Welcome! I am so excited to have Dr. Stephanie Fein with me today. We’re going to talk about a topic that can be quite sensitive. It’s about optimizing your fertility through weight loss. There’s no better person to talk about this today than Stephanie.
Stephanie attended Tufts University and received her BA in social psychology, earned her medical degree from UC Irvine, and completed her internal medicine training at UCLA. She then obtained a master’s in public health, just like me, at UCLA while finishing a research fellowship.
Stephanie is passionate about weight loss and motherhood and loves to help women optimize their fertility through weight loss.
Dr. Aimee: Stephanie, welcome to the show.
Dr. Stephanie Fein: So exciting. I love that about the MPH. I didn’t know that.
Dr. Aimee: I did, in health management and policy, from the University of Michigan.
You moved from internal medicine to focusing on weight loss and fertility. What got you interested in this topic?
Dr. Stephanie Fein: I could talk on this for hours, too, but I’ll shorten it. The first thing that happened is I love medicine. I love working with patients. What I did not love is the 10-minute visit. When you have to learn everything that you need to know about someone, because in order to really give them what they need and understand what’s going on, to me, I need more time than 10 minutes.
At the same time, I was moonlighting at a weight loss clinic during my fellowships at UCLA. They had a weight loss clinic and I loved it. I spent a lot of time with each patient, I got to know them, and it didn’t hurt that I had always struggled with my weight too, so it was a perfect match. To the point where about 12 or 13 years ago I lost 50 pounds and I’ve kept it off. I’m not a naturally thin person and I really feel like I understand all of the things that we’re going through, because it’s been years and years for me too.
That got me interested in weight loss. Then in November 2019, there was a big Obesity Week conference. I was there just to get the latest information, but what stuck with me was this one speaker who talked about fertility outcomes improving with weight loss. Now, I had known about getting off blood pressure medicines and diabetes medicines, that was an easy thing that happened all the time. But this, my ears perked up, it was so incredible.
Since then, I’ve been so interested in helping women, because I love working with patients, but my number one job is Mom. In the universe, if I’m asked about it, that’s where I want to improve the most, that’s where I want to do the most. So, I’ve been on a journey with my kids to become the best mom I can be. The way that I have found that works the bests is improving the relationship with myself, compassion for myself, understanding for myself.
When I knew that, it’s also the thing that makes me lose weight the best. When you can have a relationship with yourself, with compassion and understanding about mistakes or different decisions that you make, you’re better. I am a more patient mother because I am okay with when I make mistakes. That’s the same thing we need for weight loss.
It all just fits so beautifully together that I couldn’t be doing something I love more.
Dr. Aimee: I love hearing everything that you’re sharing with us. I want to even hear more. Tell us about your practice and your approach.
Dr. Stephanie Fein: My approach then is guilt-free, deprivation-free, and frustration-free. To me, that’s all you need. If you can do it that way, then you can keep off the weight. That’s the other thing, it gets a little tricky with fertility, because of course we want to then get pregnant and there is going to be some weight gain, which is natural and yes, we want that. But when you are losing weight in a way that has your decisions and your relationship with yourself changed, then through pregnancy and afterward it’s a completely different story.
It’s not about a crash diet three months before trying to get pregnant. That’s not how that works. It’s if we do it in this guilt-free, deprivation-free, and frustration-free way, it works to permanently change your mind and your body.
I’m sure you can relate that in terms of the guilt-free. A lot of times people, especially with fertility, will hate their bodies. They’ll feel like their body is betraying them. When you have weight issues and fertility issues, it can really be an obstacle.
I don’t know what you say about this for fertility, but you can’t hate your way to less weight, you can’t lose weight by hating yourself. You can for a little while because you can force yourself to do something that is painful and difficult, but what happens every time? You’ll bounce back up.
So, the guilt-free piece is such an important piece. That’s brain things, that’s the relationship I was talking about, more compassion for yourself and understanding. When you love something, you take care of it in a way that you don’t when you don’t love it as much, so that’s number one.
The deprivation-free piece is, to me, another important piece. If you feel deprived, again, you’re going to bounce right back up. I start with where people are. I don’t care what your diet looks like when we first start. I’m starting with where you are and we tweak it. I love that word, tweak, because it’s little tiny changes. It’s not now you’re going to go all organic vegan if you’ve been eating fast food all the time. We just tweak and it works out so beautifully.
