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Diet and nutrition in polycystic ovary syndrome (PCOS): Pointers for nutritional management

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Diet and nutrition in polycystic ovary syndrome (PCOS): Pointers for nutritional management

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PCOS patients are not always markedly overweight but PCOS is strongly associated with abdominal obesity and insulin resistance. Effective approaches to nutrition and exercise improve endocrine features, reproductive function and cardiometabolic risk profile--even without marked weight loss. Recent studies allow us to make recommendations on macronutrient intake. Fat should be restricted to < or =30% of total calories with a low proportion of saturated fat. High intake of low GI carbohydrate contributes to dyslipidaemia and weight gain and also stimulates hunger and carbohydrate craving. Diet and exercise need to be tailored to the individual's needs and preferences. Calorie intake should be distributed between several meals per day with low intake from snacks and drinks. Use of drugs to either improve insulin sensitivity or to promote weight loss are justified as a short-term measure, and are most likely to be beneficial when used early in combination with diet and exercise.
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Diet and nutrition in polycystic ovary syndrome (PCOS): Pointers
for nutritional management
H. FARSHCHI, A. RANE, A. LOVE & R. L. KENNEDY
School of Medicine, James Cook University, Douglas, Australia
Summary
PCOS patients are not always markedly overweight but PCOS is strongly associated with abdominal obesity and insulin resis-
tance. Effective approaches to nutrition and exercise improve endocrine features, reproductive function and cardiometabolic
risk profile even without marked weight loss. Recent studies allow us to make recommendations on macronutrient intake.
Fat should be restricted to 30% of total calories with a low proportion of saturated fat. High intake of low GI carbohydrate
contributes to dyslipidaemia and weight gain and also stimulates hunger and carbohydrate craving. Diet and exercise need to
be tailored to the individual’s needs and preferences. Calorie intake should be distributed between several meals per day with
low intake from snacks and drinks. Use of drugs to either improve insulin sensitivity or to promote weight loss are justified as
a short-term measure, and are most likely to be beneficial when used early in combination with diet and exercise.
Keywords
Lifestyle modification, nutrition, polycystic ovarian syndrome
Introduction
The most common endocrine disorder, polycystic ovarian
syndrome (PCOS), is becoming more common due to
increased awareness and the global increase in the pre-
valence of overweight and obesity. It is a heterogeneous
disorder that has been difficult to define because there is no
single abnormality or diagnostic test that defines the
syndrome. While precise definitions are important for
scientific studies, as a working definition, the syndrome
may be diagnosed if at least two of the following are present:
. Oligomenorrhea or amenorrhoea associated with de-
creased ovulation. PCOS is the most common cause of
anovulatory infertility
. Hyperandrogenaemia or clinical features of androgen
excess, in the absence of other underlying disease states
. Abnormal ovarian ultrasound with 12 follicles in each
ovary each having a diameter of 2 9 mm, or increased
ovarian volume
. Increased LH with increased LH/FSH ratio.
The diagnosis is more certain with the presence of an
increasing number of features. Many overweight or obese
women have menstrual irregularity, decreased fertility or
hirsutism without fulfilling diagnostic criteria for PCOS.
The pathogenesis and management of these is the same as
for women with PCOS. Specific treatments for hirsutism
and subfertility have substantially improved management of
PCOS in recent years but do not generally influence the
underlying condition which is largely due to over-nutrition
and insulin resistance. Even PCOS patients who are not
overweight are often insulin resistant, and modest weight
loss improves outlook in patients of near normal body
weight. The association of PCOS with the abnormalities of
metabolic syndrome (central obesity, dyslipidaemia, hyper-
tension and glucose intolerance) is responsible for the
documented relationship with type 2 diabetes, cardiovas-
cular disease and hormonally-responsive cancers in later life
(Ehrmann 2005; Sartor and Dickey 2005). This paper
reviews our understanding of nutritional aspects of PCOS,
and proposes an approach to diet management and
nutritional therapy in patients with PCOS. The optimal
approach to dietary management of patients with PCOS
remains to be defined (Marsh and Brand-Miller 2005). This
review sets out some general principles around which a
tailored approach to the individual patients can be designed.
Prevalence and association with obesity
The prevalence of PCOS varies between populations, as
does the strength of the association between PCOS and
insulin resistance or obesity. These differences may arise
from genetic factors and from differences in lifestyle.
Furthermore, cultural differences in attitudes to fertility
and racial differences in hirsutism may influence presenta-
tion. PCOS prevalence among young women in the
reproductive years is generally quoted at 5 10%
(Ehrmann 2005). There may also be variation within
populations with ethnic groups who are at high risk of
metabolic syndrome also being at high risk of PCOS. This
may apply, for example, to individuals of Asian descent in
Correspondence: R. L. Kennedy, Department of Medicine, James Cook University, 100 Angus Smith Drive, Douglas, QLD 4814, Australia.
E-mail: lee.kennedy@jcu.edu.au
Journal of Obstetrics and Gynaecology, November 2007; 27(8): 762 773
ISSN 0144-3615 print/ISSN 1364-6893 online Ó 2007 Informa UK Ltd.
DOI: 10.1080/01443610701667338
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the UK and to the black population of the USA. A study
from the USA (Azziz et al. 2004) in an unselected
population showed that the prevalence of PCOS for black
and white women were 8.0% and 4.8%, respectively.
Furthermore, the features of PCOS may vary among
different racial groups because of differences in body mass,
diet, and exercise habit (Carmina 2006).
