FERTILITY & WEIGHT - WHAT DO WE KNOW?
Okay, so the subject of weight is never an easy subject to broach at the best of times. When you add infertility to the mix it can be a downright tricky conversation to have. It is however an important aspect of health to discuss with everyone embarking on the fertility journey. Optimising weight and lifestyle are very important at this time as it will enhance chances of conception and improve pregnancy outcome.
We know that at the extremes of weight, both under and over, that there is an increase in subfertility and infertility. This applies to men, as well as women.
In Australia 2017-18 statistics show over 35% of the population are overweight and 30% obese.
Underweight accounts for less than 5%. Obesity is a chronic medical condition with a complex interaction of genetic, psychological and environmental factors responsible.
In the underweight group there is disturbance of Hypothalmic-pituitary function and generally anovulation results. The critical level seems to be at a BMI of 17.5 or 10-15% below normal body weight. Problems with dysfunction can persist even after regaining weight. Some groups of athletes and dancers where there is very low body fat are at high risk. This group do generally respond well to treatment with Gonadotrophins (FSH/LH), either for ovulation induction or IVF. Weight should be in the normal range before treatment starts. Care needs to be taken in pregnancy to monitor for anaemia, preterm delivery and small for Gestational age babies. Miscarriage does not seem increased.
In the overweight group there is evidence of increasing levels of ovulatory dysfunction, even in women with regular periods, with rising weight.
All causes of subfertility should always be investigated in both partners as this will influence treatment choices and allow optimisation for each person/couple. Male obesity and overweight can disturb sperm production and should be addressed as well.
During treatment there is increased resistance to stimulation with a generally lower ovarian response and estrogen levels seen. Larger doses of FSH are needed and more prolonged stimulations are common. An increase in follicular asynchrony leads to more cancelled cycles, probably due to the lower bioavailability of FSH at the ovarian receptor.
In those with a BMI >30 there is a lower implantation rate, lower pregnancy rate and lower live birth rate due to more miscarriage and stillbirth. This is due to both uterine factors (poor endometrial receptivity) and egg factors (as the effect is seen in overweight donors as well).
Pregnancy complications are higher too, particularly if co-morbidities exist such as diabetes or high blood pressure.
HOW DO I KNOW HOW MUCH I SHOULD EAT?
You can calculate your Basal Metabolic rate as follows:
The Harris-Benedict equations revised in 1990:
Men: BMR = (10 x weight/kg) + (6.25 x height/cm) – (5 x age/yrs) + 5
Women: BMR = (10 x weight/kg) + 6.25 x height/cm) – (5 x age/yrs) - 161
BMR can be multiplied by physical activity level to gain “total energy expenditure”
Activity Office worker BMR x 1.53
Moderate activity One hour run per day BMR x 1.76
Vigorous activity Agricultural worker / BMR x 2.25
Two hour swim per
You need to eat less than this to lose weight.
Once you have lost >10% body weight, you will need to subtract another 300 kcal to account for reduced TEE, that is metabolic adaptation as your body starts to fit back. This is what causes the plateau affect many notice when dieting.
WHAT ABOUT EXERCISE?
Yes, this can be helpful for two reasons : Firstly muscle is more metabolically active than fat and will burn more calories and secondly it increases energy expenditure.( see above on BMR) . However even walking 10-15000 steps a day is useful , adding spells of HIT as you get fitter (High Intensity Exercise) – see below “Fast Exercise” Dr M Moseley.
Initially strength training is particularly useful to build muscle mass.
SO WHAT CAN BE DONE?
Ideally weight loss should be achieved before treatment and pregnancy are undertaken. Often patients have struggled for years with diets and we understand their reluctance and resistance to travelling this path again. HOWEVER even a loss of 10% of body weight can help with stimulation response.
Medical management can be effective at achieving this initial rapid loss (Weight loss of 1kg every 3-4 days is possible) Maintenance can be more difficult.
Some options to consider:
VLED (Very Low Energy Diet)
600-800 kcal/day with low fat and carbohydrate (Optifast/Optislim) puts the body into ketosis within two days. This consists of meal replacements twice a day and one low Carbohydrate meal at night (150gm lean meat or two eggs with salad/vegetable) plus a tablespoon of oil. Snacks of protein are allowed the first two days and then ketones will suppress appetite. Once a loss of 10% is achieved the body will tend to fight back and readjust metabolism and weight loss becomes harder. (Metabolic Adaption)
Medications such as Duromine and Saxenda can help with maintenance at this point. The help of an experienced dietitian and psychologist can improve success.
This is hugely popular, either the 5:2 or 16:8 protocols. Essentially this involves eating minimal calories for 2 days a week and then normal eating for 5 days (the 5:2 option) or the daily 16:8 program requires you to eat only in an 8 hour window and then fast for 16 hours. For example Stop eating at 6pm and then break your fast at 10.00am the next morning (after fasting through the night for 16 hours).
