Episode 215: On this week's episode Real Health Radio, Chris is chatting with Nicola Salmon. Nicola is a fat-positive fertility coach and author of “Fat and Fertile” and the conversation focuses on all things fertility, conception and pregnancy.
Nicola is a fat-positive fertility coach and author of “Fat and Fertile”. She helps fat folks navigate getting pregnant in a weight-obsesses world and advocates for change in how fat people are treated whilst accessing help with their fertility. Nicola uses her unique fat positive framework to support people in finding their own version of health without diets, advocate for their bodies, relearn how to trust their body and believe in their ability to get pregnant.
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Chris Sandel: Welcome to Episode 215 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at seven-health.com/215.
For the last handful of weeks, I’ve been starting the show talking about the fact that Seven Health is taking on new clients. At the time of recording this intro, we have just two spots left.
Client work is the thing I actually enjoy the most. After working with clients for more than a decade, I feel confident in saying I’m very good at what I do. When I reflect on the clients that have sought out Seven Health over the last couple of years, there’s a handful of areas that come up the most.
One of the biggest is helping women get their periods back, so recovery from hypothalamic amenorrhea, or HA. I’ve had clients regain their period after being absent for 10 or even 20 years, after being told that it would never happen again, or clients becoming pregnant who’d almost given up hope of it happening.
I also work with clients along the disordered eating and eating disorder spectrum. Many clients use the term ‘quasi-recovered’ to describe where they’re at because things are better than where they were when everything was at its worst, but they still feel far away from the place of freedom that they really crave.
At Seven Health, we really believe in full recovery. I’ve had many clients who’ve had multiple stays at inpatient facilities where nothing worked, but through working together, they’ve got to a place of full recovery.
Transitioning out of dieting is another big one. Clients have had many years or even decades of dieting, and they know that it doesn’t work, but they’re really struggling to figure out how to eat and how to live without dieting.
Then body shame and hatred and a struggle with body acceptance is probably the final common area that clients are dealing with. They want to get past this and be able to be present in their life and stop putting things on hold, but they’re unsure of how to start and how to make this a reality.
In all of these scenarios, we use the core components of what Seven Health is about, which is science and compassion. We focus on the physiology, so understanding how the body works and how to best support it, but also on the psychology and understanding the mental and emotional side and uncovering people’s identity and values and priorities and traits and beliefs and how these are either helping or hindering with change.
It’s these kinds of clients that make up the bulk of the practice, and I’m very good at guiding and supporting people through this process.
If any of these scenarios sound like you and you’d like help, then please get in contact. You can head over to seven-health.com/help, where you can read about how I work with clients and apply for a free initial chat. This will be the last time I’m starting with clients in 2020, and as I said at the start, there are just two spots left. So if you’re wanting help, then please reach out. The link, again, is seven-health.com/help, and I’ll also include it in the show notes.
Hey everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. This week on the show, I am back with another guest interview, and my guest today is Nicola Salmon.
Nicola is a fat positive fertility coach and author of Fat and Fertile. She helps fat folks navigate getting pregnant in a weight-obsessed world and advocates for change in how people are treated whilst accessing help with their fertility. Nicola uses her unique fat positive framework to support people in finding their own version of health without diets, advocate for their bodies, relearn how to trust their body, and believe in the ability to get pregnant.
I’ve been aware of Nicola for a little while now. I heard her on someone’s podcast – I can’t remember whose it was. It may have been Christy Harrison’s or it may have been Dietitians Unplugged. I really liked what she had to say, so I checked out her site and her Instagram and really enjoyed what she was putting out.
I’ve done a number of podcasts on hypothalamic amenorrhea, whether with guests like Nicola Rinaldi or talking with past clients. I’ve had other guests talking about fertility issues. But I haven’t done an episode like this specifically about fat fertility and some of the misguided advice given to those in larger bodies who are wanting to get pregnant. Nicola really is the best person to be speaking to on this topic.
As part of this episode, we cover Nicola’s backstory and how she got into this work, which includes her own history of dieting and disordered eating and a traumatic life event that led her to get acupuncture for herself and then seeing the benefit and her training in the field. We chat about her two pregnancies and how they differed from what she expected. We talk about the science around weight and pregnancy outcome, looking at what are the myths and what are the facts. We cover the BMI cutoff for IVF. And we go through Nicola’s Fat Positive Framework, which includes Formulate, Advocate, Trust, and Positive Mindset.
At the end of the show, I have a recommendation that I want to make, but for now, let’s get on with the show. Here is my conversation with Nicola Salmon.
Hey, Nicola. Welcome to Real Health Radio. Thanks for joining me today.
Nicola Salmon: Thank you so much for having me, Chris. I’m really delighted to be able to talk to you today.
Chris Sandel: I’m really excited to have you on the show. It’s been a while since I’ve had a long conversation about fertility and pregnancy, so I’m looking forward to getting into that. I know you’re someone with a strong science background and you love getting into the research, so that’s also something I want to be sharing with everyone. I feel like this conversation is going to have a pretty narrow focus, where it’s everything fertility and pregnancy, but I’m also open to wherever the conversation goes, we can go with it.
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To start with, do you want to give listeners a brief background on yourself? Who you are, what you do, what training you’ve done, that sort of thing? And then we can go through certain aspects of your story in more detail.
Nicola Salmon: Absolutely. I call myself a fat positive fertility coach, which means that I support people in bigger bodies who want to get pregnant without any form of weight loss or dieting. A bit about my background: I initially trained in physical sciences and then went on to do a Master’s in medical engineering and physics, which was quite full-on. [laughs]
And then what happened was that I had something really traumatic happen in my personal life, and that led me to try acupuncture for the first time. What I found from that was that it had a really positive impact on myself and my health, and that led me to decide to train as an acupuncturist and a naturopath.
From that, what happened was I found I really wanted to specialise in fertility, so I trained and niched up in fertility acupuncture and realised that a lot of that work revolved around emotions and people’s emotional wellbeing and stresses that they had in their life too. I didn’t feel equipped to deal with that as an acupuncturist, so I trained specifically as a fertility coach so that I had those tools to be able to support people in a different way.
That led on to really looking at how I was supporting people. I’m in a bigger body myself, and I realised that there was so much talk about diet and restriction and cutting out entire food groups in the fertility world. The more I went into this, the more I realised that this wasn’t helping people, especially people who are in fat bodies, because we’re just constantly told that we need to lose weight in order to access fertility care, to get any kind of support when we’re struggling to get pregnant.
That’s when I stumbled upon the Health at Every Size model and Intuitive Eating and all these incredible frameworks and resources for health in a different perspective. It was part of my own journey as well to be able to release the hold that diets had on me and realise that actually, I didn’t have to diet in order to be happy, to be healthy, and to live a really wonderful life.
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Chris Sandel: Nice. You mentioned about being in a larger body and dieting; what was your dieting or food and that relationship with food like growing up?
Nicola Salmon: I have always been I would say a chubby kid. I probably noticed that my food was being restricted from maybe eight or nine. It only started with small things like having a different choice of crisps because they were lower calorie, or being encouraged to eat fruit rather than other things that maybe my sister was eating.
But it really ramped up when I was around 15 or 16 because I was diagnosed with polycystic ovarian syndrome, which, for those of you who don’t know, is a metabolic and hormonal condition. It meant that I had really irregular cycles, it meant I had acne, hair in places that I wasn’t expecting to have it, and the doctor basically said that I would never have children and that the only way to help it would be to take the pill and to lose weight.
That’s when it really kicked off in terms of going to more formal diet clubs and constantly being on this rollercoaster of losing weight, then putting the weight back on, then going on another diet. That continued probably until 5 years ago, when I finally kicked the bucket and decided, “No, I’m not doing any more dieting. No more weight loss. Smash the scales.” I made a promise to myself that that chapter of my life was over.
Chris Sandel: With the dieting, you said you’d get certain crisps that someone else in your household might not get. Who was encouraging this?
Nicola Salmon: It was my primary carers, my mum and my dad, and also I spent a lot of time with my grandparents as I was younger. So it was really the important people in my life, who of course were doing it from a place of love and they didn’t know any different, but it’s a really big memory that sticks out to me – my sister, who was younger and thinner, having the things she wanted to eat, and then me being told “This is your option. You don’t have full options to everything. You just have this one because this is ‘healthier’ for you.”
Chris Sandel: Yeah. That’s a pretty blunt message as well that you got from your doctor in terms of “You’ve got PCOS; this means you’re not going to be able to have kids.” That’s a big stretch.
Nicola Salmon: Absolutely. It’s not something I knew anything about. I’d never heard that word before, PCOS. We didn’t have the internet in those days; this was like 20 years ago, so I didn’t have access to any information or resources or any alternatives. I just believed it at face value.
At 16, I wasn’t ready to be having kids or even thinking about that, but looking back now, I do notice I can see my grades shifted at that point, my self-confidence plummeted. So it had a really big impact on who I was and who I became. The doctor had no basis for saying that. It was on this very limited understanding of PCOS and something I think is still quite limited in terms of what doctors know. I know people who’ve been told similar things along the same lines much more recently, so it’s still a very misunderstood condition.
Chris Sandel: Was that the point at which your dieting increased, or maybe you took the reins more? So before it was being forced upon you, where your guardians or parents were picking what you’d eat, and now this was like, “Right, I’m going to do something about this”?
