Dr Sam Manger 0:00   

Health and Wellbeing Queensland acknowledges the Jagera and Turrbal people, the Traditional Custodians on the lands on which this podcast was recorded, and the Traditional Custodians on the lands and waters on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander Elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia’s First Nations people. 

 

Dr Terri-Lynne South 0:19   

I love it when an adult comes to me and says, ‘yes, I’m looking to fall pregnant sometime in the next 12 months. I go, ‘excellent, let’s actually see what your family history is, what is your genetic risk, what is your immunisation status?’. 

 

Dr Sam Manger 0:33   

Hi, I’m Dr Sam Manger, a GP, and your host of this series, The Clinician’s Guide to the First 2000 Days, brought to you by the Queensland Government through Health and Wellbeing Queensland.  

 

Prevention across the first 2000 days offers an opportunity for healthcare professionals to support generational health improvements, but preventative health will only be successful if it is done with confidence and empathy and an evidence base.  

Over the course of this series, I will be talking to some of Queensland’s leading experts to explore how they discuss preventative health and how to create meaningful change for the next generation. Let’s get started! 

 

Our first podcast of the series starts before the beginning at preconception. And to discuss preconception healthcare, I’m delighted to be talking to Dr Terri-Lynne South and Dr Shelley Wilkinson. Dr Shelley Wilkinson is an advanced Accredited Practicing Dietitian with a PhD in psychology. She is currently working at the Mater Mothers Hospital in Brisbane and is also the Director and principal Dietitian of Lifestyle Maternity. Dr Terri-Lynne South is both a Dietitian and a GP with more than 28 years of experience in the health profession. Her passion lies in metabolic health, where she aims to provide a comprehensive health service grounded in both evidence and extensive experience. Welcome Shelley and Terri-Lynne!   

 

Dr Shelley Wilkinson 1:51   

Thank you very much.  

 

Dr Terri-Lynne South 1:52   

Great to be here.  

 

Dr Sam Manger 1:52   

So, let’s start at, as we said before, the beginning, what is the preconception period as it relates to the life course? And why is this important?  

 

Dr Shelley Wilkinson 2:00   

Well, the preconception period is frequently described as a couple of months before pregnancy, often one to three months. However, there are a number of health behaviours that we know impact fertility and pregnancy, and so sometimes it can be longer than that, depending on the health behaviour and how quickly someone needs to get their health into order.  

 

Dr Terri-Lynne South 2:19   

And so, it’s very important, because it affects not only the parent but their subsequent child. So, we’ve got an opportunity to basically deflect the life course of both the parent from that point on and their resultant child.   

 

Dr Sam Manger 2:32   

Yeah, it’s incredibly important. As you say, we’re talking about many people here and a whole family of the future, as well as the fertility aspects as well as their health. So, there’s a number of aspects here. So, what common health issues affect many adult Australians that can impact their fertility or their health of their future baby? Terri?  

 

Dr Terri-Lynne South 2:49   

There are so many, so where do we start? So particularly in regard to just the fact that parents are becoming older, so as we age, we may start to collect some of those health concerns, but the ones that are particularly affecting our current patient population is the increasing incidence of overweight, obesity and some of the complications that go with that, including Type 2 Diabetes as well as high blood pressure. So, I feel that we need to be acting early to try and as I mentioned, switch that trajectory of where that adult is going, but particularly how that peri-conception environment can be imprinting the health of the resultant child.  

 

Dr Shelley Wilkinson 3:30   

And it can also be intergenerational, because that child, or the foetus, when it’s growing, has reproductive cells. So, what the mother does in pregnancy, and I know this is jumping ahead a bit, but we’re looking at impacting three generations through what the science of epigenetics or above genetics. So, it’s not the DNA that’s modified, but the way the environment, the foetus develops in, whether it’s early life, nutrition, alcohol, drugs, can impact the foetus growth, and then the reproductive cells. 

 

Dr Terri-Lynne South 4:02   

We also know that a lot of Australians are actually deficient in micronutrients, particularly if they are of that higher risk group. And so again, we’ve got this opportunity to not just look at their health conditions that may be impacting on their fertility, their future health and their baby’s health, but also from a nutrition point of view, fitting, you know, trying to improve those things earlier can make a big impact as well. 

 

Dr Sam Manger 4:24   

And as you say, there’s the health prognostic factors around mother-baby, intergenerational change and that epigenetic thing is a fascinating field. But as you said, you’re also setting up the environment to be more conducive to health going forward. You’re making a good opportunity to say to sort of pause and reflect and go right, what’s the best environment we can create for this family going forward and this child going forward from a behavioural point of view and a social determinant point of view as well. So, it’s a great opportunity, a great window.  

 

Dr Terri-Lynne South 4:50   

I think Shelley, wasn’t it your research that showed that… that pregnant women are at their most motivated and receptive to nutritional changes, yes… and so yeah, we’ve got this window of opportunity, which is not just affecting that individual mother but all the people that she cares for. And I’m not trying to be sexist here, but often it is the female of the household who is the one who’s making those nutritional and lifestyle decisions.  

 

Dr Shelley Wilkinson 5:15   

And then some other research that we did out of the Queensland Family Cohort Study showed that partners’ behaviour aligned with the women’s behaviour in pregnancy. And so, when partners, and it was in this study, 99% were male partners, met dietary guidelines for different food groups, the women were more likely to meet that as well. So, there’s that if the man does the shopping and the cooking and the meal prep sharing, as well as the supporting and not eating chocolate in front of them on the couch in the evening, women are more likely to have a more nutritious fertility, supporting diet.   

