Dr. Angela Chaudhari (Host): Welcome to Parts and Labor, a roundtable discussion with our OB-GYN experts here at Northwestern Medicine. My name is Dr. Angela Chaudhari, and I'm a minimally invasive gynecologic surgeon and serve as the Chief of Gynecology and Gynecologic Surgery here at Northwestern Medicine. I will be your host today as we discuss PEARL, a multidisciplinary program at Northwestern Medicine designed to provide compassionate care for patients who struggle with obesity as they prepare for pregnancy.

Let's meet our esteemed physician panel today. First, we have Dr. Christina Boots, who is a Reproductive Endocrinologist and Infertility Specialist at Northwestern University. Her work focuses on nutrition, lifestyle, and PCOS and how those affect reproductive health, oocyte quality, and early pregnancy. She also serves nationally on the editorial board of the prestigious journal, Fertility and Sterility.

We are also joined by Dr. Michelle Kominiarek, a professor at Northwestern University and Maternal-Fetal Medicine Specialist at Northwestern Medicine. She's nationally recognized for her work with pregnancies affected by obesity and post-bariatric surgery. Her clinical interest include nutrition, physical activity, and gestational weight gain during pregnancy.

Next up, we have Dr. Veronica Johnson, an Obesity Medicine Physician and Assistant Professor at Northwestern University. She's board-certified in Internal Medicine, Pediatrics, and Obesity Medicine, and she sees patients at the Northwestern Medicine Center of Lifestyle Medicine. Her research focuses on obesity management and the treatment of obesity in children, adolescents, and adults, as well as integration into primary care.

And finally, rounding out our panel is Dr. Jacqueline Hairston, a Maternal-Fetal Medicine physician and Assistant Professor at Northwestern University. Her clinical interests include fetal anomalies, obesity care, and medical education.

Welcome, guys. I'm so excited to be here talking to all of you about the PEARL Program at Northwestern Medicine. This is really like a new program for me. This is not what I know a lot about. And so, I'm so excited to learn more and have all of our listeners learn more about this program. Now, I'm going to make sure I got this right. PEARL stands for Preconception and Early Assessment Care Rooted in Lifestyle Management. I'm so glad we found a good acronym for that, guys, because that is a little bit of a mouthful. But I'd love to start, Dr. Boots, can you just share how this program got started and what the goals of this program really are?

Dr. Christina Boots: Yeah. You know, it happened pretty organically originally that I think we're all really passionate about, just elevating the care that we provide to women and people at Higher BMIs. And we were all doing it in our own practices, but having-- you know, this is a, a multidisciplinary medical condition and so we needed to work together. And so, we were working together more and more and really felt like we needed to organize ourselves both so that patients can see, you know, us as fertility specialists. You know, the Maternal-Fetal Medicine specialists and the Obesity specialists, but then also having a good referral network to other multidisciplinary providers within the healthcare of women. So, that's really where it started, and just trying to do a better job of taking care of these women.

Host: I mean, I think this is such an important topic. You know, obviously, obesity is very, very common in our population, and it's not something that we always talk about or, honestly, even a lot of doctors feel comfortable talking about. And, you know, when it impacts reproductive age women, we have to think about how that's going to impact all of their lifespan, both during pregnancy and outside.

So, let's just take a step back because, obviously, we have a lot of physicians listening, but we also may have a lot of patients listening to this podcast. Can you guys just, for me, define really what clinical obesity is and really what the key criteria? I'm going to turn to Dr. Johnson because, Dr. Johnson, you're an Internal Medicine physician and this is like what you do all day, every day for patients across the reproductive lifespan.

Dr. Veronica Johnson: Right. Exactly. So, you know, I think a lot of patients, and even physicians kindly think of obesity as just a BMI being over 30. And actually, you know, obesity is such a complex disease and there's a lot of different factors involved with why one weighs what they weight. And so, I guess, a couple months ago, a publication was published in Lancet that defined clinical obesity. And it was really looking at obesity as excess body fat. And the clinical aspect of it is just looking at how that excess body fat weighs into a patient's overall health. And so, when you have clinical obesity, you have excess body fat, but you also have that impact on the health, whether that be in our particular patient population like infertility or irregular menstrual cycles, PCOS, but also just looking at the overall other health-related conditions associated with having excess body fat, like obstructive sleep apnea, like cardiovascular disease, the impact on joints like having osteoarthritis of the knees or the hips.

And so when we look at clinical obesity, I think it takes us away from just defining the disease as just A BMI being over 30, but looking at it as this is actually a disease that impacts one's overall health.