Nicola Salmon: I think it was definitely a combination. My mum was also on a weight loss journey, so we’d do these things together. It became something we’d do together in terms of bonding, almost – which sounds really strange now, but going to the weight loss clubs every week felt like something that we did together and that we were supporting each other through.
Sure, as I got older it’s something that I did more, but I also found ways to subvert it in ways. The strangest things I would do because I was restricting and then found foods to binge. I’d have secret stashes of chocolate, or I’d find whatever was in the house that would give me some kind of satisfaction that I wasn’t getting from the foods I was eating. Looking back now, I can really see how disordered those eating behaviours were.
But in the moment I just thought, “Oh my gosh, I’m such a bad person. I can’t believe I can’t stick to this.” You tell yourself all these stories around the experiences and they make you feel so responsible. I felt like it was a real flaw in the person that I was because I couldn’t do these things – even though I seemed to be very intelligent and going to university and doing all these things, yet I couldn’t solve this one problem in my life that I thought would fix everything else. It just made me feel like a failure because I couldn’t lose this weight and keep it off.
Chris Sandel: I’m trying to remember back to 20 years ago or so, what was in vogue then in terms of dieting. Was it basically just “lose weight at whatever it costs,” or was it “you’re going to have to cut out carbs” because of the glucose intolerance connection with PCOS? What was the advice you were being told by your doctor or otherwise?
Nicola Salmon: There wasn’t any advice from my doctor, but was mainly in vogue, I remember, around then was the fat being very demonized. Everything was fat-free. I couldn’t have butter; I had to have the fat-free, low-fat marg spread. It was all these Lean Cuisine type meals of counting the points. I remember one thing I went on that had like red days and green days, so you couldn’t mix fats and carbs. You had to separate them out into different days.
It just sounds so complicated and absolute rubbish when I think back to it. [laughs] But that became my normal, making sure I wasn’t eating fats and making sure I wasn’t mixing these two food groups. Looking back now with the information that I have, I’m like, oh my gosh, cutting out fats seems absurd because fats make up hormones. If I wanted to regulate my hormonal system, of course I’d need fats to build the hormones that I needed. It blows my mind.
Chris Sandel: Then how was it for you when you left home and moved – did you study in London? IS that what you said?
Nicola Salmon: Yes, I grew up in Lancashire and moved to London, and that was a real shock. I wasn’t used to having complete autonomy over the things that I ate and what I cooked.
But again, it became this up and down cycle of feeling that freedom and being able to choose and eat what I wanted to and then feeling guilty about the choices that I’d made, and then finding the next diet in which to restrict myself and lose the weight. I’d do that, but then I’d fail at that, so then I’d blow it again and go crazy, going back and forth on this cycle the whole time.
It was just exhausting. It took up so much emotional energy, physical energy, money, so much time. I feel so cross that that time was wasted for me in terms of my whole twenties being taken up by the idea of I had to be smaller and find the next diet and try this and try that in order to lose weight.
Chris Sandel: You mentioned when you were dieting later on, you were doing that with your mum, so there was maybe some camaraderie there. When you moved to London, or even before that, was there dieting with friends? Was there any bonding in that realm, or outside of your household this was something you were doing on your own and it was almost like your secret?
Nicola Salmon: I think definitely it was more I didn’t want to admit I was doing this in front of my friends. When I was house sharing and living with my friends, it’s something I felt that was a dirty secret that maybe people wouldn’t understand, or they wouldn’t see how much of a big problem this was. Because in my head, this was the biggest problem in my world. That sounds like such a privileged thing to say now in terms of the world and other people’s things they move through.
But it felt like I was such a terrible person and I didn’t want people to know that I was having this issue, and I didn’t really want to share the extremes I was going to as well. Because at some points on that journey, I was on shakes and I wasn’t eating any real food, or I was sending myself to the gym every day. Things that sound healthy in moderation, but the extremes I was taking it to, I didn’t really want to admit to other people around me.
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Chris Sandel: You said there was a traumatic event that really changed things for you. Talk about that.
Nicola Salmon: I was living in South London at the time, and I was working at a local hospital. I was living on my own at this point in a little flat on the main High Street. What happened was a guy got shot outside my flat. It was in the middle of the night, around Halloween, and I heard these really loud bangs.
My bedroom faced onto this main street, and I heard all this noise, I heard people running around, I saw shadows across the room, and what I thought what woke me up as fireworks was actually gunshots. Then the street was quiet and I heard the ambulance, and I left my room and slept in the hallway because that’s the only place I felt safe, away from the window.
When I woke up the next morning, got ready, trying to leave the house to get out for work, the whole of my front area was cornered off by police tape. What happened was a guy had got shot on the doorstep. I was in this cornered-off area, and when I looked back towards where my flat was, there were bullet holes in the tiles around my bedroom window.
I didn’t see what happened; I wasn’t in direct contact. But the very real situation totally freaked me out. In the end, I ended up being diagnosed with post-traumatic stress disorder. I had nightmares. I couldn’t leave the house except to go to work. I tried things like antidepressants and some kind of cognitive behavioural therapy, but nothing really helped me.
It wasn’t until I randomly walked into a therapy centre and said, “Is there something you can help me with? Because I’m really struggling,” and they recommended acupuncture to me. I tried it, and in a couple of months I was feeling so much more like myself. I was feeling so much more like I could move forward with my life and not let this situation and this thing that happened to me rule what was going on.
I was amazed because I’d never tried acupuncture before. I didn’t really know much about it beyond that it helped with back pain. That’s what led me to deciding to train as an acupuncturist and change the whole course of my life.
Looking back now, I’m so grateful to have done that and then gone on to do that training. But yeah, it was a very strange turn of events that led me there.
Chris Sandel: Wow. How long did it take before you had your treatments and got better and then thought “I’m going to sign up and start training as an acupuncturist”?
Nicola Salmon: It was a little while after the incident. I was on a waiting list for therapy; I thought that was going to help me. It was probably 6 months after the event that I tried acupuncture, but once I actually tried it, it was probably 2 months before I then decided I was going to train. It was a real gut instinct thing to do. I didn’t really think about it. It wasn’t something I put a lot of research into about where to train or what to do.
I just decided this was going to be what I wanted to do because I was so amazed by the results I got from it. It just blew me away. I was like, “I’ve got to know.” It was the scientist in me like, “How does this work? What is going on? Why do these needles make me feel better?” It was really quick once I was in the treatment that I decided this was what I wanted to do.
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Chris Sandel: And how was the training? How did you find it?
Nicola Salmon: It was very full-on. It was a weekend course over 4 years, so it was pretty intense because once I was feeling better, I started working again. I was working full-time and then training at the weekends.
Just the whole training around Chinese medicine was a really strange experience for me because I was so used to Western medicine and I’d trained in medical engineering, so I had a lot of Western medicine background. And then I almost felt like at the weekends, I had to then put this different hat on, because the way that Eastern cultures talk about medicine is so different.
A classic example that I like to use is that they pay their doctors to keep them well rather than paying their doctors to treat them when they’re ill. I just think that’s such a fascinating reframe of how we do healthcare. It almost felt like going back to the beginning of school and not knowing anything, because I had no real frame of reference in terms of Eastern philosophy or Eastern medicine.
But it was amazing, and I love the framework and I love the tools that it gave me to then go on and look at healthcare. I think it’s really helped me in terms of doing anti-diet work because I’m so used to now being almost on the fringes of healthcare in terms of not everybody believes you when you say that acupuncture is really helpful. Some people still view it as this ‘alternative medicine’.
I think being on that edge has really helped me to feel more confident when I’m talking about anti-diet method and not using weight loss and all these ideas around Health at Every Size because I’m okay now being on those outskirts and not having to be in the normal conversation around these things.
Chris Sandel: It’s interesting; when I reflect, I think I’ve moved in the opposite direction – and that’s not to say I don’t believe in Health at Every Size or Intuitive Eating. I’m completely on board with all of that.
I studied at the College of Naturopathic Medicine, CNM, which is the same place you did, and I think I started out much more on the fringes. Pretty much anything that was alternative, I was pretty much on board with. And then as time’s gone on, I’ve moved much more towards the centre and disavowed a lot of my previous beliefs and things I’ve learnt because there isn’t the science to back that up. So it’s interesting to hear your take on that and how it’s affected you in a different way in terms of starting from such a strong traditional science background and then moving out.
Nicola Salmon: Yeah, absolutely. For sure, a lot of the stuff that I learnt, I definitely don’t use in practice now in terms of things maybe we were taught at college. But it’s nice to be – I definitely ground all my work in research, especially around fertility. A lot of the research that I look at is so entrenched in our healthcare system, and people are quoting all these things like, “It’s really bad for people in bigger bodies to get pregnant because they have all these risks” and “It’s really bad for people to go through IVF because it doesn’t work.”
All these ideas are really entrenched, but when you actually go and look at the research, so much of it is mixed, as in it’s not all conclusive along the same line. Some of it will find a correlation; others won’t. It’s because of the researchers and their underlying fat bias that they’re making the conclusions that “We know that fat bodies are unhealthy; therefore, it must be the right conclusion that there’s increased risks of pregnancy because of this.”
