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Published in final edited form as: Appetite. 2025 Mar 28;211:107984. doi: 10.1016/j.appet.2025.107984

Emotion regulation difficulties during pregnancy mediate the relationship between childhood maltreatment and emotional, external, and restraint eating

Sara F Stein a, Alison L Miller a, Amy K Nuttall b, G Anne Bogat c, Joseph S Lonstein c, Maria Muzik d,e, Alytia A Levendosky c
PMCID: PMC12147652  NIHMSID: NIHMS2072495  PMID: 40158699

Abstract

Purpose.

Childhood maltreatment is a common and severe form of stress associated with compromised functioning in women including emotion regulation difficulties and eating behaviors associated with negative health outcomes. Although pregnancy is a sensitive period for women’s health, mechanisms by which childhood maltreatment may drive eating behaviors during pregnancy remain unknown. The aim of this study was to determine if emotion regulation difficulty was a mechanism by which women’s childhood maltreatment leads to emotional, external, and restraint eating during pregnancy and which types of maltreatment drive these associations.

Methods.

Women (N = 446) were recruited during pregnancy based on experiences of pregnancy stress, including intimate partner violence. They reported on history of childhood maltreatment and emotion regulation difficulties and eating behaviors in pregnancy. We tested if emotion regulation difficulties mediated associations between childhood maltreatment and emotional, external, and restraint eating in pregnancy.

Results.

Maternal childhood maltreatment was associated with greater emotion regulation difficulties and, in turn, greater severity of emotional, external, and restraint eating during pregnancy. Emotional abuse and neglect were each positively associated with emotion regulation difficulties and, in turn, all three eating behaviors.

Conclusions.

Emotion regulation difficulties may be a mechanism by which childhood maltreatment leads to emotional, external, and restraint eating during pregnancy. Interventions should address emotion regulation difficulties in women with histories of childhood emotional maltreatment and neglect as a way to mitigate these eating behaviors in pregnancy.

Keywords: Emotional eating, external eating, restraint eating, pregnancy, childhood maltreatment, emotion regulation

Eating behaviors that are characterized by eating in a manner unrelated to hunger have been identified as problematic or high-risk and associated with later negative health outcomes such as diet-related disease (Frayn & Knäuper, 2022; Kakoschke et al., 2017; van Strien et al., 2014). Emotional (eating in response to internal emotional cues), external (eating in response to external food cues), and restraint eating (efforts to restrict eating regardless of success) are three behaviors highlighted in this literature. Pregnancy is a time when these eating behaviors may be exacerbated given metabolic changes, changes to energy expenditure due to fetal growth, changes to food absorption due to GI track changes, nausea and vomiting due to HCG levels, and accompanying food cravings (Armistead et al., 2020; Cho et al., 2011; Thompson & Bardone-Cone, 2022). Despite known drivers of pregnancy eating changes eating, more than 50% of women gain an excessive amount of weight during pregnancy according to pregnancy weight gain guidelines (Kominiarek & Peaceman, 2017) and rates are increasing (Orloff & Hormes, 2014), suggesting the etiology of problematic eating in pregnancy is not yet fully understood. Although the relationship between weight and health is complex and likely mediated by multiple factors (Calogero et al., 2019; Tylka et al., 2014), excessive gestational weight gain as defined by these criteria has long-term health implications including associations with poorer women’s health 18 years later (Holland et al., 2015). Furthermore, pregnancy may be a particularly sensitive time for priming pathways of intergenerational transmission of eating behaviors from mothers to offspring. Eating behaviors during pregnancy have been associated with infant eating, for example (DeJesus et al., 2018; Marciniak et al., 2017). The current study examined two potential predictors of pregnancy emotional, external, and restraint eating: maltreatment experienced by women during childhood (henceforth, maternal childhood maltreatment) and emotion regulation difficulties during pregnancy.