Host: Yeah. I mean, when you talk about how obesity hits so many of our different organ systems and how it can really impact us, when we think about, you know, everyone wants to say, "Okay, obesity and cardiovascular disease, those things really go hand in hand." But listening to you and hearing all the other areas, whether that's sleep apnea, how people sleep, and how that might impact metabolic syndrome and how that might impact musculoskeletal health, I mean, from my standpoint, it sounds like it hits every organ system. How do you really counsel patients when they come in to see you even outside of their reproductive years about what those impacts might be?

Dr. Veronica Johnson: I mean, I think it's important to just tell patients that it's not their fault. And I think that when they see other healthcare professionals that sometimes they just feel like there's a lot of blame on them for their excess weight. And, you know, when we talk about it or when I see a patient, it's really looking at how their excess body fat is impacting their overall health, and also talking to them in the sense where we want to decrease the risk of them progressing to having other impacts to their health. So if we can catch like, yes, you have excess body fat, you might have pre-diabetes, let's decrease the risk of you progressing to diabetes. If you have excess body fat and your blood pressure is high, let's decrease the risk of you progressing to have a heart attack or a stroke. So, if we have that diagnosis of clinical obesity, it kind of can aid in counseling and just decreasing their risk of having other weight-related conditions long term.

Host: Yeah. I mean, it's really something how obesity and this excess body fat can really impact us and impact patients throughout their lifespan. Obviously, the PEARL Program is really designed around pregnancy. And so, I'd love to kind of hear from you guys as the experts. How does really obesity impact patient's ability to conceive, to get pregnant?

Dr. Christina Boots: I'll take this one. Well, I think we know that some obesity does, so some excess fat, can affect your ability to get pregnant, but not for everybody. So, just having a higher BMI doesn't mean that you're going to have infertility. And just because you have infertility doesn't mean it's because of your BMI.

But when it is associated, we see that having excess body fat and really, you know, an energy imbalance even on the low ends can also influence how our hypothalamus talks to our pituitary, talks to our ovary. And it's a really delicate system that can get interrupted. So, having a high BMI, certainly in the setting of polycystic ovary syndrome, that we see that excess body fat creating some insulin resistance or the insulin resistance causing the body fat. But that plays a role in hyperandrogenemia and so having higher testosterone levels and interrupting--

So, the primary way that a lot of weight affects getting pregnant is just not having regular menstrual cycles and not ovulating with consistency. It's certainly more complex than that, that even those who are having regular menstrual cycles probably have other impacts on it. But as I mentioned, it's so complicated and everybody is an individual that it doesn't affect everybody. So, it's important.

And then, you know, the part of the reason this program is so important is because age plays a role in that too. And so age, much more so than BMI, influences how likely we are to get pregnant. And so, we really wanted to create this program. We were talking to women before they were even, you know, ready to be pregnant, but starting to think about it, to just pause for a moment and say, "Hey, you know. I am 30. We just got married, and we're ready to have a family. But is there something I can do to improve my health?" And hopefully, everybody's asking that question regardless of their BMI. But especially those in a bigger body who are at higher risk of those things, that they pause and see us and say, "You know what? My ovarian reserve is really good." I have a couple of years to meet with Dr. Johnson, and I'm going to meet with, you know, Dr. Kominiarek and Dr. Hairston, and say like, "Well, if I did get pregnant now, what are my risks to my pregnancy? And is it worth taking some time off?" And that's a very different conversation than if you're 40 coming to see us. And so, I think, you know, that's a big reason why this program exists is so that we can counsel people comprehensively, but individually about what the risk-benefit of changing their lifestyle and the time it might take to get that excess body fat down.

Host: I mean, what a resource you guys really are because frankly, as somebody who worked as a generalist for many years, I know what a busy generalist's schedule looks like. And the idea of taking that extra time to be able to talk to someone about what obesity really looks like for a future pregnancy is unfortunately a time that most busy generalists don't have, despite wanting to do their very best for their patients. And so, what an awesome resource to be able to do some of this counseling for patients beforehand. I'm going to follow up though, Dr. Boots, is there any association with decreasing your weight and improved fertility outcomes?