When you’re looking at it through a more weight neutral lens, you can see that bias leaping out of the page at you. It kind of blows my mind that these things are the norm when actually the research doesn’t agree with them.
Chris Sandel: Definitely. I definitely want to go through more of that research with you. So when did you then have the shift of “I’ve studied acupuncture, I’ve finished up,” and then making the decision of “I want to work in the area of fertility”? Did you always know that? Because it sounded like it was trauma that got you there. When did that shift happen?
Nicola Salmon: I think because of my own diagnosis of PCOS and because I expected things to be really difficult for me in order to get pregnant, I was always very interested in stuff around fertility and hormones when we were training. So that felt like a really natural evolution, once I qualified, to move on to look at and specialise in fertility.
What I found when I started my practice was that a lot of people were coming to me for those conditions. It seemed to be quite a popular thing for people who were going through fertility to seek support in terms of acupuncture. So it just all fell into place in that regard.
But then it wasn’t until I had got pregnant myself, completely naturally, completely uneventful – there were no problems for me. It wasn’t until after I’d had my first son that I realised I didn’t want to pass on all the stuff that I had myself around how I spoke about my body and how I spoke about food and my relationship with food that I really gave up dieting. It was when he was starting to wean. He’s six now, so that was about 5 years ago.
Luckily, at that point, I discovered Instagram and I discovered all the community around Health at Every Size on Instagram and around Intuitive Eating. Because I had just given up this huge part of who I was in terms of dieting and weight loss – for me, that was a big part of my identity – this felt like something that was really great to fill that gap.
The more I learnt about it and the more I read the research around it and the more books I accumulated around this subject, I got angrier and angrier about the fact that I’d spent my whole life chasing this thing which is actually completely unachievable. But I just felt that I needed to talk about this in terms of the fertility world because there was nobody else talking about this idea that you didn’t have to lose weight in order to get pregnant and that you could be in a really healthy position in terms of your body and your health in a bigger body.
It wasn’t that I felt like an expert at this time, but I just felt like I had to talk about it because there was nobody else sharing this information
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Chris Sandel: Talk about your pregnancies, then. You said earlier on you were told you were never going to get pregnant, and then from your comments there, it sounded like it was pretty straightforward.
Nicola Salmon: Absolutely. I met my husband and got married just as I was graduating from college, and then I talked to him about my problems and that it was going to be difficult. We decided a few years down the line that we wanted to start trying. It was around Glastonbury, so it was around the summer and we’d got tickets for Glastonbury the October before, and we were like, “Okay, after Glastonbury, that’s when we’ll start trying because I obviously don’t want to be pregnant as I’m going to a big festival.”
But what ended up happening was that I got pregnant before Glastonbury. I ended up being I think eight weeks pregnant at Glastonbury, which was not the best idea in the world. Luckily I didn’t have too much morning sickness. But we got pregnant straightaway, without even really trying.
But the problem then was I was expecting something to go wrong. I spent the majority of that first pregnancy absolutely convinced that whatever bad things could happen in pregnancy were going to happen to me because of the size of my body and the experiences that I had with my midwives. I was labeled high-risk straightaway from my very first appointment just purely due to my BMI.
Absolutely nothing happened, really, in my pregnancy. It was completely uneventful. I had no problems. I carried till maybe 42 weeks. We wanted to hold on till the very end. And then I had a completely uneventful birth. Nothing happened. But I spent the majority of that 9 months really anxious about what was going to happen.
I ended up doing a lot of research because I really, really wanted a home birth and I really, really wanted a water birth. So I ended up doing a lot of research around is it really dangerous? Because I was told that was just not an option for me. I ended up finding this really good website called Big Birthers, which a lady called Amber runs, and she went through all the research around it’s absolutely okay to have a water birth in a higher BMI. Actually, they can’t tell you what to do; you have autonomy over your own body in terms of your birth choices.
That was such a huge turning point for me because before then, I had no idea, really, that I could say no to my doctor, that I could choose where I gave birth, even if they said that wasn’t okay for me. I had that choice. It was the very, very first time – I had a conversation with the head midwife at my hospital, and it was the very first time I’d ever stood up and advocated for my body, for myself, for my choices.
That was huge for me because in the end she said, “Okay, you can have a water birth.” It didn’t end up happening due to other things that happened during the birth, but the fact that I had that conversation and I was able to stand up for myself and advocate for myself was such a big turning point in how I approach this work and how I work with people. Just knowing the information that I had choice and autonomy was really powerful.
Chris Sandel: I remember when Ali, my other half, was pregnant and us going to the meetings at the doctor’s office, and she was very set on “I want to have a water birth and I want to do a home birth,” and I remember her bringing it up at some point, and pretty early on – it might’ve been when she was 4 months or 5 months pregnant – they said something along the lines of, “We’ll talk about that closer to the time. We’ll have to make sure that you tick all of these boxes before we can allow you to do that.”
She left that meeting and she’s like, “It’s not about them allowing me to do this. I’m the one that chooses what I’m allowed to do, and if I want to do this, I’m allowed to do this.” So I do remember having some interesting conversations like that as part of her being pregnant.
Nicola Salmon: It’s really interesting how that changes your perspective around healthcare. I think for so long, we’ve had a really patriarchal medical system in terms of the doctors hold all the power, and we’ve just got to do as we’re told and nod and agree and go along with it when actually, we can change that and we all should have autonomy of our own healthcare and medical decisions and be able to make these informed choices around what we decide to do with our own bodies in terms of health.
Chris Sandel: Yeah. There were lots of points that we reflected on with it because Ali is someone who lives in a normal or small size body, and she then gained quite a lot of weight during pregnancy – but because of where she started, no one ever raised any eyebrows. No one ever said anything to her. There was just a real reflection upon imagine if she’d started from a different starting place and how that would’ve impacted on things.
What was also interesting is one of her best friends in Scotland was pregnant two weeks after her, and both of them are normally similar bodies, similar build, and they had completely different pregnancies in terms of Ali gained a really large amount of weight and her friend didn’t gain very much weight at all. Her friend, at the point of giving birth, was probably where Ali was at 4 months. And they didn’t really do anything different. It wasn’t like anything changed. It was just this is what one person’s body wants to do as part of pregnancy and this is what another person’s body wants to do as part of pregnancy.
Pregnancy was a really great lesson – and I already knew this, but it really demonstrates it. Your body does what it wants to do.
Nicola Salmon: Yeah.
Chris Sandel: You said for the first pregnancy there was a lot of worries and expecting everything to go wrong. How was it then second time round?
Nicola Salmon: It was amazing the second time round. I felt so much more relaxed because I’d now given up dieting at this point. There’s only 21 months between my sons, so it was quite a short amount of time.
Chris Sandel: Wow.
Nicola Salmon: I got pregnant with my second son when my first one was about a year old. But at this point I had decided to give up dieting and I was very much on this journey towards Health at Every Size. I just relaxed – (A) because I already had a one-year-old to run after, but (B) because I felt like I could trust my body to do this because it had done it before, I had no problems. I knew what was going to happen. I felt so much more at ease because I believed that my body was capable of it.
I’d almost be able to quieten down that voice both internally and externally that was telling me that my body wasn’t capable of having a healthy pregnancy, which was so helpful in terms of enjoying the process.
And it’s really interesting what you said about Ali because I know people who’ve told me that when they’re going through pregnancy in bigger bodies, they’re told, “You must not gain any weight.” Sometimes they’ll say you need to lose weight in pregnancy; it doesn’t happen very often. But one of the most common things is “You mustn’t gain any weight,” and they’ll be really concerned if there’s even a pound put on. They’re really watching exactly what you’re doing.
It just really shows that difference between someone experiencing pregnancy in a ‘normal’ size body versus someone in a bigger body, and even if those relative weight gains are the same, how differently they’re treated.
Chris Sandel: Totally. It was also interesting just looking at, sure, in the first couple of months of pregnancy, all she wanted to eat was fish and chips and mac and cheese and that kind of carby, cheesy stodge, but after that, her eating went pretty much back to a lot of what we would normally eat anyway, and yet her body was choosing to put on all this weight.
There were times when I was just scratching my head. I’m like, “I genuinely don’t understand how this is working in terms of you’re eating what you would regularly eat and yet you’re getting much bigger.” The body is choosing to do what it wants to do. But if someone had said to her, “You need to stop doing this,” I don’t know how she would’ve been able to do that. You’re then into a place of “I’m going to spend my days, or large parts of my days, feeling really hungry. I’m going to be lightheaded.” It’s going to be at the detriment to her health to even attempt to do that.
00:38:15
In terms of your pregnancy, I know you said there were certain things that were mentioned, but were there things you were told you weren’t allowed to do, or told that you had to do in pregnancy?
Nicola Salmon: For both pregnancies there was definitely a case of I was monitored quite heavily. There wasn’t any real major negative comments or anything that stuck out in terms of how I was treated, but it was really just the small comments multiple times.
Obviously, you see people in healthcare professions more often than you do normally because you’re seeing them quite regularly for scans, for sessions with the midwife to make sure everything’s going okay. It was at every point in those appointments, whether it was just a really small comment about “Oh, I see you’ve gained a bit more weight” or just those really small comments that maybe on the surface don’t look that harmful, but when they add up, it can be really difficult to deal with in terms of it really starts to dig into your belief around whether your body can do this and whether it’s going to have complications.
