Jono: Welcome back to the Bite Me Nutrition Podcast. Today, round two of chatting to Stef. Unfortunately, you guys don't get to hear round one. I'm sure round two will be even better anyway. But yes, she has graciously given me double the amount of time because the first time we recorded this, IT and technology got in the way. So I won't talk too much. Stef, tell me who you are, what do you do, and why do you do it?

Stefanie Valakas: Awesome. Thanks for having me back again, Jono, and listening to my voice for twice as long. My name is Stefanie Valakas and I'm an accredited practising dietitian and nutritionist. And I'm also the founder of The Dietologist, which is a virtual dietetics practice dedicated to all things, reproductive health, fertility and pregnancy and nutrition. And yeah, myself and my team, Kaylee and Candice, we all have additional certifications in fertility and pregnancy.

Jono: Thanks for coming back.

Stefanie Valakas: We've been going for about five years now and we've helped about close to 2000 people online and several hundred pregnancies later. So yeah, it's crazy to think that what started out as a little bit of a pipe dream for me as being a fairly newly graduated dietitian, seeing a pretty big gap in the dietitian world for fertility and reproductive health specific nutrition.

 Jono : Yeah, amazing.

Stefanie Valakas: and being motivated by clients, I guess some of my nerdiness in understanding things like Barker's hypothesis and the developmental origins of health and understanding that preconception health was really pivotal in changing the health of the next generation without actually intervening at the child level, which is what I thought was preventative health was pediatrics, which is where I started my career. And also I think inspired by my own health journey and I knew something at that time was wrong with my own reproductive health, but was yet to really have it properly sorted out or properly diagnosed or investigated. And it was actually through my work that I learned that I too have endometriosis, much like many of my clients and that one in seven Australian women is the latest stat, which just keeps that bottom number just keeps getting smaller and smaller, which.

Jono: That's wild.

Stefanie Valakas: doesn't surprise me in the slightest, but often surprises many other people. And what is probably most surprising of all is the lack of attention funding and research that it gets as a result of, despite how many people have endometriosis. And so, yeah, that was kind of what fueled me to start the diatologist. And I think what keeps me going is really being able to impact more people and in a deeper way, and being able to

Jono : Yeah

Stefanie Valakas: hold their hands from that trying to conceive phase into pregnancy and often into growing their family into second and third children and being a really special part of their family growing story. It's such an honor and there's nothing better than getting a picture of a cute baby on a dreary Monday of too many emails to kind of keep you going. So yeah, that really does keep us going here at The Dietologist for sure.

Jono : Yeah, that's awesome. That's good. I'm glad too many emails is not a problem unique to I don't think it's unique to anyone really is it? Yeah, that's for now. I should have checked this before recording so I could be completely wrong. I feel like I remember us talking about the name diet like you saying like, I think I'm going to call it the dietologist. What do you think like way back? I'm pretty sure we were still chatting around like you were talking about. Yeah, moving into the space.

Stefanie Valakas : No.

Stefanie Valakas : Oh my god, did I really?

Jono: Like the name I'm gonna I'll find a screenshot. I think I'll have a lot of scrolling to do now Instagram combo But yeah, either that or I've just had a weird Alright stay tuned everybody, but anyway One in seven Wow. Well, look I'll already is it too early to start talking about another podcast episode cuz uh No

Stefanie Valakas: Oh my God. We will. There's a good search function now. We should use that.

Stefanie Valakas: Okay. Let's see how this one goes first, alright?

Jono: not re-recording this one for a third time. Yeah, well today, we definitely wanted to focus on the reproductive infertility health. That's an area that you guys have always been, I think it's probably once a quick Q&A, so most weekends I'll tag you, or maybe every second week in like a, I don't know, ask them, because you're definitely my favorite resource for the, especially the really complex, like you've talked about with the,

Stefanie Valakas: Hehehe

Jono: fertility treatments and people with a more complex kind of case. Yeah, it's, it's phenomenal. So I'm very excited to selfishly just pick your brain a bit today. So the first I wanted to, let's, I guess, step back as far as we can. If someone is wanting to do something to support their fertility from a diet perspective, firstly, should they bother? That's a loaded question, obviously. But secondly, when should they be considering?

Stefanie Valakas: Mm.

Stefanie Valakas: Hehehe

 Jono: when should I be starting to look into this stuff?

Stefanie Valakas: Yeah, I think we'll start with when and then we'll go with why they should go like, because it's probably the shorter and the longer answer and I won't get sidetracked. So when you should start to think about trying to conceive and nutrition supporting around trying to conceive would be for a healthy couple who don't have any medical history that could potentially affect their fertility about three to six months prior to actively starting to try to conceive. And for couples that maybe have some kind of health history, either partner, perhaps some PCOS, some endometriosis, perhaps you'd like to lose or gain some weight, perhaps you have a history of an eating disorder and you know, you're not at the ideal kind of body weight yet for ovulation or you've lost your cycle or for men, we see a lot of men who've had past histories of cancer treatments, for example or a whole range of different health concerns, insulin resistance and diabetes, celiac disease, so on and so forth. So if you have a condition that may affect your reproductive health, then I would start to think about it up to about a year in advance because that gives you enough time to kind of self-correct any nutrient issues, troubleshoot things without being in such a rush, which is far less stressful for you but also for us as the practitioner. We don't have that time pressure. That's probably...

