023;64. 10.54111/0001/LLL2
The perinatal period poses risk to the body image and eating behaviors of individuals, particularly those in the postpartum period. Recent findings on the relation between body dissatisfaction and disordered eating throughout the perinatal period are reviewed here. The review includes information on updated theories of this relationship and its implications for such outcomes as breastfeeding or clinical eating disorders. Opportunities and recommendations for intervention strategies, cultural considerations, and patient populations meriting further attention are discussed.
Body image is one’s perception of their body and the feelings, thoughts, and emotions associated with that perception. The overall affect produced by how pleased one is about their body compared to their perceived ideal is known as one’s body satisfaction or dissatisfaction. Body dissatisfaction has been linked with a variety of adverse outcomes in perinatal populations, such as impaired maternal-infant bonding, pregnancy-related anxiety, and an increase in postpartum BMI.1–3 The present review outlines recent findings on body dissatisfaction in perinatal populations, particularly as it pertains to disordered eating outcomes.
In this narrative review, relevant studies were identified on PubMed and APA PsychINFO using terms related to the perinatal period (e.g., perinatal, pregnan*, matern*, prenatal, postnatal, postpartum) and body image or body dissatisfaction. Additional searches were conducted including search terms related to disordered eating (e.g., disordered eating, eating disorders, binging, purging) and eating disorders (e.g., eating disorders, anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder). Search results were limited to publications from the last decade (2013-2023) which were published in English. The lead author conducted literature searches and made decisions regarding inclusion with input from the senior author. Initial searches yielded 59 unique articles on body image and disordered eating in perinatal populations. The results were narrowed by relevancy. Criteria for relevancy exclusion included the following: not assessing a perinatal population, primary outcomes not including body image or disordered eating behaviors, assessment validation studies, or a focus on child outcomes. 44 articles were deemed viable for inclusion and were included in the present review.
According to a recent national survey, approximately 55% of women in the United States are somewhat to extremely dissatisfied with at least one aspect of their body.4 Pregnancy leads to significant bodily changes, and some pregnant individuals experience changes in their feelings about their body during this time. The “ideal body” that is valued in perinatal populations is often different from that which is idealized in nonpregnant populations. Qualitative studies reveal that the idealized pregnant body has a distinctly round stomach, non-excessive weight gain, and a swift return to the pre-pregnancy body during the postpartum period. In early pregnancy, body image is also influenced by the concern that others will believe they are simply gaining weight until they confidently look to be “showing.”5,6 Qualitative interviews on perinatal body perception revealed that body dissatisfaction may be linked to a variety of changes during the perinatal period: modified self-identity, shifting feelings around sexuality, or feeling a loss of control over one’s body.7 Unfortunately, these sentiments may be negatively impacting the body image of a sizable portion of perinatal individuals. In a recent study of 161 pregnant and postpartum respondents, over half expressed that they were dissatisfied with their body image.8
Although prior research suggested that overall body dissatisfaction tends to be stable throughout the pregnancy, research in the last decade has challenged this finding.9–11 Recent longitudinal data suggests that body image satisfaction for individual components of the body may change throughout pregnancy.12 For example, an individual might become less dissatisfied with their complexion but increasingly dissatisfied with their physical strength as pregnancy progresses. Additional evidence suggests that some women may even experience a decrease in body dissatisfaction during pregnancy, perhaps due to an increased focus on bodily function rather than aesthetic or due to the legitimized weight gain. Further evidence from longitudinal research suggests that body dissatisfaction does indeed change through the course of pregnancy, perhaps in relation to how much an individual has internalized the thin-ideal.13
There has been increasing attention to the role that social media may play in perinatal body dissatisfaction over the last decade. A 2016 study found that having a Facebook account was associated with increased body image concerns, and perhaps unsurprisingly, users who spent more time on Facebook also reported increased body dissatisfaction.14 In another study, only 5 minutes of exposure to pregnancy- or postpartum-related media content was associated with poorer body image in pregnant individuals. Interestingly, the postpartum group did not report similar impairment after this length of exposure.15 Much of the research thus far on the influence of social media on body image supports the social comparison theory, in which judgments are made on the basis of comparison to others.16 However, some research has suggested the influence of social media on body dissatisfaction also fits well into the tripartite model, which posits that body image and eating outcomes are influenced by family, peers, and the media and are mediated by thin-ideal internalization and social comparison. In one study of 252 postpartum individuals, nearly half reported that their body image was negatively influenced by social media use.17 Fortunately, there is also evidence from a recent experimental study that manipulated the type of pregnancy- or postpartum-related social media content (thin-and-toned ideal versus a more realistic range of body shapes and sizes) viewed by 261 women. This study found that exposure to body-positive content – that is, content that represents a diverse range of realistic body shapes – may improve body image,18 suggesting that social media may have a particular utility in potential interventions.