I think one of the most difficult things for me was having the ultrasound scans because I was made to feel like a real problem patient. Even though I was trying to do everything right, drinking the right amount of water and doing my best to be as compliant and helpful as possible, but because of the extra fat on my stomach, it meant they couldn’t see the baby as clearly. And that’s not because of the technology that exists; it’s because of the training of the professionals and the equipment they have in the hospitals.
It meant that I had to spend a lot more time being poked, really quite hard, for them to be able to see and measure all the bits of baby that they need to see and measure. But that experience felt quite de-humanizing because of the way that I was treated. It was quite a sad thing because you’re obviously really excited about seeing your baby on an ultrasound screen. It felt quite a sad thing to have to go through because it didn’t feel joyful; it just felt like I was an imposition and I was somehow being difficult because I was fatter.
Chris Sandel: Wow. Was there anyone throughout either of your pregnancies where that wasn’t a thing, where you’re like “It feels like this person really see and hear me as a real live person as opposed to just an inconvenience”?
Nicola Salmon: I don’t think there were any people that were really positive about the experience. There were definitely some people who were lovely and kind and helpful, but I never really felt seen and understood as a person in terms of the unique way that fat people have to go through pregnancy. I never felt there was anybody who really understood what I was going through or made me feel at ease or really relaxed or comfortable about it – which is a real shame.
00:41:17
Chris Sandel: Broadening out from your experience, looking at the research or even just with clients you’ve worked with, what are people who are in fatter bodies or larger bodies – what tests are they not getting access to that someone in a smaller body is? Or if it’s not tests, other forms of support or access.
Nicola Salmon: The most common story that I hear in terms of fertility is that people will be trying for maybe a year, maybe 18 months, and they’ll go and see their doctor, their initial provider, and the only thing that the doctor will tell them is, “I can see that you’re overweight, so you’ll need to go away and lose some weight before I can help you.”
This is after they’ve waited this expected amount of time before seeking assistance, and sometimes that can be much longer because these people have already had quite negative interactions maybe with healthcare providers in the past, so they may have put off going to see their doctor for as long as possible because they know almost what to expect. It’s a really good self-preservation tool to avoid things that feel shaming or uncomfortable or difficult.
So they will be sent away and told to lose weight before they can access any kind of tests, any kind of treatments. Often the doctors won’t ask them any questions about their diet or their lifestyle or anything relevant; it’s just they see your body, they see that you’re fat, and they tell you to go away and lose weight.
Then these people are going away, trying to lose weight. Often they’ll have tried in the past because for people in bigger bodies, this isn’t a new experience, being told to lose weight. They’ll try something maybe more extreme than they’ve tried before, because obviously these people really want to have a family and this is something that’s really important to them.
And then either they will be able to lose the weight, but maybe in a way that’s quite detrimental to their health or wellbeing, so they’ll go back and finally be able to get those tests – or they won’t be able to lose that weight, and then they’ll prolong the time that they’ll go and see their doctor, or maybe they’ll feel that they can’t go and see their doctor again because they haven’t lost their amount of weight. It’s really this delay between any form of testing and any form of potential treatment or even looking into what might be going on that these people are experiencing. Because obviously when you’ve got that delay, any potential issues that might really be happening aren’t caught or aren’t seen. You’ve got that delay in diagnosis.
That is often the first interaction that people will have in terms of seeking fertility support. Then maybe they’ll decide that they have to go to the doctor again because nothing happens, so then they put themselves in this position of worry, of stress, of anxiety around these appointments, of having to try and advocate for themselves in terms of accessing some form of tests. It may be blood tests or any kind of internal scans to see if there’s something that’s not working.
But in the UK, our healthcare system is set up that if you want to seek fertility support on the NHS, which is our national healthcare system, you have to have a BMI of below 30 to be able to access that healthcare. So sometimes there’s just nowhere for you to go. If you go and see your GP, maybe they’ll do the initial blood test for you, but then there’s nowhere to seek support because the fertility specialist won’t see you unless you get your BMI below this barrier. And often there’s no wiggle room in that.
30 is quite a low barrier in terms of if you think about our population and in terms of the spread of BMI over the people who might want to be seeking fertility treatment. It’s a very low barrier. It means that a lot of people are being left out in terms of being able to access this kind of support.
It varies in other countries. These BMI barriers can be different in other countries. But again, there are often these BMI barriers in terms of being able to access any kind of fertility help.
Chris Sandel: There’s a couple things I want to ask on that. With the initial where someone goes and sees the doctor and they say, “Hey, I think you need to be losing weight to help with this,” if someone then says, “Can I see the research to support this?”, what research is being given to the patient there to show “We have this group of people; they lost weight, and it then increased their fertility or their conception rate”? Is there a paper or is there a piece of research that is being pointed towards?
Nicola Salmon: There are no dose-dependent studies that show – this research has not been done in terms of if you reduce your weight by X pounds, then your fertility will increase by X amount and you’re this times more likely to be able to conceive. That doesn’t exist.
But what the doctors will often say is, “If you only lose between 5% and 10% of your body weight” – this is a favourite phase that they have – “then often things start to work and everything goes back to normal and you can get pregnant.” But there’s no research where they get this number from, and it doesn’t matter what your starting weight is; it’s this magic 5% to 10%.
I have a whole book – let me grab it and see what it’s called. It’s called Maternal Obesity by Gillman and Postern. It’s a whole 300-page book about the research into why fertility and pregnancy is more detrimental if you’re in a bigger body. But so much of this research, like I said before, is biased in terms of the researchers who are doing it are in this world that we are all in in terms of diet culture and this belief that fat bodies are bad.
So, as I’m working through this book, you can see they’ve made this assumption – for example, looking at people in bigger bodies who may not be experiencing fertility. There’s some research that shows that actually, they will get pregnant at the same rate, but it will often take them a little bit longer than people who are in ‘smaller’ bodies.
I think a lot of that is to do with the fact that we are told it’s going to be tricky for us to get pregnant. We have this belief that it’s going to be harder for us to get pregnant, and often that can mean that our bodies are more stressed. We’re more anxious around it or we’re more depressed around it or we have all these other things that, because of that belief, are then happening. We know that shame and stress and all these things increase inflammation in the body, and that will then have an impact on how our systems are working in terms of our hormonal systems and our reproductive cycles and all the other ways that our bodies interact with them.
Chris Sandel: Yeah, it doesn’t really account for all the other things that could be causative as opposed to just correlated in terms of the socioeconomics or weight stigma. There’s so many other things that can be connected to this that isn’t weight per se.
Nicola Salmon: Something else that none of these studies ever take into account is that separation between the weight lost and the way these people change their behaviours in terms of how they’re looking after themselves. Because often people who decide to go on a weight loss program will be doing things – maybe they’ve increased their exercise, maybe they’re drinking more water, maybe they’re eating more vegetables, all these other health-promoting behaviours that we do know have an impact on our health markers, like our blood pressure and our insulin resistance. But they’re never separated out.
I know there’s research out there that exists that says if you’re taking part in these health-promoting behaviours, regardless of whether your weight goes up or down or stays the same, then your health markers are going to improve.
00:49:43
That’s something I’ve experienced personally myself. About 3 years ago now, I finally started having a good relationship with exercise. For so long, my relationship with exercise had been really, really linked with my relationship with diet, so it was always around weight loss. I decided to try CrossFit, which is something I’d seen other people doing and I thought it looked really fun. I got up the courage to give it a go and try it out and see how I found it, and I went to a place of “I’m doing this to support my health and feel stronger and have more energy” rather than from a place of “I’m doing this to lose weight.”
What I found was that when I started going consistently – I went about three times a week – my periods went from 100+ days down to between 40 and 50 days. And that was over a month. It was that quick. I changed nothing else. My weight did not change. I didn’t weigh myself anymore, but my clothes still felt the same. I didn’t look any different. But what happened was that I noticed this really positive impact on my menstrual cycles, purely from this one change in how I was moving my body.
That for me felt really affirming because it went along with this idea that it’s the health-promoting behaviours that are really having the positive impact on my health as opposed to any form of weight loss or weighing myself on the scales and trying to lose weight.
Chris Sandel: I would say you changed two things. You started the exercise and then started it with a different mental framework. I imagine if you had joined CrossFit and the goal was to lose weight or get ripped or whatever it is, you probably – and this is all speculation, but given all of the times you’ve tried these things in the past – when you’ve tried exercise in the past, am I wrong that it didn’t change your cycles then?
Nicola Salmon: No, it never had an impact. It was always this thing that I hated and I was never looking forward to. It made me stressed out. It never had a positive impact on my wellbeing.
Chris Sandel: That’s what I notice so much as well in terms of clients who are exercising, but doing it in a compulsive way and have this really tumultuous relationship with exercise, even if they’re keeping it up, and how that is not health-promoting. It’s really pushing them further away from where they want to get to. And when that changes, whether that’s from actually having a break or from changing the type of exercise they’re doing, things really shift. I’m a big believer in how much the mental side of things is important as opposed to just the actual physicalness of moving the body.
Nicola Salmon: Absolutely. I found that I enjoyed it. I never, ever in a million years thought that I would be the kind of person that enjoyed exercise. That concept felt so alien to me because it was always something I had done to punish myself for eating cake or ice cream or whatever it was. Just the fact that I was enjoying it and I looked forward to it and that it was fun – it just blew my mind that that could happen for me because I did not know that that really existed. I thought people made it up, which sounds funny.