Estimates suggest that more than one in three pregnant women have experienced childhood trauma, which is associated with negative eating behaviors in women (Demirci, 2018; Kong & Bernstein, 2009; Vajda & Láng, 2014). Pregnancy is also a time of added stressors (e.g. prenatal care; worries about unborn baby) and physiological changes that may increase emotional vulnerability (Thompson & Bardone-Cone, 2022). Yet, no work has explored how maternal childhood trauma and associated emotion regulation difficulties may underlie eating behaviors during pregnancy. Outside of pregnancy, emotional, external, and restraint eating are known negative outcomes of child maltreatment (Demirci, 2018; Kong & Bernstein, 2009; Vajda & Láng, 2014) and are hypothesized to be a form of coping to soothe trauma-related distress (Brewerton, 2011; Ruffault et al., 2018; Talbot et al., 2013). Studies of non-pregnant women have also shown that childhood trauma, particularly chronic interpersonal trauma like childhood maltreatment (Briere & Rickards, 2007; Ehring & Quack, 2010; Tull et al., 2007), is associated with emotion regulation difficulties (Badour & Feldner, 2013; Gruhn & Compas, 2020; Jenness et al., 2021). Childhood is a developmentally sensitive period and experiences during this time fundamentally shape neurodevelopment, determining the organization and function of the later adult brain (Halfon et al., 2018; Hambrick et al., 2019). As such, development of adaptive emotion regulation capacity is often interrupted in the context of childhood maltreatment, especially depending on the type of maltreatment experienced (physical, sexual or emotional maltreatment), with lifelong implications.

In studies of women who are not pregnant, emotion regulation difficulties have been associated with emotional, external, and restraint eating (Burns et al., 2012; Michopoulos et al., 2015; Moulton et al., 2015). In two independent samples of female college students (Burns et al., 2012; Michopoulos et al., 2015; Moulton et al., 2015), childhood emotional abuse was associated with increased emotion regulation difficulties and, in turn, eating disorder symptoms (Burns et al, 2012; Moulton et at., 2015). The third study (Michopoulos et al., 2015) examined a sample of primarily Black men and women (N=1,110) with low socioeconomic status and found that emotion regulation difficulties mediated associations between childhood abuse and emotional eating in adulthood. Despite this evidence, this research is limited in that, 1) two of the studies used convenience samples of female college students and focused on eating disorder symptoms, not the more common emotional, external, and restraint eating behaviors; 2) none of the studies considered the mechanistic pathway between childhood maltreatment and high-risk eating; 3) no research has examined these eating behaviors during pregnancy; 4) no studies have examined whether different types of childhood maltreatment (emotional, physical, and sexual abuse and emotional and physical neglect) might map onto to these eating behaviors during pregnancy.

Study Aims

The current study aims to address these limitations by examining whether emotion regulation difficulties are a mechanism by which childhood maltreatment leads to emotional, external, and restraint eating during pregnancy in a sample of women who experienced high pregnancy stress. We hypothesized that women’s childhood maltreatment would be associated with pregnancy emotional, external, and restraint eating, through emotion regulation difficulties. We then examined what types of women’s childhood maltreatment drive these associations through emotion regulation difficulties.

Methods

Participants

Participants were drawn from the Michigan Prenatal Stress Study (Levendosky et al., 2021), a prospective, longitudinal study of prenatal stress and mother and infant outcomes. The present study is a secondary data analysis and uses data from the first pregnancy assessment (M=17.64 weeks, SD=2.54; N=446), conducted in person at our research offices. This assessment, conducted when women were 15–17 weeks pregnant, provides an optimal window for studying eating behaviors during pregnancy. By this stage, first-trimester nausea has typically subsided (Jarvis & Nelson-Piercy, 2011), while fetal growth has yet to compress the stomach (Greenspan, 2018), which may slow digestion and reduce appetite. Women’s mean age was approximately 26 years (SD=4.27). Most women (90%) reported having received a high school diploma and more than half of the sample identified as women of color (54%).

Procedures

Women were recruited in several locations in central and southeast Michigan via flyers given out by OB/Gyn offices and posted in the community (e.g., WIC offices, laundromats, libraries, public parks). Recruitment also occurred via social media and a hospital registry of pregnant women. To be included in the study, women had to be 15–17 weeks pregnant with a singleton, 18–34 years of age, in a relationship with a man at some point during their pregnancy, and able to read and speak English fluently. As this is a vulnerable sample of women with pregnancy stress, eligibility also included endorsement of IPV in the past year or Medicaid eligibility based on household income in addition to endorsement of two or more family stressors occurring during pregnancy (i.e., family conflict, neighborhood violence, food insecurity or other money problems). Participants were excluded if they had any medical conditions or lifestyle factors known to affect salivary cortisol measures. Phone screenings determined study eligibility.

