Stephanie Fein MD [00:00:00]:
Hello, fabulous Dr. Stephanie Fein here with Weight Loss for fertility. And I was in San Diego and it was lovely. It was actually that weekend when Artemis came down and it was in San Diego. And this is just an aside, but we were in a lecture when we heard the boom, the sonic boom. It was very exciting. And then everyone ran out, poor guy who was speaking to see if we could see anything. And we, we, I mean, we all really tried it.
Stephanie Fein MD [00:00:30]:
We couldn't see anything. And then later we found out that it was something like miles off the coast, but we were right there and I'm convinced I saw them in the helicopter because the naval bases was right across the way from our hotel. So exciting. That's an aside. Totally didn't even remember that until I started talking to you. So that was pretty fun. And the weather was nice. It was, it was actually a lovely weekend.
Stephanie Fein MD [00:00:55]:
And for me that's a drive away, so it was very easy to go there. The conference is an obesity medicine conference and I had been to one many years ago. And in fact that's where I first learned that weight loss impacts fertility. Until then I had been helping people lose weight and I never knew that piece of information. And that little bee got in my bonnet and that's why we're here now with weight Loss for fertility. So I like this conference, but I hadn't been in a long time. And I'm going to tell you the things that I thought about, the things that it brought to me. The first thing I want to tell you is, and I remember this from the time I went, like I said years ago, their food is amazing.
Stephanie Fein MD [00:01:40]:
And what I mean by that is they offer it, they provide all breakfast and lunches and they are very delicious and nutritious. So they walk their talk and that's what I appreciate about it so much. When they have snacks, they're not cookies, they're protein based things and that's what they have available for the food. So it's heavily plant based, which is amazing. I made a post on this is coming out in May. The conference itself was in April, so there'll be a little lag time. But I did a post on it showing the food. It's literally gorgeous.
Stephanie Fein MD [00:02:18]:
Like, I actually do wish I could eat this way in my real life. Except I don't like cooking and you have to cook vegetables and I definitely don't like cooking vegetables. So my normal meals look nothing like this. They do. If I go out, if someone else is making the vegetables, I am all too happy to eat them. I just rely on salads because you can get them out of a bag. That's just me. This is why I can work with people who don't want to cook, but because I am that person.
Stephanie Fein MD [00:02:48]:
So I appreciate when someone else is making the food and it looks so gorgeous. So that is one of my favorite things. Also, they label all the food so you know what ingredients it is. If there's gluten in there, if there's dairy in there, is it vegan, is it vegetarian? Like all that, Which I just think is kind and so colorful, so tasty and. Right. And available. Right. It was buffet style, of course, for all the conference attendees, and they had so many places set up that you were not waiting long.
Stephanie Fein MD [00:03:17]:
You were waiting like two minutes, which, of course is fabulous when you're doing the hunger scale and you're getting hungry. So kudos to them. I remember that from before. That is an important. And it's. It really is important. I'm thinking about this. It's.
Stephanie Fein MD [00:03:35]:
I w. I do wish more people would pay attention to this for conferences, and I'm very happy to say that at least the Obesity Medicine conference does. And I do think that certainly all medical conferences should. And they don't necessarily. So one big aspect that I always love about that. The other thing that I want to tell you about was that there was nothing specifically on fertility. Now it's a relatively small meeting. What I mean by that is it's not like the asrm, the Reproductive Medicine Conference, Annual Conference.
Stephanie Fein MD [00:04:05]:
It's huge. Or the Internal Medicine Conference. Those things are enormous. This one is, gosh, how many people? I don't know, 500 somewhere around there maybe between 5 and 700. And they had some breakout sessions, but in general, most of us were in the same lectures, and none of those lectures were on fertility. And I just. Something interesting to note now, it's. I may have to.
Stephanie Fein MD [00:04:38]:
This is an area that I may have to step up at some point and be the one to do that. But part of the. I think part of the reason this is a main chunk I'm going to talk to you about is that, as you can imagine, the meeting was mostly about medications. And it makes sense because most of these doctors, and there's nurse practitioners, there's clinicians working with to help people lose weight. They're primary care doctors, most of them. Some of them are specialists in obesity medicine and they may have their own practice. There's just so few of them that are specialists. Most of the people working right now are primary doctors.