Chris Sandel: Yeah, and I’m glad you did all of the work in terms of Health at Every Size and relationship with food before getting into CrossFit. [laughs] Maybe you just got a really good CrossFit gym, but I think there’s a lot of nonsense that comes along with CrossFit training in terms of paleo and a lot of their food-based recommendations.
Nicola Salmon: I had to be quite vigilant in terms of going through that and making sure I was able to take myself out of any conversations around that because it’s insipid anywhere. Even if you’ve got a good gym, there are still people who are there to lose weight. I haven’t been going to CrossFit recently because of the way that they dealt with the Black Lives Matter rigmarole. It was a whole thing around the CrossFit community around the way they were talking about Black people and about women.
So I’ve changed again now how I’m exercising, but it was a really great introduction to me in terms of finding a movement I could love.
Chris Sandel: Yeah, and proving to yourself or discovering for the first time, “I can do movement in a way that I enjoy, that is not attached to changing the aesthetic of my body.”
Nicola Salmon: The weight lifting and that aspect of it, I was really good at it, and I have never been in a place before where I was better than other people in terms of – I was always the last one to be picked for a team or I was always the slowest in cross-country, so to be good at something felt really revolutionary. It felt amazing.
Chris Sandel: Yeah. That’s also what I see as a problem as well. Looking at you, I’m not going to guess you’re going to be good at long distance running, and you could love long distance running. But your body is not built for long distance running probably in the way that my body is.
But if I’d gone to school and the things that we did were all around power lifting, I would’ve been the last person in the class that was picked, and I would’ve had this terrible relationship with food. It’s just we have this very narrow definition of what it means to exercise or what a body should look like with exercising, and it impacts on the kinds of exercises that kids do or that we value as a society. But the fact that you’re saying you got into lifting heavy weights and you were very good at it, there’s no part of that that surprises me. I just wish you’d found that earlier.
Nicola Salmon: Yeah, me too. I think as well, going through this process, I’ve found actually I don’t have to be good at it to enjoy it as well, which is something I think we’re always taught early on at school. The people who are picked for the teams are the ones that are really good at it, and if you’re not good at it, then maybe you won’t enjoy it as much because you’re not picked.
Recently I’ve just started outdoor swimming, and you know what? I’m not the fastest, I’m not great, but I love it so much. It’s really just shifted my perspective in terms of finding things that I am capable of and that I love. It doesn’t matter whether I’m the fastest or the slowest. It’s just about finding those things that bring you joy.
Chris Sandel: Totally, and being out in nature. There’s an outdoor swimming place I found about 20 minutes from here that looks just phenomenal, but since COVID’s hit, they won’t allow new members. So if you’re a preexisting member, you can go; otherwise, it’s all on hold. I’m just waiting. I don’t know how long we’re going to have to wait till they lift that ban, but I want to get back into doing something like that. Because it’s just stunning to be moving your body in nature while looking around at trees and hills and all of that. That is how I want to be spending some of my time.
Nicola Salmon: Absolutely. There’s a really good group called the Surrey Outdoor Swimmers. You should come and join it. It’s a Facebook group. It’s free swimming, so we’re swimming in the Thames and we’re swimming in the Riverway. You don’t have to be waiting for them to open up. It seems like over COVID, everybody started to get out and find all these different things to try, which is really good fun.
Chris Sandel: Nice. I will check that out once we get off this call.
00:57:39
The other bit you talked about there in terms of the research was the BMI cutoff with fertility or with IVF on the NHS being 30. Is there any research to point towards that part of it in terms of there is something that starts to go wrong when you’re above 30, but below 30 everything’s good?
Nicola Salmon: No, it’s an arbitrary number. [laughs] It’s a nice-sounding number, right? We know that BMI is absolute rubbish anyway. It’s just a completely arbitrary number, and that’s what makes it so frustrating. And for many of the different areas where they’re enforcing this, there’s no wiggle room.
Especially at the moment, when people are at home. Maybe they’ve not got access to exercise in the same way. Maybe they’re using food as a source of stress support. And there’s no wiggle room. If you’re 30.01, “Sorry, come back when you’ve lost X amount of pounds.” It’s infuriating, and it’s infuriating that they exist at all because people should be able to access this kind of healthcare.
One of my favourite people who I follow on Instagram, someone called Jess – she’s @haes_studentdoctor – she shows these two graphs. One was a graph of the research that they have around weight and IVF, and we can talk a little bit about how that’s flawed anyway, but it shows this slow decline in terms of as your BMI increases, the way IVF works for you also decreases. Then she compares that with a – it looked at people’s age as it increases and how IVF declines in terms of how well it works for age.
Just comparing those two graphs, it blew my mind in terms of we let people access fertility treatment up to the age of 40, sometimes 42 in the UK in terms of what they can access on the NHS. If you were to use the same cutoff for the BMI, as in if we decided that this number – I can’t remember what the number is, but if we said that anybody over this percentage of it not working, which is the one for BMI of 30, then I think the number in terms of age would be 37. We wouldn’t treat anybody over the age of 37 if this is the number we decide we’re not going to let people treat over.
Just the differences in the way they’re talked about and the way they’re treated is – it doesn’t make any sense. The rules aren’t consistently applied to everybody.
Chris Sandel: Yeah. Something you said earlier in terms of when someone in a larger body walks into the doctor’s office, there’s no conversation around anything except “lose weight” – I can’t get my head around how restricting is a good thing to do prior to trying to get pregnant. Getting pregnant and then the pregnancy and the breastfeeding is such an energy-demanding task that is being placed upon the body, so to go into that from a place of restriction doesn’t make sense to me.
And also, I can’t see how someone’s ability to ovulate properly and conceive is going to be increased if restriction is the only thing on the menu. As you said before, if it does then lead to other changes, whether it be sleep or more vegetables or whatever, then fine. But out and out restriction does not sound like a recipe for increasing fertility.
Nicola Salmon: Absolutely not. The stress these people are put under in terms of the pressure to lose this weight and the stress they have when they’re going to see their healthcare professionals – all this is absolutely not necessary. This is unnecessary stress that these people are having to put themselves through in order to jump through this hoop that we have of them being able to access fertility treatment.
And unfortunately, this hoop still exists for the majority of private clinics as well. Even if they have the ability to try and access this fertility treatment through other means, if they have the financial capacity, they’re then not even able to access it majority through a lot of the private clinics because they do have BMI barriers as well. There’s maybe a handful of clinics in the UK that will support people in bigger bodies or there’s no BMI barrier in place, but they’re very few and far between.
Chris Sandel: In the same way as you billing yourself as fat fertility, are there any IVF clinics specializsing in that, and that is their branding and that’s who they want to be seeking out and helping?
Nicola Salmon: There’s no clinic actively supporting and promoting that kind of service, unfortunately. Again, I think that is mainly due to the majority of healthcare professionals would see that as not a great strategy because of the way they view fat bodies. But there is a clinic in Surrey called New Life that is really supportive in terms of the way they support people with bigger bodies. They have no BMI barrier, they don’t talk about weight loss, they don’t talk about diet. So they’re very supportive.
But they don’t actively go out and promote just for bigger bodies, which is a shame. But they’re really supportive and I definitely recommend them. I’ve had a lot of people go through them and travel from all over the UK to see them just because they’re the only clinic I know that I can wholeheartedly recommend because I know they’re not going to have any kind of “Well, if you just go away and lose weight” conversation.
01:03:50
Chris Sandel: Definitely. What about in terms of pregnancy risk? Obviously, going to the doctor’s office, they’re telling you to lose weight, or when you are pregnant there’s things that you are or aren’t allowed to do, but what are the risks that you can actually find as legitimate – and I don’t know if there is any – of being in a larger body with pregnancy?
Nicola Salmon: There’s several nuances around this topic. The first is the fact that the research is really mixed. There’s almost three main areas where this risk is seen as a problem, and they are around pregnancy loss – which they believe is higher in people with a higher BMI – gestational diabetes, and preeclampsia.
The problem when you start to delve into the research is that it is really mixed. When I looked into pregnancy loss, I found there was about 50% of the studies that didn’t show any correlation. So they looked at BMI, they looked at pregnancy loss, and they saw there was absolutely no relationship between them.
Then there was around 20% of the studies that showed there was a correlation, so they saw a pattern, but it wasn’t statistically significant, which means that there wasn’t enough data there to say “We believe this is a real correlation.” And then the other 30% found that there was this link.
So just by looking at the papers, we can see this isn’t clear-cut. This isn’t a black and white, for sure, “everybody with a higher BMI has a higher risk of getting this particular condition.”
Then when you start to look at the actual risk – I can give you some numbers. For somebody with a BMI of between 19 and 25, which is a ‘normal’ BMI, their percentage of having an early miscarriage is around 10.5%. That is just where we see early pregnancy loss happening. Then once you get above 30, where people are labeled as high-risk, labeled as having a high BMI, the risk increases to 12.5%. It’s an increase that we see, but it’s a 2% increase. It goes from 10.5% to 12.5% – which, if you ask anybody who wants to get pregnant in a bigger body if they would accept that increase of risk, I can guarantee you most of them will say “Yes, absolutely. That is an increased risk, but it’s a small risk and something I’m happy to take on as a risk.”
