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Should Fertility Clinics Deny Treatment To Women With Obesity?

>> Monday, July 16, 2018

As blogged previously, due to concerns about poor clinical outcomes and maternal/fetal risks, many fertility clinics in Canada impose an upper body mass index (BMI) cutoff of about 35-40 kg/m2, above which they will not offer fertility treatments.  Is this the right thing to do?

The new Canadian Clinical Practice Guideline for the delivery of fertility care to women with obesity reviews the evidence on this very controversial topic.

Based on survey studies of fertility clinics, whether a BMI cutoff is used, and what BMI cutoff is used if so, is highly variable and not based on any specific or clear evidence.  Most clinics that have an upper BMI cutoff beyond which they will not offer fertility treatments cite anesthesia risk as the main reason for the cutoff.

Not only are BMI cutoffs arbitrary and without consensus, getting below the BMI cutoff goals may be very difficult for many women with obesity to achieve.  Furthermore, one study suggested that over half of the fertility clinics with a BMI cutoff did not offer any weight loss instructions or guidance to their patients - sounds to me like telling a person to row a boat but not showing them how to use the oars.

Denying fertility care to women with obesity is highly stigmatizing and discriminatory, and can worsen feelings of low self esteem, social isolation, anxiety, and depression. Denying older women fertility care until they have lost weight may cost them valuable time and any chance of pregnancy.

There is no doubt that there are risks of obesity to both the mother and the unborn child, and weight loss should be encouraged and supported.  However, as the guidelines point out, the risk of obstetrical obesity-related complications does not clearly exceed the risk of complications with other pre-existing medical conditions like hypertension, diabetes, or epilepsy. In addition, obesity related health status is a better predictor of pregnancy with fertility treatment than BMI, and also a better predictor of overall health outcomes in general, so why is there so much focus on the numbers on the scale in the first place?

As the Guideline states:

In the absence of simple, safe, and effective strategies that reliably help patients with obesity lose weight in a timely fashion, it is difficult to advocate for a universal BMI cut-off in place of careful counselling, screening for metabolic abnormalities and informed consent. 

Programs that impose BMI cut-offs should offer resources for patients to help them lose weight, and should inform patients about both the risks and benefits of delaying fertility treatment.

Follow me on twitter! @drsuepedersen © 2018


Fertility Care For Women With Obesity

>> Monday, July 9, 2018

Obesity has a profound impact on reproductive health from many perspectives. We now have a brand new Canadian Clinical Practice Guideline which provides us evidence based recommendations for fertility care for women with obesity.

The Guideline, published in the Journal of Obstetrics and Gynecology of Canada, provides 21 key recommendations that answer the following questions (highlights discussed here - please see the full article for details):

What is the impact of obesity on female fertility?

Women with obesity have a risk of infertility due to a lack of ovulation that is more than twice that of women without obesity.   Even if ovulating, the physiologic ability to reproduce is still reduced.

What is the impact of obesity on MALE fertility?

While men with obesity have lower testosterone levels, it is unclear whether obesity has an impact on sperm quality and semen parameters. Men with obesity do have a higher risk of erectile dysfunction, which may be improved with weight loss.

What is the impact of female obesity on fertility treatments?

There is a lower oocyte (egg) yield with IVF. Implantation, pregnancy and live birth rates decline with increasing severity of obesity.  Live birth rates decline by 0.3-0.4% for every 1 increase in BMI over 25 kg/m2.

What is the impact of obesity on mum's health risk in pregnancy?

There is an increased risk of gestational diabetes, high blood pressure, prolonged labor, need for instrument assistance for delivery, shoulder dystocia, and C-section.   These risk increase with higher BMI.

What is the impact of obesity on baby's risk during pregnancy?

The risk of having a large baby or a baby with a congenital abnormality is increased.

What screening tests are appropriate for women with obesity seeking fertility care?

