[PREVIEW] "Is My Body Too Big To Be Pregnant?"

When your providers are emphasizing weight to you, I think this is something you can feel free to push back on and say, “Look, if I am at higher risk, we don’t know that the problem is really my weight—or the care you’re going to give me because of my weight.” 

Hello and welcome to Burnt Toast! This is the podcast about diet culture, fatphobia, parenting, and health. I’m Virginia Sole-Smith. I’m the author of The Eating Instinct and the forthcoming Fat Kid Phobia.

This is the monthly subscriber-only episode where I answer your questions. So thank you to all my paid Burnt Toast subscribers. I love you. Let’s get right to it.

Q: I’m 20 weeks pregnant and trying to navigate mainstream healthcare’s view that my body is too big to have a healthy pregnancy. I can’t believe how stuck my providers have been on my weight. Do you have any advice for dealing with this experience? 

The first resource I’m going to point you to is Plus Mommy. The blog, the Instagram, the podcast, all created by Jen McLellan, who is a mom in a larger body, a really tremendous advocate, and super knowledgeable about these issues. Plus Mommy is your first stop when you are educating yourself as a pregnant person in a bigger body, who, because of our very fatphobic medical system, is going to have to do some extra labor of self-advocacy during this experience.

Also, I forgot to say congratulations. Congratulations! This is wonderful news. So sorry for skipping over that and getting right to the resources. 

Next, I wanted to just own that I don’t have personal experience with this because I was still straight-sized during both of my pregnancies. I was sort of on the line with the second pregnancy, but my providers did not really focus too much on weight. (It was a high-risk pregnancy for other reasons. So, they were distracted, I guess.) I have a fair amount of thin privilege when it comes to this conversation. I haven’t had to advocate for myself in a pregnancy setting around weight and health care.

But even though I don’t have lived experience for you on this, I did spend a long time reporting on the research on weight and pregnancy outcomes for a feature I wrote for The New York Times Magazine. (TW for anyone dealing with infertility because it is about weight stigma in the infertility industry specifically. Although ultimately a hopeful story for the moms I interviewed in the piece, it definitely sketches out a lot of problems in that industry, like using BMI cut-offs to deny services, which is horrible and fatphobic.)

In the process of reporting that piece I went through all the research on weight and pregnancy outcomes, because that’s the main thing that comes up when you ask infertility doctors why they are denying care to women in larger bodies. There’s a lot of paternalistic language about is this person fit to be a mother? And who do we consider fit to be a mother?

Okay, so what does the research really say about weight and pregnancy outcomes? The first thing to know is so much of this comes down to provider bias. Larger pregnant people receive less careful prenatal care. That is because doctors and other health care providers have high levels of anti-fat bias. One study published in 2017 in the Journal of Patient Education and Counseling found that when researchers analyzed audio recordings of prenatal appointments between 22 providers and 117 pregnant people, they found that providers treating patients with higher BMIs asked those patients fewer questions about their lifestyle habits and shared less information. So, right off the bat, the conversations are shorter. They’re not getting as much information on these people. That’s going to impact the quality of care. That’s going to impact the pregnant person’s experience of being in that healthcare setting. It’s going to impact a whole bunch of stuff. 

An Australian study on prenatal health care found that doctors express less sympathy and less approval for their larger pregnant patients. I don’t see how you offer good health care to someone you feel no empathy or approval for. That’s a toxic dynamic to be in. I interviewed Sharon Bernecki DeJoy, an associate professor of health at Westchester University, who studies maternity care in the United States, for this piece. She told me that many providers see a larger woman and say things like, “‘Don’t eat cheeseburgers,’ even though she’s a vegetarian. There’s a lack of recognition of the evidence that shows you can be healthy and still have an ‘unhealthy’ BMI.”

I think that’s a really nice way of summing up how provider bias is informing the experience you’re having in your healthcare right now and is, across the board, informing the way that pregnant people in larger bodies are treated when they seek prenatal care. 

The data about whether weight itself does impact pregnancy is really murky. And that’s in large part because no one is controlling for that provider bias when they do these studies. When they start to try to pin down whether it’s the weight itself that causes some of the outcomes we see, they’re not factoring in the stigma question and how that’s impacting things. They’re also generally not proving causal relationships. This is a classic case of correlation is not causation. 