Fasting is a centuries old way of eating, indeed where the term “Break-fast“ originates. It does offer some great health benefits however many can find this change difficult to start if going straight from normal eating to the fasting regime. It is often best to combine fasting with another eating protocol as well – usually introducing it slowly after a few weeks so as not to over burden the body so much. Some people can also find fasting for great periods difficult if it triggers migraines or other issues so proceed with caution in this area.
(I have myself practiced Intermittent Fasting for nearly 10 years and it is very sustainable).
The FAST 800 is a new online program combining an initial 12 week weight loss component (800 calorie daily intake) and then maintenance by Intermittent Fasting. It was designed by Dr Michael Moseley and a group of dietitians following his detailed exploration of this area (check out “The Fast Diet” On Intermittent Fasting and “Fast Exercise” on the benefits of High Intensity Training.
The program offers online support, recipes and education. It uses real food rather than shakes to develop a healthier way of eating and hopefully sustainable change
Healthy Weight programs like Noom aim to re-establish a healthy relationship to food and re-program less useful behaviours. It is an online app based program. The keystones are a moderately restricted calorie intake (~1200 Calories) with daily weighs, a food diary to improve accountability and educate on portion size and caloric load. It is accompanied by self-paced education on food, psychology and behaviour changes for sustainable loss. An exercise program is also encouraged and can be logged. A Goal Coach will engage with you on your goals and how to achieve them. Later a support group is added sharing tips and experiences through the app. A 2week trial is available at no cost before signing on and cost is reasonable. It is perhaps a good program for a couple wanting to improve health and lose a moderate amount of weight (10-20kg).
‘Keto’ is all the rage at the moment however it too, along with Paleo and intermittent fasting, are very old eating philosophies. Essentially ‘keto’ is short for ketosis, or getting your body into a ketogenic state. What does this mean? In a nut shell, our westernised bodies have become ‘carb adapted’ over many years of eating predominantly a carbohydrate/sugar fuelled diet which converts to glucose in our bodies as the main energy source. We eat bread or cereals for breakfast, maybe sugar in our coffee with normal milk (lactose), carbs for lunch, sugary snacks or even fruit high in sugar, and usually dinner that consists of some form of carb on our plates. Add to this maybe alcohol, soft drinks or other drinks that are high in sugars. Our bodies have become constantly fuelled by carbs/sugar which are converted by insulin as the primary fuel source. Sugar is so rapidly absorbed by our bodies, it is the reason why we feel instant gratification when we eat high carb or high sugar foods, however as quickly as this fuel source is absorbed, it can just as quickly drop, making us feel hungry again. Often people on calorie restricted diets will quite honestly say that they are only eating x number of calories but are always starving hungry and are struggling to lose weight – it is often more about the type of foods eaten rather than the calorie content. We also have the issue of excessive consumption – taking in more carbs/sugars than our body uses for fuel which is then stored as body fat.
Now this is where keto comes in and makes things very exciting. If we deplete our glycogen stores by reducing our carbohydrate and sugar intake, our body is able to seek out a secondary fuel source in the way of dietary or stored fats which our body turns into ketones for fuel. Ketones fuel our brain and bodies alike, which is why people who embark on a ketogenic diet often make comment that they experience less brain fog after usually the first 2-3 weeks. (Yes, it is an added bonus, apart from weight loss, but that’s not the only added bonus. Often a reduction in inflammation in the body and even a reduction in cellulite is reported too. It’s the gift that keeps on giving!) Now without going into too much scientific stuff (which, by the way is really very exciting if you want to learn more – we highly recommend watching the YouTube documentary ‘Fat Fiction’, to start with), our body is capable of using whichever fuel source is most easily accessible. Of course sugar is the easiest and most rapidly absorbed source however if we remove or drastically reduce this then the body will start using fats (stored or consumed) for fuel. Yes, we know, we’ve been told for many, many years that fats are bad…and yes, some aren’t that great, but many fats are actually very good for us. By getting on the right keto program you can easily learn how to turn your body into a fat burning machine, using ketones for fuel, simply by making adjustments to your diet. Now we’re not telling you to just go out and eat heaps of fats as there is a limit to everything, but by following a nutritionally balanced ketogenic diet and being educated in the fundamentals of keto, you can quickly and easily turn your body into a fat burning machine, losing weight and getting your body back working in peak form again.
There are many keto programs and groups around but we highly recommend one that incorporates education as part of the program. Without understanding the fundamentals about how your body reacts to the different foods, how to get your body into ketosis, how to recover when you have a break or go on holidays, and how to maintain a healthy weight long term, then there is a high chance that your success will be short lived. Sorry, that’s probably a bit blunt but it’s the truth…and let’s face it – you’ve come this far so you’ve no doubt tried many diets and already know this to be true.
