Body Mass Index, Eating Attitudes, and Symptoms of Depression and Anxiety in

Pregnancy and the Postpartum Period

ALICE S. CARTER, PHD, CHRISTINA WOOD BAKER, MS,

AND

KELLY D. BROWNELL, PHD

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.

BMI body mass index; EAT Eating Attitudes Test;

CES-D Center for Epidemiologic Studies-Depressed
Mood Scale; STAI State-Trait Anxiety Inventory.

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-

From the Departments of Psychology, University of Massachusetts

Boston (A.S.C.), Boston, MA, and Yale University (C.W.B., K.D.B.)
New Haven, CT.
Address reprint requests to: Alice S. Carter, Department of Psychology, University of Massachusetts Boston, 100 Morrissey Blvd.,
Boston, MA. Email: alice.carter@umb.edu
Received for publication November 9, 1998; revision received
August 24, 1999.

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

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BMI, EATING ATTITUDES, AND AFFECTIVE SYMPTOMS

late pregnancy and 3 months postpartum, in eating
disorder symptoms, including concerns about weight
and shape. Concern about weight continued to increase to 6 months postpartum, to above the level
reported for preconception. Follow-up studies on eating disorder psychopathology in pregnancy have suggested that the positive behavioral changes that
women make in pregnancy are usually not sustained
after birth and may actually get worse compared with
prepregnancy (4).
Investigating associations between eating and
weight concerns and depression and anxiety may provide important information about affective or eating
and weight-related vulnerabilities in the postpartum
period. Eating and weight problems during the postpartum period may be exacerbated by elevated levels
of depression or anxiety. Alternatively, increased concerns about eating and weight, in addition to dieting
behavior itself, may contribute to anxiety or depression.
It is plausible to hypothesize that associations between weight concerns and affective symptoms of depression and anxiety may shift between pregnancy and
the postpartum period. Self-directed cognitions about
eating and weight seem to be less negative in pregnant
women, thus there may be a reduced association between weight, eating attitudes, depression, and anxiety compared with the postpartum period when shape
and weight concerns seem to be particularly salient.
The Reflected Self-Appraisal theory described by Ross
(20) poses that perceptions of being overweight have a
greater effect on depression when being overweight is
perceived to be less common, normal, and/or acceptable. Inversely, as acceptance of overweight increases,
its effect on depression should decrease. This theory
has not received empirical support; however, it is useful in comparing pre- and postnatal feelings about
weight. In pregnancy, when weight gain is more accepted and seen as externally driven (ie, attributed to
caring for the developing fetus), eating and weightrelated concerns may not be tied to depression and
anxiety. In contrast, in the postpartum period when
increased weight is no longer accepted and weight loss
is expected, weight and eating concerns may be associated with mood and/or anxiety.
Utilizing an existing data set, the aim of this study
was to prospectively investigate relationships between
maternal body mass index, eating attitudes, and symptoms of anxiety and depression in pregnancy and at 4
and 14 months postpartum. Specifically, we examined
three hypotheses: 1) that eating attitudes and BMI
would not be associated with symptoms of depression
and anxiety in pregnancy, but would be associated at
the two postpartum time points, 2) that women who

Psychosomatic Medicine 62:264 270 (2000)

were overweight at 4 months postpartum would be

more likely to have elevated symptoms of eating concerns, depression, and anxiety during the postpartum
phase, and 3) that BMI and eating attitudes would be
significant predictors of postpartum depression and/or
anxiety.
Methods
Participants and Procedure
The sample was comprised of 64 women who completed questionnaires at three time points: pregnancy, 4 months postpartum,
and 14 months postpartum. Mean age of the mothers was 30.9 years
(SD 6.4). The majority of mothers were Caucasian (81.0%), married or living with the babys father (98.4%), and middle class
(72.1% had an annual household income greater than $40,000).
With respect to education, 29.5% of the mothers had completed high
school, whereas 68.8% had completed college or college and graduate school. For 26 (40.6%) of the women, this was their first child.
Forty-five percent of the babies were female and 55% were male.
None of the mothers were taking psychotropic medications. Exclusion criteria included meeting a current diagnosis of substance
abuse or psychosis; however, no one screened for the study met
these criteria. The Structured Clinical Interview for the DSM-III-R,
NonPatient Edition (SCID-NP) (21) was conducted with a subset of
women (N 52) after both 4 and 14 month laboratory visits to assess
lifetime history of psychological disorders. Fourteen women met
criteria for lifetime history of depression, whereas eight women
reported lifetime histories of both depression and an eating disorder.
As part of a larger study focused on the impact of maternal
depression on early parent-child interactions and child behavior
(22), women were recruited from an Obstetric and Gynecologic
clinic in an ethnically and socioeconomically diverse health maintenance organization in an urban setting. Pregnant women were
approached by a research assistant and invited to participate in a
study about how mothers feel during pregnancy and how these
feelings relate to mothers and babies adjustment after birth. Consent was obtained at each assessment point. Women who agreed to
participate completed the pregnancy questionnaires between the
fifth and eighth months of pregnancy. Previous studies suggest that
eating concerns are more salient in the later months of pregnancy
(17). Mothers were asked to participate in two subsequent study
visits when their infants were 4 and 14 months old. The 4- and
14-month assessments included filling out additional questionnaires and participating in videotaped laboratory visits.

