Dr. Alice Domar – Mind/Body Medicine and Women’s Health

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Jonathan: Hey, everyone, Jonathan Bailor back with another bonus, Smarter, Science of Slim Podcast. Very, very exciting show today. We have a guest with us who is literally a pioneer in the field of mind/body medicine. She conducts ongoing ground breaking research which focuses on the relationship between stress and various medical conditions as well the impact of lifestyle habits on mental and physical health so we’re just talking home-runs.

She has a Master’s and a PhD and she is currently the Executive Director of The Domar Center for Mind/Body Health and the Director of Mind/Body Services at Boston IVF. She’s also an associate professor at Harvard Medical School and a Senior Staff Psychologist at Beth Israel Deaconess Medical Center. Dr. Alice Domar, welcome to the show.

Alice: Thank you so much, Jonathan.

Jonathan: Well Ali, you have done so much. I only got through a little bit of your bio. Can we back up and start with little Ali and how you got on this path to do what you’re doing today.

Alice: Well, it’s funny because when you are on the path you don’t really think about where you are heading and I was one of those kids who was always interested in medicine and I went to college thinking I want to be a physician and after college I started thinking “I don’t really care so much what’s wrong with people. I care how they react to it.” and so I decided to take two years off and work for a psychologist and a neurologist and decided that I’m going to whichever job I like better.

Then I realize, when we’re doing brain research, and I realize quickly that I will be looking at this computerized EEGs and brain activity, and I realized I really wouldn’t really care so much what’s wrong with the person. The diagnosis wasn’t interesting to me. What’s interesting to me is how people reacted to it, and so I decided to go in to health psychologist. I got a PhD in health psychology and that was perfect fit. It was the first time in my life I found school easy because it was the first time I was studying what I really wanted to do.

Jonathan: Health psychology. Those are two words that sometimes we don’t hear put together, what is Health Psychology?

Alice: Well in those days, it was a very, very new field. In fact, in a PhD program that I went to in New York, Albert Einstein College of Medicine, I was only on the third year when the program was open and the idea was that so much of physical illness involve psychology. When we think of mental health issues, we think of people who have schizophrenia or bipolar illness and depression and anxiety, and again those things honestly didn’t interest me. I had no interest in clinical psychology but I’m fascinated by medical condition which cause people to have to adapt, and I’m also fascinated about what psychological factors can cause physical symptoms.

So health psychology looks at the interaction between the mind and the body, and so the program that I went to in Einstein actually has three main components. You have to learn medicine, you have to learn research methodology and you have to learn to be a therapist. In health psychology, they primarily focus on cognitive behavior therapy, and the goal of the program is to train psychologists who can work in a medical setting and speak medicine with physicians, which is why two years of our classes were with medical students because physicians tend to speak it at very high level. They tend to be somewhat intolerant of other health care professionals that understand what they are talking about.

The idea is to train psychologist to actually speak intelligently with physicians. I was very interested with obstetrics and gynecology, and so I was actually the first student in my program to major in OBGYN. The requirement of the program was that you had to have a medical major. If you major, for example, in cardiology you would be required to know as much cardiology as an orthopedics, and so I was required to learn as much obstetrics and gynecology as a [indiscernible 04:22] I just need to know. I literally took the medical student rotation. I scrubbed in on surgery. I helped deliver babies. That was part of my training so when I got out, the idea was that I can be able to have intelligent conversations with OBGYNs.

Jonathan: What have you found to be the most, let’s say shocking in your career relationships between the mind and obstetric and gynecological health?

Alice: Well, it’s interesting because I’ve done research in infertility and menopause and PMS and breast cancer and ovarian cancer so I feel like I’ve seen a lot of conditions in terms of the mind/body connection. I have to say I think the most startling results have been infertility. I don’t know if I say that because it’s so cool to help make a baby or if it’s just that is most of my research has been spent on the mind/body connection with infertility.

Jonathan: What is the connection there?

Alice: Well, the connection is a chicken and egg question of course between stress and infertility. We know that with infertility patients…women with infertility have an extraordinary amount of distress. They are very anxious. They are very depressed. You shouldn’t be because having a baby is a very natural thing for people who want that. What I’ve seen for the last 25 years of my career is people are first of all, recognizing how distressing infertility is, which I think was not really… people just thought women were being crazy.

They are not crazy. These are mentally healthy women, who are dealing with an extraordinary stressful crisis. I have documented in some of my research how depressed infertility patients are, which I think is important for people to understand. I published a paper showing that woman with infertility were just as depressed and anxious as were women with cancer, AIDS or heart disease. Infertility is a massive, massive hit.