Dr. Christina Boots: That's a great question, and a bit loaded. There is some data that says decreasing excess body fat. When your cycles are irregular and you're not ovulating regularly, that that can make you ovulate more consistently and thus increase your rate of spontaneously getting pregnant. There have been a handful, like four to five, well-done randomized controlled trials looking at short-term weight loss and meaningful weight loss before doing fertility interventions mostly targeting unexplained infertility patients. And what we saw is that it didn't improve their life birth rate when they were seeking IVF. None of these studies were done with the newer generation, these GLP-1 receptor agonists. And so, you know, I think some of that research has yet to be done and no really wonder well-done randomized controlled trial has happened with weight loss surgery, which are two different things. But what we gathered from those studies is that losing, you know, a modest amount of weight in the short term right before seeking fertility doesn't reverse the effect that that weight and excess adipose had on your overall body. And it may have, you know, long-term health effects, but short-term, just helping you to get pregnant, we haven't seen happen. And in fact, I think we have to be really careful about recommending, you know, fast, meaningful weight loss right before we're getting pregnant because our metabolism is going to change so much. And, you know, diminishing our nutrition and our energy imbalance is probably not the best time to be growing a human. And so, some of those trials, while not statistically significant, did show high miscarriage traits when they were getting pregnant. And I'll let my obstetric colleagues talk about it, but there is, you know, data in women who have, you know, really significant weight loss, like what you get after bariatric surgery. We really counsel those patients to have a year or two from that weight loss until trying to get pregnant. So, it's complicated. But yeah, most of the time, just telling your patients, "Hey, just lose some weight and it'll happen," is not the right answer.

Host: Yeah, I mean, as a surgeon, we say the same thing to our patients about bariatric surgery, right? Like if you've just lost or if you're losing all this active weight, it's not the best for wound healing, it's not the best time to proceed with elective surgery. And it's so interesting to hear patients think, "I can do this and then I'm going to be really healthy for pregnancy." But actually, the answer is it takes a long time to get their health back, to get their nutrition back into space for pregnancy.

Okay. Let's really talk about what this means in pregnancy, because I think probably so many people listening are like, "What is the risk of obesity on my pregnancy or on my patient's pregnancy?" I'm going to turn to my two MFM specialist. What do you guys think?

Dr. Jacqueline Hairston: Would you like to go first or...? I think when we're talking about obesity and pregnancy, you know, we have a list of risk factors that are very well studied that are associated with obesity and pregnancy. One of those is excessive weight gain. So, anyone with a BMI of 30 or higher, we really say we want that weight gain in the pregnancy to be 11 to 20 pounds. But we know patients with obesity are at risk of excessive weight gain, which can then have an impact on the growth of the baby and the long-term outcome for the baby as well as they develop into childhood.

We also think about the risk of C-section and whether they can progress in labor. And if you do a c-section, that increases risk of infection. And when we're surveilling a pregnancy and we're doing ultrasound, we have to look through all of these tissue layers. And so, sometimes we're not able to detect differences in baby's body. And so, there can be associations with fetal anomalies. Those are some of the risk factors. But overall, we still want to counsel patients that they can have a good outcome, but it's important to optimize their health prior to pregnancy.

Host: Yeah. I mean, there's so many different aspects that go into healthy growth of babies. So, hearing you talk about, you know, how excess body fat might contribute to some of those complications and risk factors, I think is something that some of our patients don't always understand, which is why I think this program is so important to do some of that counseling. So, what really are the key elements of preconception counseling for these patients? What should we be telling them?

Dr. Michelle Kominiarek: Yeah. Like we said before, you know, it affects every organ system and it's complicated. And I always try not to overwhelm patients with a lot of information, so I try and break it down into pieces. And that might be with showing them how their prenatal care might be different, how their delivery might be different, and how we might differ in their postpartum care.

And just some of those specific things is that because there's an increased risk for diabetes, we might screen earlier for diabetes. We might offer them a medicine called aspirin, 81 milligrams of aspirin to help prevent something called preeclampsia or high blood pressure because they're also at risk for high blood pressure. As Dr. Hairston said, you know, we might do some extra ultrasounds to take a closer look at the anatomy to see if there is an anomaly or, even later in the pregnancy, if we're not sure like how large or small the baby might be growing, we might do some extra ultrasounds to monitor that growth.

Host: Yeah. And I know for a lot of patients, that might seem a little overwhelming, like, "Wait a second, I'm high risk just because even though I'm a young person, even though I have excess body fat?" Is there something that you tell patients in particular when they come to you in sort of this preconception notion in terms of what really is the best thing for lifestyle management as they think about getting pregnant in the next few years?

Dr. Michelle Kominiarek: Yeah. I do have patients ask me that. So, do I need to see Maternal-Fetal Medicine? And it's not always the case. It kind of depends on what else is going on. It's having a higher weight, certainly what I would say a high risk factor. But it doesn't necessarily mean that the pregnancy has to be managed by Maternal-Fetal Medicine, partly depending on the patient's wishes and their own provider's wishes too.