I don’t want people to be starving hungry and I also don’t want them to be very full, so we do work on that, about being satisfied. Not hungry and then satisfied. That’s the deprivation piece.
The frustration piece, that’s where I come in. With those 20 years of working with patients on weight loss, that’s where I’ve seen everything. When someone comes to me with something like, “I did XYZ and it’s not budging,” or whatever it is, I have seen it all. I can hold your hand and I can reassure you.
Let me tell you something. When you’re working so hard to lose weight, reassurance is what you need. You need to know you’re on the right path, because it feels like you’re stumbling in the dark sometimes. When you have someone saying, “You’re doing it exactly right,” it really feels good.
Those three pieces get you where you want to go; guilt-free, deprivation-free, and frustration-free.
Dr. Aimee: I love it. Being a fertility patient is very frustrating. I have patients who take breaks because they just don’t like how their body feels and they want to get their bodies back. They tell me so often that they’ve been eating less, restricting their calories more, exercising more, and despite all of that they’ve still been gaining weight, 10 or 15 pounds. So, it’s nice to hear that you’re able to hand-hold them through this process so they can be less frustrated.
Can you give us a sense about how weight and fertility actually work together?
Dr. Stephanie Fein: Yes. Two words: insulin and inflammation. What’s interesting about that to me is there are two pieces. There’s that underlying physiology piece separate of the piece about eating. What we can do then is work with that piece, the eating piece, and the timing piece and how your lifestyle works, but what’s happening inside is what’s important going on.
A lot of times people with extra weight will have insulin resistance. What that means then is that your insulin level goes too high sort of all the time. Actually, Dr. Aimee, you have this great picture, I think it was on your PCOS blog or something, it was awesome. I actually looked at it because it worked out so well. Anyone can look at it if you go to Dr. Aimee’s blog about PCOS, because it shows that the insulin affects the ovaries, which makes more androgens, and it also affects the liver in a way that proteins aren’t made the same.
What that ends up meaning is that testosterone can go up, you can have more. In PCOS in particular, that happens. You get manifestations of that, like acne and hair, and these sorts of things. You don’t even need that much in order to throw off the hormone balance that you can help you ovulate and get pregnant.
There are literally hormone problems with insulin. It also can lead to inflammation. I know you’ve talked about inflammation before. What happens not only with the insulin and the inflammation is that you have adipose tissue and inflammation. Adipose tissue itself is an endocrine gland, it’s endocrine tissue, because it holds so much. We used to think it was inert. It’s not. There is so much going on.
What’s also interesting is we don’t know what level the excess is. We’ll probably get into that in a little bit, because we don’t know where that number is. But we do know that decreasing fat tissue, which is always what we’re looking for with weight loss — I don’t care how much water weight you have. I mean, it’s uncomfortable and no one wants it, but it’s the fat tissue that we’re looking to get rid of. When you’re doing that, your body is changing, and that’s what we’re looking to do when we’re losing weight.
Dr. Aimee: How about IVF success rates and weight loss, is there a connection between the two?
Dr. Stephanie Fein: There is. I wish it was really perfectly defined, but it turns out it’s not so much. They’ve done some nice studies, some of them are small, then they do also med-analysis, which I’ll go into a little bit. Showing things like from what your weight is at 18, even if it’s overweight, but if you start gaining weight, it takes longer to get pregnant. Just having a little more weight on you will slow the process or make it impossible, it’s hard to know which one. Just knowing that is important.
Then they’ve shown that especially anovulatory women who are overweight, if you lose some of that weight, you can get your ovulation back and you can get pregnant either spontaneously, which a few do, or with IVF, where they couldn’t have before.
Some of these studies were done in the ’90s. The most recent one that I like the best, in terms of being the most recent, was a med-analysis of these studies. It was in 2019. I wish I could show numbers, but it did show that a BMI above 30 had poorer rates of success of live births, because that’s of course the end goal that we’re looking for.
So, there is a connection.
Dr. Aimee: That’s great to know. You’ve also referenced Geneen Roth and her work on your Instagram page. Many folks might be familiar with her work already. What have you found in your work with women and why food is such a loaded topic?
