I’m a Pregnant, Weight-Inclusive Dietitian, and This Is Why Weight Stigma in Prenatal Care Is So Harmful

Little did he know, I spent several years as a prisoner to scales in the throes of an eating disorder. I banned scales from my life about 10 years ago, which was a huge step in my recovery and reclamation of my life and body. This is why, while trying to get pregnant following a miscarriage (one of the most vulnerable and scary times of my life, might I add), I was shocked my doctor was offering the bold recommendation of buying a scale.

This is not rare. Health care is still weight-obsessed, and my doctor (and many others in reproductive care) still operate within this system. I know he wasn't intentionally trying to harm me, but if it hadn't been for my hard work in over 10 years of recovery (or knowledge of my personal boundaries), his comment may have sent me into a dangerous spiral.

Throughout my pregnancy, it's become clear just how steeped prenatal care is in diet culture—a belief system that values thinness over nearly everything. This ideal is closely related to weight stigma—or bias against people because of their body size. An example? Most mainstream resources I read about prenatal nutrition encourage eating enough, eating a variety of food groups, and gaining enough weight (which I appreciate as an eating disorder dietitian), but these directives always come with caveats like, "be sure to eat only 'healthy' foods," or "don't gain too much weight."

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Sometimes these resources will especially encourage larger-bodied women to become more rigid with food and focused on weight for the sake of "good pregnancy outcomes." But research shows it's weight stigma that often harms people living in larger bodies more than weight itself, per a February 2018 review in Annals of Behavioral Medicine. Yet weight stigma still shows up in all areas of health care and can prevent people from seeking medical treatment and getting adequate—and necessary—care, per July 2019 research in Primary Health Care Research & Development².

I acknowledge that as a thin, white woman, I can navigate this system relatively easily. But I've imagined how it would be if I didn't have this privilege. The experience with my OB/GYN may have been much worse.

How diet culture and weight stigma show up in prenatal care

From preconception to postpartum, a birthing person's weight often faces scrutiny—both in society and in prenatal health care. In fact, an August 2020 study of pregnant and postpartum women in BMC Pregnancy and Childbirth showed nearly 1 in 5 felt judged, shamed, or guilty because of their weight in health care settings, with obstetricians (OBs) as the most commonly cited source.

There's a significant focus on weight for expecting mothers, says Anna Whelan, MD, FACOG, a maternal-fetal medicine subspecialist and assistant professor of obstetrics and gynecology at University of Massachusetts Chan Medical School. "Pregnant people are told based on their initial BMI how much weight they 'should' gain," she says, and "people are often admonished if they gain above their recommended goals and are told they're harming their child."

But body mass index, or BMI, is a limited (and flawed) measurement. The formula was developed about 200 years ago by a Belgian mathematician to determine what an "average" (white) man should look like—not to determine a person's health, per Yale Medicine. It does not take into account other sexes, races, or ethnicities, yet by the 1970s, it was one of the most common ways doctors and insurance companies assessed a person's "health" and made diagnoses, per the Harvard T.H. Chan School of Public Health. For example, a larger-bodied person in relatively good health may still be considered "sick" or "unhealthy" by some doctors if their BMI is above a certain number. BMI categories became pathologized, and still today, assumptions are made about a person's health based on this number.

"I've had clients denied fertility treatment⁴ because of their BMI [and] larger-bodied clients told they are 'too high risk' by OBs and referred out," says Emma Basch, PsyD, a clinical psychologist in Washington, D.C. "I've had clients receive infantilizing nutrition information from 'concerned' providers who assume they don't eat healthily or exercise [based on their BMI], and one client whose provider used fear tactics, saying she was going to harm her pregnancy if she didn't lose weight, with no data to back this up."