Jono: Hahaha

Stefanie Valakas: one of the hardest things about being a fertility dietician is you are constantly up against the clock and you can't make nutrition work any faster for people. And so the greatest gift you can give us is time. And so if you know that there may be even, you know, a slight issue potentially that may come into play, get it checked out sooner rather than later. We prefer to see you heaps in advance than the other way around. And for otherwise, you know... I have no medical history. I go to the GP when I need to get a medical certificate for the fluid work. You're that kind of person. I don't know who you are because I rarely meet these people, but if that's you and your partner, then probably three or six months is enough. Now, why you should care in terms of fertility, there are two groups of things that we need to think about. There are. Modifiable things that you can be doing for your fertility health and your preconception health overall, and there's non-modifiable things. The non-modifiable things is what makes the news headlines. People are getting older, age. The older we get, the less fertile we become. It's a pretty steady, you know, downward line on that front, sadly. I can't reverse age you. Me don't have time machine to take your eggs or your sperm back. I'm so sorry. I know, talk to...

Jono: What? What are we even doing here?

Stefanie Valakas: I know, I know I should be building this time machine instead of doing what I do online.

Jono: Just fast. I'm pretty sure I read that fasting rolls back your biological clock, right? So just, just fast and you'll be fine.

Stefanie Valakas: Fast forever and then you'll get no ovulation at all. So age is one of those factors, your DNA, your genetics, your family history. For a lot of people, your medical history is not modifiable. Nobody can come in and wait their magic one and correct those factors and undeniably those factors do affect your fertility. On the flip side though, there are a whole host of modifiable factors. One of them is your diet, another is your lifestyle, sleep, exercise, etc. Another is your pollutants or endocrine disrupting chemicals that can influence how hormones function, both females and males, alcohol, smoking, drug use, those things are modifiable. And so I guess the question then becomes how much are you going to focus on the things that you can't change and obsess about those, or how much can we then actually shift that energy and focus it into the modifiable in a healthy, productive way, not in an obsessive, micromanaging kind of way? And I think that is really ultimately what it boils down to for most people. Now, of course, there's science to support that optimize you preconception. Health is future parents can program the way that your child's DNA is expressed, not the DNA itself, but the way that the genes are expressed, which is called epigenetics and reduce your child's risk of allergies, eczema, diabetes, heart disease, obesity, all those things. It can change the way that the risk of your pregnancy. In terms of pregnancy complications, we can reduce the risks of things like gestational diabetes and preeclampsia. We can help set you up with healthy habits to then role model those healthy habits as a new parent once you do have a toddler who's eating with you. And all those kinds of things are undeniably true. And then independently, if you do have a fertility concern, then we do know that just five simple dietary changes can enhance your fertility by about 69%. In ovulating people and it goes up to about 80% in those who don't ovulate. So diet has a really big impact, more than what it probably gets credit for. But it's also a complex system where there's lots of different things happening simultaneously. So you can't just go, well, I've got a great diet, therefore I will get pregnant. It doesn't necessarily always work that way either. And so I think that's where people get a bit confused. It's like not overstating or understating the role of nutrition. It plays a role.

Stefanie Valakas: but it's not the only thing that plays a role and you can't be blinded to that. And I think a lot of people just get blinded to a particular factor. It's the same, like for example, for me, where I'll use myself as my own case study, I could get blinded to the fact when I go to try to concede that I have endometriosis and just forget that anything else could be going on. But my thyroid could be dysfunctional, my partner's sperm could be crap. Like there's lots of other things that could be happening. We don't wish for more than one factor, but it's important not to be blinded to those other factors as well and see the whole picture as clearly as we can from the jump. So that's the most long-winded answer to that question that I could possibly give you. I apologize.

Jono: No, there's nothing worse than one or two word answers or short answers. Give me the full picture. Especially like you said, for something that is so, so multifactorial, both like, you know, genetically, environmentally. In terms of, I don't even, we're not even gonna touch, so if anyone's thinking like, oh, I've got one of those complex medical conditions, good, you will find a link at the bottom of the show notes where you can book in to speak to.

Stefanie Valakas: Mm.

Jono: someone at the dietologist, but for people who maybe are just dipping their toe in the water, they want to kind of make a few basic changes to their nutrition. What are some, what are your top three? I hate those questions and I'm about to ask you one of those questions. Damn it. But like, I guess in your experience with, are there any that people, simple stuff that people miss that or

Stefanie Valakas: haha

Stefanie Valakas: What's the big picture stuff?

Stefanie Valakas: Yeah, absolutely, absolutely. So if I was to say the kind of hallmarks or let's go by food group because I think that's probably the easiest way to conceptualize. Things that you wanna upshift is definitely your fruits and vegetables. I mean, population-wide, we know we all need to be eating more fruits and vegetables at baseline. Not universally true in the cohort of people that I work with. Some people eat so many fruits and vegetables that they're crowding out.

Jono: Yeah.

