I spoke to my female patient about her weight the other day. Wait, you say. Isn’t that against “Girl Code”? Tantamount to replying “yes” to the “Do I look fat in this” question?
Actually, I would counter that discussing excess (or not enough) weight, as a nurse to your fertility patient, is not only appropriate, it’s necessary. Here’s why.
There are many studies that show that being obese has detrimental effects on getting pregnant, staying pregnant, and on the baby. One study showed that natural fertility rates declined comparable to a year in age for every BMI (body mass index) unit over 30. That means that your ovaries act ‘older’ the higher your BMI category, and everyone knows that age and fertility are natural foes.
While we are not sure of the exact mechanism of how weight affects fertility, we know that ovarian, uterine and sperm function are all affected (yes, regardless of your weight, an overweight male partner also puts you at a disadvantage). We know that as BMI increases, so does time to conception, the amount of fertility medications needed, and the chance the cycle will be cancelled due to poor response.
Once you are pregnant, elevated BMI increases the chance of stillbirth, or pregnancy complications, such as gestational diabetes, and labor complications. Finally, a suboptimal uterine environment, such as that caused by gestational diabetes or obesity, can cause gene mutations in the fetus that follow him or her into adulthood, such as Type 2 diabetes, obesity, and cardiovascular disease.
One of the most common questions I get as a fertility nurse practitioner, and I’m sure that you do too, is, “what can I do to improve my chances/outcome?”
We would then discuss any necessary lifestyle changes (such as stopping alcohol, smoking, etc), so why exclude a discussion about weight with someone whose BMI puts them in the very overweight/obese/morbidly obese category, giving them less of a chance to conceive than other age-matched patients?
Armed with the information above, I think we can now all agree that excess weight is not helpful when trying to conceive, but how do we discuss it with our patients? In my opinion, it can be done honestly, appropriately, kindly and in context.
Let’s start with how to appropriately introduce the topic when speaking to your patient. I was speaking to a patient the other day whose BMI was 46 and she asked me if there was anything that she can do while waiting to proceed with IVF (in vitro fertilization). In my mind, that number, 46, was like a flashing neon light in her record that I couldn’t ignore. Just as I would honestly and openly discuss elevated blood pressure or an abnormal lab value, that is how I treat BMI.
Someone’s weight doesn’t define them, but it can be an obstacle.
So, I say something like, “Your BMI category is ‘x’ (underweight, overweight, obese, etc) and I fear that this is hindering your ability to conceive.” Realize that most people underestimate their BMI category, so obese patients think the they are “just overweight” and very obese patients think that they are “mildly obese,” etc.
The BMI category matters, because, as stated above, as BMI category increases so, potentially, do the adverse effects of it on a patient’s fertility potential. I feel comfortable discussing the topic of weight mostly because I am passionate about it, but also, importantly, because I have the support of the clinicians in my practice, www.rmact.com, and we have an in-house nutritionist. This is important, because I don’t have to introduce a challenge without offering a solution.
You should develop your own “script,” or wording that you feel comfortable using, that you can refine with time and experience, while starting to impress upon the rest of the clinicians and staff at your practice the importance of support for patients of all sizes.
Once you have that script, when is it appropriate to broach the topic? I prefer to discuss a patient’s weight after I have established a relationship or rapport with her, maybe during her diagnostic cycle as that generates many phone calls and interactions.
I hope, that after having spoken with me, she realizes that I have an emotional investment in her and her child’s outcome, and discussing her weight is just another aspect of this. But sometimes, a patient’s BMI needs to be discussed during the initial consult, as perhaps your practice has a BMI cut-off for services that your patient exceeds. How, you may ask, can you initiate this conversation when you first meet a patient, before you have developed a relationship?
One way is to embed questions about weight in your new patient questionnaire, such as “Have you had a significant weight gain or loss in the last year,” or, “On a scale of 1-10, how motivated are you to make a change in your weight.”
Then, as you review the questionnaire with the patient, you can not only use the questions as a segue into a discussion about their BMI, but also assess their motivation to make a change at this point. Another way is to assure that you have a “healthy office.” This means an office that is equipped with the equipment (large blood pressure cuffs, cloth gowns and stools without wheels, etc) needed to properly care for overweight or obese patients. It is also one that has a staff who has been prepared to sensitively care for overweight and obese clients, keeping in mind the influence of weight bias, a form of discrimination that, arguably, most of our overweight or obese patients have experienced at some point by people who take care of them, including health care providers.
It is an office that has healthy magazines and maybe cookbooks in the waiting room to give clients a first impression that health is important to those who work there, which helps to facilitate a conversation about weight in the context of the general health of your patients. The clinical suggestions above and more are available from the UConn Rudd Center (www.uconnruddcenter.org) which offers a great online course on this topic.
I don’t enjoy the potential embarrassment that can be generated by a discussion about weight, but I don’t use discomfort as an excuse to avoid it. In my opinion, this conversation must occur in order to provide comprehensive, individualized care to overweight or obese patients. In fact, I would argue that all staff in fertility settings should, at the very least, be sensitive to this patient population, be knowledgeable about the effects of weight on fertility and pregnancy, and strive to find ways in their office setting to incorporate discussions about weight.
If you are interested in this topic, please contact me at firstname.lastname@example.org or surf this website to view services that your practice might find helpful.