Much of the previous research on body dissatisfaction has pointed to the postpartum period as particularly high risk. Pressure to “bounce back” to one’s pre-pregnancy body has been frequently reported as an influence on postpartum body dissatisfaction,7 which is an often unattainable ideal. In support of the tripartite model, body dissatisfaction in the postpartum period is influenced by media, peers, and partners; family influence has also been found to have a direct influence on postpartum body dissatisfaction.19,20 Partners and families may be influencing postpartum body dissatisfaction through their interactions with new moms; intimate relationships that are very critical may negatively influence body image, whereas supportive relationships may be protective. However, more research is needed to understand these influences throughout the course of the postpartum period.
Empirical evidence linking body image and disordered eating behaviors has been robust and consistent across a range of populations.21 This relationship is also observed in perinatal populations, which presents particular concerns for both mom and baby.22,23 Previously, the literature has suggested that poor body image may negatively affect perinatal eating attitudes and behaviors. Particularly for individuals with a high BMI, gestational weight gain and the perceived pressure to bounce back from weight gain in the postpartum period can motivate undesired behaviors, such as restrained eating and emotional eating.24–30 This type of dissatisfaction with weight is an element of negative body image that has been associated with restricted eating, feeling out of control when eating, and emotional eating.31,32
Eating disorders as defined in the DSMV include a range of clinical disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, rumination disorder, and pica. In addition to eating behaviors that meets criteria for these specific disorders, subclinical eating pathology can also be clinically relevant and harmful, especially in the perinatal period. Subclinical eating pathology during the perinatal period encompasses a variety of attitudes or behaviors, including: a fear of gaining weight during the pregnancy, restrained eating, binging, and emotional eating. In addition to negative body image, dysfunctional eating behaviors during pregnancy are also associated with having a higher BMI, poor marital relationships, perfectionism and negative attitudes toward the pregnancy.30,33 And similar to findings on body dissatisfaction alone, the postpartum period signifies a period of particular vulnerability to disordered eating.34 In a prospective cohort study of 249 women, restrained eating and concerns about body shape increased in the postpartum period. In one model, disordered eating behaviors like these are most strongly predicted by body dissatisfaction.35 This model found support for the negative relationship between self-compassion and disordered eating, which may help to inform potential intervention approaches.
Social comparison appears to be particularly relevant in understanding the relationship between body dissatisfaction and disordered eating among postpartum individuals. Thompson and Bardone-Cone36 found that rather than comparing oneself to celebrities or peers, postpartum individuals are most often engaging in self-oriented comparison, comparing their postpartum body to their pre-pregnancy body. This self-oriented comparison explained the variance in eating pathology, dietary restraint, and body image concerns. This same group expanded on their original findings when they found evidence that self-compassion acted as a buffer in this relationship between self-oriented comparison and eating pathology.37
There are mixed findings on whether individuals with an eating disorder history, past or current, may see improvements in body image and eating disorder symptoms during the perinatal period.38–40 One study of 18 individuals with current eating disorders and 128 controls found that body dissatisfaction did not improve for either group during pregnancy, but that it improved in women with eating disorders during the postpartum period compared to pre-pregnancy levels.39 However, in one study comparing the postpartum experiences of individuals with past (n=29) versus current (n=31) eating disorders, both groups improved in eating disorder symptoms by the third trimester but during the postpartum period, individuals who had previously recovered from their eating disorder were presenting symptoms comparable to those with current eating disorders.38 Similarly, a meta-ethnographic review of 11 studies found that many individuals return to previous eating disorder behaviors and thoughts during the postpartum period, when so many women feel pressure to lose weight.40
Recent literature has suggested there are negative implications of postpartum body dissatisfaction and disordered eating behavior on breastfeeding.41 In one study testing a model proposed by Rodgers et al.,42 increased body dissatisfaction and appearance-related barriers to breastfeeding in a sample of 151 postpartum women predicted both disordered eating symptoms and poor perceived breastfeeding self-efficacy. Objectification theory has been suggested as a useful framework to interpret these findings; this theory posits that an individual views themself more in reference to aesthetic than function,43 which may explain why appearance-related barriers predict breastfeeding behaviors in some individuals. Rodgers et al.44 later expanded on the original model to include partner influences and thin-ideal internalization. The model only explained 13-15% of the variance in exclusive breastfeeding; the authors recommend investigating such additional elements as parity and the maternal pressure to return to work as potential factors influencing breastfeeding beyond body image. Moreover, individuals with clinically significant eating disorder symptoms report early breastfeeding discontinuation and lower breastfeeding self-efficacy.45
