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Journal of Clinical and Diagnostic Research. 2018 Jun, Vol-12(6): IC06-IC09
66
DOI: 10.7860/JCDR/2018/30133.11686
Original Article
Health Management
and Policy Section
Effect of High Fibre, Low Calorie Balanced
Diet in Obese Women with Hirsutism: A
Randomised Clinical Trail
INTRODUCTION
As the commonest endocrine disorder, the disorder related to
irregular ovulation and menstruation is observed in gynaecological
field. The commonest problems in this field are hyperandrogenism
and hirsutism. Hirsutism is defined as an increase in the growth
of terminal hair in women with male patterns [1]. Systematic
reviews reported its prevalence as 5-10%, which varies in different
communities and races. In different countries, different studies have
focused on the prevalence of hirsutism, and different prevalence
rates of increase in androgen rates have been reported. Prevalence
of hirsutism among Taiwanese women was reported to be very low,
4.3% in English women, 7.1% in Spanish, 8.3% in Turkish, 38% in
Greek, 5.4% in American and in Iran was 10.8% to 22.8% [2-5].
A large percent of these women were suffering from obesity or
overweight, and the combination of these two problems caused
negative effects not only on the quality of life among these individuals,
but also on the efficiency of the treatments [6].
Obesity is a disorder that involves all age groups, races, and
classes. Since it is associated with problems and complications
during productivity age and pregnancy, it should be paid closer
attention and followed up in such women. Although, there are
numerous programs, treatments and attempts employed to cure
obesity, this disease is still one of the health problems in developing
and developed countries and is increasing day by day [7,8]. On
the other hand, obesity can affect the emergence of hormonal and
hyperandrogenism problems. The rate of hormonal changes in
obese individuals is remarkably different with that of individuals with
normal weight [9].
By causing insulin resistance, obesity leads to problems in
individuals suffering from Poly Cystic Ovary (PCO). Therefore, weight
decrease through increased insulin sensitivity can be useful [10,11].
Since medical treatments of hirsutism and PCO are expensive and
accompanied with side effects, today most of the studies put emphasis
on the role of nutrition in such individuals. Some researchers believe
that using low calorie diet to a large extent leads to the modification
of hormonal disorders and menstruation in these individuals [12,13].
Some studies highlighted the advantages of diets that are limited to
carbohydrates, and some referred to the importance of decrease in
fats and increase in proteins. At present, there is no special diet for
such individuals. On the other hand, due to hormonal and metabolic
changes, such individuals face numerous problems in losing weight
[14-16]. The present study was carried out in order to investigate the
effect of high fibre diet on hirsutism related hormones in obese or
overweight women suffering from hirsutism.
MATERIALS AND METHODS
The present study was a randomised clinical trial (IRCT Code:
2014102119624N1) carried out from July 2014 to March 2015
on 50 women of 18 to 45-year-old who had referred to the clinics
affiliated to Shiraz University of Medical Sciences in Iran and were
diagnosed with hirsutism. They were randomly selected using a
purposive convenience sampling method and based on the study’s
objectives. The study inclusion criteria were: BMI≥25, no special
diet or medicine; no pregnancy or breast feeding and no smoking.
The study exclusion criteria was presence of medical problems
including hyper- and hypothyroidism, adrenal hyperplasia, kidney
and liver problems, lack of tendency to cooperate with the study,
any problem while using the high fibre diet and pregnancy.
The executive protocol of the experiment was explained to the
participants. Afterwards, the advantages and limitations caused by
the proposed diet were explained, and in case of the individual’s
ATEFEH KROUNI1, SEDIGHE FOROUHARI2, MARZIEH AKBARZADEH3, MOHAMMAD HOSSEIN DABBAGHMANESH4,
FARIDEH JOWKAR5, MOUSA SALEHI6, ELNAZKHAYER7, FERDOWS MOHAMMAD ALIAN8
Keywords: Fatness, Rich fibre diet, Rotundity, Sex hormones
ABSTRACT
Introduction: Hirsutism is both an endocrine and cosmetic
problem therefore, it becomes necessary for investigations to
be carried out to determine the probability of an underlying
disease, its effect on sexual performance and reproduction. The
appropriate diet composition for individuals with hirsutism has
not been specified yet.
Aim: To investigate the effect of high fibre, low caloric balanced
diet on some related hormone levels in obese or overweight
women with hirsutism in Iran.
Materials and Methods: In the present randomised clinical
trial, 50 obese or overweight women suffering from hirsutism
were randomly assigned into two groups. The intervention
group received a high fibre, low caloric balanced diet while the
control group followed a normal diet for three months. The level
of Body Mass Index (BMI) was measured and blood sampling
(on the 3rd-5th day of menstruation) was carried out before and
12 weeks after the intervention, and the collected data were
analysed using SPSS software version 22.0.
