International Lifestyle Recommendations for Polycystic Ovary Syndrome (PCOS)
If you missed this great webinar Dietitians can still earn 1.0 CPEU by watching the video at https://oneop.org/event/22060/
Q: Is PCOS on the rise in the US and/or around the world?
A: The current worldwide prevalence of PCOS is estimated to be 8 – 13%. However, there continues to be substantial debate over the most appropriate criteria to diagnose the condition, as well as differences in how PCOS is evaluated across providers, health centers, and countries. These issues make it challenging to capture changes in the prevalence of the condition over time. Nonetheless, because obesity is linked to the pathogenesis of PCOS, it is possible that the rising prevalence of obesity may be associated with an increase in the number of women affected by PCOS. Longitudinal, observational studies are needed to corroborate such a relationship, though.
Q: How is PCOS diagnosed? And is it ever something that can be cured/go away?
A: PCOS is diagnosed based on the combined presence of two of three cardinal features: (1) anovulation (which is judged by evidence of irregular menstrual cycles), (2) androgen excess (which is judged by evidence of male-patterned hair growth [hirsutism] or elevated circulating androgens), and (3) polycystic ovarian morphology (which is judged by evidence of increased antral follicle number or ovarian size on ultrasonography). Different lifestyle and pharmacologic treatments can be used to reduce the severity of PCOS, but we do not know whether the condition can be “cured,” per se. The answer likely depends on the etiology of PCOS – that is, whether it is of genetic or environmental origin.
Q: What are your opinions on intuitive eating and PCOS, which seems to be a growing approach to treat PCOS? Intuitive eating seems to go against the idea of caloric restriction.
A: The main assumption of intuitive eating is that the mind and body are connected and that as a result, we can be aware of our body’s hunger and satiety cues. There are 10 principles, most of which remove the negative stigma surrounding food and weight while refuting the one-size-fits-all approach to eating. However, these principles do not need to be mutually exclusive from caloric restriction and can be addressed based on individual patient and clinician preferences. After all, if we listen to our body’s cues and stop eating when we feel full, then we will likely be eating fewer calories.
Some studies have reported that women with PCOS have lower cholecystokinin and meal-stimulated ghrelin secretion than women without PCOS. These results suggest that women with PCOS are more likely to be hungry and unsatiated after meals, indicating that the mind-body connection may be disrupted in PCOS. Therefore, intuitive eating may be more difficult for women with PCOS. However, there are certain philosophies that may resonate with some patients more than others. Literature outside of PCOS has shown that in engaged individuals, the action of tracking their diet can help an individual learn about their eating habits and self-monitor their dietary intake. Calories can serve as a traditional benchmark for patients that prefer objective measures with defined goals.
If the intuitive eating approach helps to stimulate weight loss in women with PCOS, then that is great, too! In such cases, we strongly encourage using the shared care approach. For example, provide a list of the principles of intuitive eating and ask the patient about the principles that they can see themselves adopting into their lives. Then, based on their answers, create a plan with the patient to encourage healthy eating behaviors using SMART (Specific, Measurable, Achievable, Realistic, Timely) goals.
Q: Do you recommend chromium supplements for women with PCOS?
A: The evidence regarding the role of dietary supplements in PCOS is heterogeneous and still emerging. Experts agree that there is insufficient high-quality data, at this point, to generate population-level clinical recommendations. Some randomized controlled trials have shown that chromium supplements reduce insulin resistance in women with PCOS. However, there is no evidence to suggest that women with PCOS exhibit deficiencies in chromium, wherein supplementation would be expected to exert a physiologically beneficial effect. Given that high doses of chromium can cause liver or kidney damage, we urge caution in recommending these dietary supplements until more evidence is available.
Q: I am curious about the outcomes or impacts of PCOS as they related to age of presentation?