Stephanie Fein MD [00:05:18]:
So they're seeing everyone, heart disease, diabetes, urgent care things, but often chronic diseases. And so they don't have tons of time. Which is why medical weight loss, if it wasn't in a specialty, was challenging before these medications, because it was hard to get a lot of weight loss in a doctor office that was a primary doctor, that wasn't their primary focus. And so these medicines can be a game changer for them. If they're just writing a prescription and they're seeing you again in three months, we're going to talk about what works when you aren't taking medicines and it's not seeing someone every three months. I'll tell you that so many people are very excited about these medications because a lot, if they have a rural population or something, they will have a large percentage of their practice with people with BMIs, 40, 50, 60, and being able to treat the root cause of the diabetes and hypertension and hypercholesterol by helping them lose weight in a meaningful way without the support that works, because that isn't so much an option in primary care. What I mean by that is what works is weekly support. And especially physicians who are not specializing in obesity medicine, they do not have half an hour every week to see the same patient and help them with behavioral modification, cognitive behavioral therapy, the stuff that works.
Stephanie Fein MD [00:07:03]:
And so this is the tool they have. And so they're very excited to have the tool, understandably. So it can help a lot of people. So I'm going to just tell you a couple things that I learned about these medications just so you have them as they're coming down the pike. Now, I have been around weight loss long enough that fen phen was around when I was starting, and then it had. It was pulled because of the problems with the heart valves. So I am just a skeptical person in general, and I worry about these things. So I'm wondering what we're going to find out years down the road, which is what happened with Fen phenomena.
Stephanie Fein MD [00:07:48]:
Maybe nothing. Maybe we'll find some great things. But in this meeting, there were some things that pointed to it, and I'm going to talk to you about that. A couple things to go along with the medications. Not everyone is a responder. I just want you to know that. Because sometimes people think that this is the magic bullet, it can help people, but it's not the end all, be all for everyone. Some people do not respond, and that's not because they're wrong or they're bad or there's.
Stephanie Fein MD [00:08:15]:
It's likely something to do with genetics. They don't have all the processes worked out with how these medications exactly work. So we don't know. There could be something going on there. There's just a lot of unknowns, which, of course, is the thing that makes me nervous. So the only thing they had besides the medication now used to be bariatric surgery. That was the only thing that could get you significant results. And again, not everyone responded, but a lot of people did, and they saw a reversal in diabetes and all that sort of thing with weight loss.
Stephanie Fein MD [00:08:50]:
So it was predicted that it would happen with bariatric surgery. Bariatric surgery has taken a hit with these new medications coming out, because they can get results that come close to it. The only medicine that does come close is Tirzepatide. And the semaglutide, which is the Ozempic, is not as effective as Tirzepatide. Tirzepatide has two medicines in it, and semaglutide only has one. And so the tirzepatide now rivals bariatric surgery in terms of outcomes, and bariatric surgery still has its place. That was an interesting thing I learned, because with the medications, it looks like at 72 weeks, which is about a year and five months or so, there's a plateau. That's when you hit the extent of the weight loss, and then it pretty much stays there on whatever dose you landed on.
Stephanie Fein MD [00:09:52]:
And I think you know this, but if you stop the medication, you gain the weight back. So this is designed as a chronic medication, just like you would for blood pressure. You don't stop taking the blood pressure medicine. You do if you lose weight and it was impacted by weight loss. So there's that. But if you have it and need it and it's not going to be affected by a change in weight, then you're going to be taking it for the rest of your life. Same thing with these medications. The newest ones are oral, so they literally just came out.
Stephanie Fein MD [00:10:26]:
There's an oral semaglutide, which must be taken on an empty stomach. This is a little tricky. It has to be in the morning, 30 minutes. You can only take it with a teeny amount of water, and that's because it's the same peptide that's in the injection. But if you put it in your stomach, you have stomach acids in there, and it can digest and degrade the peptide. So it needs to be taken in that scenario in the morning. No food, a little bit of water in order for it to be effective. What just came out is another one called Orforglipron, and it is also a GLP1 receptor agonist, but it's a small molecule.
Stephanie Fein MD [00:11:09]:
They formulated it so that it doesn't break down in the stomach. And so it's not the exact same formulation as tirzepatide, but it is effective like tirzepatide, which is an injectable, except not as much. So the oral semaglutide is not as effective as the injectable, and the Orforglipron is not as effective as tirzepatide. But they're playing with the idea because it just came on the market. So they don't know exactly, but they're playing with the idea of being. You can transfer to that once you hit the 72 weeks to maintenance on the pill. And it's easier that you can take because it's a small molecule. Any time of day, you should still take it the same time every day, just so you have the.
Stephanie Fein MD [00:11:57]:
A steady state. But you don't have to only be on an empty stomach, only anything like that. And the main one to watch out for that's next down the pike is retatrutide, and that's a weekly injection. And that has three medications. So semaglutide has one, Tricipatide has two, and the retrotrutide has three. And it has even more weight loss than the other two. Now, the thing about there was this was a discussion like, where are we going to stop? You know what I mean? Like, people are like, where do you draw the line? So that's something out there. This one isn't out yet, but it's coming soon.