Measures

Childhood Maltreatment.

Women’s childhood maltreatment was assessed using the 28-item brief screening version of the Childhood Trauma Questionnaire (CTQ; (Bernstein et al., 2003), which has been shown to be valid and reliable (Bernstein et al., 2003; Cruz, 2023). Participants responded to items about experiences during their first 18 years of life on a 5-point Likert-type scale ranging from never true (1) to very often true (5). Example item includes, “I thought that my parent(s) wished I had never been born”. The CTQ generates five maltreatment type subscales: emotional (5 items, α=.90), physical (5 items, α=.87), and sexual abuse (5 items, α=.96) as well as emotional (5 items, α=.90) and physical neglect (5 items, α=.79). A total maltreatment score is calculated by summing the five maltreatment subscales (α=.95). Higher scores indicate greater childhood maltreatment severity.

Emotion Regulation Difficulties.

Women’s current emotional regulation difficulties were assessed using the Difficulties in Emotional Regulation Scale (DERS; (Gratz & Roemer, 2004), which has been shown to be valid and reliable (Fowler et al., 2014; Gratz & Roemer, 2004).. Participants respond to items on a 5-point Likert-type scale ranging from almost never (1) to almost always (5). Example item includes, “I experience my emotions as overwhelming and out of control”. A total score (α=.91) was calculated by summing all 36 items with reverse scoring as appropriate; higher scores indicate greater emotion regulation difficulties.

High-risk Eating Behavior.

Current eating behaviors at were assessed by the 33-item Dutch Eating Behavior Questionnaire (DEBQ; van Strien et al., 1986), which has been shown to be valid and reliable (Wardle, 1987). Women respond to each item on a 5-point Likert-type scale ranging from never (1) to very often (5). Example item includes, “Do you have an urge to eat when you are irritated?”. The DEBQ generates 3 subscales: emotional eating (13 items, α=.0.95) external eating (10 items, α=0.85), and restraint eating (10 items, α=0.91). Each subscale is calculated as a mean of corresponding items with reverse scoring as appropriate; higher scores reflect more problematic eating behaviors.

Covariates.

Covariates are recent trauma exposure (intimate partner violence victimization (IPV)) during pregnancy and demographic characteristics given known associations with emotion regulation and emotional, external and restraint eating (Hermes et al., 2021; Longmire-Avital & McQueen, 2019; Rosenqvist et al., 2022; Shriver et al., 2023).

Pregnancy IPV.

Experiences of IPV victimization occurring since the beginning of the pregnancy were included as a covariate and assessed using the physical and sexual IPV victimization subscales of the Severity of Violence Against Women Scale (SVAWS; (Marshall, 1992), which has been shown to be valid and reliable (Marshall, 1992). Participants responded to frequency of pregnancy IPV victimization acts by all intimate partners on a 4-point Likert-type scale ranging from never (1) to many times (4). Example item includes, “Held you down, pinning you in place”. The SVAWS generates physical, sexual, and threatened violence IPV victimization subscales. The current study created a total score of IPV physical and sexual victimization by summing items from the two respective subscales (α=.98), with higher scores reflecting greater frequency of physical and sexual IPV victimization.

Demographic risk.

A demographic risk score (Evans et al., 2013) was included as a covariate in all analyses. Women responded to questions on their race/ethnicity, income (determined by Medicaid eligible status), marital status, and education. Individual responses were coded dichotomously: a score of “1” was given if a woman endorsed being a racial/ethnic minority, had an income below the Medicaid cutoff, were single, and had a high school or less education. Scores ranged from 0–4, with higher values indicating higher demographic risk.

