Ep. 17/ Intuitive Eating In The Perinatal Period
Intuitive Eating in the Perinatal Period
By: Christine Wulbecker, LCSW, PMH-C And Suzie Hester, LCPC, PMH-C
In our current society, body image issues are highly prevalent in the general population. Body Image struggles are an additional challenge for folx in the perinatal time period (pregnancy and postpartum). In addition to our personal experience, research reveals that between one third to one half of pregnant people experience body dissatisfaction (Roomruangwong et al, 2017). It is so important for mental health professionals to talk about body dissatisfaction, as it often co-occurs with mood and anxiety disorders. It can be difficult to say with certainty which came first, the body image dissatisfaction or the mood/anxiety disorder, and is likely a case by case basis type of question. It can be a tricky thing to figure out for anyone, and particularly for perinatal folks dealing with body changes and stressors associated with pregnancy, birth, breast/chestfeeding, and parenting young children. One study showed “over 80% of study participants indicate that they would have been interested in participating in an intervention to address body image and eating concerns in the perinatal period if it had been offered to them” (Vanderkruik et al, 2022). This presents an opportunity for mental health clinicians to provide support and intervention during what can be a high-risk period of time.
Even for people not in the perinatal period, there is conflicting advice about what we should be aiming for in terms of the ever-elusive concept of health. One problematic feature of the current cultural context in regards to body image is the “thin ideal” and subsequent fatphobia, both internalized and externalized, despite the lack of any interventions that demonstrate evidence-based, long-term weight loss. Nevertheless, we are inundated with diet advice from everyone from our primary care doctors to our peers to social media gurus, all with their own ideas, experiences, and biases. The primary aim of the advice, it seems, is to help us be as small as possible.
It’s pretty easy to imagine body dissatisfaction arising for many folks in the perinatal period. Am I supposed to be “eating for two,” or is that a myth that will leave me “ugly” or “unhealthy” by societal standards? There is pressure to nourish another human being while avoiding toxins, processed food, sushi, and lunchmeat, with even random strangers on the hunt for unacceptable eating habits in pregnant people. Then, there’s the language of “bouncing back” and “losing the baby weight,” even when folx are breast/chestfeeding which certainly has hormonal implications due to lactation. In fact, one of the “selling points” to breast/chestfeed is that it will help us to lose weight! Additionally, we are inundated with images in media glamorizing thinness, and some studies show particular susceptibility to body dissatisfaction during pregnancy in response to these types of images (Coyne et al, 2017). Eating disorders are common among women of childbearing age; at least 5% of women have “inappropriate eating behaviors during pregnancy,” and 7.5% have an ED (Dos Santos et al, 2017). ED are “correlated with poor perinatal, obstetric, and neonatal outcomes including depression, birth weight issues, vomiting, hyperemesis, bleeding, and anemia” (das Neves et al, 2022).
Our relationships with our bodies and with food over the lifespan can feel very fraught. Since the perinatal period can be a high risk time for body dissatisfaction, it makes sense to be cautious not only about maintaining a certain weight, or exposure to certain substances, as current dietary culture is very focused on, but to also take care with our approach to eating more broadly. What are the goals and values the client is prioritizing in making choices about how and what to eat? Restricting certain foods in efforts to manage weight can increase risk of later binging behavior and weight cycling, rather than sustained weight loss as promised by many diets. As dietitian Natalia Stasenko says, “It’s impossible to feel control around a food if you are never allowed to get enough of it.” Restricting during the perinatal period can be particularly dangerous for clients who already have a history of disordered eating, but even for those who don’t, can contribute to complications in eating behaviors throughout life. It bears mentioning that many perinatal folks also play a role in providing foundational teaching for children in their household who are learning to eat and assess their own health and bodies.
Intuitive Eating is an approach which focuses on hunger and fullness cues rather than externally-imposed serving sizes or governing principles like “the clean plate club” that some of us were raised with. Studies have shown that utilizing a weight-neutral approach “is associated with statistically and clinically relevant improvements in physiological measures (e.g., blood pressure, blood lipids), health behaviors (e.g., eating and activity habits, dietary quality), and psychosocial outcomes (such as self-esteem and body image) … more successfully than weight loss treatment and without the contraindications associated with a weight focus” (Bacon et al 2011). Intuitive Eating has been correlated with “lower odds of high depressive symptoms, lowself-esteem, high body dissatisfaction, unhealthy weight control behaviors (e.g., fasting, skipping meals), extreme weight control behaviors (e.g., taking diet pills, vomiting), and binge eating” (Hazzard et al 2021). Specifically regarding the perinatal population, one study in 2019 found that pregnant participants “with intuitive eating styles … were more likely to have higher body image satisfaction … less disordered eating attitudes … and lower depressive symptomatology” (Lee et al). Additionally, IE has been shown to support pregnant individuals in managing glucose levels while facing gestational diabetes mellitus (Quansah et al, 2019).
The IE framework promotes self-regulation of body nourishment, supporting a healthy body through body confidence. As one becomes more present to self in the experience of eating, trust and confidence in the body can emerge. This is something that mental health clinicians can support within our scope of practice by teaching clients tools of the Internal Family Systems approach. Even with all of this information about the positives of IE, folx can be resistant to let go of diet culture and all of its pressures and messages. The idea of deconstructing our relationship and rules surrounding eating can leave us vulnerable due to the widespread cultural “buy in” of a system built on keeping us small. As a clinician, I find that clients are hesitant in trusting their hunger, satiation, and desires due to years of messages that breed mistrust. So, how do we break this cycle and change the narrative to one of trust?
One way can be to use the lens of Internal Family Systems to explore parts that are burdened by the years of living in diet culture. When doing this in therapy, it is important to explore what Self-Energy feels like by understanding the 8 C’s of Self. In his theory, Richard Schwartz describes the self as an inner leader that guides us towards our values. The self is marked by compassion, curiosity, calm, connection, clarity, courage, and creativity. When we know what self energy feels like in our memories, in daily life, and how it feels in our bodies; we can better understand the protector parts that are attempting to keep us safe by gaining acceptance in society. The rules and diets we live by are the active protectors managing our image so the exile does not feel the shame and hurt it has felt in the past. Our firefighter parts are the reactive protectors in our system that respond in a way to lessen the pain of an exiled part. Understanding our parts helps us better understand our own resistance in trusting our bodies and allows us to lead ourselves into a more helpful direction where we can grow and flourish.
It is important to honor the process of learning to place trust in self again. This process will take time and is not a linear process. Part of learning to trust our system is to respect that parts will struggle in different seasons and to attend to their needs. Some birthing persons find that pregnancy is triggering to their body shame, while others find comfort in pregnancy only to struggle in postpartum. Using IFS and IE to help our parts in the triggers allows us to understand the pressure and job the part is serving in the system. We can also help this part integrate into a new role that will support our systems to align with the values of self-energy and build intuitive trust in our body’s needs.