Another expert I interviewed for the piece is Chloe Zera, MD who is a maternal fetal medicine specialist at Beth Israel Deaconess Medical Center in Boston. Dr. Zera told me, “I wouldn’t go so far as to say we understand why maternal weight is associated with negative outcomes. Obesity can require special care, but a majority of women with BMI over 30 don’t have a complicated pregnancy and do have healthy babies.” This is someone whose job it is to care for high risk pregnancies and she is saying this is not something the data has nailed down. The reason she’s saying that is when we look—on a population level, which is what most of these studies do—we can find correlations between higher body weight and certain birth outcomes, but we’re still talking about really rare events. Even if the risk increases as body size goes up, we’re still talking about only a handful of occurrences. When Stanford University researchers analyzed more than 1.1 million birth records in California, they found the overall prevalence of stillbirths was five per 1000 deliveries. And among women with a BMI above 30, the rate ranged from seven to ten stillbirths per 1000 deliveries. So, that’s as much as a twofold increase, but still a rare event: Ten or fewer stillbirths per 1000 babies born.

I just want to underscore that Stanford study did not establish a causal relationship between BMI and stillbirths. It may be that the medical care that fat pregnant people are getting is increasing their risk for stillbirth, not their bodies. Some experts I talked to for this piece talked about how it can be harder for doctors to detect fetal complications in bigger bodies as a result of technological limitations. Mostly what they’re talking about is doing those early ultrasounds in larger bodies there can be limitations with what the wand picks up. This is technology’s fault! We need better ultrasound equipment for fat people. Once again, stigma compromises care. It’s not your body. 

When your providers are emphasizing weight to you, this is something you can push back on and say, “Look, if I am at higher risk, we don’t know that the problem is really my weight or the care you’re going to give me because of my weight.” If they say, “Yeah, we don’t feel like we can safely do your ultrasounds or perform your routine prenatal care,” then I want you to be with a doctor who can. I don’t want you to stay in a practice that doesn’t feel like they are equipped to deal with your body. You deserve better than that!

And I know that’s easy to say and not easy to do, because switching doctors, especially mid-pregnancy, is really stressful. Sometimes you’re limited by insurance and with travel logistics. But to whatever extent that is possible, or if there’s an option to bring in a doula or a support person who can help you advocate in these appointments, I think that’s worth doing. It’s certainly more worth doing than pursuing weight loss, which is suggested far too often for pregnant people in larger bodies. We know that won’t work. And we also know that weight loss during pregnancy can be dangerous.

Bottom line, Richard Legro, MD who is a professor of public health services and Chair of Obstetrics and Gynecology at Penn State University, told me, “There is no BMI cut point above which it is absolutely unsafe to have a pregnancy.” And I just want to add to that all of the doctors that I interviewed for this piece were super mainstream. They were not Health at Every Size advocates. They were not ready to throw out BMI. They were not radicalized on these issues at all and they were still saying, “No, we are taking this conversation too far.” So, whatever your providers are telling you, it is not evidence based, and it is not the final word on this conversation. I wish you luck in engaging in these conversations with your providers or, if you have to, seeking help from a different provider.

Q: What is your advice for a kid who has gotten extremely concerned about wasting food? My seven year old has a lot of anxiety about wasting things in general: scraps of paper, toys with missing pieces. A lot of that is a whole separate bag of issues, but when it intersects with food, it’s creating a dynamic I’m not really sure how to respond to. I want him to try new things and to eat as much as he wants and to listen to his own hunger cues. I have never, ever put an emphasis on clearing your plate or shamed the throwing away of food. To my mind, whether you eat it or toss it, it’s gone, but he’s gotten extremely obsessive about it. Anyway, if he gets full before all his food is gone, he sits there begging someone else to finish it so it doesn’t get wasted. And if no one will, he will often sit there, crying and stuffing bites into his mouth. It’s extremely frustrating and upsetting. I serve him small portions but some things come pre-portioned, like the Pillsbury biscuits at Thanksgiving dinner for example; bagels which I already serve cut into quarters to try to minimize anxiety over wanting more but not so much more, etc. I am struggling with neutral language to use when it comes to this. When he begs me to eat his food, I have gone as far to say, with mild frustration, that my body is not a trash can, that it isn’t a place to just throw food we don’t want and that I don’t want to eat food I’m not hungry for any more than he does, and that that’s okay. It’s okay to thank the food for being there and also decide we don’t want it. We’ve also talked about going back for seconds versus taking huge servings the first time around as a way to make food more, quote, save-able. But I don’t know. There’s so many feelings mixed into this issue: his, mine, and our culture’s. And in the moment, I always find myself casting about for neutral words and phrases to use to stop him from sobbing and cramming more food than he wants into his body, or begging and pleading with someone else to eat his scraps. 