Host: Yeah, I know. I'm sure that there's some providers listening who take care of patients out in the community and they're thinking, "Oh my gosh. I think it would be really helpful to do at least a one-time visit to get my patients on track as they think about pregnancy, or they are pregnant," and wouldn't it be nice to have a one-time visit? Is that something that's available through the PEARL Program?

Dr. Jacqueline Hairston: Yes, it is available. And we see patients prior to pregnancy and in pregnancy. And if it's something where a hospital doesn't feel like they can care for a patient depending on their BMI, we have availability and we have special or beds, especially in terms of delivery that we can accommodate patients with a higher BMI.

But I do think it's interesting in terms of the patient perspective that, in pregnancy, this is the one time where we say we expect weight gain, and that's a frame shift for patients. It might be unexpected, especially for patients who have encountered bias along their way based on their weight. The expectation of weight gain might be different for patients. And so, that's a new narrative that we're introducing in pregnancy.

Dr. Christina Boots: Can I jump on that a little bit?

Dr. Jacqueline Hairston: Sure.

Dr. Christina Boots: You know, I think two things that we haven't quite touched on is that I think coming to see us, even for just a one-off consult can sometimes be just the start of a conversation. And then, I mentioned our multidisciplinary team, but, you know, I can talk about things for 45 minutes, but then ultimately like following up with a dietician to talk through, you know, even if they're not losing weight, but the quality and the quantity and the timing of their food is better, their relationship with their food is better. Movement and moving our bodies and exercise, and it doesn't have to be a torture treadmill run. You know, this can be going for a walk, taking the stairs, hula hoops, like whatever brings you joy, but that's the best antioxidant you can give your body.

And so, I think going back and connecting them, I have a lot of patients who say like, you know, I want to meet with a dietician, but my doctor said I didn't qualify or something. I'm like, if somebody wants to meet with a dietician, we will find you one. Um, so I think, you know, just helping connect patients to that.

And then, the second comment I want to make, that Jackie sort of alluded to, is the mental health piece of this. And, you know, so much of weight does feel like blame, as Dr. Johnson said. So even from their physicians and their moms, gosh, like, you know, we're all blaming them for their size. And then, you combine that with being a mom, there's a lot of guilt with being a mom and infertility and that diagnosis. So, making sure that we're connecting them maybe with a dietician, maybe with a mental health provider, as they're going through a weight loss journey or weight gain, that it comes with pregnancy, that they have some just really good support, both from their, you know, general physicians, but also from psychologists and family and things like that too.

Host: You know, you guys have talked so much about the stigma and bias that comes along with having excess body fat or falling into these obesity characteristics, both from probably people in their communities as well as from even their own healthcare providers. We have a lot of healthcare providers listening. Is there any piece of advice that you can give them to try to sort of connect with these patients in a less stigmatized way that's a sort of easy tip you can give someone that's in a busy PCP office or a busy general OB office?

Dr. Veronica Johnson: I mean, I think it's just not looking at the appearance of the person because I feel like obesity is the one disease that we all wear. And like you can look at someone and be like, you have obesity, but you don't know what they actually have. That person may have a higher BMI and appear to have obesity, but they actually had bariatric surgery and lost 100, 150 pounds, and they're at their healthiest self, like their blood sugar's improved, they've decreased their blood pressure. You can't judge a patient by what they look like. And it's important to actually listen to your patients and really, you know, don't dismiss their feelings because I think sometimes in a busy practice, it's very easy to be like, your patient will say, "Oh, I have knee pain." And they're like, "Oh, you just need to lose weight." And then, there's no evaluation about what else could be causing the knee pain besides excess weight. So, I think it's important to treat all our patients regardless of their weight, with equal time, respect, and listening to them so that everyone can get the equal amount of care when we're seeing our patients in practice.

Dr. Christina Boots: Can I add on that? I was just going to say that, you know, when they come to see Dr. Johnson, it's usually about weight, but for us it's not. And so, just asking like, "Hey, would it be okay if we talked about your weight today?" And some patients think that's dumb, but some are like, "Wow, nobody's ever asked me that before." And it earns some trust that, you know, I'm being respectful about that. And I think come right out and saying like, "Hey, this isn't your fault. There's some something genetic about you that's really good at storing calories, but there are some things we can do to help." So, take away blame, but then empower a little bit. I think that helps.

Dr. Michelle Kominiarek: To add to that too, there are some tests that you can take yourself. They're not long, but you can assess like your own biases, and weight and obesity is one of those, if you're just curious on kind of where you fall on the spectrum. And then, along the lines of just initiating the conversation, in our prenatal practices, or even when patients get admitted to delivery, there's some things we do differently in Labor and Delivery. We might put a match under the patient to help move them from side to side. And we want to start out, you know, being respectful of why we're doing that.