Then, we’ve also shown, I think more excitedly, that mind/body programs can actually, not only lead to a lot less distress, actually, it can get people; women to be in the normal way in terms of anxiety and depression and we can reduce physical symptoms of stress like insomnia and abdominal pain. We also have shown through two large [indiscernible 06:48] control trials that women who go through this mind/body program are much more likely to get pregnant. That’s what I mean when I say it’s really fun to help people make babies.

Jonathan: I’m sure you are not the only person who may have made that statement at some point in time in their life.

Alice: Yes, but I am a girl.

Jonathan: Well, Ali, you mentioned that individuals who are struggling with infertility can be as hit by it emotionally as individuals struggling with cancer, AIDS or heart disease and it’s my impression, please correct me if I’m wrong, that the rates of infertility are going up at quite a rapid clip. What are some of the reasons for this and can we avoid it?

Alice: Two really, really good questions. The rates do seem to be going up. It sort of like breast cancer, they always say it’s one in eight. I think right now the rates have probably gone up. This article came out. In fact, I have it here. Hold on. I can tell you exactly date if I was smart one to keep it.

An article just came out about a month ago. It says if you follow the traditional one, the definition of infertility, women in this country 15.5% have infertility so it’s a minority. I understand 15.5% is a minority but still awful lot of people. Probably one of the number one reasons for the increase is that people are waiting longer to have babies. Used to be at the average age of first conception in this country was 21 and I think now it’s 25. The rate of women trying to get pregnant in their thirties and even forties has sky-rocketed. Unfortunately, for both men and women, aging is not your friend when it comes to fertility.

Jonathan: I know there is some pretty cutting edge in genetic research in terms of actually quantifying age, and this has to do with looking at genes and telomeres on the ends of genes and what is actually aging. The reason I ask that question is it possible for someone who is, let’s say, in their thirties, who gets sufficient sleep, eats a very nutritious diet, is physically active and is healthy in every sense of the word to be younger from a fertility prospective than someone who maybe practices very unhealthy lifestyle behaviors or when we talk about fertility, is it really a chronological age?

Alice: I have to say yes and no to your question because I think one of the hardest things to explain to patients is I think a lot of people feel if they take really good care of themselves and they do get a lot of sleep and they eat really good food and they exercise and they don’t smoke, they don’t drink a lot of alcohol and they maintain a normal weight, those people tend to look younger than you’d expect. The expectation is because they are so healthy and they have such great lifestyle habits and they look younger than their age that would then translate into being fertile later. I’d say that is not the case. Our ovaries don’t really know what we look like, they just tend to know when the birthdays are passing.

I had patients at the age of 45 who look 30. They’re gorgeous, their skin is beautiful, they have beautiful bodies and yet they are going to be fertile like a 45 year old not like a 30 year old despite by how they look. It’s tough to outsmart age, so that’s the no question or the yes. I don’t know which way you asked it but on the other hand, we do know that there are many lifestyle habits which are bad for fertility and so the one on smoking that I think is just the most dramatic. A 25 year old smoker is as fertile as a 35 year old non-smoker so in effect, smoking adds ten years to reproductive age, which in this world is bad. So, there are… go ahead. I’m sorry.

Jonathan: That’s amazing and I am curious, do we know why? Is it something unique about cigarettes or is it that cigarettes do something which stress the body in a way where we could say “Wow, these other things also stress the body in that way.” or is it something unique to cigarettes?
Alice: Well, they literally found nicotine in the fluid where eggs grow and nicotine is toxic. They also know that women who smoke go into menopause earlier than women who don’t smoke. So clearly it has some acute effects that is in that fluid and then it almost has the stomach effects to just make the body age faster, so it makes ovaries age faster, or maybe deplete the ovaries more quickly. I think smoking is the most dramatic example in terms on the impact of lifestyle factors.

There are a lot of infertility clinics in the country who won’t even accept patients who smoke because they know that their odds are so much lower. If you have a smoker and she stops smoking within a few months her odds of her getting pregnant do increase so the results of smoking or are not all permanent.

Jonathan: And why is smoking obviously not helpful, seems like there is quite a bit of research saying that carrying around excess body fat is also not helpful from a fertility perspective and if that is correct, why is it that carrying around excess body fat has a negative impact on fertility?