Stephanie Fein MD [00:12:44]:
Couple things about the medications, as I mentioned, they plateau at 72 weeks. They work by significantly decreasing appetite, both in the brain and in the stomach, as it affects the GLP1, which is made in the intestines, so your appetite is suppressed, but also you're nauseous. So there are significant GI effects. Not everyone has them. Some people have them worse. Some people can't stay on it because of that. But. But in general, there is nausea, vomiting, some people have diarrhea.
Stephanie Fein MD [00:13:21]:
And that is part of how it helps you not eat and have fewer calories. There you are. That's partly how it works. Not everyone responds to it, as I mentioned, staying on it for life. And if you get off of it, you regain. And of course you are paying for it because right now insurance doesn't cover it. Now, the orals are gonna be less expensive because they are less expensive to make than the inject. There'll be something there.
Stephanie Fein MD [00:13:50]:
But the most important thing for us here is that all Those medications, the GLP1s, are contraindicated in pregnancy and they must be stopped two months before transfer or conception so that the medication is out of you because we do not know what they do to fetuses. It looks like there had been some effects in baby mice. There is a registry being collected and I actually gave my email address to someone there, Elay Lilly. They were going to do some research for me on the registry and the fertility. But for people who accidentally got pregnant while they were on it and to follow those babies and see what happens there, there was a very thought provoking talk and it was from a doctor who loves macrophages, which is part of our immune system. And that had her ste the connection between the immune system and metabolism. And the point she wanted to get across is that immunity and metabolism are inseparable. This is a really interesting idea and it makes sense basically that all of our systems support each other and interact and that just makes intuitive sense to me.
Stephanie Fein MD [00:15:07]:
She was very detailed and I will not go into all of that here. And some of it was above and beyond my pay grade. But one of the things she talked about was this connection between sickness, so the immunity and weight loss. And the word that we use for sick weight loss, meaning uncontrolled weight loss, like unintentional weight loss when you're sick, if you have cancer, that kind of thing is called cachexia. And it's profound muscle wasting. And there's nothing you can do about it. You can't eat enough to gain weight. Like when this is triggered and you're sick.
Stephanie Fein MD [00:15:54]:
And she's thinking that there's a connection there. And of course the concern would be, that's what's happening, right? Is that we're telling the brain act like we're sick. And if it just meant weight loss, that might be okay, but we don't know what else it's going to trigger. And that's the piece that can get so tricky. And I hadn't known that or thought of that before. And it makes sense because of the muscle loss that happens with the weight loss, with the medications. But this is something to watch for. And also the brain, she told us the brain, and we knew this, that the brain has the GLP1 receptors.
Stephanie Fein MD [00:16:37]:
And because immunity is impacted by the GLP1 being on board, the forces that keep Alzheimer's plaques in place may be weakened. So if the immune system is responsible for keeping Alzheimer's at bay, by keeping the plaques sequestered, if the immune system is no longer working well, it may relax its impact on those plaques and then Alzheimer's could come earlier. This is all speculation. This is not proven at all. Just in her research with the immune system and metabolism, this is something she's posing as a question, and it's an interesting one because I was concerned that the long term issues with the medication would affect the thyroid. And that was because it's contraindicated in people with certain hormonal and thyroid cancers. And so I thought that meant that the thyroid would be the thing that would be impacted long term and particularly in developing fetuses. That's what I was wondering about.
Stephanie Fein MD [00:17:50]:
But now with this idea, she has me thinking that it will have more to do with brain inflammation and this sickness, the cachexia that happens and it's just something to look out for. I don't know. But I do know that we don't know. And that's the part I don't like. And I like to know things and when I don't know them, I get a little nervous. And so now I think we'll be looking more at brain and muscles than maybe at thyroid. I'm sure there's someone looking at thyroid, although no one was speaking about that. The other thing she talked about is the idea of the constant exposure to the GLP1 receptor agonists in the bloodstream instead of pulsed exposure.
Stephanie Fein MD [00:18:40]:
So the GLP1 is created in our intestine and when we have meals, it's secreted. So it tells us that we're full, that we've had enough food in our language that would be satisfied. And so we're looking for that signal. It happens when we eat and we have natural GLP1 in our body, but it's short lived. It comes, it tells us, it goes. But when we take the GLP1 receptor agonist, it's not going, it's staying and it stays constant for a long time over the entire week. And there may be issues related to that. And the one that sort of makes sense, and I don't know if that is responsible for the plateau at 72 weeks, who knows, but is resistance to GLP1 and that's a similar model to insulin resistance.