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

with maternal age (r 0.27, p .05); older women had

higher CES-D scores. Finally, maternal education was
associated with pregnancy CES-D, such that pregnant
women with less education reported more depressive
symptoms (F(1,59) 6.22, p .05).
No associations were found between demographic
variables and BMI, EAT total, or EAT Factor I scores.
Parity was not related to either prepregnancy or
4-month postpartum BMI (r values 0.02 and 0.10).
Criteria for demographic covariates consisted of association with outcome variables at least two time
points; no variables met this criteria.
Descriptive Statistics
Mean BMI for prepregnancy, reported retrospectively at 4 months postpartum, was 24.7 kg/m2 (SD
5.5); 22.0% of women had BMIs 27 kg/m2 and 12.5%
had BMIs 30 kg/m2. Mean BMI at 4 months postpartum was 25.6 kg/m2 (SD 5.1) with 26.6% of women
27 kg/m2, and 17.2% 30 kg/m2. Change in BMI
across time was analyzed using an ANOVA, repeated
measures design. Maternal BMI at 4 months after birth
was significantly higher than prepregnancy BMI
(F(1,63) 10.92, p .01). Pre- and postpregnancy BMI
were highly correlated (r 0.91, p .01). Means of the
EAT, CES-D, and STAI, as well as changes in these
variables across time, are presented in Table 1.
Associations Among Dependent Variables
Bivariate correlations were examined to test hypotheses regarding associations between BMI, eating
attitudes, and symptoms of depression and anxiety.
Consistent with previous findings, EAT scores, both
total and Factor I, were not associated with BMI at any
time point (28). Correlations were compared to assess
whether there were significant differences in associations between pregnancy and 4 and 14 months postpartum (Table 2). Steigers test for significance of dif-

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

TABLE 1. Means of the EAT, CES-D, and STAI in Pregnancy

and at 4 and 14 Months Postpartum (N 64)
Pregnancy

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.

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BMI, EATING ATTITUDES, AND AFFECTIVE SYMPTOMS

TABLE 2.

Pearson r values of BMI, EAT, CES-D, and STAI (N 64)

CES-D

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**

Note: Correlations in the same row with subscripts

* p .05; ** p .01.

a,b

or

c,d

differ significantly at p .05.

ference between two dependent r values without a test

in common (29) was used for correlations including
the EAT. For comparing correlations involving BMI, in
which two different variables were associated with the
same measure of BMI, Hotellings solution for comparing correlations with dependent samples (30) was
used.
BMI and Symptoms of Depression and Anxiety. As
predicted, measures of BMI (prepregnancy and
4-month postpartum) were not significantly correlated
with the CES-D or the STAI during pregnancy, but
there were significant associations at both 4 and 14
months postpartum (Table 2). Direct comparisons of
correlations involving BMI revealed significant differences in associations at different times. Correlations of
the STAI with BMI in the postpartum period were
significantly higher than those in pregnancy. Correlations of the CES-D with BMI were higher at 14 months
postpartum compared with pregnancy.
EAT and Symptoms of Depression and Anxiety. As
hypothesized, there were no significant relations during pregnancy between eating attitudes (EAT total),
dieting attitudes and shape concerns (Factor I), and
either the CES-D or STAI. Although the predicted associations were found between eating attitudes and
affective symptoms at 14 months postpartum, there
were no significant associations between the EAT and
the STAI or CES-D at 4 months postpartum. Comparisons of correlations involving the EAT and CES-D did
not reveal significant differences in associations at different times; however, the correlation between EAT
total score and the STAI was significantly higher at 14
months postpartum than in pregnancy.
Because of the relatively small sample size, we decided to control for Type I error for the correlational

Psychosomatic Medicine 62:264 270 (2000)

analyses post hoc by comparing the ratio of significant

to nonsignificant results. Using this approach, risk of
Type II error could be minimized while maintaining
the ability to assess the probability that significant
results were due to chance. Of sixteen correlations
(Table 2) that were predicted to be statistically significant, 12 (75%) were consistent with the hypothesis; as
predicted, none of the eight pregnancy correlations
were statistically significant.
Comparison of Overweight and Nonoverweight
Women
To investigate whether being overweight imparts
unique risk for eating concerns, depression, or anxiety
in the postpartum period, one-way MANOVA, between-groups design, and discriminant function analysis were used to examine differences between women
with 4-month postpartum BMIs 27 (N 17) and
women with BMIs 27 (N 47). Women with BMIs
27 were classified as overweight (31). BMI at 4 months
postpartum was used to determine overweight status;
it was considered to be more reliable because it was
not reported retrospectively. Analysis revealed a significant difference between the two groups on EAT
total, CES-D, and STAI scores from both postpartum
time points (Wilks : F(6,57) 5.33, p .01). Structure coefficients of the discriminant function suggested that the variables that best differentiated the
two groups were 4-month postpartum STAI (0.65) and
CES-D (0.57), as well as 14-month postpartum CES-D
(0.89). Coefficients less than 0.50 were not interpreted.
Means and univariate tests for differences are presented in Table 3.
The difference between groups in depressive symp-

267

A. S. CARTER et al.
TABLE 3.

Means (SD) and Univariate Comparisons (ANOVA) of

EAT, CES-D, and STAI by Weight Groupa

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

Bonferroni type adjustment made to avoid inflated Type I error

rate.
* p .008.