So, some of the things we ask our patients when I talk about weight, "What terms do you prefer that I use? Is that weight? Is that BMI or are there terms that you prefer I don't use at all?" And that just kind of helps build your confidence and trust with your patient.

Host: I love that so much. Just calling it out and really being honest and upfront with patients about this is what we want to talk about because it impacts your health, it impacts your care on Labor and Delivery. It impacts your every day and how you move around the world. You know what really struck me with what you guys said is obesity is worn on the outside, right? And we think about how particularly we are with all of our patients in other medical things where they might look really healthy, but they're suffering from mental health disease or they look really healthy. But actually, this like healthy, thin runner has blood pressures that are through the roof, putting them at stroke risk, right?

So, we think about it in other ways, and I think it's so thoughtful to say, you know, obesity is worn on the outside and that patient has to live with that disease that the world is judging them on. And so, in a healthcare provider's office, we should really be recognizing that for one and giving them some autonomy back into how they want to talk to us about it so that we can continue to really improve their health in a partnership.

And so, you guys, the work you do, I'm so impressed with all of you. So, tell me really, what are the scope of services offered in PEARL? What do you guys all do and how can we get patients to you to participate?

Dr. Veronica Johnson: I'll start because I'm usually one of the first providers within the team that the patient will see. So, I counsel on lifestyle modifications and including nutrition, physical activity. I talk about stress and sleep and how that has a role in the weight. I have access to dieticians. I have access to health psychologists. So if there's any concern around disordered eating, I can always refer patients to one of our health psychologists.

One of my big things is also using anti-obesity medications in patients who are candidates, for treatment, obviously not approved in setting a pregnancy. So, we have to have that discussion if they're interested in using them when we have to stop prior to planned pregnancies. And so, those are some of the services I provide. So, I don't manage any patients during pregnancy, but I hopefully get them to the healthiest weight that they can be prior to getting pregnant.

Host: Awesome. And then, how are people referred in? Obviously, Dr. Johnson, you refer a lot of people to our OB-GYN specialist, right? As you're kind of working with them to get them to their healthiest weight, how can people on the outside get to all of you?

Dr. Christina Boots: So, you can call any one of our offices. And if you mention it, then there are schedulers who know to put them with us within our divisions. And then, you know, if these are NM doctors listening here today, you can always shoot us an email or an EPIC message and we'll help get you connected.

Host: Amazing. I think, you know, that's going to be a big thing, and I'd love to include our direct departmental websites, both in lifestyle management, High-Risk Obstetrics and Maternal-Fetal Medicine, and Reproductive Endocrinology and Infertility. Here at Northwestern Medicine where you can reach out to Dr. Boots in Fertility, Dr. Kominiarek and Dr. Hairston in MFM, and Dr. Johnson in Lifestyle Management. You guys, I am so excited about getting more patients into your program because really this is such a need for our patients here in Chicagoland. I don't think anything like this exists, actually never heard of this program anywhere in the country. You guys may know more about that than me. But what I'm really excited about is bringing this out to our community so people know that this exists and these patients really don't feel like they need to be alone, that they really have support from healthcare providers who are really very specialized in this. Any final thoughts before we finish up today?

Dr. Christina Boots: Something I was thinking about as you were saying, this is like a shout out to the other physicians who are doing this work. And if you're interested in collaborating with us, please shoot us a message and let us know, because I think we'd like to just build this network of people who really we want to provide excellent care to women in bigger bodies, people in bigger bodies. So if you're doing this work already, please let us know. We'll come at you on our website, and we'd love to share patients together and broaden who we're seeing, you know, general gynecology and complex family planning and complex contraception and every aspect of women's health and more primary care doctors as well too.

Host: Great. I love that. More collaboration.

Dr. Christina Boots: Yeah.

Dr. Michelle Kominiarek: I just also want to give a shout out to one of our founders of this group, Charlotte Niznik, who is an advanced practice nurse that helped coin this term PEARL and got us off the ground too.

Host: Oh, and Char recently retired, is that true? Yes?

Dr. Michelle Kominiarek: Retired. I love Shar. We're sorry to see her go, but I'm hoping she's already starting to enjoy her retirement.

Host: Fantastic. All right. Well, thank you so much for being here today and thank you to all of our listeners out there. Feel free to reach out to any of our colleagues if you have any thoughts, want to collaborate, or have patients you'd like them to see. Thank you so much.

Dr. Veronica Johnson: Thank you.

Dr. Christina Boots: Thank you for having us.