Data analytic strategy

We used Mplus (Version 8; (Muthén & Muthén, 2017) to test sequential mediation in to test indirect effects of women’s childhood maltreatment on pregnancy high-risk eating through emotion regulation difficulties, controlling for pregnancy IPV and demographic risk. We employed a bootstrap resample approach (Shrout & Bolger, 2002) to test indirect effects with the gold standard of 1,000 resamples (Hayes & Scharkow, 2013; Preacher & Hayes, 2008; Shrout & Bolger, 2002). This allowed us to construct bias-corrected bootstrap 95% confidence intervals around the product coefficient for inferring the indirect effects of mother’s childhood maltreatment via the hypothesized mediational pathway of emotion regulation difficulties on each eating behavior. Standardized confidence intervals (Cheung, 2009) and parameter estimates are reported. All path models were saturated. Mplus uses full information maximum likelihood estimation to account for missing data, which was determined to likely be missing completely at random (χ2 (48) = 61.97, p > .05).

Results

Descriptive statistics and correlations for variables are presented in Tables 1 and 2.

Table 1.

Descriptive statistics and bivariate correlations for study measures (N=446)

M (SD) 1 2 3 4 5 6
1. Childhood maltreatment 49.79 (21.20) -
2. Emotion regulation difficulties 86.48 (26.20) .26*** -
3. Pregnancy IPV 7.73 (14.46) .20*** .20*** -
4. Demographic risk 2.39 (1.23) .24*** .07 .13* -
5. Pregnancy emotional eating 1.17 (0.28) .06 .34*** .01 −.14** -
6. Pregnancy external eating 3.16 (.71) −.01 .24*** .02 −.06 .61*** -
7. Pregnancy restraint eating 1.07 (.26) −.06 .24*** −.07 −.27*** .30*** .06
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Note:

**

p<.01

***

p<.001

Table 2.

Descriptive statistics and bivariate correlations for study measures (N=446)

M (SD) 1 2 3 4 5
1. Childhood emotional abuse 11.54 (5.86) -
2. Childhood physical abuse 8.87 (4.73) .68*** -
3. Childhood sexual abuse 9.41 (6.58) .50*** .47*** -
4. Childhood emotional neglect 11.46 (5.33) .73*** .55*** .36*** -
5. Childhood physical neglect 8.59 (4.13) .64*** .58*** .38*** .68*** -
6. Emotion regulation difficulties - .28*** .17** .12*** .29*** .16**
7. Pregnancy IPV - .17*** .14** .18*** .15** .10
8. Demographic risk - .18** .21*** .19** .20*** .13*
9. Pregnancy emotional eating - .10* −.00 −.04 .10 .09
10. Pregnancy external eating - .05 −.03 −.04 .01 −.03
11. Pregnancy restraint eating - −.06 −.11* −.02 −.08* −.02
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Note:

*

p < .05

**

p < .01

***

p < .001

Associations of childhood maltreatment with eating through emotion regulation difficulties

Women’s childhood maltreatment was associated with emotion regulation difficulties during pregnancy (b =0.233, se=0.056, p<.001), which were, in turn, associated with pregnancy emotional (b= 0.363, se=0.052, p<.001), external (b =0.264, se=0.058, p<.001), and restraint eating (b =0.289, se=0.048, p<.001; see Figure 1). There was a significant indirect effect of women’s childhood maltreatment via difficulties in emotion regulation on emotional (95% CI [0.042, 0.143]), external (95% CI [0.028, 0.111]), and restraint eating (95% CI [0.031, 0.111]). All of the direct effects of childhood maltreatment on emotional, external, and restraint eating were not significant.

Figure 1.

Figure 1.

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Mediation model testing the effect of childhood maltreatment on high-risk eating through emotion regulation difficulties with standardized parameter estimates.

Note. *p<.05; p<.01; **p<.001. Control variable paths are represented with dashed lines. Covariances are represented with dotted and dashed lines

Associations of maltreatment types with eating through emotion regulation difficulties

Emotional abuse.