 

Dr Sam Manger 5:48   

And we see that behaviour change more broadly, don’t we, when there’s a social aspect, a support aspect, it’s very hard when one person in the house is doing it. So that makes sense. But do we see these healthcare components change with age? Because obviously it’s quite a broad range that we’re talking about here.  

 

Dr Terri-Lynne South 6:03   

Oh, look, absolutely. And that’s because I think, as I mentioned before, as we get older, we need to understand that fertility declines. That’s one of the biggest impacts on fertility, is the age of the parents. But also, there is some concerns with regards to increased risk of immunisation coverage, as well as chromosomal abnormalities, as well as… as I mentioned coming in and potentially being at increased risk of some of those chronic conditions that we talked about before.  

 

Dr Sam Manger 6:31   

Well, let’s get into that a little bit more than from a GPs point of view, because you mentioned a number of important points there, around screening, around immunisation status, around chronic disease status. So, what would you say are the most important things to consider in preconception health? Which is not a small question, but let’s go for it! 

 

Dr Terri-Lynne South 6:47   

To be honest, I think the most important thing is that 50% of Australians are falling pregnant unplanned. And so, I really think the most important thing is to take the opportunity for our fertile population, both male and female, and using every opportunity to bring up potential future family planning or even just healthy lifestyle, even if they are, you know, 20 something, and laugh at you when you talk to them about, are you looking at starting a family at any time? Are you on contraceptive? And just again trying to bring in aspects of improving healthy habits, lifestyle, nutrition, exercise, sleep, stress, all of those sorts of things for the betterment of our future generations.  

 

Dr Shelley Wilkinson 6:47   

And because we said, you know, the preconception stage often, when we look in scientific articles, it’s one to three months. But these healthy habits take a lot longer. They’re habits for a reason. They’re easy, they’re quick, they suit us, but sometimes they don’t facilitate our healthiest lifestyle. And so sometimes it takes a lot, or sometimes a lot of times, it takes a bit longer than one to three months to change the direction of these habits. And so, working with a health professional over a period of time is required to improve these habits. And so yes, having those conversations early and often, allows those health habits to be adjusted. And when we talk about that preconception health of one to three months, often it’s because it takes an egg about three months to develop. It takes a sperm about three months to develop. So, we want to be thinking ahead of time to have a very nourishing diet to support and lifestyle to support healthy egg and sperm. 

 

Dr Sam Manger 8:27   

We want the best ones off the rank.  

 

Shelley Wilkinson 8:29   

Yes. That’s right  

 

Dr Sam Manger 8:30 

So that they’re ready to go when we want to make that baby. Now, Terri, to your point around screening, sort of, pregnancy intentions, the current RACGP guidelines do identify that all people of childbearing age should be engaged in that conversation, even if it may be a bit of a sort of, laughable topic to some younger people, but it’s still important, because you just never know, and we shouldn’t assume. But can we come back to maybe that preconceptive care from a GP point of view, and what else you think is important, or indeed, what may be missing? 

 

Dr Terri-Lynne South 8:58   

I think a lot of the times, we don’t understand how much of that young adult population have waning immunity and so, particularly in regard to varicella and rubella immunization, these are something to look out for, for all adults, not even those potentially planning pregnancy, but to know that if they were to become pregnant, then those vaccination are contraindicated. So, it’s something that we need to look for just general health screening. In addition, I think it’s important that, you know, thank goodness that our food supply has been supplemented with some of the deficiencies that are… particularly micronutrient deficiency…that are particularly important in pregnancy, for example, folate and iodine. But you know, that’s picked up some of those risks, because our food supply has changed, and Shelley can talk to that in a bit more detail. And so, I think that’s one step.  

 

But then, you know, to actually put this little seed of…of education in potential parents’ minds, that this is something that for their, if they can, best plan and come and see a Healthcare Professional to have that preconception advice.  

 

So, I love it when an adult comes to me and says, ‘Yes, I’m looking to fall pregnant sometime in the next 12 months.’ I go, ‘excellent.’ Let’s actually see what your family history is, what is your genetic risk, what is your immunisation status. Let’s get some baselines. And so, we’ve got some time to actually look at that. Let’s look at nutrition. Let’s look at your weight, let’s look at your physical activity. So, it’s a great opportunity. And I love doing the preconception GP consult, because they’re highly motivated patients as well, so, it’s actually a pleasure to have that consult.  

 

Dr Sam Manger 10:33   

And so, you mentioned varicella, rubella being very important ones to check for immunity level, because obviously we can vaccinate with that, and as you say, not…not a good idea during pregnancy. But what about genetic screening? Because that was something that used to be, from a preconception point of view, five odd years ago, quite expensive to do. Even though it was recommended that we have that discussion, most women were not taking it up because of the cost. But it’s come on Medicare more recently, so can you tell us a little bit about that? 

 

Dr Terri-Lynne South 10:55   

I think that what’s really important is that we should still do the family history, so a genogram, and then talking about the pros and cons of actually doing a specific DNA carrier sequence. And definitely we need informed consent. So, I think that’s so important, and not just think that it’s a very easy thing to do, because we can… we definitely need informed consent of both of the parents and what a positive slash negative outcome would…would mean for them and the ramifications of that. So, it does need a GP to feel comfortable about the principles of genetic screening carrier testing.   

 

Dr Shelley Wilkinson 11:31   

And can I jump in with a question? Are there any medications that someone might be on…preconception period, that will need to change once they become pregnant? 

