Академический Документы
Профессиональный Документы
Культура Документы
AND
Objective: This report describes associations between body mass index (BMI; kg/m2), eating attitudes, and affective
symptoms across pregnancy and the postpartum period in a sample of 64 women. Methods: As part of a larger study,
women were recruited during pregnancy and followed prospectively to 14 months postpartum. Measures included
self-reported prepregnancy and 4-month postpartum BMI as well as pregnancy, 4-month, and 14-month postpartum
eating attitudes (EAT), depressive symptoms (CES-D), and anxiety symptoms (STAI). Results: During pregnancy,
symptoms of depression or anxiety were not significantly correlated with concurrent eating attitudes or measures
of BMI. However, at 14 months postpartum, measures of eating attitudes and both depression and anxiety symptoms
were associated. Measures of BMI were associated with depressive and anxiety symptoms at both 4 and 14 months
postpartum. Four-month eating attitudes and BMI predicted 14-month postpartum depressive symptoms, beyond
pregnancy, and 4-month postpartum measures of affective symptoms. Results suggested that overweight women
were at risk for elevated anxiety at 4 months and depressive symptoms at both 4 and 14 months postpartum.
Conclusions: These results provide evidence for a significant, albeit moderate, relationship between BMI, eating
attitudes, and symptoms of depression and anxiety in the postpartum period that are not present during pregnancy.
Key words: BMI, eating, depression, anxiety, pregnancy, postpartum.
INTRODUCTION
There is a large body of research on mood and
anxiety in pregnancy and the postpartum period, and
there has been an increase in studies on eating and
weight concerns during these periods of a womans
life. However, there is a paucity of research examining
associations among depression, anxiety, and eating
and weight concerns during pregnancy and the postpartum period. Moreover, there is limited research on
pre- and postnatal relationships between actual body
mass index, depression, and anxiety. Identifying factors that contribute to, or exacerbate, psychopathology
at this time in a womans life is important for both
maternal and infant health. Both postnatal depression
(13) and maternal eating problems (4 6) have been
associated with negative consequences for infant development. Moreover, understanding relationships between BMI and affective disturbance during this period could prove useful in the prevention or treatment
of postpartum weight retention, which has been iden-
264
0033-3174/00/6202-0264
Copyright 2000 by the American Psychosomatic Society
tified as a potential contributing factor to the development of weight disorders in women (7, 8).
Research has consistently described associations
between eating psychopathology and both depression
and anxiety (9 11), although causality remains a subject of debate. The association between weight itself
and both mood and anxiety is less clear (12, 13). Some
studies have found a direct relationship between obesity and depression, whereas others have found no
association or an inverse relationship (13, 14). There is
a need for research examining these associations during pregnancy and the postpartum period. A recent
study (15) provides support for this area of research,
reporting that during the third trimester of pregnancy,
higher deviations from medically ideal weight predicted increased dysphoria in European American
women.
Pregnancy is often accompanied by positive behavioral and attitudinal changes with regard to eating and
weight, but it seems that underlying concerns about
eating and weight persist (16) and may reemerge as
pregnancy progresses (17). The postpartum period is a
vulnerable time for weight concerns. In the early postpartum period, a majority of women are carrying more
weight than they did prepregnancy and, in contrast to
pregnancy, may no longer attribute the weight gain to
positive aspects of providing for a developing infant.
Hisner (18) reported that 75% of women were concerned about their weight in the first few weeks postpartum. Baker and colleagues (16) found that 70% of
women were trying to lose weight at 4 months postpartum compared with 8% during pregnancy; moreover, 57% of women who were not trying to lose
weight before pregnancy were engaged in efforts to
lose weight at 4 months postpartum. Thus, efforts to
lose weight in the early postpartum period are normative. Stein and Fairburn (19) found increases, between
Measures
Sociodemographic Variables. Information was gathered about
age, race, family income, maternal education level, and parity.
BMI. At 4 months postpartum, subjects reported current height
and weight as well as prepregnancy weight. Weights, reported in
pounds, were converted into standardized BMI units (kg/m2). Although self-reported weight and retrospective reports of prepregnancy weight are limitations of the present study, research documents that self-report and objective measures of weight are highly
correlated (23), even among pregnant women (15) who, like postpartum women, are experiencing shifts in shape and weight.
Depressive Symptoms. Participants completed the CES-D (24)
during pregnancy and at 4 and 14 months postpartum. The CES-D is
a 20-item self-report measure, typically used to assess depressive
symptoms in the general population. The measure has good internal
265
A. S. CARTER et al.
consistency ( of approximately 0.85 for the general population and
0.90 for a psychiatric population), excellent concurrent validity, and
good known groups validity (25). Because of potential confounding
with normative elevations in somatic symptoms in the prenatal and
early postnatal periods, the CES-D was modified by removing three
somatic items (Item 2. I did not feel like eating; my appetite was
poor; Item 11. My sleep was restless; and Item 20. I could not get
going). The pattern of results was similar when the data were analyzed using the 20-item CES-D.