Results: Variations in BMI in intervention group was seen. There
was an average reduction of 1.89 units in intervention group while
it was increased by 0.3 units in the control group. This observed
difference was statistically significant (p<0.001). The observed
variation in the level of free testosterone hormone in the two
groups was significant (p=0.034) i.e., mean±SD free testosterone
in intervention group (before intervention was 0.49±0.49 and after
intervention was 0.43±0.57) and in control group (before 0.38±0.30
and after it was 0.49±0.57). Moreover, there was a remarkable
decrease in LH hormone and increase in Sex Hormone Binding
Globulin (SHBG) was also observed.
Conclusion: A high fibre diet led to a decrease in BMI in the
intervention group, and this decrease had a remarkable effect
on improvement of androgenic parameters; as a result, it is
recommended that the diet of individuals with hirsutism should
be considered and attended.
www.jcdr.net Atefeh Krouni et al., High Fiber, Low Caloric Balanced Diet on Some Related Hormone Levels in Obese or Overweight Women
Journal of Clinical and Diagnostic Research. 2018 Jun, Vol-12(6): IC06-IC09 77
Hormones Intervention
Mean±SD
Control
Mean±SD p-value
FSH -0.44±1.48 -0.30±2.91 0.839
LH -1.08±3 0.73±3.42 0.058
SHBG 5.47±12.93 -0.48±7.59 0.068
17OHP 0.10±0.77 0.34±1.1 0.394
DHEAS 0.14±0.39 0.05±1.39 0.507
Free testosterone 0.06±0.19 0.1±0.31 0.034
Androstendione -0.35±1.14 0.28±1.22 0.072
[Table/Fig-3]: Comparision of the difference in mean changes in the level of the
hormones before and after the intervention in the intervention and control groups.
17OHP: 17-Hydroxypregnenolone; FSH: Follicle stimulating hormone; LH: Luteinising hormone;
SHBG: Sex hormone binding globulin; DHEAS: Dehydroepiandrosterone sulfate
Variable Intervention
Mean±SD
Control
Mean±SD p-value
Age 28±4.75 26.4±6.05 0.328
Menarche age 13.62±1.34 13.78±1.34 0.707
Hirsutism 9.33±2.66 9.13±2.22 0.779
BMI 31.03±6.47 27.46±2.97 0.020
FSH 4.1±67.34 5.2±2.78 0.408
LH 6±4.05 5.82±4.71 0.890
SHBG 29.93±16.47 29.59±15.85 0.942
17OHP 0.92±0.61 1.21±0.67 0.127
DHEAS 2.06±0.92 2.78±1,50 0.054
Free testosterone 0.49±0.49 0.38±0.30 0.815
Anderestendion 2.59±1.33 2.49±0.87 0.439
[Table/Fig-2]: Comparision of mean and standard deviation of age, age of menarche,
BMI, hirsutism score and hormones in the intervention and control groups.
17OHP: 17-Hydroxypregnenolone; BMI: Body mass index; FSH: Follicle stimulating hormone; LH:
Luteinising hormone; SHBG: Sex hormone binding globulin; DHEAS: Dehydroepiandrosterone
sulfate
groups in terms of the mean variation in hormones of 17OHP,
androstenedione, DHEAS, and FSH. The difference between
the two groups was significant only in terms of free testosterone
hormone (p=0.034). The average changes in the intervention group
at the level of LH dropped (p=0.058) and the mean changes in
SHBG experienced a remarkable increase in the intervention group
compared to the control group; however, this difference was not
statistically significant (p=0.068) [Table/Fig-3].
willingness, the consent letter was signed by the participants.
After that, the demographic questionnaire was filled out, and then
the researcher designed questionnaire (Cronbach’s coefficient
alpha=0.7) of daily and weekly diet for three days was filled by all of
the participants, so that their base diet could be determined and if the
individuals’ diet was not balanced based on that questionnaire, they
were excluded from the study. Balanced diet is a diet consisting of
a variety of different types of food and providing adequate amounts
of the nutrients necessary for good health [17].
The hirsutism score was calculated using Freeman-Galway
scale [18]. In order to measure the hormones of 17-
Hydroxypregnenolone (17OHP), free testosterone, androstenedione,
Dehydroepiandrosterone Sulfate (DHEAS), Sex Hormone Binding
Globulin (SHBG), Follicle Stimulating Hormone (FSH), and
Luteinising Hormone (LH), 10 mL fasting blood was taken from
the participants before and 12 weeks after the intervention. Blood
sampling was carried out on a random day for individuals with an
irregular menstruation and on day 3 to 5, for those with a regular
menstruation.
All participants (control and intervention groups) received same
basic diets but the intervention group diet was supplied by higher
amount of fibre foods containing 600 gm fruits, 50 gm nuts and 300
gm Vegetables to provide 20-35 gm of fibre daily.