Stefanie Valakas: you know, more energy dense things and that causes problems. But certainly for a great percentage of people, increasing fruits and vegetable intake is really important for a variety of reasons. Number one, they're independently linked with enhanced fertility outcomes, reduced rates of miscarriage being one reason. The next reason is because they'll also be one of your greatest sources of dietary antioxidants. And basically you wanna arm yourself with as much dietary antioxidants, both females and males, to help support those reproductive cells to be healthy. We're not going to be able to change the chromosomes, not going to be able to change the DNA that's within them, but we can protect the cell and we can also protect that DNA from any other damage that could occur in that final spring to conception. Now for men, you're lucky, you get a clean slate every 74 days or so, and you get to go again. So you get kind of clean slates, as long as you don't have any kind of long-term issue, like a structural issue, or you've had cancer treatments or something like that, usually get a clean slate to go again. Women, not so lucky. We carry all the eggs that we've got from the time that our moms were 20 weeks pregnant up until the day that they ovulate. So we have a lot more historical impact on our eggs, which means some of it's not in our control. Some of it's just inborn and some of it, we may have some control over in that final 90 to 120 day kind of sprint or runway up until about ovulation, which. The egg is going from a primordial follicle, which is an itty bitty can't see it in the ovary type of follicle into the dominant follicle, which is the one that's most likely to be ovulated. If you put an ultrasound wand, you would see it. And so that kind of final sprint of it becoming one of the largest single cells in the body is where it's most vulnerable to free radicals, inflammation, inflammatory proteins, cytokines and whatnot. So upshifting your focus on antioxidants from fruits, vegetables in season, colorful, also extra virgin olive oil. We know that is the highest antioxidant oil that we can kind of get and that we'll be able to maintain that with cooking temperatures and as well dried or fresh herbs and spices super underrated source of dietary antioxidants and they kind of make everything taste better so win-win-win.

Jono: Wins. Yeah.

Stefanie Valakas: Wins all round. So certainly those things are like universally kind of beneficial for everybody to be focusing on female, male, irrespective of fertility history, almost in all cases. The next thing would probably be seafood intake and specifically omega-3 rich seafood intake seems to be particularly pertinent. Seafood intake is one of the most strongly linked to reducing time to pregnancy in couples that consume seafood on average twice per week. So in one study, they looked at twice per week. And in the couples that I think that were under 35, 94% had conceived in 12 months and the normal statistic is 80%. So you actually get a pretty decent improvement in consuming seafood. And also I'm just been in the midst of preparing our research Monday little segments that we do on our Instagram. And I was just talking about this study which looked at omega-3. Fish oil supplementation specifically, and that improved fertility and time to pregnancy as well as IVF outcomes. So certainly omega-3s alone are beneficial. So our oily fish like salmon, ocean trout, mackerel, sardines, and anchovies, and certainly non-oily fish based seafood such as white flesh fish, prawns, shrimp, calamari, octopus, mussels, oysters, et cetera, are also beneficial. But you don't want to sacrifice the Omega-3 rich for the white based stuff. You kind of want to do an additive approach. If you don't like seafood, allergic to fish, you're vegetarian, you're vegan. Do not pass code. Do not collect $200. Just take an Omega-3 supplement. Don't mess around with chia seeds and walnuts and that this and that. It's not really going to do the job for you sadly. So I would say of the things to increase those things, certainly I think a few other things that really stand out are things like nuts and seeds. Which is hallmark feature of the Mediterranean diet, which is classically known for its fertility benefits. Just before we hit record, I was just mentioning to John a study that showed that people that complied more to a Mediterranean style diet by five points in terms of the scale had a 2.7 times higher chances of a live birth from IVF specifically. And that's in a cohort of people that have a known.

Stefanie Valakas : Issue with trying to conceive which affects about one in six to one in eight couples. So I think at baseline most people could benefit from adopting some of the principles of the Mediterranean diet. I think it also does have its flaws in the sense that we're probably not going to reach iron targets, we're probably not going to reach calcium targets, all those kinds of things like what do you do with people that can't tolerate high volumes of legumes for example, which is another hallmark feature of the Mediterranean diet. But I think nuts and seeds you know, a healthy handful kind of thing. We know that has a myriad of other health benefits and certainly will prioritize some of those key nutrients, healthy fats and zinc, especially, and Brazil nuts for selenium, which is really helpful for both male and female fertility as well. So just one or two of those. I would say that they're the main things you wanna upshift. The things that you wanna kind of reduce your focus on are foods high in saturated fats. So excess amounts of butter, coconut products, coconut oil, palm oil. Fatty cuts of meat, so choosing lean varieties where you can, chocolate pastries, cakes, ice cream, all the things that taste nice. Those things in terms of fertility, we have much higher saturated fat intake, we see much higher rates of inflammatory proteins around the eggs, and we don't really like that. So we wanna try and minimize those within that kind of less than 10% of our total caloric intake, kind of classical. Range that we talk about and certainly the same with trans fats. We want to keep those to an absolute minimum. So avoiding excessive amounts of deck fried foods, we don't have a huge trans fat problem here in Australia, thankfully. But things to keep in mind. So if you're like me a few years ago, where I had the world's longest craving for hot chips, but over time that ended up affecting me quite significantly with my endometriosis and inflammation. And so, If that's something that regularly features in your diet or you're somebody that cooks with a lot of butter or something like that, then that's something to keep in mind and kind of downshift from. The other things that people broadly will ask very straightforward pinpoint questions about, well, I call them my fertility FAQs and they are caffeine and alcohol. So caffeine, how much caffeine is okay and how much isn't. So caffeine.