 

Dr Terri-Lynne South 11:40   

There’s a huge list. And look, part of the problem with that is we don’t actually have a lot of research in the peri-conception as well as pregnancy population of actually how concerning these medications are. But in general, there are some good guidelines and information that prescribers can access, but these are usually at the big hospitals in regard to level of evidence and level of risk. So, it’s not just about what GPs might be familiar with, with categories A, B, 123, C, D and X, but also, with some of the information that you can get from the bigger hospitals, it actually puts it in grades, both with regards to pregnancy and lactation. A lot of it will come down to weighing up the pros and cons and risks for how changing that medication would affect the health of the mother, but also the developing foetus. And so, I’m finding that rather than being black and white advice about medications, it’s about risk reduction, both for the foetus and for the mother. So it might be, for example, with some of the mental health medications changing to one that has less of a risk, or in regard to some of the anti-thyroid medications or some of the anti-epileptic medications. It’s about again, pre-pregnancy planning.  

 

Dr Sam Manger 12:55   

And as you say, any… any components along that, with regards to medication monitoring, is very important, and there are some actually really great, as you say, with the big hospital services, both online, but also phone services with pharmacists and likewise, that you can speak to if you’re really not sure how to take it. So those are available.  

So, we mentioned nutrients quite a few times, and in particular a few nutrients of concern, iodine, and folate. So, from a dietitian’s perspective, can we talk more about these specific nutrients or diet types that may be a cause for concern and things we should be aware of in our patient population when they’re obviously trying to conceive.  

 

Dr Shelley Wilkinson 13:25   

Certainly. So, despite a lot of marketing that’s around at the moment, there’s no specific supplement that will make someone fall pregnant, despite advertising that might suggest otherwise. So, supplement wise, the only nutrient that’s essential to take is folic acid at 400 micrograms for them, at least the month before pregnancy. In the first trimester, there are some people who need five milligrams if they’ve got a history of neural tube defects, diabetes, or women living in a larger body.  

 

I generally recommend that iodine is taken as well daily, as Australia’s food supply is deficient. It’s been detected that there is mild iodine deficiency across Australia, and that should be 150 micrograms a day, just because it’s required every day in pregnancy. There’s also been food modelling that’s worked out these amounts of supplements that women need to take. So, we know that women should be also consuming about three slices of, at least three slices of bread a day, because iodine is added to salt. So iodized salt has been in the food supply for bread making since 2009 folic acid has been added also into bread.  

So, often I find that women are carb conscious and cut out the breads and cereals and grains group. And some of the research we’ve done show that less than 1% of women are meeting the breads and cereals and grain group before pregnancy, as well as in pregnancy. And so that’s quite detrimental, because the modelling has worked out women are eating this much and should be taking this supplement to top them up.  

 

Unless someone has a diagnosed deficiency, they don’t need to take iron and vitamin D. So that’s something to talk to the GP about and get a blood test. Zinc and selenium are in the maybe group. There’s not strong evidence around it in simple terms. The studies have yet to be done, but there’s not enough data to tell us the answer. Some studies suggest that micronutrient supplementations help in males. There’s inconsistent data in females, but essentially, it shows that it won’t cause trouble if people want to take it. So, zinc and selenium are in that grey area.  

 

A lot of people like to focus on omega threes; they’re important for brain and eye development as baby grows in the womb and reducing overall inflammation at a cellular level. Now there was a study called the Time to Conceive Cohort, and it was found that there was no strong association between serum omega three and the probability of conceiving naturally in a group of 200 women from this study. However, the same team looked at 900 women in this cohort who were undergoing IVF, and there was an association between omega three and conceiving, although they noted that this wasn’t the type of high-level study that said this causes this. It was just this happened at the same time.  

 

We say with omega three, it’s better to get this from a food source, because also, we know from the Heart Foundation, they find that it’s only triglycerides that are affected and helped by omega three supplementation that supplement taking with omega three doesn’t affect anything else, that the benefits come from food first. And so similarly, in this space, it’s potentially a food first approach for omega three, which is great because the oily fish are high in protein and good sources of all sorts of things.  

 

Now there’s also something that people love to recommend in this space, and it’s Ubiquinol, or Coenzyme Q10, which is a very powerful antioxidant, protecting the cells from oxidative stress and supporting energy production. Many fertility blogs like to recommend taking a COQ10 supplement to, in inverted commas, help improve egg quality in women and sperm quality in men. But the parameters have shown in a number of papers recently not to be helpful. So, there was one group of Greek researchers who found that oral supplementation of COQ10 had no effect on live birth rate and miscarriage when compared with no treatment or a placebo. They did note that COQ10 may increase a clinical pregnancy rate, but not the overall pregnancy rate. And then another study from clinician research team in Australia and New Zealand, including one of the big fertility groups in Australia, found that when they gathered many studies together, they found there was very low-quality evidence to show that taking an antioxidant supplement may benefit sub fertile women. They concluded there was limited evidence to support these antioxidants. However, we need to remember, as a Dietitian, nature’s antioxidants, which are fruit and vegetables, and the guidelines say going for two fruit and five veg day will provide antioxidants, and this also improves gut health and reduces inflammation.  

 

And a bit like breads and cereals, where we’re not eating enough, less than 1% of women are meeting breads and cereal guidelines. We see that only one in 10 women consume enough fruit and vegetables, and so rather than focusing and shelling out money on Coenzyme Q10, if we’re spending money on having two serves of fruit and five serves of vegetables a there’d be much bigger benefit to both fertility and health. And the Australian, I think, Fruit and Vegetable Consortium found that for every… if people increased one serve of fruit and vegetables a day, there’d be a billion dollar drop in health expenditure over five years. 

 

Dr Sam Manger 18:14   

So, there’s a number of really interesting points you make there, Shelley, now, folic acid, yep. So noted, you talk about the evidence around the impact on conception amongst a number of these things, the omega threes and zinc. But is Iodine, for example, you recommend it…that’s not because of conception, is it? That’s because of brain development and those sorts of development and those sorts of aspects. So clearly, there are other benefits…these supplements, not just around conception?  