Anxiety Symptoms. Participants completed the state subtest of
the STAI (26) in pregnancy and at 4 and 14 months postpartum. The
STAI is a widely administered self-report questionnaire with welldocumented psychometric properties.
Eating Attitudes. At all three time points, participants completed
the Eating Attitudes Test (EAT-26) (27). The EAT is a 26-item selfreport measure that can be used to identify eating disturbances in a
nonclinical population (28). The EAT has good reliability ( 0.90
for an anorexic group) and acceptable criterion validity (eating disorders vs. controls; Ref. 27). Three subscales of the EAT have been
identified (27). There is evidence to suggest that, although Factor I
scores are reliable in pregnancy and the postpartum period, EAT
Factors II and III may not be reliable for use with a pregnant population (16). Consequently, only total and Factor I scores were used in
this study. Factor I, dieting, assesses preoccupations with shape
and pathological avoidance of fattening foods.
Analytic Plan
Before testing, all variables were examined for normality. To rule
out influences due to demographic differences, associations between demographic information and all relevant variables were explored. Initial descriptive analyses examined changes in BMI, eating
attitudes, depressive symptoms, and anxiety across the three time
points. To investigate the hypothesis that eating attitudes and BMI
were not associated with symptoms of depression and anxiety in
pregnancy, but were associated at the two postpartum time points,
analyses investigated differences across time in the associations
among these continuous variables. To examine clinical significance
of overweight, we examined BMI as a categorical variable. Using
multivariate analysis of variance (MANOVA) and discriminant function analysis, we tested the hypothesis that women who were overweight were more likely to have elevated symptoms of eating concerns, depression, and anxiety. Multiple regression was used to test
whether BMI and eating attitudes were significant predictors of
postpartum depression and/or anxiety.
RESULTS
Demographics
Associations between demographic variables (race,
income, age, education, and parity) and BMI, eating
attitudes, and symptoms of depression and anxiety
were examined. One subject was missing information
on race, whereas three subjects were missing information on income and on education. An association was
found between income and 14-month postpartum anxiety (F(1,59) 6.74, p .01). Women with lower
incomes ($40K per year) reported more symptoms of
anxiety than women with higher incomes ($40K per
year; mean 40.4 and 32.6, respectively). Depressive
symptoms at 4 months postpartum were associated
266
EAT total
EAT Factor I
CES-D
STAI
4 Months
14 Months
Mean
SD
Mean
SD
Mean
SD
6.0
4.0
15.8
33.2
6.1a
4.7a
6.2
8.3
7.3
5.1
16.6
35.1
7.2b
5.0c
5.0
11.6
6.7
4.5
15.6
34.6
7.0
5.0
3.9
11.0
Note: Means in the same row with different subscripts differ significantly by one-way ANOVA with repeated measures contrast: a,bsignificant at p .05 level and a,c significant at p .01 level.
BMI
Prepregnancy
4 months postpartum
EAT total
EAT Factor I
CES-D
Pregnancy
4 months postpartum
14 months postpartum
STAI
Pregnancy
4 months postpartum
STAI
Pregnancy
4 Months
14 Months
Pregnancy
4 Months
14 Months
.02a
.14a
.13
.13
.27*
.37**
.16
.12
.49b**
.55b**
.34**
.36**
.09c
.02c
.01c
.05
.29d*
.41d**
.17
.17
.31d**
.31d**
.30d**
.31**
.15
.23
.38**
.04
.01
.17
.18
.61**
.47**
.24
.19
.61**
.29*
.33**
.42**
a,b
or
c,d
267
A. S. CARTER et al.
TABLE 3.
Postpartum variable
BMI 27
(N 47)
BMI 27
(N 17)
F(1,62)
4-Month EAT
14-Month EAT
4-Month CES-D
14-Month CES-D
4-Month STAI
14-Month STAI
6.3 (7.1)
6.0 (7.1)
15.6 (4.0)
14.3 (3.0)
32.4 (8.3)
32.7 (10.6)
10.2 (6.6)
8.7 (6.3)
19.5 (6.4)
19.1 (4.2)
42.6 (15.7)
39.6 (11.0)
4.1
2.0
8.2*
24.9*
11.2*
5.3
toms may have clinical significance. In previous research, a CES-D score of 16 has been used as a cutoff
for depressed vs. a score of 15 for nondepressed
(14). At both 4 and 14 months postpartum, overweight
women had mean CES-D scores above 16.