Statistical analysis of the quantitative variables was carried out
through paired and independent t-tests. And for qualitative variables,
chi squares test and McNemar’s test or other non parametric tests
were employed at a significance level of 5%. In doing so, SPSS 22.0
was employed, and the results were reported as mean±SD.
RESULTS
At the end of the study and after the intervention, there were 47
participants (24 in the intervention group and 23 in the control
group); three were withdrawn because of pregnancy [Table/Fig-1].
[Table/Fig-1]: Flowchart of the study participants.
The mean age of the intervention and control participants was
28±4.75 and 26.4±6.05 years respectively. In the beginning of the
study, there was no significant difference between the two groups in
terms of their demographic factors. They were significantly different
only with regard to their BMI (p=0.020) [Table/Fig-2].
After the intervention, BMI changes in the two groups were
compared, based on which BMI in the intervention group dropped
by 1.89 on average while the control group experienced an increase
of 0.3 units in their BMI, which was significant (p<0.001)
After the hormonal parameters were measured in the beginning
and end of the study, there was no difference between the two
DISCUSSION
With regard to the effect of diet composition on weight loss and
hormones in women suffering from PCOS, contradictory findings
were achieved, and the appropriate diet composition is still under
question. Some studies compared full protein diet with simple sugar
diet and concluded that the former led to more decrease in weight
and BMI [19].
Administrating the high fibre diet for 12 weeks led to a significant
decrease in the level of free testosterone and LH and increase in
SHBG in the intervention group as compared to the control group.
However, changes in LH and SHBG were not significant, which can
be attributed to the small size of the sample. The intervention group
experienced a significant decrease in their weight while the control
group had an increase in their weight and BMI.
Shishehgar F et al., in their study compared the dietary intake
between PCOS and eumenorrheic with investigations of non
hirsute women and reported that PCOS group consumed more
food items with high glycaemic index (p=0.042) and less legumes
(p=0.026) and vegetables (p=0.037) than control group. Noted that,
compared to Shishehgar’s study, present research was a clinical
and interventional trials while there was no intervention in those
research [20].
Atefeh Krouni et al., High Fiber, Low Caloric Balanced Diet on Some Related Hormone Levels in Obese or Overweight Women www.jcdr.net
Journal of Clinical and Diagnostic Research. 2018 Jun, Vol-12(6): IC06-IC09
88
In the present study, the decrease in weight had a remarkable
effect on the decrease in androgens. Since one of the problems
of individuals with PCO and hirsutism is sterility, the researchers
believed that if weight loss does not directly influence ovulation, it can
increase the chance of response to infertility treatment medications.
An increase in BMI leads to a decrease in ovarian response to
common treatments with clomiphene [21,22]. In previous studies,
it was found that lowering testosterone level and increasing the
level of SHBG play an important role in the family level of Insulin
Growth Factors (IGFs) and their binding proteins. An increase in
these binding proteins leads to a decrease in free IGFs and synthesis
of androgen through the cytochrome system of p450c17 [23]. On
the other hand, recent studies have indicated that at least 50% of
women with PCO suffer from an increase in serinephosphorylation of
insulin recipient and thus the effect on enzyme p450c17. Abnormal
serinephosphorylation leads to insulin resistance and an increase in
the level of androgens in the blood of such individuals [24,25].
In some studies, decrease in androgen was obtained as a result of
weight drop [14,26], and in the present study, a decrease in BMI
resulted in a significant change in the level of some androgens like
testosterone.
Mehrabani H et al., carried out a study aiming at examining the effect
of low calorie, high protein, low glycaemia diet on sex hormones,
inflammatory markers, lipids, and insulin on women suffering from
PCOS compared to Conventional Hypocaloric Diets (CHCD). They
randomly chose 60 obese women with PCOS and assigned them
into two groups receiving 2 different diets for two weeks. The diets
included CHCD with protein (15%), and Modified Hypocaloric Diet
(MHCD) with protein (30%) and foods with low glycaemia. The results
of the statistical analyses indicated that the level of testosterone
dropped in both groups while other factors had no remarkable
change [14]. The results of that study were similar to those of the
present study. Moreover, the study period and the method were
also similar. The present study, however, concentrated on high fibre,
low calorie diet while that study focused on a decrease in dietary
calorie and fibre was not examined.
A study carried out by Bhargavain A at USA aimed at investigating
the relationship between nutrition and the concentration of
insulin, estradiol, LDL, HDL, and TGSHBG. It consisted of 379
postmenopausal women in the control group and 615 ones in
the intervention group for a period of 12 months. The intervention
women were given recommendations on consuming lower amounts
of fat and higher levels of grains, fruit, and vegetables. The results of
that study indicated that there was a remarkable difference between
the two groups before and after the study in terms of the amount
of their LDL, HDL, and SHBG, and that insulin level and lower TG
were correlated [26].