A: Oh, this is really tough. I love that you said your body is not a trash can. I think that is a great answer and a great point to underscore with kids. I think, kids in general, in this age and younger, and probably older, too, have a tendency to view their parents as not quite human. Like, we should just be available to take their gross tissue or lick something off their face. Children do not expect us to have boundaries around this and I think it’s good to set some boundaries and say, I don’t have to put food in my body just because you don’t want it. This is a mutual body respect thing that I think it’s good to start cultivating.

You are also modeling intuitive eating to him, which is great. You are modeling trusting your body and respecting your body. I think you’re doing everything really right there and I’m sorry it’s not immediately fixing the problem. Like so many things with kids and eating, and with parenting in general, you can be doing the right thing and it doesn’t mean that the problem magically disappears. Progress is often slow. 

You mentioned that this is part of a constellation of anxiety issues, so of course my other advice would be to work with a therapist to help with some reframing and strategies. It sounds like you’re already on that, but a responsive feeding therapist could be a useful touchpoint or conversation to bring into this. I will link to a resource for that, if that’s something you want to explore. 

In terms of other more practical stuff to throw at you, I like that you said you’re already serving small portions. I would also involve him in seeing how you store leftovers, Maybe that can even be his job, to put the leftovers away in containers. Maybe you get creative together in how you’re going to repurpose the leftovers. Like if it’s fruit, stuff like a banana that he’s taken one bite out of—that’s how every banana is eaten in my house, one bite taken out of them and then the child is done with that. Those go in the freezer and we use them for smoothies. Amy Palanjian of Yummy Toddler Food has a good blog post about food waste that might give you some more ideas.

I think you want to engage him in being part of the problem-solving on all of this and not just say “Don’t worry, this is what’s happening to it.” Because it sounds like he’s wanting to control the food experience by wanting you to finish the food, so instead you can say “I’m not the solution, but here is the solution you can seek out.”

The other thing I’m going to suggest, if you’re not doing it already, is composting. You might even just try getting some books about composting. We have this funny board game my brother-in-law found called Rush to Recycle, where the whole point of the board game is to sort your recycling and your compost. My four year old loves it. Who doesn’t love a board game about recycling? So you could just start by talking about the whole process if you don’t want to actually do it, but I think it could be a good project to consider. You can compost most if not all of your food scraps and then the food is not wasted. It’s going to turn into dirt which is food for plants! This is something kids can grasp really easily and clearly and I think it’s super reassuring if they’ve got anxiety around this.

I do hate suggesting a project that does come with a little bit of work and mental load. There’s definitely a learning curve to composting and the equipment is a bit of an investment. You need a bin to keep in your freezer or under your counter where you collect all the kitchen scraps, like at meals and when you’re cooking. Here is the bin we use for under-counter collection and then the composting tumbler that we keep in our garden. That’s where, when the bin is full, you empty it into the tumbler and you spin it every once in a while. It’s amazing how much the tumblers can hold and you eventually get compost to use in your garden, if you care about that. Your kid will just feel reassured that it’s going to a “purpose,” whether or not you end up using the compost.

There are definitely cheaper ways to do it. If you don’t want to buy a lot of stuff, you could just have a gallon Ziploc bag you keep in your freezer where you’re adding food scraps and then eventually that goes out to a compost pile in some corner of your yard, if that’s an option. And there are also smaller scale composters, there are worm composters, which I bet a seven year old would be obsessed with. I don’t want my kids to know that’s a thing because I don’t really want to take on worms, but you can go to town with this. Corinne Fay, who works on this newsletter with me, endorses composting in a cardboard box, which looks so cool.