Predicting Affective Symptoms at 14 Months
Postpartum
Hierarchical regression was used to assess whether
eating attitudes and/or BMI predicted symptoms of
anxiety or depression at 14 months postpartum. To
avoid multicollinearity, one measure of BMI (4 months
postpartum) and the EAT total score, which provides a
broader measure of eating disturbance than Factor I,
were included as predictors.
Predicting 14-Month CES-D. The first step of the
model included previous reports of depressive and
anxiety symptoms (see Table 4). These variables were
included because we were interested in the predictive
value of eating and weight-related concerns above and
beyond other significant predictors, which included
prior symptoms of depression and anxiety. Without
BMI in the model, EAT scores predicted depressive
TABLE 4. Summary of Hierarchical Regression Analysis for
Variables Predicting Depressive Symptoms at 14 Months
Postpartum (N 63)
Step 1 B
(SE B)
Variable
Pregnancy CES-D
4-Month CES-D
Pregnancy STAI
4-Month STAI
Pregnancy EAT
4-Month EAT
4-Month BMI
R2
F
Step 2 B (SE B)
Step 3 B (SE B)
0.10 (0.07)
0.12 (0.12)
0.04 (0.06)
0.11 (0.05)*
0.12 (0.07)
0.09 (0.11)
0.01 (0.06)
0.11 (0.05)*
0.24 (0.11)*
0.28 (0.10)**
0.26
5.11**
0.35
5.16**
0.10 (0.07)
0.06 (0.10)
0.04 (0.05)
0.07 (0.05)
0.15 (0.11)
0.19 (0.09)*
0.28 (0.09)**
0.45
6.43**
* p .05; ** p .01.
268
us to look at potential predictors of postpartum affective symptoms. This information could be valuable for
identifying women in pregnancy or early postpartum
who might be at risk for continuing or exacerbated
anxiety and/or depressive symptoms due to weight
status or concerns about eating and weight. Testing for
factors that predict depressive symptoms past 6
months postpartum is particularly important in light
of evidence that protracted maternal depression seems
to confer risk in mother-infant interactions (32). Although eating and weight-related factors did not seem
to be important predictors of anxiety symptoms at 14
months postpartum, both early postpartum eating attitudes and weight status were relevant for predicting
depressive symptoms. Our results suggest that there
may be value to identifying women who have significant eating-related concerns in the early postpartum
period. But the more valuable marker for risk of late
postpartum depressive symptoms may simply be a
womans BMI, with increased BMI imparting potential
risk. Although BMI at 4 months postpartum was included in the regressions, prepregnancy BMI could
also be considered a potential marker for risk given its
high correlation with postpartum BMI.
There were limitations to the study that need to be
addressed in future investigations. Ideally, body
weight would be assessed through objective means in
addition to self-report. Although self-reported weights
of both nonpregnant individuals and pregnant women
seem to be highly correlated with observed weights
(15, 23), it is possible that there are biases in selfreported weights among individuals who have experienced in the past, or are currently experiencing, significant eating concerns or symptoms of depression or
anxiety. It was unfortunate that we did not have information on womens weights at 14 months postpartum.
In addition, a comparison group of nonpregnant
women would allow us to rule out threats to internal
validity and assess whether the changes in relationships we observed were unique to the process of pregnancy and childbirth rather than simply the passage of
time. The demographic profile of the sample limits the
generalizability of the findings.
In summary, this study suggests the presence of moderate relationships between BMI and eating concerns and
both depressive and anxiety symptomatology in the postpartum period. BMI, as well as eating-related concerns in
the early postpartum period, may be potentially useful
predictors of depressive symptomatology in the later
postpartum period. BMI itself seems to be a particularly
important marker of risk for increases in maternal depressive symptoms in the first year after delivery. Although correlations with the EAT suggested the expected
pattern of association, comparisons between all but one
269
A. S. CARTER et al.
time point did not reveal significant differences. Research involving larger and more diverse samples is necessary to further explore associations between eating attitudes and depression and anxiety during pregnancy
and the postpartum period.
REFERENCES
1. Murray L. The impact of postnatal depression on infant development. J Child Psychol Psychiatry 1992;33:543 61.
2. Radke-Yarrow M, Cummings EM, Kuczynski L, Chapman M.
Patterns of attachments in two- and three-year olds in normal
families and families with parental depression. Child Dev 1985;
56:884 93.
3. Stein A, Gath DH, Bucher J, Bond A, Day A, Cooper PJ. The
relationship between postnatal depression and mother child
interaction. Br J Psychiatry 1991;158:46 52.
4. Lacey JH, Smith G. Bulimia nervosa: the impact of pregnancy on
mother and baby. Br J Psychiatry 1987;150:777 81.