Those two studies [14,26] are similar to the present one with regard
to high-fibre diet and increase in the level of SHBG. Study duration,
sample size, the participants, and factors such as insulin and lipid
were different in those two studies. These differences can explain
the reason why the results are different.
In the study carried out by Gaskins AJ et al., the effects of high
fibre diet was investigated among 259 women at their reproduction
age, and they were followed up for two cycles of menstruation.
The results of their study showed that the level of LH decreased by
receiving high levels of fibre [27]. In the present study, a decrease
in LH was observed; however, it was not statistically significant,
which may be due to the smaller sample size compared to the study
carried out by Gaskins AJ et al.
Moreover, numerous studies like those conducted by Katcher HI et al.,
Cui X et al., Gann PH et al., and Bagga D et al., focused on the role of
diet in the hormones and reported remarkable changes in the increase
in the amount of SHGB as a result of consuming high fibre diets which
is similar to the results of present study [28-32]. As opposed to the
previous studies, the study conducted by Goldin BR et al., referred to
a decrease in SHBG as a result of low fat, high fibre diet [33].
In their study, Nicolas M et al., examined the relationship between
obesity and hyperandrogenism in 23 women with hirsutism. They
gave low calorie diet (1,500 Kcal/day) to the participants for four
months. The results of their study showed a drop in BMI which led to
a remarkable increase in SHBG; however, no change was observed
in other androgens. With regard to decreased BMI, the results of that
study are similar to those of the present one. Regarding androgens,
however, the results of the present study indicated a significant
change in the level of free testosterone (p=0.034) while the results
of Nicolas’s study showed no change in this hormone. Moreover,
the present study, like the previous one, showed a statistically
remarkable increase in SHBG in the intervention group [34].
Most studies put emphasis on the decrease in calorie and the
type of diet composition like full protein or low carbohydrates and
low fat, and their results are conflicting; therefore, the present
study was carried out in order to examine the effect of high fibre
diet on hormones related to hirsutism in obese women suffering
from hirsutism since there were few studies focusing on high fibre
diets. The hypothesis in the present study was that consuming
high fibre foods led to a decrease in BMI and change in the level of
hormones in the intervention participants. According to the results
of the present study, a significant drop was observed in BMI and
free testosterone of the intervention group, which confirms the
hypothesis, and decrease in BMI and testosterone is one of the
strengths of high fibre diet compared to normal diets. In theoretical
terms, a decrease in androgens can have an effect on improving
hirsutism state and menstrual and ovulation regularity, which was
not possible in the present study due to the existing limitations; thus
it is recommended that future studies consider this issue.
LIMITATION
In general, due to BMI difference in two groups and the time-
consuming trend of weight loss, large number participants were
being excluded, which is one of the limitations of the present study.
The cultural situation and the climate dominating the family are
effective in following the diet, which was also another limitation.
CONCLUSION
The present study indicated that high fibre diet can lead to a
decrease in weight and some androgens like testosterone in obese
and overweight women suffering from hirsutism. The results of the
present study showed the importance of paying attention to changes
in diet among women with hirsutism and polycystic ovary. Since
health team has a special place in this regard and is encountering
this group of women, it is necessary that they receive necessary
trainings with regard to diet and health of this group of patients.
ACKNOWLEDGEMENTS
The present article was extracted from Atefeh Krouni’s M.Sc. thesis
in midwifery (thesis grants No: 93-7186). Ethics committee code:
CT-9376-7186. The authors would like to thank the Research Vice-
chancellor of Shiraz University of Medical Sciences for financially
supporting the study.
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www.jcdr.net Atefeh Krouni et al., High Fiber, Low Caloric Balanced Diet on Some Related Hormone Levels in Obese or Overweight Women
Journal of Clinical and Diagnostic Research. 2018 Jun, Vol-12(6): IC06-IC09 99
PARTICULARS OF CONTRIBUTORS:
1. Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
2. Infertility Research Center, Research Center of Quran, Hadith and Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Social Determinants of Health
Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
3. Department of Midwifery, Fatemeh (P.B.U.H) School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.
4. Endocrine and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
5. Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
6. Department of Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
7. Department of Midwifery, Estahban Branch, Islamic Azad University, Estahban, Iran.
8. Midwifery Counseling Postgraduate Student, College of Nursing and Midwifery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Sedighe Forouhari,
Infertility Research Center, Research Center of Quran, Hadith and Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
Social Determinants of Health Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
E-mail: forouharism@yahoo.com
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: May 14, 2017
Date of Peer Review: Jul 11, 2017
Date of Acceptance: May 24, 2018
Date of Publishing: Jun 01, 2018
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