Women’s childhood emotional abuse was significantly associated with emotion regulation difficulties in pregnancy (b=0.189, se=0.089, p=.033; see Figure 2), which were, in turn, associated with pregnancy emotional (b=0.353, se=0.052, p<.001), external (b=0.249, se=0.058, p<.001), and restraint eating (b=0.314, se=0.049, p<.001). There was an indirect effect of women’s emotional childhood abuse via emotion regulation difficulties on emotional (95% CI [0.009, 0.137]), external (95% CI [0.008, 0.108]), and restraint eating (95% CI [0.007, 0.128]). All of the direct effects of emotional abuse on the three eating outcomes were not significant.

Figure 2.

Figure 2.

Open in a new tab

Mediation model testing the effects of five types of childhood maltreatment on high-risk eating through emotion regulation difficulties with standardized parameter estimates.

Note. *p<.05, **p<.001, ***p<.001. Non-significant direct paths between the maltreatment types and the high-risk eating behaviors were omitted for figure simplicity. Covariances are represented with dotted and dashed lines. All maltreatment covariances were significant at p<.001 (.37<b >.73). IPV victimization and demographic risk variable covariates were omitted for figure simplicity. Pregnancy IPV victimization was significantly associated with emotion regulation difficulties (b=.15, se=.07, p<.05) but was not significantly associated with any of the high-risk eating outcomes. Demographic risk was not significantly associated with emotion regulation difficulties or external eating but was associated with emotional eating (b=−0.152, se=0.047, p<.01) and restraint eating (b=−0.249, se=0.046, p<.001).

Emotional neglect.

Women’s childhood emotional neglect was significantly associated with emotion regulation difficulties during pregnancy (b=0.222, se=0.079, p<.01), which was, in turn, associated with pregnancy emotional (b=0.353, se=0.052, p<.001), external (b=0.249, se=0.058, p<.001), and restraint eating (b=0.314, se=0.049, p<.001). There was an indirect effect of women’s childhood emotional neglect via emotion regulation difficulties on emotional (95% CI [0.025, 0.142]), external (95% CI [0.020, 0.115]), and restraint eating (95% CI [0.020, 0.124]). All of the direct effects of emotional neglect on the three eating outcomes were not significant.

Physical and sexual abuse and physical neglect.

There was not a significant indirect effect of women’s physical or sexual maltreatment or physical neglect via emotion regulation difficulties on emotional, external, or restraint. Direct effects of these maltreatment types on the three eating outcomes were also not significant.

Discussion

The present study sought to examine emotion regulation difficulties as a mechanism explaining associations between women’s childhood maltreatment and emotional, external, and restraint eating in pregnancy in a sample of women with significant pregnancy stress. The study also tested whether specific types of childhood maltreatment were primarily responsible for these associations. First, we found that emotion regulation difficulties partially mediated associations between women’s childhood maltreatment and pregnancy emotional, external and restraint eating. Second, we found that it was specifically emotional abuse and emotional neglect that drove these associations through emotion regulation difficulties.

Our finding that emotion regulation difficulties mediate associations between childhood maltreatment and high-risk eating behaviors in pregnancy aligns with a growing body of research in non-pregnant samples, suggesting that childhood maltreatment compromises emotion regulation capacity which, in turn, drives emotional, external, and restraint eating, potentially as a form of coping (Burns et al., 2012; Michopoulos et al., 2015; Moulton et al., 2015). Our study extends this research by highlighting these associations in pregnancy, a critical period when these patterns may emerge or be exacerbated, likely due to pregnancy-specific stressors and physiological changes that increase emotional vulnerability (Thompson & Bardone-Cone, 2022). These findings are consistent with models of eating as a coping strategy for managing trauma-related emotional distress (Brewerton, 2011; Ruffault et al., 2018; Talbot et al., 2013) and underscore the importance of screening for childhood maltreatment and addressing emotion regulation in interventions to address eating during pregnancy.