5. Stein A, Fairburn CG. Children of mothers with bulimia nervosa.
BMJ 1989;299:777 8.
6. Stein A, Woolley H, Cooper SD, Fairburn CG. An observational
study of mothers with eating disorders and their infants. J Child
Psychol Psychiatry 1994;35:733 48.
7. Ohlin A, Rossner S. Trends in eating patterns, physical activity,
and socio-demographic factors in relation to post-partum body
weight development. Br J Nutr 1994;71:45770.
8. Rossner S, Ohlin, A. Pregnancy as a risk factor for obesity:
lessons from the Stockholm Pregnancy and Weight Development Study. Obes Res 1995;3:267S75S.
9. Brewerton TD. Toward a unified theory of serotonin dysregulation in eating and related disorders. Psychoneuroendocrinology
1995;20:56190.
10. Cooper PJ. Eating disorders and their relationship to mood and
anxiety disorders. In: Brownell KD, Fairburn CG, editors. Eating
disorders and obesity: a comprehensive handbook. New York:
Guilford Press; 1995. p. 159 64.
11. Grubb HJ, Sellers MI, Waligroski K. Factors related to depression
and eating disorders: self-esteem, body image, and attractiveness. Psychol Rep 1993;72:100310.
12. Friedman MA, Brownell KD. Psychological correlates of obesity: moving to the next research generation. Psychol Bull 1995;117:320.
13. Palinkas LA, Wingard DL, Barrett-Connor E. Depressive symptoms in the overweight and obese older adults: a test of the jolly
fat hypothesis. J Psychosom Res 1996;40:59 66.
14. Istvan J, Zavela K, Weidner G. Body weight and psychological
distress in NHANES I. Int J Obes Relat Metab Disord 1992;16:
999 1003.
270
15. Cameron RP, Grabill CM, Hobfoll SE, Crowther JH, Ritter C,
Lavin J. Weight, self-esteem, ethnicity, and depressive symptomatology during pregnancy among inner-city women. Health
Psychol 1996;15:2937.
16. Baker CW, Carter AS, Cohen LR, Brownell KD. Eating attitudes
and behaviors in pregnancy and postpartum: global stability
versus specific transitions. Ann Behav Med. 1999;21:143 8.
17. Fairburn CG, Stein A, Jones R. Eating habits and eating disorders
during pregnancy. Psychosom Med 1992;54:66572.
18. Hisner P. Concerns of multiparas during the second postpartum
week. J Obstet Gynecol Neonatal Nurs 1986;16:195203.
19. Stein A, Fairburn CG. Eating habits and attitudes in the postpartum period. Psychosom Med 1996;58:3215.
20. Ross CE. Overweight and depression. J Health Soc Behav 1994;
35:6378.
21. Spitzer RL, Williams JBW, Gibbon M, First MB. Structured clinical interview for DSM-III-R: nonpatient edition (SCID-NP, Version 1.0). Washington DC: American Psychiatric Press; 1990.
22. Carter AS, Garrity-Rokous, FE, Chazan-Cohen, R, Little, C,
Briggs-Gowan, M. Maternal depression and comorbidity: predicting early parenting, attachment security, and toddler socialemotional problems and competencies. J Am Acad Child Adolesc Psychiatry. In press 2000.
23. Stunkard AJ, Albaum JM. The accuracy of self-reported weights.
Am J Clin Nutr 1981;34:15939.
24. Radloff LS. The CES-D scale: a self-report depression scale for
research in the general population. Appl Psychol Meas 1977;1:
385 401.
25. Fischer J, Corcoran K. Measures for clinical practice: a sourcebook. New York: The Free Press; 1994.
26. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA.
Manual for the State-Trait Anxiety Inventory (Form Y). Palo
Alto (CA): Consulting Psychologists Press; 1983.
27. Garner DM, Olmsted MP, Bohr Y, Garfinkel, PE. The Eating
Attitudes Test: psychometric features and clinical correlates.
Psychol Med 1982;12:871 8.
28. Garner DM, Garfinkel PE. The Eating Attitudes Test: an index of
the symptoms of anorexia nervosa. Psychol Med 1979;9:2739.
29. Steiger JH. Tests for comparing elements of a correlation matrix.
Psychol Bull 1980;87:24551.
30. Walker HM, Lev J. Statistical inference. Austin (TX): Holt, Rinehart, and Winston; 1953.
31. National Institute of Diabetes and Digestive Kidney Diseases.
Understanding adult obesity, NIH Publication No. 94-3680. Bethesda (MD): National Institutes of Health; 1993.
32. Campbell SB, Cohn JF, Meyers T. Depression in first-time
mothers: mother-infant interaction and depression chronicity.
Dev Psychol 1995;31:349 57.