A: PCOS imparts serious consequences on women’s health across the lifespan. Menstrual cyclicity, androgen status, and ovarian morphology (i.e., the diagnostic features of PCOS) are normally altered during the pubertal and menopausal transitions. Efforts are currently ongoing to define abnormality at these life stages, but age-related phenotypes of PCOS remain poorly defined. Some longitudinal studies have shown that menstrual cycles can become more regular, androgens can decline, and follicle number and ovarian size can decrease in post-menopausal women with PCOS. Importantly, although risk factors emerge earlier in life, diabetes mellitus, cardiovascular disease, and gynecologic cancers (i.e., common comorbidities of PCOS) are more likely to effect women in later decades of life.
Q: What about the use of metformin for PCOS? Is metformin used with women with PCOS?
A: Metformin is recommended for the management of weight, metabolic, and reproductive outcomes in women with PCOS. It may be used alone or in combination with lifestyle or other pharmacologic therapies. It may be especially helpful in cases where lifestyle changes cannot achieve desired goals and/or in women with high metabolic risk, e.g., those with risk factors for impaired glucose tolerance or diabetes mellitus.
Q: All these recommendations sound like the same guidelines that should be followed for anyone overweight/obese. So, is there really anything different than for treating PCOS?
A: Yes, the recent International Evidence-based Guideline for the Assessment and Management of PCOS supports the use of population-level recommendations for dietary intake and physical activity. Use of population-level recommendations is based on evidence that healthy lifestyle approaches (e.g., caloric restriction in obese patients, and balanced dietary composition and physical activity in all patients) can improve the metabolic features of PCOS. However, women with PCOS demonstrate an increased risk for psychological issues (i.e., anxiety, depression, low self-esteem, eating disorders) and chronic diseases (e.g., diabetes mellitus, cardiovascular disease, gynecologic cancers) compared to the general population. Women with PCOS also report poorer perceived control over their health outcomes and lower levels of social support than women with PCOS. Collectively, the main difference from a treatment perspective is that there is a clear need for healthcare providers to acknowledge these unique risk factors and concerns.
Q: There seems to be quite a bit of anecdotal evidence for myo-inositol supplementation. Thoughts?
A: Myo-inositol is a sugar alcohol and may influence hormones that are dysregulated in PCOS, such as follicle-stimulating hormone and insulin. Some studies have shown that myo-inositol improves aspects of ovulatory function, due in part to the role of hyperinsulinemia in anovulation and the beneficial effect of myo-inositol on insulin resistance. However, the studies are heterogeneous with differing definitions of PCOS, inclusion and exclusion criteria, and dose and duration of treatment. Until more consistent evidence is available, we are cautious about recommending myo-inositol to treat the symptoms of PCOS to prevent raising false hope in patients.
Q: I don’t understand the lack of effect regarding a lower carb diet. as a nutritionist, when I have patients who have low blood sugar in relation to PCOS, the smaller meals, lower carb and protein/good fat with each meal has stopped the hypoglycemia in every patient that I have tried this with.
A: To date, very few studies have evaluated the role of macronutrient composition in health outcomes in PCOS. Therefore, there is insufficient evidence to generate a population-level recommendation that any specific diet is better than any other for PCOS. However, we appreciate that there is anecdotal evidence that low carbohydrate / high protein diets can work well in women affected by the condition. Providers can feel comfortable individualizing care – so long as there are no known adverse effects.
Q: How do you address self-image in counseling?
A: Several studies have shown that women with PCOS have lower self-confidence related to body image. Lower self-confidence can be exacerbated by a patient’s beliefs that it is more difficult for her to lose weight (and easier for her to gain weight). Lower self-confidence may increase risk for anxiety and depression. Studies have also revealed that women with PCOS often feel “unfeminine,” especially if they live with absent menstrual cycles and male-patterned hair growth. We recommend listening to a patient’s concerns related to nutrition and weight loss and paying close attention to how she views herself in these conversations. Some potential things to consider:
- Does she blame herself for developing PCOS / infertility?
- If so, then emphasize that there are many unknown causes of PCOS / infertility and that healthy diet behaviors have been shown to be effective in improving PCOS outcomes.