Screening should include testing for diabetes, cholesterol levels, high blood pressure, cardiovascular disease, breast cancer, and endometrial cancer.   These screenings should be done before starting fertility treatment.

What are the most effective treatments to help infertile women with obesity lose weight?

Modest weight reductions (5-10%) improve metabolic risk. Help should be offered for lifestyle modifications.  Medications to treat obesity, or bariatric surgery, should be considered for those who do not have success with lifestyle changes.

Women in their late reproductive years who have had bariatric surgery should be advised that the possible benefits of waiting for 1-2 years after surgery to conceive should be balanced against the decline in fertility related to advancing age. 

Bariatric surgery lowers the risk for large babies, gestational diabetes and hypertension, but increases risk for small babies.

Is there data demonstrating a difference in fertility outcomes for women who lose weight before pregnancy, compared to women who proceed directly to fertility treatment?

Yes - weight loss improves spontaneous fertility rates.

Should there be a national BMI cutoff for access to fertility care?

In Canada and around the world, concerns about poor clinical outcomes and maternal/fetal risks have resulted in many fertility clinic medical directors imposing an upper BMI cutoff to their program, above which they will not offer fertility treatments.  Stay tuned on this one - I am going to dedicate a whole blog post to discuss this very important and hotly debated topic.

Follow me on twitter! @drsuepedersen © 2018


Should I Be Tested For Diabetes?

>> Tuesday, July 3, 2018

Diabetes is common, and it is on the rise.  It is estimated that 9.3% of Canadian adults have diabetes, and about 22% have pre diabetes.  You read that right - that's almost one third of Canadians that do not have normal blood sugar.

It is important to know if you have diabetes, as diabetes can lead to many health issues and complications, especially if it goes undiagnosed and/or untreated. Diabetes can go on for many years without any symptoms, so just because a person feels well doesn't mean they don't have it.  Prediabetes (when blood sugars are between the normal and diabetic range) can also be associated with health complications even before diabetes develops.

As per the 2018 Diabetes Canada Guidelines on screening for diabetes in adults,  you should be tested if you are:

  • Age 40 or older - and retesting at least every 3 years
  • If you have risk factors that increase the likelihood of developing type 2 diabetes, you should be tested more frequently and/or start screening earlier. Some of these risk factors including having a family history of type 2 diabetes; a history of pre diabetes or gestational diabetes; being a member of a high-risk population; or having overweight or obesity.  

You can use the Canadian Diabetes Risk (CANRISK) Calculator to assess your risk for diabetes.

Follow me on twitter! @drsuepedersen © 2018


Diabetes Canada Guidelines 2018 - Complementary And Alternative Medicine

>> Monday, June 25, 2018

Many people turn to natural health remedies in an effort to improve their health, and diabetes is no exception.  There is a lot of confusing information on the internet about these products, so I'm thrilled that the 2018 Diabetes Canada Clinical Practice Guidelines has systematically updated their review of the available medical literature on herbal remedies for diabetes, and summarized this in a fantastic chapter that also includes evaluation of other therapies such as yoga, acupuncture, and reflexology.

People with diabetes: if you are taking a natural approach as part of your diabetes management, read on!

Health care providers:  anywhere from 25% to 57% of people with diabetes report using complementary medicine or alternative medicine - so this discussion will be highly relevant to anyone's practice.

Check out the lists in the chapter to look for data on a particular remedy.  Here's a summary:

  • About 30 natural health products have been shown to improve type 2 diabetes control - but - noting that these are mostly single and small trials, it is premature to recommend their widespread use, and further research is needed.  This includes ginger, nettle, and a list of Chinese herbs, amongst others.
  • A list of supplements that did NOT show improvement in type 2 diabetes control, or had studies less than 3 months, or were non randomized or non controlled.  This includes ginseng, flaxseed oil, soy phytoestrogens, vitamin C, vitamin E, vitamin D, and others.
  • A list of supplements that have shown conflicting results for diabetes control, including cinnamon, coenzyme Q10, omega 3, probiotics, and zinc
  • Chromium gets special attention due to its popularity - with studies being small, short, with most not showing a benefit to improve diabetes control. Studies of vanadium are too short to tell if it improves diabetes control or not.