Stefanie Valakas: There hasn't been very specific studies done on fertility, but there have been very, you know, good limitations and things set in place for pregnancy. And we transpose those to fertility, hoping that you'll become pregnant. So the max is about 200 milligrams per day. If you go a little bit over now and then, it's not a big deal. What would be the implications? We don't really know is actually the true answer to that. Maybe some altered estrogen metabolism. We don't really know. So same kind of goes for men. We say no more than two, 300 milligrams per day. Weirdly men that have a lot more caffeine are more likely to be fathers of twins. So I don't know, take about what you will. Don't know what's going on there. Swimming faster, I don't know. I don't know what's going on, but that was a funny association. Hit that pre-workout. No, I'm kidding. So caffeine is certainly one that people

Jono: So if you want twins, then... Alright, okay.

Stefanie Valakas: probably stress more about than what most people need to worry about. If you're having, you know, one to two cups of, you know, a single shot espresso worth of coffee a day, you're probably fine. If you're somebody that's drinking, you know, a few of those or four or five of those, or you're having that in a few cups of tea, often we have bigger problems because you're often not eating enough. Um, and you're using caffeine laden drinks to kind of replace food. So. that kind of naturally improves as you work on your diet and me telling you, you're having too much. So decaf is fine, you only get 1% of the caffeine. So that's an easy way that if you just want the flavor in the afternoon, for example, then you can switch that out. Alcohol, it's a very bias. The studies are a lot tighter on females than males. So only up to two standard drinks per week. or more for females seems to show some link with increased risks of miscarriage. And for men, sperm health doesn't seem to be impacted unless you are binge drinking, which keep in mind binge drinking is like, what is it? Three or more standard drinks in a drinking session. It's not that many or four. Yeah. It's not that much really, cause I mean, most premixed drinks are not one standard drink, if you think about it, most of them are close to like two. Um, so.

Jono: And through a four, four standards in a session. Yeah.

Stefanie Valakas: You know, binge drinking certainly is a problem for both sexes, but certainly more so for males, because you'll get this big suppression event on sperm. And also, overall, like habitual drinking, it's about 14 standard drinks per week. Once you go over that, you start to see negative effects. It's really interesting. I recently went to a conference that specifically looked at one man's sperm health over about two or three years. He gave samples like once a week on average, say. And he went from super sperm could be a donor to would need IVF in the, in the context of those years because of different things that were going on in his life. Sometimes he'd get really sick and a fever and it would completely obliterate his sperm. And then sometimes he would be going through a phase of binge drinking and partying a lot and his sperm would just completely drop down. And so habits and, and just because sperm is healthy once in one test doesn't mean you can assume it's going to stay the same because you do have that regeneration factor. So certainly keeping alcohol as close to zero as possible is the ideal and the government's recommendation and I've been part of the people that review the government campaigns for alcohol education is that we should be advocating for no alcohol if you are trying to conceive and certainly after you've ovulated as a female. If you are actively trying to conceive, you could potentially be pregnant. And so the follicular phase may be quote unquote, a safer time and the luteal phase is quote unquote, you know, a riskier time. And yeah, I think in an ideal world, we would completely abstain, but then you'll get people who've been trying to conceive for six years and what do you say to those people who want to go to a wedding and... have a champagne for their best friend, you know? So it's tricky. It's not as simple as don't drink alcohol and just suck it up because there is more to life than trying to conceive. And I do see particularly, and what I say to my clients when I have this conversation is obviously it's personalized, but I usually say the more, kind of the more factors that are stacked against you, fertility wise, the tighter you're gonna have to be about some of these things.

Jono: Yeah.

Stefanie Valakas: Like if you're 40 and you're trying to conceive and you've got this long history of reproductive health issues but you're going out and having six or seven drinks every weekend, that's probably a bigger thing that we need to deal with because we need to be more controlling the controllables in that versus someone who's 25 and has only been trying to conceive for two months and no health history and wants to have one drink on once a month. Like it's a very different thing that we need to factor in.

Jono: Yeah.

Stefanie Valakas: And so I don't mean that to sound ageist, but I mean in the sense that you kind of need to do your, your sums of like working out what, how much is, is it going to make a difference, how much is not going to make a difference? Is it stressing you out? Is it not stressing you out? All these different factors. And, and yeah, I think all those things come into play. So just to summarize my long winded thing, upshift things, fruit, veg, extra virgin olive oil, nuts and seeds.

Jono: Mm-hmm.

Stefanie Valakas: dried herbs and spices, fish and seafood, particularly your omega-3 rich, downshift things like saturated fats, trans fats, alcohol and moderate your caffeine intake. So if I was saying that's the overarching kind of things to think about, that would be some of the key points.

Jono: Yeah, awesome. Yeah, we already answered. And this is not a question that I had already flagged with Stef, by the way. So she didn't know it was coming about the seafood and then the, what do I do if I don't like seafood? So it's good to know that the Omega threes are the prime. I know there's like the zinc and iron, there's lots of other nutrients that you get, but if it's primarily the Omega threes, it's good to know that supplementation is still a good option. Yeah. And is that algae and fish oil? Like is there, it's probably not tons out there to be honest. Yeah.

Stefanie Valakas: Yeah.

Stefanie Valakas: Yeah.