Dr. Stephanie Fein: I do love Geneen Roth. She has a book called Women, Food, and God, and I highly recommend it to anyone listening here. It is a phenomenal read. She has some ways of thinking about it, and it comes down to this compassionate piece. A lot of her work is about your relationship with yourself and your food. What she talks about, ultimately, she has seven rules, and it includes hunger.
What’s important about that is a lot of us totally lose our connection to what our body telling us. You don’t know when you’re hungry, you don’t know when you’re full, you don’t know when you’re tired, because you’re just going and giving and giving and going and doing. That piece about being able to reconnect with yourself with hunger ends up being really helpful.
I have absolutely seen what’s called intuitive eating where people can lose the weight and get to where they want just with this hunger piece. In my experience, it takes a longer time, so I incorporate that as part of it because learning that whenever you can is amazing. I also like to have some data, some numbers that we work with. I like to incorporate some of Geneen Roth, but also this piece about the data. If I can, I’m going to go back to that. There are some numbers that are really important in weight loss and fertility.
BMI is a very important number to know, because 35 and 30 are important numbers, sort of like thresholds where we’d like to be. 25 and below, and not too below, is in the normal range, meaning that losing weight then wouldn’t make a difference. From 30, it would, 35, it would, and beyond.
Here’s the other great number; 5% and 10%. This is why I’m so excited about this, 5% weight loss will make a difference in fertility. Now, when you do tests, it’s on groups of people. As you well know about statistics, we get statistics and it’s very helpful, but each person is different.
If we can start with the 5% — so, if you’re 250 pounds and you go down 13 pounds — this is the way I think about it, your body meets you, so a willingness, a change that is meaningful starts you down the road. Then 10% is our next number. If we hit 5% first, it’s amazing. We hit 10% next, and then we go for the lower BMIs.
Those numbers end up being really important. What I love about them is that they’re hopeful. It’s not that you have to lose 150 pounds. Although, of course, it’s going to be amazing, and if you want to, more power to you. But 5%, 10%, and then the BMIs. There is data on 50 pounds as a number, they did do studies on that, too, so that’s another magic number that we have. But we have all these numbers to hit on the way down.
Dr. Aimee: Why is BMI such a controversial topic? I find sometimes when I bring it up people get triggered and they don’t like when I bring it up. Why is there controversy there?
Dr. Stephanie Fein: There’s a couple of things about it. It’s the same for men and women, which whenever anything is the same for men and women, I’m always thinking how is that possible, because we are very different. In fact, for men, I actually take the numbers even higher just because it’s very thin.
It depends on culture is what I’m looking at, because 25 and below is a very thin weight for our culture right now. We have a lot of overweight and obesity, so when we see that it’s very strange to have this number be very low. I think that’s what it’s about.
When they did the studies, that’s the reason we use BMI, it’s a shorthand, it’s like a placeholder. We had to pick a number and we picked that. I think then the numbers can be so high, because if you’re in the 40s and that sort of number, of course it can feel challenging. I think of it as it was just sort of arbitrary. Not exactly, but sort of an arbitrary place, and then we can just use that number like a target.
Dr. Aimee: Why is food such a loaded topic also? What makes it so hard to lose weight?
Dr. Stephanie Fein: Oh my goodness. I think consistency and culture. This was a while ago and I wish I took it out, but I was looking at a People Magazine and it had Jennifer Aniston in it and she had what she eats in a day. She’s very thin, by the way, if people don’t know who Jennifer Aniston is. It was a beautiful thing that she was eating, it was not a lot of food. She ate beautifully, it was healthy food and whatever, but I wanted to show everyone to say, “See?” It’s not that she’s going out to breakfast, lunch, and dinner.
We are in a culture that thinks that you should be able to eat out food, either fast food or made by someone else, three times a day. It’s just not how bodies were made. I think that our thinking is a little off.
People make food that you want to keep eating, so we do have a little bit of, whether we call it addictive. Refined sugar and flour really are things that trigger brain chemistry that do make it hard to stop eating. There’s so much going on.
The other piece about consistency is that people a lot of times on their own can try for a bunch of days to try to do something to lose weight, it feels like such a big change in what they normally do, and then after three or four days they don’t see five pounds off and it just feels very defeating, it feels very challenging. That’s where that frustration-free comes in. When you know you’re going to be talking to someone every week about what’s exactly going on, you can hang on for the week.
So, I think consistency and culture really make food a very difficult issue.