If we were to look at something like gestational diabetes, for a body mass of between 18 to 25, the risk of that is around 2.3%. Then if you jump to above 35 on BMI, that jumps to 11.5%. It’s a slightly higher increase, from 2.3% to 11.5%, but the way that risk is being conveyed to people is that you are five times more likely to get gestational diabetes. When you say it like that, it automatically sounds like a really big, scary risk. “You are five times more likely to get gestational diabetes, so I want you to go away and lose weight because otherwise it’s just not healthy for you and your child.”
That sounds scary, and that is often how these risks are given to people by their healthcare professionals, by the media, by everybody around them. They are told that they are so much more likely to get this condition. It’s almost like they’re setting them up like you’re almost guaranteed. They go away believing this is going to happen to them, in the same way I believed everything bad was going to happen to me during my first pregnancy.
But when we look at the percentages, we see it’s 2.3% to 11.5%. A big jump, but still, 88% or whatever percent, nearly 90% of people who have a higher BMI will still not get gestational diabetes. And if you were to give them the risk like that – I firmly believe in informed consent; I think if people were aware of what the actual risks were, they would still be happy to consent to them.
We know that people in smaller bodies get gestational diabetes. We know that we can manage it and take care of it and look after people, and we know there’s a really high genetic component to diabetes and insulin resistance. So the fact that people are using these numbers to deny people healthcare is really, really poor healthcare and really not an ethical way to treat people.
Chris Sandel: On the gestational diabetes, there are two things that come to mind. One, if people already have PCOS and they’re in a larger body, does that make it more likely that they’re going to get gestational diabetes? And if that is the case, that’s kind of like a preexisting condition that’s going to fudge the numbers up a little bit.
Nicola Salmon: Absolutely. If you’ve got insulin resistance already – and we know that the majority of people have insulin resistance when they’re diagnosed with PCOS – then it absolutely will fudge the numbers, like you say. I don’t think, in a lot of research, that’s taken into account.
Chris Sandel: The other one I was going to say on this as well – and I was trying to find this all morning to work out where I had read this. I thought it was in Robert Sapolsky’s Behave book, which is like 700 pages, so I was trying to look through that. But there was something I read that blood glucose during pregnancy is actually affected a lot by the genetics of the sperm, and how that has then affected the growing foetus, and that will dictate whether there’s going to be more glucose staying in the blood and staying with the mother or more of the glucose going to the child.
I’ve read that somewhere; I couldn’t find a reference, I couldn’t find the paper connected to that. But is that something you’ve heard before?
Nicola Salmon: I have not heard that before, but that sounds really fascinating. It’s definitely something I’ll have to go and look for as well. There are so many variables that we’re not aware of in terms of our health, in terms of pregnancy. There’s so many parts of pregnancy which we still don’t understand. We don’t know what makes labor happen. We can’t predict when people are going to give birth because we still don’t know the full mechanism behind that.
I think because there are so many unknowns in terms of PCOS, in terms of insulin resistance, pregnancy, healthcare, how can we decide and dictate that these people aren’t worthy of treating and being helped purely because of these increased risks? It makes absolutely no sense to me.
Chris Sandel: Yeah. Then the third one was preeclampsia. Sorry, I cut you off before you got to explain that.
Nicola Salmon: Again, that’s a similar ratio. It starts at about 3.3% and goes up to about 10.9% in terms of body mass index. But the other nuance around this is the fact that people in bigger bodies experience weight stigma. They experience this idea that we get delayed treatment and tests. We don’t get listened to in the same way when we see healthcare professionals. Our appointments are often shorter when we go and see the midwife. Our concerns won’t be listened to in the same way people in smaller bodies would be.
All of those things, we know, contribute to increased risk. The research around weight stigma is growing, and we’ve seen it in all areas of healthcare where the increased risks for people in bigger bodies are actually due to this idea of weight stigma and weigh cycling rather than any physiological reason caused by the extra fat on our bodies. So I believe a huge portion of these risks are actually around this idea of weight stigma and not being cared for in the same way as our smaller counterparts.
Chris Sandel: Definitely. The psychological stress that is causing, and even the physiological stress if someone is in that scenario and is trying to restrict what they’re eating and the knock-on effect that’s going to have on someone’s physiology.
Nicola Salmon: Mm-hm. It’s not as simple as just a fat person’s going to have a higher risk of getting this, right? [laughs]
Chris Sandel: No, there are many variables that need to be teased out.
01:12:58
What about, then, treatment efficacy?
Nicola Salmon: Yeah. Another reason why people are often denied IVF and why it’s used as a barrier, I think, in the NHS is around this efficacy and the cost. Obviously, when we have a free healthcare system like we do in the UK, you want to make sure that you’re getting your most bang for your buck. You want to make sure that the people who are going to benefit the most from it and are going to have the highest success rates are the ones that access the care.
A lot of the research that is based on is really flawed in terms of the fact that a lot of healthcare professionals believe that IVF doesn’t work as well in bigger bodies. There are kind of two camps in terms of the research. There is a whole host of research that shows actually IVF is as effective for people in all BMIs, and that’s great. It’s something I’ve put together for a lot of people to be able to show their healthcare professionals and say, “Look, IVF does work on people of all sizes. There’s no reason why you should be denying me IVF.”
Then there’s another host of research papers that show that IVF is less effective and other drugs are less effective, such as clomid and letrozole, which are used to induce ovulation, are less effective for people with these BMIs.
What we know from other areas of healthcare – specifically something which is called Plan B in the U.S., which is the morning after pill – actually, that doesn’t work for people over a certain weight limit. We know in some circumstances when it comes to hormones, when it comes to fertility, that sometimes people in bigger bodies may need a higher dose to have an effective treatment.
What we’re finding in the studies around IVF is that in the studies where they’re looking at BMI and it shows that there is a really negative outcome in terms of it’s not as effective for people with a bigger BMI, but everyone’s been given the same dose. So no matter what your body size is, you’re given exactly the same drug protocol. Which makes sense I guess if you want to keep everything consistent in terms of uniformity for your study, but what that means is that people who have a bigger body aren’t given enough dose for them to have the same response to those medications.
So it’s meaning that a lot of their cycles are being cancelled during these studies, and it means that they are getting fewer eggs when they are going through IVF. Basically, they’re having poorer treatment outcomes because they are not given enough dose for their body. So when they’re doing this protocol where everybody’s on the same amount of drugs, they’re showing that IVF is less effective for people in bigger BMIs.
But the research that shows that it works for everybody, what they’re doing there is maybe using the second or third round of IVF for these people, and they’re then tailoring the doses, so they’re giving them more dose because they maybe haven’t responded well in the first cycle. So they’re getting the dose they need for their body, and therefore they are getting equivalent outcomes as people in smaller bodies because they’re finally being given the dose they need for their body.
Chris Sandel: Wow. Have you had clients who have then taken that information with them so the first time, or maybe the second round if they don’t believe them, but it’s meant that they’ve got there quicker because there’s some research they can point towards to say “Hey, I think you need to up my dosage to start with”?
Nicola Salmon: I’ve only just been collating this research, so I haven’t had any clients going through this just yet, but I have with the clomid in terms of ovulation induction. A lot of the research around that showed that actually you should be starting on 100 with the clomid and going up to like 250 in terms of a standard dose for somebody with a higher BMI. Normally they’re started on 50 in terms of clomid.
So I’ve had people who’ve started their clomid cycles on a higher dose and got pregnant the first time because they’ve started on the higher dose. Other people I know who started on 50 and then have gone through several cycles of that and then had it increased. It’s just a long drawn out process – which, again, is more stress for these people who just want to get pregnant. Really, having the higher dose doesn’t have any negative impact. So it makes complete sense to start at the higher dose when the research supports the fact that this works better for people with a bigger BMI.
Chris Sandel: Yeah. More broadly on that, when you’re working with clients, is there a lot of chat around setting boundaries at the doctor’s office, or “This is the way you should be approaching this thing because I think you’re going to get the best outcome if you do it in this way”?
Nicola Salmon: Absolutely. One of the main things we focus on is advocacy and boundary setting so that we can reduce the weight stigma they’re facing in their healthcare appointments. Arming them with these tools, with the research, we’ve been able to change clinics’ minds in terms of them declining treatment versus supporting treatment.
It goes a long way when you’ve got this knowledge, but it is such an exhausting process to have to go through in terms of finding this information, collecting this information, sharing this information. It just is not something that these people should have to go through. They’re already in the most vulnerable time in their lives, the most stressful time in their lives. For them to have to do all this extra work is just not acceptable.
Chris Sandel: Totally. Also, on the NHS, it can take so long to get the appointment, so you’re like, “I’ve waited 4 months to get this appointment and now, do I want to speak up or do I want this to just go smoothly?” I think there’s probably those concerns as well.
Nicola Salmon: Absolutely. We haven’t had as much luck with people being able to access things on the NHS, but I’m really hopeful that’s something that will change in the future in terms of completely getting rid of this BMI barrier because it’s just so unethical.
01:19:18
Chris Sandel: You’d said earlier on about doing fertility coaching. You did the Integrative Fertility Coach Training. What are some of the things you got out of that that you use really regularly with clients?