Stefanie Valakas: effective. Yeah. The studies only looked at fish oil, but we do use algae. Yeah, we do use algae interchangeably in those who are allergic or vegan or whatever the situation is. Um, but we're, we're really fussy about the way that we do supplementation. I know Johnna knows this, but like, we really do try and think about three to four steps ahead. So we're not going to give you a stinky fish oil that makes you gag every morning. Because if you become pregnant, that is going to be horrific for you. So.

Jono: Yeah.

Jono: First trimester.

Stefanie Valakas: We do try and select things that are not only efficacious on a nutrient level, but actually going to be practical and will hopefully serve you well moving forward into pregnancy where omega-3s are considered quote unquote mandatory with the latest Cochrane review around preterm birth and preterm labor as well. So yeah, there's certainly, we think about a lot of those factors when it comes into how we design supplementation plans as well.

Jono: Yeah, yeah. Great segue. Let's go there. We could come back to other stuff later. Supplements. Especially around Fischl, like in terms of starting with Fischl and then moving to other supplements. Do you also have specific brand, and I'm not asking you to share them, but specific brands that you look at from a safety and, well, I guess efficacy, but mostly safety perspective as well.

Stefanie Valakas: Hahaha

Stefanie Valakas: Yeah, for sure. So with fish oil, the biggest qualm that people typically will have will be about mercury because we do recommend avoiding mercury rich fish species. So very large fish, shark, marlin, broadbill, orange ruffy, catfish, even barramundi is quote-unquote borderline moderate mercury content depending how big the barramundi is. So certainly mercury is not something we want to be concentrating into a supplement. The good news is Australia's got one of the most notoriously difficult supplement markets in terms of regulations and so mercury cutoffs are very tight particularly in anything that is marketed or can be marketed to people who are pregnant or breastfeeding or trying to conceive. So yeah, when we select brands and dosing and all those kinds of things, we do try and select ones that not only meet but actually exceed those standards and also use very small fish in the fish oil. So some of our favorite brands, they'll extract their fish oil from sardines or anchovies. So the smallest of the Omega-3 rich fish rather than things like salmon, which... baseline don't have a lot of mercury, but if you start concentrating things down into and really try and compacting it, that's where mercury accumulation becomes potentially an issue. So yeah, we do look for companies that have tested it, exceed the standards so that we've got like maximum kind of safety reassurance. And that's particularly important because yeah, mercury is a reproductive toxin, neurotoxin, not healthy for baby, not healthy for mom. So that's not something you want to mess around with, that's for sure.

Jono: What about Krilo in that scenario? Is that a suitable... Yeah.

Stefanie Valakas: Don't use it. I don't use it. And I don't know why I think it's just out of preference. Um, and I've never needed to, uh, but I would imagine it would be fine. Cause it's so small. We definitely do not use cod liver oil ever. Um, cause of the vitamin A content will over accumulate. Um, and in a formal life of mine, I used to, um, go to GP conferences and.

Jono: Yep. What's that?

Stefanie Valakas: educate them on a particular product and I would be at the stand and I heard a few too many GP stories about cold liver oil and hyper vitamin A levels as a result and I was like never, I would never touch that. I just, it's just like I know that's not evidence based but in your brain you're just like too scary. Vitamin A, pregnancy, no go. No need to.

Jono: flagged yeah

Jono: Mm. 

Jono: Totally. Yeah, well, that's the other thing I guess, right? It's not like you're playing a risk versus reward game because the reward is kind of similar to what you could get from, for sure. Or an algae or something, yeah. In terms of, this could be another whole podcast in and of itself, I guess, like other supplements. I guess the first question that I get asked a lot, do I even need to supplement? Like if I'm doing all those things you told me and I'm eating fatty fish.

Stefanie Valakas: Yeah, exactly right. Exactly right.

Stefanie Valakas: Yeah.

Stefanie Valakas: Hmm.

Jono: Can't I just get everything from food?

Stefanie Valakas: Yeah, it's a great question. Um, you know, I think most people are pretty surprised to find out, you know, if you run your food diary through a food analysis software, what gaps you're going to find. Yeah. And like, we're not immune to that as dieticians too. And it's really funny to put our own diets through. Um, and I would probably say the top nutrients that people think that they're fine, if I've never think about that. That they genuinely consistently aren't getting enough are probably iron, calcium and iodine. I'd probably say those micronutrients are the top three. Probably closely followed by some other kind of minerals like zinc or selenium or sometimes folate depending on their vegetable and fruit intake. But you don't need to do that to find out that you've got dietary gaps. You can talk to a dietician and they can usually spot it pretty quick. But that's not why you need a prenatal vitamin. It's not just to fill in those gaps. It's because you have a genuinely higher demand for key micronutrients like folic acid and iodine once you become pregnant. And if you come into pregnancy behind the eight pool on those things, there can be significant consequences to the baby. And so we don't roll that dice. And so that's ultimately what it is. And we do know that from implementing recommended, not mandatory, but implementing prenatal supplementation that we can reduce risks of things like neural tube defects, reduce risks of thyroid problems in mom, in baby, creatinism, lower IQ due to inadequate iodine, things like that. So certainly folic acid and iodine are in the RANS-COG, which is the Royal Australian New Zealand College of Ops and Guides by the NHMRC. So like everybody should be doing that at a minimum. Do not pass, like again, do not pass go do not collect $200. I don't care how great your diet is. Everybody takes it. It's just a flat line, non-negotiable. Personally, I think that's really lied on. And I think that's probably overly optimistic as to what most people's diets truly are. And I think that as well, I think it's a little bit.