 

Dr Shelley Wilkinson 18:36   

Yes, the iodine is important once someone falls pregnant, and so it’s just a handy one. I don’t like to recommend names, but you can buy a supplement that has iodine and folic acid in it, and that sometimes, rather than then having to go out and get something else, we’ve done some recent work around multivitamins and in pregnancy, and find that essentially, it’s expensive wee, and often women are taking too much, and higher levels in some of these things that are in the supplements can cause problems, and we recommend just the folic acid and the iodine in pregnancy. And so, I just tend to say, start like you wish, to continue and be on something with iodine and folic acid in it. 

 

Dr Sam Manger 19:10   

Stay with us. We’ll be right back to continue our conversation. 

 

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Dr Sam Manger 19:50   

And now back to the conversation! And with omega three, you said it doesn’t necessarily increase the success of conception, but is there any longitudinal data? Because one would think, given it’s such an essential fatty acid, that it would have longitudinal benefits. 

 

Dr Shelley Wilkinson 20:05   

Well, there is some. There’s a study called the ORIP Study, and it’s around extending… looking to see if omega three extends pregnancy time and reduces prematurity. And the data from that is often misrepresented. So, they, some people say that it reduces prematurity, but when you dig into the New England Journal of Medicine original paper that they published, they said that was only in a small cohort of singleton pregnancy X, Y and Z, so it’s not in everyone. And they actually said it didn’t have any effect. And they also said the amount that they were trying to give people in supplements wasn’t palatable, and not many people took it. So sometimes we take… we cherry pick from the studies.    

 

So essentially, a food first approach is probably a better approach. And our dietary guidelines, one of our dietary guidelines is a wide variety of nutritious foods, because we know that there’s good things in foods, but we also don’t know what’s in foods that we’re missing, so it’s the pattern of eating, rather than focusing on that sub that nutrient, that’s important, I think. 

 

Dr Sam Manger 21:10   

And the complex interaction between all these different things that we don’t know. Now, along those lines, you mentioned gut health and…and I’m curious about probiotics, because we… there is some evidence around, as far as I’m aware, potentially reducing risk of ATP and sort of eczema and those sorts of things in certain strains for pregnant women, is there any evidence in… is that, I’m guessing, not particularly strong? But is there much evidence in preconception and or antenatal for probiotics?  

 

Dr Shelley Wilkinson 21:35   

I don’t think so. I think the more and more studies that are done are actually showing there’s less and less support for it. There is support for, inverted commas, prebiotics, which is essentially the fibre containing foods that support the gut health to do the job that they need to do. And so, that’s again, the breads and cereals and grains and fruit and vegetables, which give us the soluble and insoluble fibre and the resistant starch. Which, if we want to know the mechanisms, it’s dropping the pH in the gut to support the gut bacteria to produce through the production of short chain fatty acids, butyrate, acetate, and propionate, that then feed the colonocytes, set up chemical messages that go around the body and support inflammation…reducing inflammation, boosting immunity, harvesting energy from food. So now we know why our mothers told us to eat fruit and vegetables, but we see the mechanism! 

 

Dr Sam Manger 22:24   

Our natural GLP-1 agonist. 

 

Dr Shelley Wilkinson 22:26   

That’s right. 

 

Dr Sam Manger 22:26   

Yeah, the short chain fatty acids. Yes, very interesting. Well, I’m sure we could talk about this for a lot, for a lot longer. So, are there any sort of fad diets, though? Because this is, you know, you mentioned an iodine and the need to add it, partly because what we’re seeing in culture is a move away from, say, processed foods, which is generally a sort of good scepticism being applied, but it means people aren’t having their iodine in the salt, or because they’re having sea salt or Himalayan salt, or they’re not having their iodine in the bread because they want to have their local sourdough, so they’re not getting these supplements. So, there is risks with certain cultural current dietary trends. Are there any things that we should be really aware of and discuss, I think, along that line?   

 

Dr Shelley Wilkinson 23:06   

So, we, when we’re at the Mater Mothers, we surveyed 500 women coming to our fertility clinic to see what they were eating, and that’s where we found out that nine out of every 10-woman women weren’t having enough cereals and grains, and so they were missing out on that gut healthy fibre, missing out on folic acid, and it can undermine fertility through hormone disruptions and inflammation. Also, if we think two thirds of our thiamine come from breads and cereals and grains, and so this is important in energy metabolism, growth, and development. Missing out on B1 or thiamine can lead to things including fatigue, irritability, poor memory, loss of appetite, sleep disturbances and abdominal discomfort. So that’s a reason to have more bread and cereals and grains.  

 

People are often fearful, carb conscious, thinking that it leads to weight gain, and often when I present that these are the food groups and how much to eat from each food group, people say that’s a lot of food, but we know that a third of Australians calories come from junk food and that ultra-processed foods, and it’s…. I’m all for chocolate, but when it pushes out more nutritious foods, that’s where the problem lies.   