Nicola Salmon: The main thing I took away from that was the skills that I use now to be able to coach people and to talk to people around how they can support their wellbeing in a way that feels easy and feels helpful and feels useful rather than this normal idea we have of goal setting that just involves us finding this goal that we really want to get to, like weight loss, like getting pregnant, and just putting our heads down and doing everything we can in order to get there.
I have a much more gentle approach in terms of setting goals that are really helpful. Maybe you want to get more energy or feel a bit stronger or get more sleep or all these things that are really achievable, and then breaking it down into really small steps that people can realistically achieve in a week. Because we’ve all got so much going on, especially right now with so many of the factors we’ve got in our heads. Just being able to reach those small goals every week is really good in terms of our mental health, to feel that we’re achieving something.
But those small things really build up and can create a big change. We’re just not used to seeing goals set like that. We’re so used to seeing our goal be like “I must lose three stones. I’ve got to keep plugging away towards that.” Having a goal of getting pregnant is amazing, but we have no way of knowing how far or close we are to that goal. There’s no way of ever assessing “you’re three-quarters of the way to getting pregnant.” It’s nice to have that and hold that as a vision, but working with goals I feel is much more helpful to be lighter and to pick things that are going to have a really positive impact in your life that you can work towards and achieve.
Chris Sandel: Totally. In a sense, the goal of getting pregnant you don’t have control around, but there are other things you can do that maybe make it more likely that that outcome is going to occur. I’m completely on board with you around goal-setting. This is something I’ve really focused on over the last handful of years, 5-6 years, for how to be a better coach.
Really, I’ve changed my approach with this with clients. It’s like, let’s set the bar stupidly low. What makes it feel like when we chat in two weeks, you’ll have been able to do this really easily? Let’s make that the goal. The reason is (A) as you said, it’s motivating, it keeps momentum. It feels good that you’re meeting that goal. But (B) you’re not going to change everything in two weeks. The idea is, how do you do things that become sustainable, that you’re able to keep up, that then become the new norm?
Making small changes that build momentum is the way to do that. Some moonshot type thing can feel motivating on Day 1, but motivation is something that really waxes and wanes. You don’t want to be having to rely on motivation, day in and day out, to achieve anything. You want to set it up so the right choice becomes the easiest choice and you’re doing things almost on autopilot because it feels like “this is just what I do.”
I think that’s definitely the way I approach goals. There will be exceptions to that where, especially with the clients I work with, they’re having to challenge things with their food and having to challenge things with their exercise, but even there, it’s like, what feels challenging but is also doable? I’m completely on board with that as an approach because I think otherwise, it feels sexy and it feels like “we’re going to do big things here,” and normally none of that comes to fruition.
Nicola Salmon: Absolutely. Physiologically, we’re not set up to do that. Our old, ancient brain at the back, the lizard brain, it doesn’t like change. It likes things to stay safe and everything to stay the same because we’ve managed to stay alive while everything has been exactly like this. So whenever you introduce those big changes, your little lizard brain at the back is going, “No, no, this is dangerous! This is unsafe! We’ve got to go back to the old habits.”
It’s those tiny little things that just are pushing yourself a little bit that way, a little bit that way, that definitely make the hugest difference.
Chris Sandel: But I guess the problem with that is that’s not what people see online. They see the 12-week transformation and they see the person who’s like “I started from nothing and I’m earning six figures or seven figures in 8 months” or whatever. You become normalised to that’s what you should be doing if you’re setting a goal as opposed to “How can I be doing this slow and steady, because long term, my likelihood of success with this is going to be increased dramatically,” as opposed to the 0.01% of people who just fluke it and are able to do some transformational things in a very tiny amount of time.
Nicola Salmon: Yeah. Another big component of this in terms of fertility is for so many people, they put their whole life on hold in order to achieve this goal of getting pregnant. They’ll change so many things about their lifestyle. They won’t drink any alcohol, no coffee, they’ll cut out every social event because of the food choices they’ll be given, they’ll change careers because of the implication that has on their maternity leave. There’s so many things they put on hold in order to achieve this goal that by changing those goals around to be things that will be really supportive in their lives and will look after them, it can really help in terms of allowing them to keep on living their life while they’re waiting for this to happen.
01:25:43
Chris Sandel: Definitely. With your work, I know you have the Fat Positive Framework. I know there’s four parts to this, so let’s go through each of them. You can give a little bit of an overview to start with.
Nicola Salmon: A lot of them we’ve already touched on, but it’s based on 4 key principles.
The ‘F’ is for formulae. This is around what we’ve just been thinking about around goal setting without any kind of weight loss or dieting. It’s all around things that are going to be really supportive and affirming for your idea of health, because obviously for everybody, health looks different. We have a very ableist view of health in our culture in terms of what’s achievable for everybody. So it’s really important for me that that’s your version of health, and that’s what we’re aiming for: exactly what you want your health to look like.
The ‘A’ in Fat Positive stands for advocate. Again, we’ve already touched on this in terms of really learning the tools of how to advocate for yourself and for your body and for the choices that you want to make around your healthcare because we aren’t ever taught those skills to advocate. For people in bigger bodies, they’re really important skills for fertility and also through pregnancy and postpartum, and really for the rest of our lives while we live in a system that makes it more difficult for fat people to access things. So that’s a big part of my work as well: teaching people how to advocate for themselves.
The third one, ‘T’, is around trust. Again, we’ve touched on this briefly, but really looking at how we can recreate our relationships with our bodies and food where we’re able to trust that our body is capable of pregnancy, but also that we’re able to pick the foods that are going to be supportive for us and we can move our bodies in ways that feel good. It’s really just around getting back to when we were kids and we were able to run around in the playground and do things that felt good and eat foods that felt good, and really figuring out how we can trust our bodies.
Then the final part of it is around the Positive, creating that positive mindset. This talks again back to the beliefs that we’re told, but also that we internalise around whether our bodies are capable of getting pregnant, whether we’re capable of having a healthy pregnancy. Everybody around us – doctors, media, a lot of the messages we receive are around the fact that this isn’t possible for us. When you internalise that, that can impact the choices you make in your life and how you look after your body and how you treat yourself.
By redesigning those beliefs and really looking at what impact they’re having on the choices you’re making in your day to day life, we can really look at the motivations and reframe the way you see your body and the things you want to be telling yourself in your monkey mind of all those thoughts that are going round and round.
So it’s an all-encompassing, holistic model that really looks at lots of different factors. But I’ve found for people who are in bigger bodies, all of those components are really important in terms of supporting them to both feel well in themselves, but also to access healthcare and to go on to get pregnant and have a healthy pregnancy.
Chris Sandel: Nice. I know we’ve chatted about some of them already, but I’d love to focus a little bit more on the trust piece and then the positive mindset piece.
With the trust piece, is a lot of what you’re teaching built around Health at Every Size and Intuitive Eating? Or are there other components that have come in that have had a really big influence on you and how you think about this trust piece?
Nicola Salmon: A lot of it I’ve brought back from my own lived experience in terms of how I’ve been able to shift my own relationship with my body. That has been through the Health at Every Size model and Intuitive Eating, and also things around body image and almost how we treat our bodies in terms of how we see them.
An important piece for me was around clothing. It’s very difficult, often, to get clothes that feel good, that make you feel in your style as a person in a bigger body because access is a lot more difficult.
So it’s around really naming that it’s not that you’re too small for the clothes, but the clothes aren’t made for your body. It’s about shifting a lot of those beliefs and ideas that we have that our bodies are wrong or our bodies are broken and reclaiming the fact that actually, our bodies are just fine as they are, but we need to look at how we can navigate the world in these bodies in the best way that we’re able to.
Chris Sandel: Nice. In terms of the positive mindset, what have been the things that have most influenced you in this area?
Nicola Salmon: Again, this has been a lot of personal stuff, but also a lot around the Health at Every Size framework has really supported me in terms of looking at how health is viewed within our Western culture and how alternative frameworks for health can be really important in terms of our beliefs that we have.
Often one we’re set in a belief, we’ll use everything that fits with that belief to build a bank of evidence around it. If we believe that our body isn’t capable of getting pregnant, then we will find every newspaper article, every research paper, everything any doctor has ever told us to back up that belief as evidence.
What I’ve found helpful for people is that once we’re able to really investigate and explore what those beliefs are, then we can look and see if they’re helpful and whether they’re serving us on our path to getting pregnant. By using the research from Health at Every Size, by using the research in the way around fertility that I’ve been able to find, we’re able to back up these new beliefs in terms of “My body is capable of getting pregnant. IVF will work for me. I am totally worthy of becoming a parent.”
By being able to reframe those beliefs and then back those up with evidence from all aspects of this field, from all the things people have done before me, we’re able to really help people change that belief around.
It’s never instant; it always takes time because we’re entrenched in these beliefs, and those are what we’ve been using, and we’ve based so much upon those foundations. But by changing them and being able to consistently keep providing evidence and help people find that evidence to support the fact that your body is really capable of going for a run or walking up those stairs or doing something that maybe you’ve been told isn’t a possibility for you in your body, then people can begin to – it feeds back into the trust section.
They’ll be able to trust their body to do that. They’ll believe their body is able to do that, and they’ll be able to switch that inner monologue around of “I’ll never be able to do that and I’ll never get pregnant. The doctor’s just going to tell me I’ve got to lose more weight.” We always go down these negative spirals of thought. It’s about creating a more positive spiral of thought so people feel capable and supportive and have that resilience and that energy to sometimes have these difficult conversations they might need to have.