Unsurprisingly, the widely accepted weight-gain guidelines for pregnancy are based on BMI, per The American College of Obstetrics and Gynecologists. But "healthy weight gain during pregnancy is nuanced and complex," according to reproductive dietitian Rachelle Mallik, RDN, who defines it as "the amount that someone gains [while] regularly engaging in health-promoting behaviors in a way that's accessible to the individual." This means engaging in practices like:

• Eating meals and snacks regularly
• Incorporating a balance of food groups (i.e., carbs, fiber, protein, and healthy fat)
• Generally honoring hunger and fullness cues
• Moving your body regularly
• Getting decent sleep
• Going to prenatal visits

Of course, it's also important to acknowledge that weight can be linked to (but not the cause of) health complications—and this is no different during pregnancy. Not everyone in a larger body will develop health conditions as a result. Despite this, Dr. Whelan says some of her larger-bodied patients have been tested for gestational diabetes two or three times simply because their other doctors couldn't believe they didn't have it.

"People in larger bodies are told they're going to get gestational diabetes and preeclampsia, [and] while there is an increased risk, the majority of people in larger bodies will have healthy pregnancies," she says. "Those who do get gestational diabetes often feel they have failed, but [it's] caused by placental hormones and individuals have no control over this."

It's true—the causes of gestational diabetes are more complex than just overweight, and more commonly include the following, per the National Library of Medicine:

• Genetic predisposition
• Being over age 35 during pregnancy
• Having previously had a large baby (over 9 pounds) at birth
• Polycystic ovary syndrome (PCOS)
• Prediabetes

Instead of focusing on her patients' weight and BMI, Dr. Whelan says she looks at vital signs, like blood pressure and heart rate, along with lab results. While weight—especially from deep belly fat (called visceral fat)—is associated with higher risks of diabetes, heart disease, and stroke, per the Cleveland Clinic, it doesn't guarantee those diagnoses. Weight is only one piece of the larger health puzzle, and "shouldn't be used solely to assess risks of complications in patients," says Dr. Whelan.

If anything, September 2013 research in Intrapartum Care shows second-time, larger-bodied mothers without underlying health conditions, like pre-existing diabetes or high blood pressure, may have lower risk of birth complications than first-time, thin moms.

Weight is only one piece of the larger health puzzle. It "shouldn't be used solely to assess risks of complications in patients." —Anna Whelan, MD, maternal-fetal medicine subspecialist

Weight stigma affects women of color even more

Because of "intersecting factors such as racism, socioeconomic disparities, and cultural norms," weight stigma disproportionately affects women of color trying to conceive or while pregnant, says Kira Denney, LCPC, a national-certified counselor and co-founder of Pearl Wellness Practice. "These women may face additional layers of discrimination and pressure to conform to society's narrow beauty and health standards."

Unfortunately, rates of mistreatment by health care providers are consistently higher for pregnant women of color than white women in the U.S. (about 27 versus 18 percent, respectively), per a June 2019 study in Reproductive Health. According to the study, this mistreatment can look like being shouted at, ignored, or denied prompt treatment at doctor's appointments or in hospital settings. And "stereotypes experienced by individuals at higher weights, such as lack of education, laziness, and poverty, are experienced at exponentially higher rates by patients of color⁷ than white patients at similar body weights," Dr. Whelan says.

This can lead to a lack of adequate and quality care—increasing the risk of pregnancy complications and even death. "Maternal mortality rates for Black women are three or four times higher⁸ than for white women, [and] rates of preeclampsia are higher among individuals of color due to systemic racism and intergenerational trauma experienced by these populations," Dr. Whelan adds.

Ultimately, Black and brown women may feel increased pressure to maintain certain weight standards, and therefore miss out on care for themselves and their babies. They're harmed by both sexism and racism in medical care, says Linda Baggett, PhD, psychologist with Well Woman Psychology. "The harm multiplies, as they are having to navigate anti-fat bias, weight stigma, systemic medical racism, and gender bias, and the ways in which these systems of oppression intersect," she explains.

Why this style of care doesn't really work

While weight stigma in prenatal care (and health care in general) negatively affects everyone, it undoubtedly affects larger-bodied folks the most. Dr. Whelan says such hyper-focus on weight can lead to shame or even dangerous consequences for mother and baby. "Instead of approaching prenatal care as a collaborative effort between patient and provider, it puts focus on the health of the pregnancy as something that is entirely affected by body weight, and thus, if there is a complication, individuals feel it is a personal failing," she says.