Stefanie Valakas: naive to think that people's diets from preconception into trimester one is going to stay the same. And so I think that's where the question then becomes of like, yeah, you think your diet is good now, that's lovely. But you know, once you're one of the 80 to 85% of women that get hit with some form of nausea and vomiting in trimester one of their pregnancy, and all you want is a say-oh cracker. Your nutritional status and your micronutrient status isn't something that you want to be stressing about. And so I do see that there is a huge need to fill those gaps once you're pregnant and into pregnancy ongoing. And something that I often quote a lot to give scale to this, because then people go, oh, okay, well, once I'm 12 weeks pregnant, then I don't need my prenatal vitamin anymore because the neural tube is closed. I've had my 13 week scan, baby's fine. Don't worry about it anymore. But Kayleigh, who works for us at the diatologist in her honors project, did a study of about 540 pregnant women in their third trimester at John Hunter Hospital, which is up in Newcastle. And they showed that in the third trimester, where you would imagine most people would be unaffected by things like nausea or significant enough symptoms that would impact their intake hugely, of course, things like reflux, constipation. All those delightful things that still hang around, but largely the nausea for most people would have gone. And yet only four out of 500 of the 34 women were able to meet key micronutrient targets without a prenatal multivitamin. And so it gives you scale that on mass, most people, and I don't mean this on like, I'm not talking to you individual listener, I'm talking like on mass, people overestimate how good quality their diets are. And when we research it. We're always like, what? This is so much worse than what we thought. And so it just highlights that a prenatal vitamin is not only going to help your chances of conception, we have independent research on folate and iron supplementation, enhancing fertility and enhancing chances of ovulation and protecting you from some pregnancy related complications and ensuring your baby is set up for a healthy, happy life ahead.

Stefanie Valakas: but also just for you so that you're not a shell of a human being at the end of it and that your micronutrient stores aren't depleted because ultimately being pregnant with a baby it's a parasitic relationship they will take yeah bub just takes it doesn't matter like it'll be your bones your iron your this your that and so ultimately and some of those things we can't test are not visible may not show up for 10-15 years
 
Jono: I say, bub steals, hey.

Stefanie Valakas: And so ultimately we need to be thinking about that and how that looks over archingly. Yes, we don't want to oversupplement and over like polypharmacy somewhere with supplements, but on the flip side, we have all this literature showing omega-3 status needs to be a lot better than what it is. That is not routine yet, despite the Cochrane studies that have come out about preterm labor, preterm birth. Preterm labor, preterm birth is a serious thing. Ask anyone who's delivered a baby early. We've got NICU, we've got potential risks of long-term issues with baby. We've got potential, sadly, neonatal deaths. We can't mess around with some of this stuff. And so omega-3s, folate, iodine, and I think other nutrients like choline in particular has just, I don't know, I just feel like I see a new study on choline all the time about it enhancing. baby's brain development, enhancing behavior in school-aged children, in those children that were supplemented in pregnancy and all these kinds of other things, it's gonna be the new kind of brain thing like Omega-3. And ultimately those things are not standard. And so it's up to you then as a potential future parent to seek out this information and to filter out what's right and wrong for you.

Jono: Mm.

Stefanie Valakas: I mean, you can also go to your doctor. Your doctor will typically give you one or two brands to consider because that's what's at their conference. And I mean that with all due respect, it's not their job to sit there and, you know, know exactly what is in every prenatal vitamin, what is best, what is not. And there is this concept from medical practitioners. And I just saw it the other day. All doctors think that all prenatal vitamins are the same. It doesn't matter what you take, if it's been approved for pregnancy and by the TGA, doesn't matter, it's all the same. That is not true. Some things are much higher, lower. Some things will sit better with you. Some things won't. You know, again, back to compliance. Some things will stink to you and you'll be like, get that away from me. I took a prenatal vitamin just to give it a try, just to put myself in my client's shoes and the smell every morning made me wanna gag and I was not even pregnant. And I was just like, I can't prescribe this. It stinks. Like.

Jono: Yeah, jeez. Yeah, yeah.

Stefanie Valakas: I want to spew every time I take this, I can't do it. Like it's those things make a difference. And so I think ultimately, if you're somebody who thinks, I have a great diet, this doesn't affect me. It does. Um, and I think you need to give yourself as well enough time. You want at least three months on a prenatal vitamin to ensure that you're not behind the eight ball and any of your key micronutrients and that sits outside of, Hey, am I deficient? Hey, my vitamin D sucks. Those things need to be corrected independently. And you can't expect a prenatal multivitamin to do absolutely everything for you. Um, usually when we see our clients, it's always a combination approach because trying to get an all in one, it never really works out too good.

Jono: Yeah. Well, I think you mentioned that it's not the doctor's job to know what's in every prenatal supplement because you're right. They've got so many other things to do, but I do know someone whose job it is. And so science have to sales very quickly, but even sales just if you want to get this sorted, the dietologist team do have an express supplement option. Tell me about that.

Stefanie Valakas: I'm gonna go.

Stefanie Valakas: Mm. Yes, so we offer Express Prenatal Supplement consults, which I think I invented, but I'm not sure. Yeah. Look.

Jono: Missed the word consult. No, look, I've seen no one else do it, and I know everything. So therefore, I'm signing off on this. Don't quote me on that.