Chris Sandel: Yeah, definitely. I think having the difficult conversations or reading material around that can be really helpful. When I reflect on our journey, I think it was 2-3 years of us trying where we had a number of miscarriages, whether there was an ectopic pregnancy.
Yeah, it can be a long journey, and trying to deal with the heartache of that – and also, it’s a topic that a lot of times people aren’t talking about. It was really interesting when that did happen then hearing from other people that that happened to them, and I had no idea that that had happened beforehand. So I think there’s some of this that is a little bit taboo or people don’t talk about.
Nicola Salmon: Absolutely. In the fertility world in general, that really exists, and then it’s even more almost closeted for people in bigger bodies because of what people will say to them if they say they’re struggling to get pregnant. Because so often, even well-meaning people will be like, “Have you tried this diet? Have you tried this weight loss thing?” It’s such a difficult conversation for these people to have, and have more shame and more guilt on them because they feel responsible for the fact they haven’t got pregnant yet.
Fat people in bigger bodies are even less likely to have those conversations with people around them.
01:35:00
Chris Sandel: Are there specific resources you’re pointing people towards, or conversations you’re having around the piece of when it’s taking a really long time to get pregnant? In so many of the other examples you used in terms of someone not knowing they could do exercise and then they’re able to prove that to themselves, pregnancy is kind of that leap of faith where you just don’t know it’s going to happen until it finally does. And you’re then going to have to keep that positive mindset or that belief in mind for what can be a really long time.
So I’m just wondering how you deal with that psychology piece or if there’s specific resources around it.
Nicola Salmon: Yeah, absolutely. For the people I work with, we talk a lot about that resilience piece in terms of maintaining the idea that they are worthy of this treatment and support, if it’s taking a long time. Sometimes they’ll have to continue that advocacy work because if it’s taking a really long time, there may be something wrong. There may be something physiologically going on that can’t be fixed with exercise and vegetables and rest. Sometimes there are physiological things going on.
But the fact is that if people are in bigger bodies, often they won’t find out because they won’t get the tests and the treatments they need. So it’s about supporting them and pushing for that advocacy, supporting them in seeking better healthcare professionals if they’re in a position to do that, so that they do get the tests. And giving them the information about the tests maybe they do need so they can ask specifically for those.
Information is power. It’s just about empowering people with the knowledge so they know what to ask for and they have ideas and strategies of how to ask for that, so that they can keep pushing. I tell people to be difficult patients because sometimes that’s the only way they’re going to get the healthcare and the treatment they need.
Chris Sandel: Definitely. I remember when Ali was pregnant, the positive birth movement we found quite helpful. I don’t know if that’s something that you recommend, or maybe it’s not helpful for people in larger bodies. I maybe had some blinkers on then, so I don’t know if it’s universally helpful.
Nicola Salmon: It’s not something I know much about, but I love the name. [laughs] Hopefully it’s something that is going to be beneficial for people.
But again, it’s difficult sometimes to find resources for people in bigger bodies because so often, a lot of the resources – even the pregnancy books – you have to be so careful. I have to be really careful recommending pregnancy books for people because I need to make sure I’ve read them to make sure they don’t have any form of fatphobia or weight loss talk or diet talk in them. It is so surprising how many of those books do have that stuff in.
Even in my business books and self-development books I read, some of them I have to put down for a bit because they then go and talk about their latest weight loss strategy or how they’re using weight loss as an example for this business thing. It’s everywhere, and it’s something I really want to protect my patients and my audience from.
Chris Sandel: Definitely. What are your favourite pregnancy books or conception books, or just in this realm, are there go-to’s that get recommended really regularly?
Nicola Salmon: There wasn’t a fertility book. I wrote one. [laughs]
Chris Sandel: Sure. [laughs]
Nicola Salmon: I’ve written a book called Fat and Fertile, which is the only fertility book I know of that is supportive in that way.
There’s not a book, but an online guide that somebody called Jen wrote. She’s Instagram handle @plusmommy. She’s an American who’s done a lot of advocacy work around birth for people in bigger bodies and pregnancy, and she’s written a really great pregnancy guide, which is on her website, which I think is plusmommy.com. That’s really helpful in terms of being able to access resources, and she has a guide where you can look for size-inclusive OBGYNs and things like that, which is really helpful.
Chris Sandel: We’ve had her on the podcast before. I think Lu interviewed her at some point, so I can link to that episode in the show notes.
Nicola Salmon: Brilliant. She’s wonderful. She’s been doing this work for a lot longer than I have and been plugging away at advocating for people and supporting people in bigger bodies.
Chris Sandel: Nice. Is there anything else that we didn’t go through that you wanted to chat about today?
Nicola Salmon: I don’t think so. I think we’ve covered a lot. [laughs]
Chris Sandel: Yeah, definitely. Where can people be going if they want to find out more information about you?
Nicola Salmon: The main place I’m most active is on Instagram. My handle is @fatpositivefertility. I share a whole mix of research things that I’ve found and personal stories and courses that I’m doing and all kinds of information on there. So that’s a really useful resource.
I also have a website, nicolasalmon.co.uk. I have a few blogs on there. I tend to blog infrequently, but when I blog it’s a long blog. I’ve got big posts about miscarriage, I’ve got a resource on there that helps people find clinics that might be able to support them in a bigger body. And I’ve got my book, Fat and Fertile, which is a great introduction to this work and a great introduction to the ideas we shared around the framework. So that’s a good place to start as well.
Chris Sandel: Perfect. I’m going to put everything in the show notes. Thank you so much for coming on the show. I loved chatting with you. I love what you’re doing and the research you’re doing in this area. It was great to be able to share this with everyone.
Nicola Salmon: Thank you so much for having me, Chris. This has been brilliant.
Chris Sandel: That was my conversation with Nicola Salmon. I’m glad that there is someone like Nicola out in the world doing this work. If you’re trying to get pregnant, and especially if you’re doing this in a larger body, then I really recommend checking out her work.
01:41:12
I wanted to give a recommendation for something to check out. I was doing this for a while, and then I haven’t done it for quite a few episodes. The truth is, work has really taken over the last couple of months. When I haven’t been working, I haven’t been sitting down and watching TV or movies or series. I haven’t really been reading much outside prepping for the podcast or for client work.
It really does feel like a long time ago that I was watching Tiger King or The Last Dance or making my way through Community. I simply haven’t made any recommendations because I haven’t really had much to make in this realm.
But last week, I listened to Episode 464 of Tim Ferriss’ show – which isn’t something I’ve done for a while. Many years ago, it was Tim who really got me into podcasts and listening to podcasts, and I loved hearing his interviews with celebrities. It was the first show I had found that was doing this.
But with time, I found his interviewing style started to frustrate me a little bit, and I found other people that I preferred listening to. So now I only very occasionally listen to his episodes, and it’s normally if there’s a guest that I’m really interested in.
But why the recent episode grabbed me was I saw it come through my emails, and it wasn’t because of a particular guest, but rather, it was about Tim opening up about childhood sexual abuse. This episode is Tim talking about his journey over the last 5 to 6 years to deal with this trauma and the various things he has used as part of this.
The episode is actually Tim chatting with Debbie Millman, and she is a writer, a designer, an educator, an artist, a brand consultant, and she hosts a podcast called Design Matters. She has been a guest on Tim’s podcast before, and she shares her story of abuse as well and the therapy she’d been undertaking for the past three decades as part of this.
There are a number of things I really liked about this episode. The first and the most important is that this is not a subject that is talked very much about. There is a huge amount of shame around it, so it keeps being hidden away. Tim has a huge platform, and for someone to be speaking about this issue and doing it in the way that he does, I’m really hoping this starts to make a dent and leads to a bit of a sea change.
What I also liked about the episode was the different approaches they’ve both taken as part of their healing. Tim has been much more drawn to the nonverbal therapies and psychedelics, and this explains why he’s got so involved in promoting this research and donating large sums of money to places like Johns Hopkins, while Debbie has taken a more talk therapy or traditional approach. She’s been consistently doing therapy every week, multiple times a week, for decades.
In the episode, they make reference to many books and documentaries and modalities that are helpful, and the show notes for this episode on Tim’s blog are such a great resource, with so many different things.
I do think this is a hugely consequential episode and one that I’ve already recommended to many friends and to clients. Obviously, this is very heavy stuff, but both Tim and Debbie do a phenomenal job and are really compassionate and empathetic. I really highly recommend checking it out because based on the statistics, there are going to be many people in your life where something like this occurred. So hearing about this I think is really important.
That is it for this week’s show. As I said at the top, Seven Health is taking on clients for the final time this year, and we have just two spots left at the time of recording this.
If you are struggling with infertility or conception or hormonal issues related to your cycle or reproduction or are dealing with disordered eating or an eating disorder or being stuck in quasi-recovery or wanting to get over dieting or really any of the other topics that I regularly cover on this show, I’d love to be of service. Head over to seven-health.com/help. You can find more information there.
That is it for this week’s show. I will catch you next week. Take care of yourself, and I will see you then.
Thanks so much for joining this week. Have some feedback you’d like to share? Leave a note in the comment section below!
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