"Weight stigma can lead to an individual's concerns being attributed to their weight and may lead to ignoring warning symptoms of problems. For example, larger people may be told they don't feel their baby move because of their body size, but this is not the case, and decreased fetal movement should be investigated carefully, as it could be a warning sign for fetal health," Dr. Whelan adds.

Other negative effects of weight stigma during pregnancy can include the following, per November 2020 research in Seminars in Reproductive Health:

• Decreased reproductive health care quality
• Mental health symptoms
• Poorer health behaviors
• Adverse pregnancy outcomes

Even conversations rooted in weight stigma and diet culture can lead to disordered behaviors with food and exercise, such as cutting calories and excessively exercising to try to control weight—in a time when calories and being gentle with our bodies is more important than ever. Research reflects this: An August 2019 study in Social Science & Medicine showed pregnant people facing weight stigma report increased unhealthy dieting and emotional eating behaviors.

Such conversations also put those with a history of eating disorders at risk of relapse. "I've had clients in recovery who are in smaller bodies feel pressure to track their food, change their diet, and have been triggered by doctors who insist on weighing them at all appointments," adds Dr. Basch. (PSA: You don't have to be weighed at a doctor's visit.)

Plus, shaming people about their weight doesn't even lead to weight loss in most scenarios. If anything, there's an association between weight stigma and excessive weight gain and retention in pregnancy and postpartum, along with increased depressive symptoms, per 2019 research in Health Psychology.

Of course, when it comes to physical health concerns, there is a link between higher body weight and conditions like gestational diabetes and preeclampsia, but it's not "causal," meaning, having a higher body weight doesn't cause (or mean all larger-bodied people will develop) such issues, according to Dr. Whelan. "There are other factors, such as prior history, underlying medical conditions, genetics, and placental factors which increase the risk of these complications," she adds. Instead of focusing on weight, she says "the best way to decrease risks is to focus on close monitoring and optimizing health, including pre-pregnancy blood pressure and blood sugar."

Weight stigma and diet culture also create the assumption that a lower weight is always "better." But an unhealthily low weight can lead to health complications, too. You can experience amenorrhea (loss of periods) and infertility, per the Mayo Clinic, or harmful pregnancy side effects including miscarriage, premature birth, fetal growth and development problems, and low birth weight.

How to safely navigate weight stigma in prenatal care

There are ways to safely navigate prenatal care, despite the presence of weight stigma. Here are some approaches I've found helpful as an expecting mother and weight-inclusive registered dietitian:

1. Consider learning how to eat intuitively while pregnant

Intuitive eating is a framework that helps improve your connection to your body's hunger and fullness cues. It guides you to challenge your beliefs around diet, weight, and emotional eating as a means to cope. It can also help you honor your body's natural state, your satisfaction with meals and snacks, and your overall health.

My intuitive eating practice has come in handy this pregnancy, especially in the first trimester when extreme nausea limited the variety of foods I could tolerate. It's also helped now in my third trimester, as my energy (i.e., calorie) needs are higher than they were pre-pregnancy. Instead of forcing myself to eat salads in the name of "health" (just the thought of one made me ill), I trusted my body to tell me what it could tolerate in those first three months—mostly carb sources like rice, pretzels, and fruit, and proteins like peanut butter, chicken, and yogurt.

Now as I prepare to give birth, I let my body tell me how much food it needs at each meal and snack, instead of counting every calorie. Of course, there are certain things you can't eat during pregnancy (like raw fish) and certain supplement requirements, but that can be woven into your prenatal intuitive eating practice.

2. Incorporate joyful movement

In listening to my body's needs, I've noticed it wants gentler forms of exercise while pregnant (like walking over running) and I trust that's what's best for me and my baby. Instead of worrying about it not being enough, or what others are doing while pregnant, I try to find joy in my movement. This helps "challenge harmful messages about 'ideal' pregnancy bodies and allows for space to celebrate the diversity of maternal experiences," says Denney.