- What is her overall objective for coming to the visit?
- If she keeps describing factors associated with her appearance, then acknowledge her feelings while reframing her mindset to appreciate other factors outside of physical attributes. For example, ask about her level of fatigue or the types of activities that she would like to do as she loses weight. Then, explain how a healthy diet and increased physical activity can help.
- How does she conquer slips (i.e., short-term breaks from healthy behavior practices) and slides (i.e., extended breaks)?
- Emphasize that slips are bound to happen for everyone but will not hurt her progress.
- Ask her how she deals with slips to prevent them from turning into slides.
- Some strategies might include identifying high risk situations, visualizing how one would deal with that situation, and encouraging positive thinking by keeping things in perspective.
- Empathy and social support from clinicians are key to combating negative self-image.
Q: When were the women diagnosed in these studies? If they had already been diagnosed, they were probably trying to eat better.
A: In some of the studies that examined baseline differences in diet and physical activity between women with and without PCOS, women were categorized into groups based on their existing diagnosis of PCOS. However, there were other studies that categorized women using internal diagnostic criteria, without revealing to the women that their symptoms were consistent with PCOS. The number of women who had received official diagnoses was not usually reported in these studies. It is tough to confirm with existing evidence, but we agree that reverse causation may exist, and that woman may have improved their lifestyle behaviors following their diagnosis of PCOS.
Q: Do you think that the recommendation of 300 mins of moderate exercise or 150 mins of vigorous exercise is realistic?
A: We believe that the recommendation is realistic, particularly because the newest Physical Activity Guidelines for Americans accept all bouts of physical activity (i.e., not just 10 minutes) as counting towards the goals of 150 – 300 minutes. To help patients meet the recommendations, we suggest the use of stepwise goal setting, which depends on how adherent a patient is to physical activity goals. It is helpful to keep in mind that exercise includes structured activities (e.g., running on a treadmill), while physical activity reflects any body movement that uses energy (e.g., household activities).
Q: Long question (sorry!) re: difficulty losing weight, whenever you can answer – I worked with a pt with PCOS who according to her diet recall significantly reduced portions and increased exercise, however, her weight dramatically continued to increase during the months that we worked together. She was frustrated and it was difficult for me as well because I wasn’t sure what else to tell her to do- she couldn’t adjust/reduce her diet any further and her activity was consistent. Have you seen anything like this in your experience?
A: We can definitely relate to such a scenario. Many of our participants with PCOS have shared similar experiences with us. Besides the potential impact of medication, there are a few things that come to our minds that might be helpful to discuss:
- What is her normal daily caloric intake? There is some evidence to suggest that women with PCOS have lower basal metabolic rates than women without PCOS and that excess visceral fat can modulate energy balance. Anecdotally, some of our participants have been so committed to weight loss, that they have reduced their caloric intake to <1000 calories per day, likely further slowing their metabolism. Moderate caloric reduction (i.e., by 500 calories per day) has been shown to be most effective for weight loss in this population; anything more could be counter-productive.
- How likely is she to use a mobile diet tracking app and would she consider it to be a convenient tool to use? For patients who are engaged and very interested in losing weight, such a tool can be helpful for identifying potential areas to target for weight loss. Portion sizes can be challenging to estimate, so apps that provide an opportunity to take pictures of meals/snacks may be effective. Additionally, tracking foods in real-time creates self-awareness of dietary behaviors and has been shown to lead to greater weight loss over time.
- What is her normal level of physical activity? Some patients may not understand the definition of “moderate intensity physical activity” and consequently may perform less activity. We like to recommend that, during bouts of physical activity, patients should reach a level of exertion where they can still talk but cannot sing. Physical activity of any kind can be helpful in women with PCOS.
We are happy to answer other questions or provide further explanation! Please feel free to reach us at the following email addresses:
- Annie W Lin (email@example.com)
- Brittany Y Jarrett (firstname.lastname@example.org)