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

symptoms at 14 months postpartum, over and above

previous symptoms of anxiety and depression. The
final model including both BMI and eating attitudes
was significant, as was the R2 (F(1,56) 10.18, p
.01) from step 2. The two variables significant in the
final model were 4-month postpartum eating attitudes
and BMI. Early postpartum eating attitudes and BMI
predicted later depressive symptomatology, even after
controlling for all of the other variables in the model.
Predicting 14-Month STAI. A similar hierarchical
regression was performed to assess predictors of 14month postpartum anxiety. Neither BMI nor eating
attitudes were significant predictors over and above
prior symptoms of anxiety.
DISCUSSION
To our knowledge, this is the first study to examine
relationships between eating attitudes, body mass index, depression, and anxiety in a partial prospective
design across pregnancy and the postpartum period.
Results confirmed the hypothesis that associations between eating attitudes, body mass index, and depression and anxiety are different in pregnancy compared
with the postpartum period. Although comparisons of
correlations did not reveal significant differences
across time in most associations involving the EAT,
the pattern of correlations suggests that relationships
might exist in the later postpartum period but not in
pregnancy or early postpartum.
One consistent pattern that supported our hypothesis was that measures of anxiety and depression were
not significantly correlated with eating concerns or
with BMI during pregnancy. This supports previous
research findings concerning changes in eating attitudes and behaviors during pregnancy. Negative selfdirected cognitions concerning eating, weight, and
shape seem to be less pervasive during pregnancy (16)
and consequently may be less apt to impact mood
and/or anxiety. Women may feel more justified to eat
during pregnancy to care for the infant. The meaning
of weight may be altered if changes in weight are
perceived to reflect growth of the developing fetus and
competence in the nurturing role of motherhood.
Thus, priorities and role identification may shift such
that eating concerns still exist but are not as important
and thus less likely to influence mood or anxiety.
Women may also experience weight gain and shape
change during pregnancy as socially sanctioned, and,
consequently, being overweight in pregnancy may feel
less stigmatizing. The Self-Reflected Appraisal theory
(20) proposes that when increased weight is accepted,
as perhaps it is perceived to be in pregnancy, higher
weight will be less likely to influence depression.

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BMI, EATING ATTITUDES, AND AFFECTIVE SYMPTOMS

The pattern of significant correlations with affective
symptoms at 4 and 14 months postpartum was different for BMI and for eating attitudes. Consistent with
predictions, BMI was associated with anxiety and depressive symptoms in both the early and later postpartum periods, and many of these correlations were significantly different from those in pregnancy.
Predictions for eating-related concerns were partially
supported. Eating attitudes were not associated with
affective symptoms during pregnancy, but were related at 14 months postpartum. The expected associations at 4 months postpartum were not found.
One of the questions raised by the results is why
BMI, but not eating attitudes, was associated with depressive and anxiety symptoms at 4 months postpartum, whereas both were related to affective symptoms
in the later postpartum period. BMI reflects the state of
ones body, whereas the eating attitudes measure contains more information about ones actual eating and
dieting behavior. As already proposed, in the early
postpartum period, the state of a womans body may be
related to affective symptoms because of distress associated with pregnancy weight gain and the desire to
return to prepregnancy shape and weight. In contrast,
womens eating behaviors may not be associated with
negative affect because the women may still be hopeful
that their behaviors will lead to weight loss or shape
changes.
Correlational findings related to BMI were supported by analyses comparing women with BMIs 27
to women with BMIs 27. Women in the overweight
group had higher ratings of depressive symptoms at 14
months postpartum and anxiety symptoms at 4
months postpartum. The group differences in depressive symptoms may be clinically significant, in that
overweight women had CES-D scores in a depressed
range (14). Thus, being overweight at 4 months postpartum may be associated with continued risk for depression in later postpartum, suggesting that intervention for women who are overweight and report
elevated depressive symptoms is warranted. Of interest, eating attitudes showed the expected associations
with depression, anxiety, and BMI despite the fact that
the observed EAT scores in this sample, which included eight women with a lifetime history of an eating disorder, were low relative to previously studied
college student and eating disordered populations
(28). More research with pregnant women who have
clinically elevated EAT scores is needed to fully understand the clinical implications of these findings for
eating disturbances. In addition, norms on measures of
eating attitudes and behaviors need to be established
for noncollege-aged populations.
The partial prospective nature of the data allowed

Psychosomatic Medicine 62:264 270 (2000)

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.
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