Depending on what trimester you're in, your energy levels may wax and wane, and this can help you determine what kinds of movement are best for you. Sticking to exercises that make you feel joyful is important, so long as your doctor gives the "okay" that it's safe.

3. Find a new (weight stigma-free) care team, if necessary

One way to tell if a care team is right for you? Scan the initial paperwork you fill out, says Lucy Chapin, CNM, a certified nurse-midwife. "Does it make you feel shame or fear, or overly focus on weight? And check in with yourself after each appointment—did your care provider focus intently on weight or weight-related concerns?" If you're left feeling fearful or ashamed, chances are it's not the ideal place for you.

If you're looking for new providers, some helpful resources I recommend to find weight-inclusive care are:

• Health at Every Size (HAES) provider directory
• Bare Health's size-friendly doctor website
• Fatfriendlydocs.com (a list of fat-friendly health professionals)

And "if there are limited available providers where you live, seek out a HAES-aligned doula, [and] whether you are using an OB, midwife, or family practice physician, make sure that provider gives personalized and individualized care," Chapin says. You can also consider adding a weight-inclusive therapist or dietitian to your team to help support your health, nutrition, and body image in pregnancy.

4. Set boundaries and speak up at your appointments

Remember that you're allowed to set boundaries with your care team. For example, "you don't have to be weighed at each visit or you can choose to be weighed and not see your weight," says Dr. Whelan. I chose the latter suggestion—at my first midwife visit, I requested she blindly weigh me and only confirm that I'm gaining weight as the pregnancy progresses, because that's what felt most important to me.

"Let your health care team know that focusing on your weight is triggering and that you'd rather not discuss it unless medically necessary," Mallik suggests. "If you have a history of or active eating disorder, please discuss monitoring your weight with your health care provider."

And don't underestimate the power of speaking up. If you don't understand the recommendations your doctor is making, Dr. Whelan recommends asking them to clarify or explain it a different way. "Talk frankly with them about your concerns regarding weight and size. Make a list of your questions to ask your provider at each visit."

More specifically, if you're dealing with a medical condition during pregnancy, and you're feeling uncomfortable with the recommendations being made, Mallik suggests asking, "What treatment options would you recommend for someone with this condition in a smaller body?" If that feels too confrontational, you can ask, "What treatment options can you recommend besides weight loss or weight management?"

5. Surround yourself with support, both in-person and online

It's important to surround yourself with people who feel emotionally safe to you and support your choices throughout pregnancy—including how you care for your body. Baggett says bringing such a support person to prenatal visits can also be helpful, especially when navigating potentially triggering conversations.

Continuing that support with online sources is helpful, too. "I would strongly recommend expecting mothers to connect with resources that specifically address weight stigma in prenatal care, are fat positive, and evidence-based," says Baggett. Her favorites include:

• Nicola Salmon (@fatpositivefertility)
• Jen McClellan (@plussizebirth and @plusmommy)
• Ragen Chastain (@ragenchastain), who offers a helpful online workshop about navigating weight stigma at the doctor's office.

Baggett also recommends unfollowing or hiding triggering social media accounts, and curating your feed with more weight-inclusive prenatal content.

6. Understand your autonomy

We are conditioned to believe everything our health care providers say, but if something feels emotionally unsafe for you (like getting a scale was for me), you can choose to decline their recommendations (as long as, of course, it's not putting you or your baby in danger). The second my doctor told me to get a scale, I knew I wouldn't, to protect my mental health, recovery, and ultimately, my baby. But Basch adds an important note to keep in mind—of course it's easier to decline recommendations "if you're in a smaller body [and] hold thin privilege, and do not hold a marginalized identity."

Finally, I always remind myself I can choose what prenatal information to take in, and what to leave out. For example, I use a prenatal app that I love—primarily for strength-training exercises—which happens to include blogs and videos on topics like weight gain/nutrition that I skip because they use diet culture language. The bottom line is: Take what feels healthy for you and leave the rest.

—reviewed by Andrea Braden, MD, OB/GYN