Stefanie Valakas: I mean, Jono is Google. I kind of saw a need for people that do have a decent diet at baseline and maybe don't need dietary advice, but just want to get out of the chemist warehouse or pharmacy aisle and get just a really specific tailored plan based on their lab work, their diet, their preferences, things like, are you veg or are you vegan? Do you need halal? Do you need kosher? Are you celiac? Do you need to make sure it's gluten-free? Like all those small things, but not really big. And of course, like where your fertility and medical history is at, all those factors we take into account and we design a specific prenatal supplement plan where we are able to, in that format, disclose what brands, what dosage, what time to take them to maximize your... absorption, what foods to avoid them with, so on and so forth. And also the full micronutrient breakdown that plan will give you in comparison to your requirements. So it's very clear to you in black and white as to what this is covering and what it's not. And also it never covers a hundred percent of a hundred percent. So of course, you still got to eat the foods. So that's a really important document and that's something that you can share with your care team as well so everyone's on the same page. So that is something that we offer they're just 30 minute zoom consults so you're welcome to book in any time for one of those and you'll usually have a plan in your inbox within 24 hours with what to take where to buy it and all that good stuff.

Jono: Amazing. Yeah. It's a no brainer guys. And as we've discussed the inventor of the, I think I forgot the word consult when I said it, but no.

Stefanie Valakas: I think so. I didn't see anyone do it before me, so I'm gonna claim it. Ha ha ha.

Jono: Nah, definitely, definitely yours. I'm gonna, if I could steal a little bit more of your time, last question. Well, other than the classic where to find you and all that, which we'll go through at the end, definitely. Just off the back of supplements, folate, folic acid, you sort of mentioned those interchangeably, and I would not mention them interchangeably, sorry, but you know, they've both come up. Do you mind going through without, please don't give me biochem flashbacks.

Stefanie Valakas: Absolutely.

Jono: But going through I'm still I'm still not ready Going through just loosely the difference between them and If and when that difference is important

Stefanie Valakas: Yeah. I can't promise.

Stefanie Valakas: Yeah, absolutely. So it's probably one of the most popular questions that I've gotten over, particularly the last couple of years. No, that's fine. And I think it's good to have a, like I have a podcast episode on this as well. And I'm just like, just listen to this because I don't want to have to re-explain, re-explain my DM 16,000 times. Yes, absolutely. So essentially,

Jono: Sorry, that's what I had to ask.

Jono: Well, give us the short one and then I'll link the big one. Yeah.

Stefanie Valakas: Vitamin B9 is what we're talking about. So there's two forms of vitamin B9. There is folic acid, which is the synthetic form, which you will find fortified in our bread flour, wheat bread flour, non-organic bread, wheat flour should be more specific. Most like a lot of breakfast cereals, not mandatory, but they often do add folic acid. And is what is in your conventional? prenatal supplement, you know, most things that you walk into the pharmacy, pick up will be synthetic folic acid. And you'll know this because it will say as folic acid on the label, which is fair enough. And this is the form of folic acid that has been studied in terms of neural tube defects such as spina bifida and reducing the risk of that. Synthetic folic acid is kind of one camp. The other camp is our folate, which is typically referred to as food folate sometimes, or in the body it's often referred to as methylated folate or to simplify activated folate. As in this is the form, the final form, if you will, that's going to go and do the work in terms of supporting the cell replication, DNA formation. Obviously, lots of cells are being replicated when you're making a baby, so folate is an important ingredient there. So food folate will come from our food sources such as avocado, spinach, leafy green vegetables, oranges, strawberries, lentils, legumes, beans, et cetera. There is more than that, but that's a good top line view. Now, there is some people who struggle to convert the synthetic folic acid fully into the active form of folate. Now that percentage of people is reported differently in different populations, in different studies. So it can range from 20 to 60% of the population may have a change in their DNA code that may mean that their body is unable to fully take that synthetic folic acid and turn it into methylated or active folate. Now, how impactful is that given that the food folate form or the active folate form is gonna go and do the work?

Stefanie Valakas: Well, it depends on how much of an impact their particular DNA code has had on that process of conversion. So some people only have a 10 to 20% loss of functionality. Really that's negligible. It's not really gonna have a huge impact. But other people who have, you know, maybe more than one copy of this, the gene that can encode the enzyme that does the job that takes A to B, but anyway, that's biochem nightmare flashbacks.

Jono: What is the no don't it's right. We won't make the enzyme joke. We can if you can we make the enzyme joke. Yeah, sorry. Never mind.

Stefanie Valakas: No, no, every time. Inside jokes, inside jokes between dieticians. The ultimately the some people will have a significant impact on that conversion. So I always talk about it as rice in a funnel. That's probably the like the best, best analogy I give in terms of this talking about this. If you've got a funnel with a really skinny, tight neck, right? And you put a bucket of rice at the top. It'll start, but it will slow down, right? And it may even completely come to like dribs and drabs, hardly anything. If you widen that neck, what happens? Everything flows nicely. So your DNA code determines how wide or skinny that funnel neck is. Now, once we're getting too skinny, we start to... raise the question of like, okay, well, we can't know for certain how much is going to be converted. You know, maybe it's going to be really low. For example, there are ways to test this. We can look at things like serum folate. We can look at things like B12. We can look at things like homocysteine, which is a waste product of folate metabolism. We can look at the DNA code and test for these genes as well. It's not typically done because medicine doesn't acknowledge that this has a significant impact on fertility outcomes or miscarriage rates or, I don't know, stroke and it affects other elements of health too. So it's kind of been poo-pooed largely because that and the confusing part for most people is a lot of people will come back with this, if you test, will come back positive for this genetic code, right? Like turning it to 50 to 60. And so then it's like, well, what the heck are we going to do here? Do we put everyone on the active folate? But then we don't have any data about that form when it comes to spider bifida and neural tube defects. So we don't want to do that because that's a risk. But then on the flip side, if you meet someone who's had a history of recurrent miscarriage and things aren't working and we've got all this other stuff going on, and maybe they need up to 10 times the normal amount of folic acid than what we would normally prescribe