Alice: Well, they found for both men and women that being obese is associated with lower fertility; not just spontaneous consumption, which is what we call couples who actually have sex but even in couples who go for the highest tech treatment which is invitro fertilization, if either member of the couple, and obviously if both members of the couple are obese, even with the best medications and the best forms of treatment, their chances of getting pregnant are lower than women who have normal weight.

Jonathan: Do we know why that is? What is going on in the body of someone who is overweight or obese that causes the fertility to drop?

Alice: Well, we know that obesity affects ovulation. It can also affect sperm production. If obese women lose weight their fertility tends to normalize. In fact, a small study was just presented in California a few months ago, where they looked at women who were obese. They found that the women who lost about ten percent of their body weight have 88%pregnancy rate versus the women who only lost a few pounds, I think they have a 26% pregnancy rate so there is no question of being obese.

Most of the research actually looks at women and men whose BMIs is about 35 so I am not really worried about women who are 20 pounds, 30 pounds overweight. We’re talking about people whose BMIs about 35. Maybe, most of the medications that are used for treatment are injections, and if you’re injecting somebody who’s in normal weight, the medication tends to go into muscle versus if you are injecting somebody who is obese, the injection goes into fat and fat probably processes the medication differently.

I went to an all-day symposium last year on how to counsel patients who are obese and the physician running that one section said “If a woman is 38 or above and obese, she should go straight to high-tech infertility treatment that gives her, her best chance of getting pregnant but if she is under 38, it makes sense for her to try to lose some weight and then see what happens.

Jonathan: We’ve been focusing so far on the impact of carrying excess and lots of it. You don’t look like someone on the cover of a magazine, we are talking someone who has morbid obesity. We talked about the impact of getting the baby to get started. What is the impact… because I know there is some research on birth weight and things like that once nine months have passed and the baby is done, have you seen a research there?

Alice: It’s funny because we started a weight lost program here Bos90F a couple of years ago, and we were told by all these focus scripts and marketing that you don’t scare people by saying that “If you’re obese, you have less of a chance of getting pregnant. You have an increased risk of miscarriage. You have an increased risk of birth defects. You have an increased risk of premature birth.” They said “No, turn it around.” so our marketing materials for our weight loss program says “If your BMI is below 35, you got an increase chance of getting pregnant, a decrease risk of miscarriage, a decrease risk of premature birth and a decrease risk of birth defects.

Scaring people per say doesn’t seem to work. People need to be encouraged and supported. I saw a patient last week who was obese and it’s a really hard conversation to have because she is under 38 and so in fact, it really does make sense for her to try to lose some weight. When I said this new study came out showing that women who lost ten percent had these amazing pregnancy rate. I can just sort of see in her mind. “Oh my god! How am I going to lose 30 pounds? That’s a lot weight to lose.” That feels really frustrating on top of the devastation of going through infertility.

[Crosstalk 16:36]

Alice: Now, could I just add more thing?

Jonathan: Oh, please. Oh, please.
Alice: We focus so much on more than obesity, but very similar data exists for women who are very thin. How many fertility statues that you’ve seen look like twigy? In most fertility statues worldwide show these fertilities models are they have breast and they have curves and they have hips so being very thin even with treatment can also decrease your chances of getting pregnant.

Jonathan: Excellent, Ali. Excellent. I love your tag line for lack of better terms for your Domar Center for Mind, Body/Health that’s grounded in science, inspired by compassion and to the point we were just talking to about maintaining a healthy body composition, which it sounds like that’s the sweet spot we’re after. It’s like Goldilocks, not too hot not too cold, just right in the middle that grounded in science inspired by compassion.

It seems I’m curious with your research on the mind relating to the body that if our goal in terms of body composition is motivated by say a number on the scale, that’s not very inspirational, where as if it were inspired and guided by creating life as resiliently and robustly and healthfully as we could, man, that’s a great reason to eat more greens.

Alice: Absolutely. I think a lot people after trying to get pregnant for a while, the last thing in the world they want to hear is, “We need you to lose weight.” No one likes to hear that from anybody, but when you’re emotionally and often physically depleted by a medical crisis, figuring out how to lose weight takes a lot of energy and time and attention and a readiness for change. A lot of these couples are depleted, and so you’re basically taking somebody whose cup is empty and saying keep on pouring and that is really hard.

Jonathan: What do you do there, Ali? Because on some level if an individual is really, really struggling with their weight, on some level they know what needs to happen. They may be engaging in certain behaviors that they know on some level they should not be engaging in but at that point it’s an emotional, there’s an emotional thing happening there, so how do we as individuals overcome those emotional hurdles?