Findings from the last decade are consistent with previous findings that perinatal populations are at high risk for poor body image, which may be associated with disordered eating behaviors—particularly in the postpartum period. While there have been mixed findings on which trimesters of pregnancy, or which forms of social comparison may present the most risk, the postpartum period has consistently emerged as the most vulnerable time for body dissatisfaction. Moreover, for individuals with a history of an eating disorder, the postpartum period is a particularly vulnerable window for a reuptake of disordered eating behaviors. Several critical issues for future research are apparent. Specifically, we recommend attention to the following areas: (1) tailored interventions are needed to address body dissatisfaction and eating behaviors throughout the perinatal period; (2) future research should attend more adequately to understanding cultural context of body image, body dissatisfaction, and eating behaviors in the perinatal period; (3) research should more systematically include populations that are underrepresented or missing from the current literature, including sexual and gender minorities, young adults and adolescents, and individuals who experience alternative ends to pregnancy. We discuss each of these areas below.
There have been some physical activity-based interventions designed for the perinatal period which have found small improvements in body image; however, not all interventions have shown improvements.46–49 Greater work is needed in this area to develop and test interventions that are most effective in targeting body image and subsequent disordered eating outcomes. 21 These physical activity interventions in the broader perinatal population that have produced secondary improvement in body image may be able to be modified to address body image specifically (in discussion, goal-setting, or the structure of the intervention itself). These interventions may then need further validation or alterations for populations with past or current eating disorders.
Additionally, findings reviewed here may inform a variety of approaches to intervention development, perhaps by restricting social media consumption during pregnancy in an effort to reduce social comparison. Specific to the high-risk postpartum period, there is some evidence that women who are more informed in advance about postpartum bodily changes and intuitive eating (eating behaviors guided by one’s hunger and satiety cues) during the postpartum period report less body dissatisfaction,17,50 suggesting that perhaps there is a use for education-based interventions. Further, it is theorized that body image interventions should not only focus on reducing negative body image but also on promoting positive body image. Positive body image is thought to be a distinct construct from negative body image (rather than on the same continuum) and characterized by a variety of factors, including an appreciation for one’s body and a flexible perception of one’s body that incorporates new information in a protective manner.51 Interventions which not only attempt to reduce body dissatisfaction but also to promote body positivity may see better outcomes for body image and its associated self-esteem and self-efficacy. Thus, we recommend that future interventions with perinatal women examine the impact of an explicit focus on body positivity.
Following the development and testing of interventions for body dissatisfaction in the perinatal period, providers and policymakers will be integral to the dissemination or adoption of empirically supported interventions, including access to targeted intervention programs. It will also be critical to update education and training for providers who interact with perinatal women so that high-risk patients can be identified and support resources can be shared appropriately.
Over the last decade, research on body image and disordered eating in the perinatal period has been conducted by researchers across the globe. In the present review alone, we have incorporated literature from Australia, Germany, Iran, Japan, Pakistan, South Korea, and the United States. Culture is known to affect rates and presentations of eating disorders in the larger population.52,53 and yet many studies of perinatal body image or disordered eating do not explicitly examine this or provide context for how cultural factors may shape their specific findings. It is important to acknowledge cultural variation that may be contributing to some of the contradicting findings on perinatal body dissatisfaction and its associated outcomes, such as breastfeeding.54 While some authors have defined the specific body ideal held in the population on which they are reporting, there may yet be additional considerations to be made when interpreting findings. For example, family influence or the pressure to return to work may be influencing the relationship between perinatal body dissatisfaction and disordered eating; such influences are sure to be influenced by culturally linked expected family dynamics, typical maternity leave experiences, or local health education, which may differ by country. Variations in larger systemic contexts may be contributing to the contradicting findings, particularly on the course of body dissatisfaction and eating behaviors over the postpartum period. Interpreting findings with a sociocultural lens may help to parse through existing contradictions or identify new directions for research.