Stephanie Fein MD [00:19:36]:
When we have a lot of insulin in our bloodstream, we start to down regulate the receptors so that they're not overwhelmed all the time. And then we have insulin resistance, more insulin in the bloodstream fighting for smaller number of receptors and that leaves us with more insulin in the bloodstream. Than we want. And then with insulin, at least it stores fat. So we're not sure what happens if we have too much GLP1 in our bloodstream for long periods of time. It was an interesting point to make. So that's the other thing I'll be looking out for, too. And then a couple tidbits I wanted to tell you that I thought were interesting.
Stephanie Fein MD [00:20:24]:
And this is just a reminder that obesity is cumulative. On average, we gain a pound per year starting in our 20s. So by the time we're 40, it's £20, 60, £40, that sort of thing. And that's generally. And it's cumulative. It happens slowly over time. It's insidious. So sometimes there was something that happened, like we used to do college athletics and then we had a desk job and then we gained weight in a shorter period of time.
Stephanie Fein MD [00:20:56]:
But sometimes we're doing similar things and we're just like, I don't know what's happening. This is what's happening. Where if we just gain a pound a year, but over time it adds up. It's not good for pounds, but it's great for. That's how you. If you put money away and then you wait 20 years, you can have more. We don't want that with fat, though. But that is what happens.
Stephanie Fein MD [00:21:18]:
Another little tidbit is protein without stimulus will not build muscle. So if you're not using your bones and muscles when you're having your protein, you won't build the muscle. Now, I don't think you have that issue because if you're doing your daily stuff, you're walking to the. Even walking to the car, getting up from a chair, like doing all that stuff, you're using your muscles and your bones. But weight bearing, exercise, weightlifting, yoga, Pilates, that sort of thing, resistance training two times a week is really helpful. And when we're eating protein to preserve muscle in weight loss, we do want to make sure there's a stimulus there too. So it builds it up rather than just having protein floating around in our bloodstream. The last tidbit is that it's better to pulse the protein than to have a big bolus.
Stephanie Fein MD [00:22:17]:
So what I mean by that is having protein at each meal instead of one big protein meal works better for the natural GLP we have, and the GLP1 receptor agonist also. But for the rest of us who are not taking the medication, 30 grams per meal is a good target. You are getting about 100 grams in the day, but it's broken up over the meals. All right, Those were my observations. And what I want to tell you is because of course I look for this. There was a nutrition lecture, there was a CBT lecture, which all of these were great things. And studies still uphold that weekly support works. The thing, the reason I love that is because it's permanent.
Stephanie Fein MD [00:23:08]:
When they're talking about all these things, that's the piece that can be missing, is the permanence. Even if we use the medications, listening to our hunger cues is important. The medications can make it very obvious because you're vomiting and then you know, you're not hungry. But we're doing the same thing when we learn to do it with our brain. Cognitive behavioral therapy does that. There's a study about talk therapy versus antidepressants medications. And it. I think it fits here for a mild depression, not a severe depression.
Stephanie Fein MD [00:23:52]:
They're equal, meaning they do the same thing. So the pill affects the brain chemistry, but so does talk therapy. And that is what we do. We. It's not talk therapy, so it's not exact. What I mean is we're rewiring the brain with your thoughts, with techniques, with noticing thoughts, with. With shifting them, with looking at things differently. It changes the brain chemistry, and that ends up being permanent.
Stephanie Fein MD [00:24:25]:
You practice it, and then it's a skill you have forever. And to me, that is so important. Whether down the road you go on a medication or not, you will need these skills. You will benefit from these skills. Learning to listen to your hunger changes your brain and therefore your gut hormones. Actually learning to notice your thoughts and the feelings they lead to mean you are more connected to how you work. So you can treat yourself with understanding and love. And it's the closest you'll get to your owner's manual.
Stephanie Fein MD [00:24:59]:
Listening to your thoughts, feeling your feelings that are based on those thoughts, is your owner's manual. You will then learn how to treat yourself best so that you can thrive, so that you do better, you feel better, you know what you need. These skills are so important, and they don't come with the medications. And I don't have anything against people being on the medications. I just am seeing these differences, and they matter to me and to the people that I help. And so if that's the kind of thing you're looking for, then here's the place. And of course, there are no side effects to the way that we lose weight here, except more joy and presence. And there is some discomfort in feeling uncomfortable feelings, but we are experiencing them anyway.
Stephanie Fein MD [00:25:55]:
And experiencing them gives us so much more. It points us in the right direction. It's our real life, it's what's really going on. And then we can do something about it. There's no GI side effects. And these skills translate to the rest of your life. And my favorite place that they translate to is parenting. And that's what we're here for.
Stephanie Fein MD [00:26:22]:
So that's my wrap up. I am sending you so much love. If you have any questions, I'm always happy to answer them. You can contact me on my website, stephaniefeinmd.com there's a contact me button. There's a lose weight with me button. You can always DM me on Instagram @stephaniefeinmd. I am sending you so much love. Until next week.