 

And so, what we’re trying to say is reduce this and put in more of the foods from across the food groups. We also know whole grain and cereals are inversely associated with Type 2 Diabetes. So, more intake of whole grains, you get a lower incidence of, or risk of, Type 2 Diabetes. I think the cereals and grains get caught up in the processed foods, and people think that those sorts of foods are processed. But even white, high fibre food, which looks naughty and bad, in inverted commas, is actually great because it’s a good source of resistant starch. So, it’s looking for better sources of the whole grain foods 

 

Dr Terri-Lynne South 24:41   

There are some messages around fertility and pregnancy planning with regards to body weight. And what my concern is that…that message might be overplayed in regard to reducing weight to increase fertility and pregnancy. But if that is a severe focus, and someone is desperately trying to lose weight fast, they may actually be putting themselves at increased risk from a significant, what we call, protein catabolism, and this might actually be harming their quality of the sperm and the egg. And so sure, their weight may reduce, but what are they going to be the implications for their progeny? And also, I think that severe restriction, from a dieting point of view, really does increase the risk of disordered eating and eating disorders, and that’s, again, not going to be something that where we’re going to be looking at healthy habits. That’s actually a significant risk. And if this is particularly severe, it might actually interfere with their hypothalamic pituitary access, and therefore the regularity of their menstrual cycle and ultimately their ability to fall pregnant, which is why they may be motivated to have lost or trying to lose weight in the first place. So, I think it’s very concerning that sometimes our messages are oversimplified and overplayed.  

 

Dr Sam Manger 26:03   

So whole foods and mostly plants as the sort of…as the sort of…guidelines indicate, rather than…sort of…sudden, major shifts following certain cultural sort of current diet trends or fads. Now you mentioned there, Terri, around overweight and obesity, and we know that living with overweight or obesity is considered a risk factor across pregnancy, but also conception and so given that you mentioned there that we don’t want to overcook the fact that it may be such a big factor, and we don’t want to cause anxiety, we don’t want to cause sudden weight shifts that can affect this process, so how do we…this seems like a sort of delicate area, then to approach…so how do we best approach this? 

 

Dr Terri-Lynne South 26:44   

I think that… what’s really important is to take a very individual approach, and what’s important for the patient, patient in front of us.   And obesity management is not just about weight loss, and in particular, if someone is wanting to improve their health and they are living in a larger body, it is about changing the healthy habits, changing again, their nutrition, changing their physical activity, their sleep, their stress, all of those pillars of lifestyle management. I think, as a minimum, we could try and help someone try and prevent an ongoing trajectory from a weight gain point of view, and that in itself, is hard. You know, the average adult in Australia is gaining anywhere between half to one kilogram a year. So, it may not be about weight loss, it may be about stabilizing someone’s trajectory. Or if there has been a recommendation for weight loss, it doesn’t need to be a lot, so, 5%, particularly in patients who might have some insulin resistance, some polycystic ovarian syndrome.   

 

It’s not trying to target an arbitrary healthy weight range or BMI. It may be a small 5% weight loss over a period of time where we’re establishing those healthy habits, and not just on the number on the scale.   

 

Dr Sam Manger 27:56   

Demonstrates the importance of knowing the intention of pregnancy well in advance, doesn’t it? Because…because weight loss is not something that is necessarily easy or quick, and it shouldn’t necessarily be quick either, especially in this context. So, planning in advance. 

 

Dr Shelley Wilkinson 28:08   

Yeah, that preconception stage could be six months, or a year, or 18 months. It’s not that one to three month before falling pregnant. 

 

Dr Sam Manger 28:16   

Yeah, and given the high motivational aspect, this might actually be a great time to start changing that trajectory in a healthy, healthy habit, point of view, way.  

So, Shelley, what about bariatric surgery? You know whether it’s Rouen-en-Y’s or sleeves becoming a lot more common, in particular… bands are definitely out of out of fashion. But are there any specific considerations, you know, nutrient or medical, from when undergoing bariatric surgery or post bariatric surgery, who are wanting to fall pregnant. 

 

Dr Shelley Wilkinson 28:41   

So, it’s very important that a woman is linked-in with a maternity dietitian throughout her pregnancy, with a minimum of seeing her at every trimester. The consult would cover a full dietary assessment, not only of her intake and adequacy, but assessing the impact of surgery and how pregnancy symptoms are affecting intake. There’d be advice around supplementation, which is different from what we’ve recommended about that folic acid and iodine, and also assessing deficiencies, giving a baseline, and then correcting those, and then advice and support for healthy gestational weight gain. As these women are still growing a baby, and we need to balance outcomes for both mum and bub, and then, at a minimum, seeing a Dietitian, as I said, every trimester, but also linking in with the wider team. And you’re struggling going back to the multidisciplinary team, the surgery team. 

 

Dr Sam Manger 29:43   

So that raises the importance of just the way we look at the model of care, or actual consultations when we’re doing preconception care, and you’ve highlighted there, Shelley, how clearly important it is, not just in post-bariatric scenes, but in pretty much every setting, the importance of being proactive about this, about raising it and screening it.   

So, Terri, given how important this, this consultation is, but there’s perhaps not quite the awareness, how important it is, and hopefully with this podcast that helps! How can we better integrate routine preconception care into our consultations?   

You know, recognising, as we’ve said, that motivations and priorities may may differ during this period, and some may not want to actually get pregnant at this point in time. But how do we still bring it in in a helpful but respectful way?  

 

Dr Terri-Lynne South 30:23   

I think, you know, in general, primary health care professionals should be doing what I would say is universal health promotion about healthy habits and trying to meet the patient where they are in front of us. So, you know, we may be talking about reducing alcohol consumption, some of those discretionary foods, increasing fruit and veg, because we know that, in general, all Australian adults could improve from those healthy habits point of view. So, I think it’s really about that universal health promotion and looking for clues in the consultation where we can use that to try and… and I don’t really want to say, hook that patient, but that’s actually what I’m trying to find. Where is this person in their life trajectory? And how can we look at what their concerns are at this point in time, even though, like you said, it may not be future family planning on their radar yet and make those little nudges that are slowly improving their healthy habits and meeting them where it is relevant to them at this point in time.    

So, it’s funny, Sam, I don’t know if you’ve got any anecdotes, but back when we actually did cervical screening, that was a, you know, a pap smear with a speculum. You know, one of the conversations I would have with a woman who may have some atypical cells was pointing out the association between that and smoking. And this was a timely thing that they…were happening at this point in time was relevant to them because they had some atypical cells, and actually linking them back to a health habit, which they may not have been motivated to change, but it became very, you know, important to them in their own personal experience.  