Stefanie Valakas: you know, their BMI or they have diabetes or they have celiac disease or a malabsorbative condition. You know, often the advice that my clients get given if they find out that they have MTHFR, which is the enzyme and a difference in that genetic code is often told to take more folic acid, which doesn't really make biochemical lots of sense. So, yeah, like we're just putting more rice, we're not actually like putting it at the bottom of the funnel. So

Jono: or rice, right?

Stefanie Valakas: That's I think a big frustration point for people that when they do learn a little bit about this and they may have an issue with it Is that well the prescription is more of the thing that might be causing problems So I think in those people that need you know Like I just mentioned ten times more folic acid than everybody else you have to be pretty clever then about okay How certain are we you're going to utilize this because we're about to put super physical super physiological doses of folic acid in. Um, is this going to make a big difference in really low doses or in people that only have one gene? It's probably not a big deal. Like it's probably fine. Like you'll convert enough and you'll be okay. If you have two copies of the gene, um, particularly one gene over another, or your compound heterozygous, like me, um, you may have some issues with actual serum folate levels, um, and that will show up, um, in your lab. did mine but I'm probably look I'm probably the only patient I've ever seen and I don't treat myself usually but you know in this context let's just pretend I'm probably the only patient I've ever seen with truly horrific serum folate levels it's usually always fine it's just a check step so you can always do that check step and check but I don't see us ever doing a study comparing active folate versus folic acid because it won't get approved by ethics. But I was recently informed that they will do a retrospective study on people that elected to take active folate because of their health history and then look at their outcomes and what their rates of NTDs were to try and help, you know, establish a better safety profile for it. So it then becomes about risk tolerance, education, informed consent, all these other things that need to go into it. So it does become a very complex and nuanced conversation and people are gonna have different perspectives. And I think the most important thing that I tell people, this isn't a natural equals good and synthetic equals bad conversation. It's about understanding what's relevant to you and where it's relevant to you. It's not relevant to everybody. I would say it's relevant to a percentage of people, but not everybody. And I think a lot of times people become really anxious, worried, stressed.

Stefanie Valakas: about this decision, like it's the most critical pivotal decision in becoming a parent and it's probably not. And we just got to like downscale that, that anxiety down with some education, some knowledge and understanding like, this is what you can do. You know, if you wish to do these additional tests, you can, they may be at your own cost, but if that makes you feel better, that's cool. You can do that. That's a very different conversation to someone trying to conceive for the first time and they haven't even started yet, to someone who's coming to me with, you know, a whole long history of things not going to plan for, you know, 10 years. You're going to go over things with a finer-tooth comb. And that's scaled appropriately to their story.

Jono: Mmm, yeah.

Jono: Amazing. So if that weirdly didn't answer your question, we will also link the larger podcast, but I feel like that was great. That was, yeah. Amazing. I've already taken up too much of your time twice now, as we discussed. So to wrap up, firstly, thank you so much for both times, but knock on wood this time, which will be the good time, the successful time, and for all your expertise and sharing all that with us.

Stefanie Valakas: I do try.

Jono: If people, not if, because everyone's going to want to find you, if they are weirdly following me and not following you, that's going to be silly. But if there's some of those strange people, what's the best place to find out about you, find out about the team, plug into your extra resources.

Stefanie Valakas: Yeah, yeah, absolutely. Thanks for having me. Thanks for letting me doing my little pluggy plug. So you can find us on Instagram, which is at the underscore dietologist. Our website is the dietologist.com.au where you can find our services, more about us. We're hoping to launch a bit of a like service and practitioner matching tool soon. So you'll be able to kind of give us some details about your story and then we'll be able to hopefully somewhat accurately. tell you which service and dietitian is right for you. And if not, that's what our lovely admin assistant is for. And you can also tune into our podcast, Fertility Friendly Food. There's 120 episodes, so there's probably something for you in terms of, we cover all sorts of things, endo, PCOS, fertility, pregnancy, yeah, a whole host of different topics. So if you wanna drill down deeper into a particular topic than that I've mentioned today, then definitely check that out. And yeah, I think that that's enough plugs. That'll do.

Jono: No, that's great. Like as always, I'll put them all in the show notes. So make sure you check out those links, but yeah, amazing Stef. Thank you so much for your time and your brain and your knowledge. And yes, well, I'll plant the seed of, maybe another podcast in the future, but let's wait and see, make sure that the audio works on this one first and foremost. Amazing. Thank you. Thanks guys. I'll chat to you next time. Bye.

Stefanie Valakas:
Yeah.

Yeah.