Alice: Well, what we do here because we’re shrinks is we focus on health. I say to patients “No, we’re not going to focus on weight. We’re not going to focus on fat. We’re not going to focus on size. We’re going to focus on your health.” They’re supposed to think is, “Oh, my god! I have to lose 30 pounds.” Let’s reframe it to say, “How can I live my life more healthfully? We have a nutritionist here. She’s one of these really realistic people who eats chocolate cake and she’ll talk about how to live a healthy life and when you think of it in terms of health, when you think it in terms of creating a place where baby will want to grow, it makes it a little easier.

Jonathan: When we go back to speaking of making it a hospitable place, making your body a hospitable place for life as well as enjoying your own life, we go back to the studies around nicotine and actually finding nicotine there in the blood and approximate to the eggs. What is your take on the… so there is eating food, like even chocolate cake. The chocolate cake you make at home using real flour, real eggs, real food, quote unquote versus a Hostess CupCake, which is made with all kinds of stuff that you would never make.

These chemicals, these edible products which now make over 40 percent of our most Americans caloric intake. Do you think there is a chance that the chemicals in those foods could be doing something like nicotine or is it really more just about calories and fattened sugar?

Alice: I don’t think anyone’s looked at it. I have no idea. Certainly the research looks at BMI, there’s a very little research on diet per say in terms of what people eat. What makes me crazy is when my patients come in and say “Yeah, I saw this alternative medicine practitioner. He told me to avoid eggplant.” or “He told me to only eat blue food or to avoid pineapple.” The fact is there’s very little research on specific foods per say.

What I tell my patients is to eat good food. Eat what your grandmother would have told you to eat, which means fruits and vegetables and whole grains and lean meats and you can have chocolates. What we teach our patients in our programs is what’s called the 80/20 plan, which means that 80 percent of what you eat is the good stuff, the other 20 percent can be what you want. The recent reason for that is a relatively well research phenomenon or… there’s not a woman in this country who does not know what she should be eating.

There certainly not an infertility patients in this country who doesn’t know truly what she should be eating. If you have your greek yogurt and fruit for breakfast and you have salad with a grilled chicken for lunch and then you eat a donut, meaning you will then experience what is called the ‘what the hell’ effect and you will then eat fettuccine alfredo for dinner topped off a pint of Häagen-Dazs . What we teach our patients is if you’ve done your 80 percent, you can have a couple of cookies because then you won’t have the ‘what the hell’ effect. I’d far rather see one of my patients eat a couple of cookies a day rather than to eat nothing sweet for four days and then eat a whole box.

Jonathan: It seems that is right in line with… if our goal is to avoid disease, to do what seems natural to humans. To humans it seems natural to not become sick prematurely, to not die prematurely and to be able to create life if you happen to be a female human, so the way you would eat if your goals are to do that seems much more tractable and let’s say less aggressive than if your goals were to have six-pack abs, which actually may be counterproductive to some of those goals.

Alice: A very rigorous exercise may also reduce infertility. I think the body knows what it’s doing and then the people who are most fertile are sort of mid weight range, they eat good food and they exercise moderately. The ancient part of our brain, sort of lizard part of our brain is the part that controls reproduction, and that part is very conscious of “Are we getting enough food? Are getting enough rest? Are we in any danger?” If any of those bad conditions exist, not a good time to get pregnant because the body really wants things to be good before it will allow conception to occur.

Jonathan: Well, Ali, what’s next for you in the Domar Center?

Alice: Well, I should have tripped over a whole new area of study about a year ago. I was made aware of the risks for infertility patients and pregnant women who have taken antidepressant medication while they are trying to get pregnant, while they’re pregnant, and so I published a review article with a high risk obstetrician in January basically pointing out the risks of taking SSRIs during pregnancy, and so I become very interested in how women who are trying to get pregnant or who are pregnant, who have a history of depression looking at other ways to treat their depression other than medication.

Jonathan: Well, certainly it’s very, very exciting and noble in supporting your mission of being grounded in science and inspired by compassion. Folks, our guest today is obviously a wonderful doctor, Dr. Alice Domar doing some wonderful work. You can learn more about her and her center at DomarCenter.com. That’s D-O-M-A-R-C-E-N-T-E-R.com. Ali, thank you so much for joining us today.

Alice: Thank so much, Jonathan.

Jonathan: Listeners, I hope you enjoyed today’s show as much as I did. Please remember, this week and every week after, eat smarter, exercise smarter and live better. Chat with you soon.