Dr. Aimee: Yes. Then not only that, when you’re a fertility patient, you’re also more emotional, you’re on hormones that are making you more emotional. How do emotions and feelings come into play when thinking about food?
Dr. Stephanie Fein: It’s such a good question. When people are not doing fertility treatment, so in the time before they’re doing that, then there’s just the regular emotions. If we only ate for hunger, that would be one thing. We eat with boredom, we eat sad, we eat lonely, that sort of thing.
A lot of us learned that as a kid, it was the only way we had to soothe ourselves to feel better. As a kid, you don’t have access to much, but sometimes you can have access to food. If we had parents who were able to tell us how to process our feelings, that would be amazing, but most of us didn’t have that, or many of us didn’t have that. I did not have that.
Learning to deal with emotions in a different way than eating really makes a big difference. Now, as soon as you put infertility and hormones, there’s real stuff there. What I’ll say is, like I was saying before, water weight is not the main thing we worry about, so we want fat loss. There may be retention, there may be things that are doing that.
When you’re learning to cope with feelings without food, then you have more chances of not overeating in those moments. That’s the piece. 100% there is emotion. When we’re learning how to deal with it without food, then we can see the benefit there.
Dr. Aimee: I think that’s really great advice. What kind of recommendations do you have for patients who are doing treatment who are facing that challenge, being emotional and using food to self-soothe?
Dr. Stephanie Fein: Of course, it’s one of those things that’s prevention. It’s always better to have the tools before you need them. But if you are actually going through it, one of the things that I would highly recommend is first know that it’s going to be an emotional time, accepting that this is what you’re going to go through.
It’s not a surprise that we’re going to be emotional with this. First of all, it’s an emotional topic, so if even if the hormones themselves didn’t make you more emotional, period, it’s waiting, it’s anxiety-producing, it’s OMG. Knowing and preparing for that.
I just heard one of your podcasts that talked about this. You had a things-to-have, a team and these sorts of things. This is exactly the same thing for weight loss, there’s no difference at all. Preparing yourself, knowing you’re going to go through this, is really important.
Depending on the foods that you were eating before, you can pick ones, you can decide what you’re going to eat if you’re feeling this way. You can decide what show you’re going to watch. You can decide which friend you’re going to call. You can decide which walk you’re going to go on. There are so many things there that you can do.
The other thing, too, again you talked about this as mindfulness, is journaling. Part of this is processing the feelings that are happening and being in them, meaning feeling them, tolerating feeling anxious. Oh my gosh. It’s not easy, but it’s usually happening when you’re going through fertility stuff, so being in it and tolerating it rather than eating it.
Dr. Aimee: I love it. Along the lines of eating it, are there some foods or kinds of foods that are better for people who want to embark on a health weight loss journey, especially fertility patients?
Dr. Stephanie Fein: Again, that’s a great question. The answer is likely yes. However, that’s not where I go, because again we’re starting where people are.
Sometimes the nutritionist can be so good at foods that have more magnesium and all these sorts of things, but when we’re talking about starting from someplace where we’re just trying to get the fat tissue off, then those kinds of things can stress someone out. If they have to know that they have to have this much of kale and this much of that. I really am tweaking and just by eventually adding fruits and vegetables where you can, it ends up making such a big difference. The Mediterranean-style diet is such a good one, but if it’s so far off from where someone is, then it’s just a target I work for later.
It is so important to just make the little tweaks. What happens when you do that is you’re successful, you can keep doing it, it doesn’t feel painful, you’re not going to rebel against this rule that you made for yourself. That’s how I think about it in terms of food.
Dr. Aimee: I joke with patients. I say things like, “Do you exercise,” and I bring up the fact that I’m allergic to it, it makes me red, and it makes my heart race, and I just get this weird drip on the side of my face. I feel like what people don’t realize is you can accomplish so much just with what you eat and don’t have to shame yourself about not jumping on the Peloton three times a day.
Dr. Stephanie Fein: Yes. It’s even more than that. It’s at least 85%, if not 90%, of weight loss is food related. Sometimes I don’t even ask that anyone start exercising, because that’s just then another habit that they have to pile on top of the other habits that we’re trying to change. Exercise is amazing for your heart and your mood, and all these other things. It’s not the best for weight loss. I definitely take that into consideration.
Dr. Aimee: I’m glad you agree with me. Then I just want to talk about you mentioned hunger, feeling full versus satisfied when eating. Why is this important to understand?