So, I think there’s a number of different ways that we can and then again, I don’t really want to use the word manipulate, but it’s about opportunistically helping the person in front of us with the extra knowledge that we have, and they may not be any aware that is relevant to them. 

 

Dr Sam Manger 32:11   

Yes, hopefully inspiration is a better rather than manipulation.  

 

Dr Terri-Lynne South 32:16   

Inspiration! Yes, inspiration! 

 

Dr Sam Manger 32:17   

Now there’s a number of different angles we can go with this, because this is really important content. So, let’s…let’s break this down. The first is, is, is sort of zooming out a little bit and thinking about the partner, which, as you say, 99% of time is a man, but may not always be. So, Shelley what strategies can we use to encourage partners to actively participate in this process? And considering societal expectations that often this is placed, as we said, sort of directly on women. So how do we empower the whole unit to become sort of active participants? 

 

Dr Shelley Wilkinson 32:46   

Yeah, so that’s a good, good question, as we talked before. It should come as no surprise that we know from a lot of research around healthy habits that if a woman’s partner eats a healthful diet or shares the mental load, women are more likely themselves to follow health affirming diet and lifestyle. It takes two to tango, so to speak. So, it’s not only healthy egg that’s needed at this time, but men’s health habits affect the quality and motility of their sperm, so eating better and moving more helps a fertility journey from both angles, I’d say. 

 

Dr Sam Manger 33:13   

You mentioned zinc and selenium before as micronutrients for both men and women? 

 

Dr Shelley Wilkinson 33:19   

Well, there was very limited evidence for women. There was shaky evidence for men, but as long as it was taken under the upper limit of what’s recommended it would be safe to take.  

 

Dr Sam Manger 33:30   

Are there any other aspects that health professionals, and this question is to both of you who are talking to the whole family, but in particular, with men in mind that we should be discussing when it comes to fertility and conception?   

So, we’ve obviously covered the lifestyle factors, nutrition, physical activity, alcohol, and smoking seems to be a very big one…a very big one. Are there any other aspects that we should raise?  

 

Dr Shelley Wilkinson 33:51   

I think, just finding out, as Terri said, finding out their why, and I’ll often include this when I’m seeing a patient, I say you’ve been referred for X, Y and Z…what is it that you’re hoping to get out of this consult? And find out and work with their motivation. We want a healthy pregnancy…we want to… and this is a trajectory for a healthy family lifestyle. And so, starting early and setting those habits in place is often something that people say that they want to do.  

 

Dr Sam Manger 34:18   

What about in families or women or men who are from different cultural backgrounds, so maybe First Nations or culturally and linguistically diverse groups. How can we address different cultural approaches or beliefs or practices that may influence preconception health? You know, obviously tailoring our advice to those in front of us, Terri? 

 

Dr Terri-Lynne South 34:38   

I think this is where it’s important for primary health care professionals to know the community in which they work and serve and how different that might be. Work out what those particular cultural sensitivities might be. So, this might be, for example, you know, some of the health hubs, some of the local health services, and being very mindful of, yeah, what are the individual community needs, and the particular cultural diversity that may be in where they practice, which might be completely different from where that practitioner lives themselves as well. So, it’s about knowing what’s happening in their community and what works, and particularly using some of those healthcare promotion departments organisations that can actually indicate what those particular needs might be if the individual doesn’t know them themselves.  

 

Dr Sam Manger 35:26   

And would these be things like PHNs, local health districts, you know, community centres, those sorts of things, we’ll have more information on that, and often be able to provide resources and direction for that as well.  

 

Dr Shelley Wilkinson 35:37   

You know potentially even to the level of, I know, with Indigenous health workers and interpreters, and so partnering with community to deliver care.  

 

Dr Sam Manger 35:47   

It seems like the interpreters could be a really important factor. Because obviously, if English is not the first language, there seems to be an absolute necessity because we’re talking about very important things here. We’re talking about preconception health, and they can also be…there’s all the medical and science stuff, which we’ve talked about, but there can obviously be many overlays or underlays of cultural or ancestral practices that fall into this as well. We just have to make sure we’re all on the roughly the same page when we’re… when we’re communicating about it, so we can make a plan.  

 

Now we talked before about, Terri, you mentioned around the hook, which I think is a reasonable word to use. Or, you know, what are the motivational factors for a person? What is actually the thing that connects with them at a value based, meaning based level that they actually want to progress on? So, Shelley this must be something, you know, Dietitian and a Psychologist and now consulting on different behaviour change and models of care. So, excellent background!  

So, when we’re trying to help people on an ongoing basis to maintain these health these behaviours, and if they’ve got waning motivation, what can we do? Especially when it’s… we’ve already said that… it’s a fairly high adherence rate around potentially contraception, but what have you seen to be sort of best practice in this regard? 

 

Dr Shelley Wilkinson 36:56   

I think this is where the patient centred care comes to the fore and ties in with what we know helps or supports that ongoing behaviour change. So, if we look at the literature around behaviour change, we know that, yes, behaviour is influenced by knowledge. We can tell someone what to do, but that’s only the part of the problem or part of the situation, especially if they already know. Some don’t. So, once you’ve told someone, we don’t keep doing it until we’re blue in the face, because that’s not particularly good for rapport. We need to also look at capability, opportunity, and motivation. So, do they have the skills? Do they have the means? Do they want to make these changes? And these are quite nuanced in themselves.  