As much as possible, if you decide to compost to help manage his anxiety around this, make the composting his project. This is something he can learn about. He is, at seven, definitely old enough to be in charge of collecting everybody’s scraps and taking them out to the compost heap. I think that’s a great chore for a kid to be in charge of, and may help ease a lot of the anxiety around this issue. Because he will then be seeing the entire process from A-to-Z. From eating the food, to composting the food, to doing whatever you want to do with the compost later. You could find a community garden to donate it to or give it to a friend who gardens, that kind of thing, if you don’t have a personal use for it.

If composting is totally unappealing, my last suggestion is, if you don’t have one, maybe get a dog because dogs are also great at eating your leftovers! But also, again, you’re doing everything right, this may just need to be a storm you ride out. 

Q: Thanks so much for your newsletter. I originally subscribed because I was working as a nanny and trying to understand what the heck was going on with the kids at lunchtime and I’ve since been exposed to so much helpful anti-diet stuff through your work, which I’m very grateful for. I’m now in grad school and no longer a nanny. And I’m here to ask you a question about feeding yourself on a budget, especially while a single person.

I’ve been buying a lot of cheap TV-dinners lately, which I find much easier than taking on the mental load of meal planning. And honestly, I get more vegetables that way. Many of them are advertised as being for “two people,” clearly something intended for couples to share instead of cooking themselves. I often find myself taking that to heart and trying to make myself only eat one half of whatever it is and saving the other half for the next meal. I told myself I was doing it for many reasons, but that’s not true. It’s because I feel guilty eating two people’s worth of a meal in one sitting, even though I’m usually hungry enough for it. Can you offer any advice or guidance for thinking my way out of this food-limiting mindset? 

A: First, I think it’s great, you’re recognizing this for what it is. Yes, this is a food limiting mindset. You are limiting yourself and not honoring your hunger when you try to follow this very arbitrary rule. The next thing I want to say is, TV dinners are great! They are a super practical, easy way to feed yourself on the cheap. And I’m here for that. But a lot of these brands are marketed with a fair amount of diet culture rhetoric, or what I consider oppositional diet culture rhetoric. Like playing into the idea of “indulgence” and “being bad” and whatever. So either way, whether it’s like an “indulgent” TV dinner or a “responsible” TV dinner, they often play into this mindset. And that doesn’t make the food bad or the meals bad but it does mean you have to deliberately decide when you buy the meal to be tune out the noise.

So after you go grocery shopping, as soon as you get the TV dinners home, take them out of their packaging. If you need to, cut out the cooking time instructions or take a picture of just that part of the label on your phone. Do that, and then throw out the packaging, and especially throw out the nutrition facts and the portion size because you don’t need it. If you don’t want to completely throw it out, you could use a black Sharpie to scribble out all the calorie counts and all the other information that’s just going to mess with your head. And again, do that right when you get home. So then when you go to eat them later, it’s not a conscious decision you have to make during the process of feeding yourself. You’ve dispensed with that information. It’s not relevant to you. It’s not something you’re going to be looking at when you’re preparing the meal. So, hopefully just doing that will help you then eat the meal the same way you would eat the meal if someone had put down a bowl of pasta for the whole table and there were more people there. You would take a serving, but you would eat as much as you were hungry for. You wouldn’t be thinking I am only entitled to exactly one half or one quarter of this. 

If that doesn’t quite do it, some other thoughts on how to reframe this. Since you used to nanny, consider whether you would have policed a kid in the same way? A lot of kids’ snacks are sold in single serving pouches. But the person who decided the size of the granola bar or the yogurt tube, does not know your child and does not know their hunger. And they cannot say that this is not a two- or three-granola-bar-day versus a one-granola-bar-day. You deserve that same permission. Your hunger is valid. You eat these at a time of day when you’re really hungry. It completely makes sense to be as hungry as you are because that’s what your body is telling you. And you deserve to eat as much food as you’re hungry for. The food delivery framework should not change that. And no one else knows your hunger the way you do. Certainly not a faceless corporation that never met you before they wrote up their serving size information. So I hope that helps and I hope you enjoy your TV dinner tonight.

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The Burnt Toast Podcast is produced and hosted by me, Virginia Sole-Smith. You can follow me on Instagram or Twitter.

Burnt Toast transcripts and essays are edited and formatted by Corinne Fay, who runs @SellTradePlus, an Instagram account where you can buy and sell plus size clothing.

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Tommy Harron is our audio engineer.

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