Keto turns the food pyramid as we know it, upside down. There is a very strong push in most western countries of the world to have the food pyramid re-written putting fats, proteins, vegetables towards the wider bottom section (consume more), and carbs and fruits at the pointy top end (minimal intake). Fats and protein fill us for longer, are more slowly absorbed into the body and as such maintain more even blood sugar levels, reducing major peaks and troughs experienced on a carb/sugar diet. This is particularly good for diabetics too and many people have experienced returning to normal insulin levels after years of being diabetic (again, another bonus).
Essentially a nutritionally balanced ketogenic diet would consist of healthy fats from a variety of sources (olive oil, coconut, butter, full fat cream, unhomogenised full fat milk, nuts, cheeses, etc), proteins, lots of leafy greens plus other ‘above the ground’ vegetables with low carb content, bone broth and plenty of fluids. Low carb flour alternatives such as almond flour, coconut flour, etc., can be added in later on to expand the eating program. There are ample keto recipe books and online groups providing lots of keto recipes however we suggest starting with the basics and learning keto from a highly trusted source.
The Ketogenic Switch www.ketogenicswitch.com is a program by Deborah Murtagh, a world-renowned nutritionist and weight loss coach specializing in science-based nutritional coaching. She has over 23 years experience in this area and has put together a sensible proven keto program that has seen many thousands of people around the world finally be able to tackle their weight loss issues. The program addresses the diet side of things as well as mindset and general well being. It is a holistic program designed for long term success, not just short term loss.
Throughout the year Deborah runs an introductory ’30 day challenge’ (promoted as ’30 days, one dress size challenge’) which is a fabulous Facebook based program giving an in-depth introduction to keto to get you started on the right track. At the time of writing this the month challenge was US$47 and is highly recommended. You will learn what to eat, when to eat, how much to eat, as well as being given a substantial list of foods to choose from, most that you would find in your normal supermarket. You are guided on how to get through each stage of the 30 day challenge, how you will feel (usually pretty crappy for the first 3 days whilst your body detoxes from all the carbs/sugars in your system) and then addresses mindset issues, understanding your inner critic and identifying other triggers that may have caused you issues in your weight loss attempts in the past. Often during the 30 day challenge participants have the ‘light bulb’ moment when they can finally see why all their attempts over the past years/decades of dieting have not lasted and they feel confident that they now have the key to long lasting and easily maintained weight control.
But don’t take our word for it – look up ’30 Days, one dress size Challenge’ on Facebook and sign up. You have nothing to lose….but weight….and heaps to gain.
For some surgery may be the eventual solution. On average a loss of up to 30% of body weight is achieved over a year.
The Medical Weight Loss Clinic at Buderim is one site locally which can provide this. Their website has information on the procedures and costs in addition to how assessment is made on suitability for each individual. It is worth a visit if you are considering a surgical option.
Developing a new relationship with food is necessary for long term maintenance. Psychologic support is essential.
DIET GUIDE FOR VERY LOW ENERGY DIET
Medical Management - Weight-loss phase
Foods ALLOWED on VLED
• Tomato, capsicum, radishes, alfalfa sprouts, cucumber, watercress, lettuce, mushrooms, spinach
• Eggplant, asparagus, fennel, garlic, onions, celery
• Broccoli, bok choy, cabbage, cauliflower, squash, silverbeet, zucchini
• Beetroot (fresh), carrot (max 1/day), avocado (max 1 quarter/d)
• Brussel sprouts, snow peas, green beans Sauces and Condiments
• Lemon juice, vinegar, worcestershire cause, soy sauce, mustard, tomato sauce, stock cubes, bonox, herbs, spices
• Water, diet soft drink and cordial, mineral water, soda water, tea and coffee (small amount of milk)
Sugar free foods
• Artificial sweeteners, sugar free gum, diet jelly
Foods NOT ALLOWED on VLED
• Corn, green peas, pumpkin
• Potato, sweet potato, parsnip
• Lentils, legumes (eg, Kidney beans, butter beans)
Sugar Containing Drinks, Fruit Juice, Alcohol
• Fruit juice, regular soft drink, regular cordial, all alcohol (wine, beer, spirits)
Grains and Cereals
• Breakfast cereal, porridge, rice, pasta, noodles, bread, crumbed or battered foods
• Dry biscuits, sweet biscuits, pastry products, cakes, muffins, dim sims
• Yoghurt, ice cream, cheese, milk drinks
All Sugary Foods
• Sugar, honey, maple syrup, sweet stir fry sauces, lollies, chocolates
TIPS / HINTS
Drink at least 2L calorie free fluid each day
Have two cups of starch free vegetables each day to help prevent constipation
Include on tablespoon of olive oil or coconut oil per day to empty your gall bladder
Use sugar free breath mints if required to help with the ketotic (slightly sweet) smell of breath
Test urine with ketone sticks to check for ketones