 

So, if we’re thinking about motivation, we can explore things that underpin it, rather than, you know, we’ve all heard the health professionals say this patient’s just not motivated or not engaged, or that means we haven’t engaged with someone in a way that helps them understand or helps them link in the hook so find out their personal beliefs, their capabilities, their beliefs about the consequences of these behaviours for themselves, their intentions, their goals. What would reinforce and reward these behaviours? And they can be big conversations, especially in the fertility space, which is all well and good, but we all have limited consult time, so being able to have that patient centred care find out the why, and if it’s beyond scope, or our core competency, whichever health professional that we are knowing that we can refer to, potentially a psychologist or someone else who has more time and has this valuable skill set to spend time exploring, to help the motivation and the ability to make those changes. 

 

Dr Sam Manger 38:29   

Yeah, you mentioned the COM-B model. There are some excellent theories, models or frameworks out there to almost you can use as a checklist of sorts when you’re sort of going through the person around the case. So, let’s because there are many things within capability, opportunity, I see different types of internal, external motivation and these…it does sound like, kind of complex, and it is complex, but there are some resources out there that can help us sort of guide a consultation around that. But as you say, it can be potentially time consuming, especially if you’re not used to doing it. But sometimes just having a consult, just for that, can be actually a very rewarding process, because you might have been hammering on something for years, on a, let’s say, old school education format, but thinking again, when I switch it up a little bit to a sort of more coaching behaviour change format, and you often see breakthroughs. 

 

Dr Shelley Wilkinson 39:13   

Yes, the light bulb moments just happen!  And you just see the progress and people moving through. And they appreciate, you know, the inverted commas they but I tend to find people appreciate when you ask them questions in different ways and explore different things that sit below the surface but often don’t get covered because they are…can be tricky, tricky conversations, but people really appreciate some of that deep digging to help them move past where they’ve been stuck.   

 

Dr Sam Manger 39:37   

Yeah, and that appreciation is so important because it builds on that therapeutic relationship. Once you’ve got that therapeutic relationship set, you know, you’ve got the rapport set, the rest of pregnancy is going to, sort of, from a doctor patient point of view, going to fall into place a lot more easily. 

 

Dr Shelley Wilkinson 39:50   

And you know, when we look at the psychology research, a large proportion of, inverted commas, success of someone, is from that therapeutic relationship. It’s not what you’re doing, it’s that relationship that you have and people. It’s… you know, people will do anything for someone that they respect and trust in a health professional role. So yes, it’s spending that time to talk and discover and learn to build that therapeutic relationship. 

 

Dr Sam Manger 40:13   

Don’t go anywhere! Our conversation continues after these messages.  

 

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Dr Sam Manger 40:50   

And now back to the conversation! 

 

I saw a study some years ago, and I don’t remember it exactly, but the context was when they invested more in the therapy relationship in the beginning. So, the consult went something like five minutes longer for the first consult, they found that they saved like three or four minutes for every consult respectfully thereafter, because less education required less persuasion, less he’s like, ‘okay, well, you know, we’ve already built this bridge’, you know, I’m happy to walk it with you now. So, it, whilst it sounds like, as you said, doing this behaviour change stuff sounds a bit onerous, you actually do save a lot of time, yeah, and heartache, because it’s, it’s an easier relationship broadly.  

 

Are there any technical, because often we’re talking about behaviour change here, or preconception health from a clinical consultation point of view. But let’s now move into, you know, technology which is which is everywhere, telehealth, mobile apps, people listening to this on podcast now, so to make preconception care more accessible or engaging, especially those who may be limited, aka financially or really remotely geographically and so on. 

 

Dr Shelley Wilkinson 41:53   

It’s such an interesting space, and I think it’s really creating a more equitable and accessible health system, as you’re saying. But we need, as health professionals, we need how to learn…how to use it well…inverted commas… digital health strategies, which could be, as you say, telehealth apps, text messages, which are what we call broad reach, low intensity. So great because it’s cheaper and it reaches more people, and it allows us to move away from expecting that person to front up in front of us at a time that suits us but may not suit them or their lifestyle or their budgets. Rather than that one visit with a health professional, we know that doesn’t change behaviour, we need… it’s the supportive, corrective, directive health care that provides success in change and maintenance. But one of my biggest bugbears is that an app is not the solution, it’s a tool…it’s a…it allows care to be delivered, but the app isn’t the intervention itself. So, we need to spend time, again this is bringing in the behavioural science, is to find out what helps and hinders people to change their behaviour and incorporate the behavioural science strategies to be delivered via text message or app or blended care. So, the tools should just be incorporated into the patient journey, rather than expecting it to be the be all and end all, silver bullet. 

 

Dr Sam Manger 43:06   

Yeah, there has to be some substance around that technology, in some respect, some human substance, because, as you say, the long term data around adherence to apps is very poor, very low adherence, partly because there’s a reliance on just the app to do all the work and humans, most of us don’t work that well, except for the hyper, type A’s.  

 

Dr Shelley Wilkinson 43:24   

That’s right. And I think, you know some there’s a lot of research that shows apps are accessed once and never again. And one of my colleagues, Dr Jane Wilcox, and her teams down in Victoria, have done work around the use of text messaging in the era of bling, which is the apps, and finding that boring old text messages are cheap and easy and accessible. It’s…it’s asynchronous time delivery. A text can come in and can be read at any time, and if it’s co- created with the patient group that the care is being delivered to, it can be very, very powerful. And we’ve seen this in some of the research we’ve done in gestational diabetes and in weight management in pregnancy as well.   

 

Dr Sam Manger 44:01   

Yeah, and I in my own clinical experience, and I’m sure you both probably would share this, is that just a good old fashioned phone call… 

 

Dr Terri-Lynne South 44:09   

Oh yeah. 