Dr. Stephanie Fein: It’s so important. It goes to understanding when you’re emotionally hungry versus physically hungry. What I like to teach people is a hunger scale. The hunger scale is, literally numbers. I start at +5, which is like Thanksgiving-full, like you’re undoing your pants because you’re so uncomfortable. It goes through 0 to -5, which is completely empty, you have symptoms of feeling completely empty.
Where we’re really supposed to be is -2 to +2. We’re never supposed to be at 3, 4, and 5. What will happen is a lot of the time people will not eat all day, so they’ll get to -5. When you get to -5, you are so over-hungry that you end up eating to 5 and you get so many more calories in there than if you had been eating along the way. The -2 to +2 is where we want you to be.
+2 means satisfied, which is a really interesting word. It means you’re not hungry, but you’re also not full. Learning how to do that really takes some practice.
-2 means you’re starting to get hungry. It doesn’t mean ignore it and pretend it will go away and hope it will go away. It may go away for a moment, but then it comes back as a 3, and then it comes back as a 4, and then it comes back as a -5, and that’s a problem because of the overeating.
We want to learn how to eat when you’re just hungry, which is -2, and then stop when you’re satisfied. It’s a process to learn.
Dr. Aimee: Wow. I imagine you take your patients through that as well.
Dr. Stephanie Fein: Definitely, yes.
Dr. Aimee: If someone wants to find out more about you and your programs, where can they find you?
Dr. Aimee: Great. What kind of goals do you have for your patients as far as weight loss? If someone were to come to you and they needed to lose 40 pounds, what kind of timing can they expect?
That’s the thing everyone wants to know, “How fast can I get pregnant? When can I do a transfer?” I imagine that’s a question they ask you, too. “I want to lose 20 to 40 pounds,” or even that 50 pounds, “How long will it take me to get there?”
Dr. Stephanie Fein: Yes. Oh my goodness. That’s why I love all of the different numbers that we talked about, the 5% and 10%, the 50 pounds, all that sort of stuff. It absolutely depends on each person. I’m sure that you end up saying the same thing, but it really depends.
Oftentimes, if you have more to lose, it can come off faster. That’s not always the case, but sometimes.
What I know to be true is if you’re losing weight, especially in the way that I do it where we’re tweaking and it’s not anything dramatic or eating 500 calories a day, you are improving the physiology the whole way along, so you are in a better position to do IVF, to get pregnant, any of those things, the whole time that it’s working.
We want to get to those special numbers, there is data to show certain things, but remember statistics are useful, but they don’t necessarily mean you. I always feel like that willingness, that real change that’s happening is worth a lot. I think it shows up physiologically, but also in the attitude and what you’re doing.
I wish I could give a number. It can go relatively quickly. I do three-month chunks, that’s how I usually work with people.
Dr. Aimee: Got it. Great. Thank you for all of your work helping fertility patients. I love everything about you, your website, I love that it is speaking to fertility patients. I imagine you work with men as well.
Dr. Stephanie Fein: That’s a great point. Not as much. Usually it ends up being women, but I could because you’re absolutely right, there is data to show about the men also that it’s helpful. I will say that a lot of times men will lose weight when their wives or partners do. The couple ends up losing weight together when one person is affected because they’re starting to make different choices for themselves and that just naturally affects the other person, so two-for-one.
Dr. Aimee: Thank you for being on today. I really appreciate everything that you’ve shared with us. Is there anything else that you’d like to add?
Dr. Stephanie Fein: I am just really excited to be part of this community. First of all, your community is amazing. I know that people who are going through infertility are heroes. They are heroes. I always thought that about people who were trying to lose weight, too.
Anyone trying to make a huge change or trying something that seems impossible is a hero to me. I want people to feel that for themselves, because often that’s not what’s going on. It is not a little thing to go through infertility treatments. It is not a little thing to lose a lot of weight. I know it can be done and I just honor anyone who is going through this.
Dr. Aimee: I couldn’t have said that better myself, especially now with COVID. Imagine going through the pandemic and having fertility issues. Truly, each and every one of them is a hero to me as well.
Thank you again, Stephanie. I appreciate you. We all appreciate you. Keep up the great work and continue to inspire us to be our best version of ourselves. Thank you again.
Dr. Stephanie Fein: Thank you so much.
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