The chapter goes on to review data on natural products for treatment of complications of diabetes and other cardiovascular risk factors like cholesterol and blood pressure. While there is some interesting data, the studies are again short and small, making strong conclusions difficult.

Importantly, the Guidelines warn us that side effects and toxicities have been reported with some natural remedies, giving examples ranging from diarrhea to liver failure to inducing abortion.  Concerns exist about standardization and purity of these compounds. Some natural health products contain pharmaceutical ingredients, and even toxic substances. Herbs can also interact with prescription medications, which can be dangerous. Again, the theme is that studies are too small and short to really understand safety of natural remedies in general.

Yoga has shown some benefit in diabetes control, but acupuncture and tactile massage have not. The chapter also reviews a smattering of data that exist looking at tai chi and reflexology - have a read of the whole chapter to get into these details.

Key Messages: 

Some natural products have reported a lowering of A1C of 0.5% or more in trials lasting at least 3 months in adults with type 2 diabetes, but most of these are single, small trials that require further large scale evaluations before they can be recommended for widespread use in diabetes.

A few more commonly used natural health products for diabetes have been studied in larger randomized controlled trials and/or meta analyses, and have refuted the popular belief of the benefits of these compounds.

Health care providers should always ask about the use of complementary and alternative medicine as some may result in unexpected side effects and/or interactions with traditional medicines.

Key Messages For People With Diabetes: 

Although some complementary and alternative medicines may have the potential to be effective, they have not been sufficiently studied, and others can be ineffective or even harmful.

It is important to let your health care provider know if you are using complementary and/or alternative medicines for your diabetes.

Follow me on twitter! @drsuepedersen © 2018


Diabetes Canada Guidelines 2018 - Vaccinations

>> Monday, June 18, 2018

The 2018 Guidelines have expanded the vaccination chapter to now include recommendations for not only the flu shot and the pneumococcal vaccine, but also information regarding hepatitis B and shingles.

Key Messages For People With Diabetes:

You should receive routine vaccinations as recommended for anyone with or without diabetes.
Check if you are up to date with your vaccinations.

You should receive:
  • the flu shot, every year
  • the pneumococcal vaccine initially when you are over age 18; and again, when you are over age 65 IF your first vaccination was given under age 65 and it's been more than 5 years since you had it

It is now recognized that people with diabetes are at a higher risk of hepatitis B infection compared to people without diabetes.  Outbreaks can happen in places where there is assisted glucose monitoring if hygiene protocols are not adhered to - for example, there have been cases of outbreaks reported in long term care facilities.   The Guidelines do not officially recommend Hepatitis B vaccinations, but do go through some of the pros and cons to consider. 

Though the data is scarce, the existing information suggests that people with diabetes are at an increased risk of getting shingles (herpes zoster), which is a reactivation of the chicken pox virus.  The Diabetes Canada Guidelines list the recommendations for Canadians as a whole for shingles vaccination, with the point of making sure that people with diabetes are vaccinated according to these recommendations. 

Follow me on twitter! @drsuepedersen © 2018



I am excited that you have arrived at my site, and I hope you are too - consider this the first step towards a Healthier New You!! As a medical doctor, Endocrinologist, and obesity specialist, I am absolutely passionate about helping people with weight management. Though there is certainly no magic cure for obesity, there IS a successful treatment plan out there for you - it is all about understanding the elements that contribute to your personal weight struggle, and then finding the treatment plan that suits your needs and your lifestyle. The way to finding your personal solution is to learn as much as you can about obesity: how our toxic environment has shaped us into an overweight society; the diversity of contributors to obesity; and what the treatment options out there are really all about. Knowledge Is Power!!

Are you ready to change your life? Let's begin our journey together, towards a healthier, happier you!!

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