 

Dr Sam Manger 44:10   

…makes a huge difference. Like a nurse following up with someone saying, ‘how’d you go finding those, you know, the folic acid and the iodine supplements, and how’d you go booking in with the psychologist’, or whatever it was? And, you know, one, it’s just a very good motivational behaviour change component, but it’s also a fantastic therapy relationship component, because people know this person, they’re thinking about me…I’m touching base. And so that, like, you know, that falls under telehealth, technically, but just a good old phone call, you know, it goes a long way. I wonder, are we seeing any advance in artificial intelligence along here? Because artificial intelligence is sweeping the planet, are we going to see some Mum-bot come through at some point?  

 

Dr Shelley Wilkinson 44:46   

Well maybe so. When I worked at UQ, a team of clinician researchers and some students, we did a systematic literature review in this area, and we wanted to look at what programs were in this fertility preconception space and how engaging with these programs helped changed healthy habits. So, we did a systematic literature review looking at face to face versus blended….so face to face supplemented with some sort of digital health strategy.  

 

And we found 10 studies, nine RCTs, one pre-post, about 4500 patients were included, and we found a wide range of delivery, including AI, mum-bots, and some, but also text messages, web based educational materials, social media, phone apps, online forums. But, yeah, they called them conversational agents. So essentially, what you get when you call up…it’s been a bot that’s chatted to me, but it’s infuriated me more than anything else, but essentially it is one of the strategies that’s available. But in all the studies, we found the ones that were longer that blended face to face with that rapport with the ongoing support that sometimes is less “cost effective” for us to deliver face to face, if we have these texts or some sort of messages that are…that the nudging to keep within the realms of where we’re trying to support people to be, is the most effective for changing healthy habits. So, there is potential, but there’s a lot of problems with AI. 

 

Dr Sam Manger 46:10   

Yeah, I get, again, it’s this sort of concept of over reliance on one, right…yeah, one method. And it’s not just one nutrient, it’s the whole thing, you know? So, let’s, let’s learn that lesson.  

 

Dr Shelley Wilkinson 46:21   

And the human factor with it. Remembering this, there’s the… there’s a human interaction with…there’s a warmth and a tailoring that I don’t think can be achieved with AI.   

 

Dr Sam Manger 46:31   

Not yet, but let’s see what happens. So, Terri, you must use a lot of different practical tools and resources that you recommend. What would you recommend to health professionals who are listening that can improve their consultation skills and care around preconception health?   

 

Dr Terri-Lynne South 46:45   

There’s a lot, but if you want a bit of a one stop shop, I do like the Health and Wellbeing Queensland hub that talks about pregnancy and preconception counselling. So, there’s a lot of different resources from that one stop point. And then I also like from a universal health promotion, from a healthy habits point of view, the RACGP Healthy Habits program, which is an app, but a little bit different from just telling people about it, you can register your medical centre with that app, and so all practitioners as a registered medical centre can then actually have some of that asynchronous, two way conversations with their patients. That helps there as well. And so even if a GP is not using that individually with a… with a patient, there’s some good resources that are nationally focused.   

So, both we got some state one stop shop helps, and then also some National Healthy Habits apps for universal health promotion with our patients.  

 

Dr Sam Manger 47:38   

Yeah, I’m glad you mentioned that, because I was also thinking about the RACGP Healthy Habits app, which is sort of emerging as a tool more broadly. And it’s free to download and clinicians to use, and patients and all that. But you can set tailored goals within that. The clinician dashboard can monitor those, and then you can send, as you say, messages which we talked about, and track people a bit more effectively, as opposed to now, where we sort of do a set and forget, and if they come back in three months. Good! I’m glad they came back, but we didn’t, there wasn’t a sort of monitoring component there. And so now we can do more of that. And there are certain, I think it can be a little overwhelming when you bring these technologies into practice. Where do I use it? How do I use it? So…yeah, but if we just focus, perhaps, on a cohort, and this is a great cohort to focus on, because, as we said, the evidence and the benefits are there across preconception, antenatal care and post but we’ve also got a high engaging adherence sort of population, and so it seems to be the right mix where we can actually use this app to develop some goals and support people in that way. So worth checking out for, the listeners. And I believe allied health can now use the app as well, not just GPs. Okay, so now just to look at if there’s any, I’m sure there are many, because Queensland is a great state…but are there any examples of successful preconception care across Queensland, just to wrap up this excellent episode, or even wider a field across Australia that we can adapt to our own context.   

 

Dr Shelley Wilkinson 49:01   

I’m not aware of any specific ones, but I would say that if anyone was delivering one, I’d link back to that systematic literature review that I talked about and…and you’d want to construct it with face to face supported by technology. You’d want to map it to behaviour change, you’d want to implement behaviour change strategies that were mapped to the cohorts’ behaviours, the barriers and enablers, so co create with the cohort that you’re working with and making sure that the content is evidence based, excellent. 

 

Dr Sam Manger 49:28   

All right. Well, thank you both so much for your time and your expertise. Today. It’s really very helpful, very interesting. So, I’m sure we could talk for a lot longer, but we must wrap it up. So, thank you again, so much for your time. 

 

Dr Terri-Lynne South 49:39   

Thank you.  

 

Dr Shelley Wilkinson 49:40   

Thanks for having us. 

 

Dr Sam Manger 49:42   

Today we’ve been talking to Dr Terri-Lynne South and Associate Professor Shelley Wilkinson about preconception healthcare.  

For more information on today’s topics, visit the Health and Wellbeing Queensland website at www.hw.qld.gov.au. If you’ve liked today’s conversations, be sure to subscribe for future episode updates.  

We’ll see you next time on The Clinician’s Guide to the First 2000 Days.