Sexual and Gender Minorities
While not specific to the perinatal period, research suggests that the prevalence of body dissatisfaction in sexual and gender minority (LGBTQIA+) populations is similarly high to rates of the overall US population, although some studies have found that sexual and gender minority individuals have been found to be at risk for disordered eating behaviors and clinical eating disorders.55–57 Sexual minority young adults are 1.5 times more likely to engage in unhealthy weight control behaviors and the lifetime prevalence for anorexia nervosa, bulimia nervosa, and binge-eating disorder is higher among sexual minority adults than cisgender heterosexual adults.56 Thus, it is important to understand whether or not sexual or gender minority individuals may face similar levels of risk during the perinatal period, or if there may be lower risk due to some protective factors, or higher risk. More research is also needed to capture the perinatal experiences beyond those of heterosexual, cisgender women. Particularly relevant to the introduction of partners into contemporary models,19,44 research should seek to understand how well such models fit a variety of partnerships and family structures.
Young Adults and Adolescents
Although limited, there is research on body image and eating outcomes for adolescents and young adults in the perinatal period, although much of it is conflicting.58 There is evidence that gestational weight gain may even positively impact body image in some young adults,59 but yet the risk for adverse outcomes on body image and eating after the pregnancy remains consistent with older populations.60 The contradicting findings for this age group suggest additional research is needed to clarify these associations and better document the experiences of younger individuals who are pregnant and postpartum. A better understanding of the factors that may buffer young adults from some of the negative impacts of gestational weight gain on body image during pregnancy could unveil potential opportunities to intervene with a wide range of ages.
Individuals Who Experience Alternative Ends to Pregnancy
Findings over the last decade support the notion that the postpartum period is the most high-risk perinatal timeframe for body dissatisfaction and adverse eating outcomes, in populations with or without clinical eating disorders. As individuals have reported in the qualitative literature, this may be influenced by stress, pressure to return to work, pressure to bounce back, or because they feel engaging in disordered behaviors no longer puts their pregnancy or developing child at risk. Individuals who experience a pregnancy termination, miscarriage, or stillbirth may experience similar pressures to return to a pre-pregnancy body or a freedom to return to disordered behaviors after a pregnancy has ended. Notably, there is evidence to suggest that among individuals with an eating disorder history, the way one feels about the pregnancy may influence risk for disordered eating behavior in the perinatal period.61 Such considerations should continue to be made for individuals who do not carry a pregnancy to term.
Body dissatisfaction is a prevalent issue for individuals across the globe, and the clinical presentation and unique risks of body dissatisfaction – including associated experiences of disordered eating – are critically important to understand for individuals who are pregnant or postpartum. Over the last decade, research has supported the relation between body dissatisfaction and disordered eating behaviors in the perinatal period. Individuals are particularly vulnerable during the postpartum period, especially those with a past or current clinical eating disorder. Further research is needed to understand this relation in currently underrepresented populations and within the context of cultural influence. Additional findings will inform the development of intervention procedures for those at risk and will help promote the provision of more informed and sensitive care.
The author(s) have no relevant financial disclosures or conflicts of interest.
Ms. Halwes is a Research Assistant working with Dr. Cynthia Battle at the Warren Alpert Medical School at Brown University. She recently completed her undergraduate training at Vanderbilt University with majors in Honors Psychology and Child Development.
Dr. Battle is a Professor of Psychiatry & Human Behavior at the Warren Alpert Medical School of Brown University and Associate Director of the Psychosocial Research Program at Butler Hospital. Her research focuses on women’s mental health, in particular developing and testing novel non-pharmacologic interventions for mental health conditions during pregnancy and the postpartum period. She received her Ph.D. in clinical psychology from the University of Massachusetts Amherst and completed NIH-funded postdoctoral training in treatment intervention research at Brown University.