We also found that that emotional abuse and neglect, but not sexual abuse or physical abuse or neglect, were the primary drivers of pregnancy high-risk eating through emotion regulation difficulties. This finding is consistent with prior work in non-pregnant people showing that childhood emotional abuse is associated with eating disorder symptoms and psychopathology (Burns et al., 2012; Moulton et al., 2015) and emotional eating (Michopoulos et al., 2015) though emotion dysregulation. Our study expands on this evidence by showing associations of childhood emotional abuse and neglect with emotional, external, and restraint eating during pregnancy. Furthermore, our study adds evidence that emotional abuse and neglect impact these eating outcomes though emotional functioning in pregnancy. This may be because emotional abuse and neglect have been shown to have specific effects on the developing brain (Blair et al., 2019), and therefore might be more strongly associated with compromised emotion regulation capacity than others (Egeland et al., 1983). Furthermore, these early negative experiences may disrupt the foundational processes of attachment and emotional regulation development during childhood (Gruhn & Compas, 2020; Van der Kolk, 2003) and lead to high-risk eating behaviors potentially as a form of coping during pregnancy.

In contrast, physical and sexual maltreatment were not significantly associated with pregnancy high-risk eating through emotion regulation. This may reflect differences in how physical and sexual trauma is processed and coped with across the lifespan compared to emotional trauma (Dye, 2020). Alternatively, the lack of significant findings for physical and sexual maltreatment may be due to the specific focus on emotion regulation in our mediation model, as physical and sexual trauma may impact eating behaviors through other pathways, such as dissociation or post-traumatic stress symptoms, which were not measured in this study. Continued research is needed to characterize the role of physical and sexual maltreatment in high-risk eating behaviors in pregnancy.

Clinical implications

Findings from this study have important implications for interventions targeting high-risk eating in pregnant women with histories of childhood trauma. Given the potential mechanistic role of emotion regulation difficulties linking childhood emotional maltreatment and high-risk eating behaviors in pregnancy, interventions that focus on enhancing emotion regulation skills may help mitigate the negative impact of childhood trauma on maternal health. Dialectical behavior therapy (Linehan, 2014) or emotion-focused therapies (Greenberg, 2017; Schwartz, 2013) could be particularly effective in helping women manage distress to reduce high-risk eating behaviors during pregnancy. Addressing these difficulties in pregnancy could not only improve maternal health but also potentially reduce the risk of transmitting high-risk eating behaviors to the next generation (DeJesus et al., 2018). Furthermore, findings underscore the importance of screening for childhood trauma, particularly emotional maltreatment and neglect, in prenatal care settings. Women who present with high-risk eating behaviors during pregnancy may benefit from trauma-informed care focused on emotion regulation.

Limitations

While this study is the first of its kind to examine mechanisms linking childhood maltreatment and high-risk eating behaviors during pregnancy, several limitations should be noted. First, our findings relied on sequential mediation, which may produce biased estimates over repeated-measures modeling of mediational processes (Mitchell & Maxwell, 2013). Future work should assess these constructs over time and use longitudinal, repeated measures mediation (Mitchell & Maxwell, 2013) to better characterize pathways between childhood maltreatment, emotion regulation difficulties, and pregnancy high-risk eating. In addition, as effect sizes were small, it is likely that factors in addition to emotion regulation may also play a role in linking childhood trauma and high-risk eating. Future research should explore alternative pathways (e.g., mental health, body image concerns, pregnancy nausea, food aversions) and investigate the interplay of multiple mediators. Continued longitudinal research is also needed to track these processes across pregnancy into the postpartum period to determine how these patterns evolve over time and lead to intergenerational transmission of high-risk eating.

Conclusion

This study provides evidence that emotion regulation difficulties are one mechanism linking childhood emotional maltreatment and neglect and high-risk eating behaviors in pregnancy. These findings highlight the importance of addressing emotion regulation in interventions aimed at mitigating high-risk eating in pregnancy among women with histories of childhood trauma. By addressing these difficulties in pregnancy, we may improve maternal well-being and also interrupt intergenerational transmission of high-risk eating behaviors.

Funding source:

This work was supported by the National Institute of Child Health and Human Development NICHD R01HD085990 and the American Heart Association Postdoctoral Fellowship 825916.

Footnotes

Ethics statement: The study was approved by the University of Michigan Medicine Institutional Review Board (IRB MED; HUM00121071). Written informed consent to participate in this study was provided by participants.

Declarations of interest: The authors have no potential conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Data availability statement:

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. The lead author has full access to the data reported in the manuscript.

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Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. The lead author has full access to the data reported in the manuscript.

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