Insulin resistance is present in women with PCOS
independent of body mass. However, obesity in PCOS is
associated with greater insulin resistance, and a higher
incidence of dyslipidaemia and diabetes. The incidence of
diabetes and lipid disorders is higher. At least 50% of
women with PCOS are overweight or obese (Gambineri
2002). Abdominal adiposity or android pattern obesity
(waist hip ratio 40.85) is also common in PCOS
(Kirchengast and Huber 2001; Yildirim 2003). Android
fat distribution is also present in 70% of lean women with
PCOS, placing them at risk of metabolic disturbances
(Kirchengast and Huber 2001). The risk of glucose
intolerance among women with PCOS is 5- to10-fold
higher than normal and the typical age of onset of impaired
glucose tolerance or diabetes is in the third or fourth
decades, earlier than in the general population (Pelusi et al.
2004). In later life, the risk of developing type 2 diabetes is
potentially increased seven-fold in patients who have had
PCOS (Wild 2002). As in the non-PCOS population,
obesity in PCOS is associated with endothelial dysfunction,
decreased adiponectin and other changes in adipokines that
contribute to metabolic and cardiovascular risk (Carmina
2006). Several mechanisms have been proposed for insulin
resistance in PCOS, including peripheral target tissue
resistance, reduced hepatic clearance or increased pancrea-
tic sensitivity (Ben-Haroush et al. 2004). In obesity, free
fatty acids and tumor necrosis factor-a (TNF-a), released
from adipose tissue may play a key role in pathogenesis of
insulin resistance (Salehi et al. 2004). Other pro-inflam-
matory cytokines are also increased, including interleukin-6
(Glintborg et al. 2006) and interleukin-18 (Khang et al.
2006; Escobar-Morreale et al. 2004). As with metabolic
syndrome and type 2 diabetes, plasma adiponectin is
decreased and there is increased leptin and resistin
(Glintborg et al. 2006). The complex pathogenesis of the
condition and its relationship with metabolic syndrome is
demonstrated by a recent study (Corton et al. 2007) where
gene expression profiling of visceral fat from patients with
PCOS was carried out. There was increased expression of
pro-inflammatory genes, as well as those involved in
regulating immune function, oxidative stress, lipid meta-
bolism, and insulin signaling.
Obesity has significant effects on the clinical manifesta-
tions of PCOS: Menstrual/ovulatory disturbances tend to
be more marked in the obese; Androgen levels are higher
contributing to hirsutism and acanthosis nigricans (Mor
et al. 2004). Fertility is decreased and the rate of
spontaneous abortion increased (Wang et al. 2001).
Obesity is clearly a major determinant of many of the
long-term consequences of PCOS including glucose
intolerance and the risk of cardiovascular disease. Both
obesity and insulin resistance are major influences on
whether patients with PCOS develop features of the
metabolic syndrome (Elting et al. 2001; Goodarzi et al.
2003). The increased risk of endometrial carcinoma in
patients with PCOS may also be more marked in patients
who are obese and insulin resistant (Hardiman et al. 2003).
Patients with PCOS who become pregnant are at increased
risk of developing gestational diabetes (Loctal 2006).
Emotional factors including stress, depression, and dis-
torted body image are important determinants of symp-
toms and presentation, but also of response to treatments,
including lifestyle interventions (Gulseren et al. 2006;
Himelein and Thatcher 2006a,b; Diamanti-Kandarakis
and Economou 2006). The influence of psychological
factors must always be taken into account when consider-
ing treatment options. Low self esteem and impaired
quality of life are common among women with PCOS
(Coffey et al. 2006), and if the effect of these factors is not
appreciated lifestyle interventions, in particular, are likely
to prove ineffective.
Calorie requirements and restriction
Many studies in overweight and obese subjects have shown
beneficial effects of even modest (5%) weight loss on
well-being, insulin sensitivity, and cardiovascular risk
profile. There is every reason to believe that these benefits
extend to women with PCOS (Marsh and Brand-Miller
2005). Studies in patients with PCOS confirm that modest
weight loss improves glucose tolerance, cardiovascular risk
profile and reproductive function (Crosignani et al. 2003;
Norman et al. 2004; Stamets 2004; Douglas et al. 2006).
Modest weight loss achieved in the short term may also
improve some of the endocrine abnormalities associated
with PCOS: Hyperinsulinaemia contributes both to in-
creased androgen production in response to LH in the
ovary and also to the increased levels of free androgen by
decreasing SHBG. Peripheral aromatisation of androgens
to oestrogen adds to the relatively high oestrogen state
which may increase the long-term risk of certain cancers,
and exacerbate the endocrine abnormalities seen in
patients with PCOS. Short periods of calorie restriction
lead to decreased androgen levels, and this is sufficient in
some patients to restore normal LH pulse frequency and
amplitude with consequent restoration of normal men-
struation. However, LH secretion remains abnormal in
some patients suggesting that they may have intrinsic
abnormalities of pituitary ovarian axis function (Van Dam
et al. 2002, 2004). Leptin is a hormone that is produced
exclusively by adipocytes and is responsible (in the
physiological state) for decreased feeding, and therefore
energy intake, when the organism is replete. It is also
involved in regulation of reproductive function and
decreased leptin production with weight loss may help to
normalise reproductive function. Ghrelin is a 28-amino-
acid acylated peptide secreted by the stomach in response
to imminent feeding. It is an endogenous ligand for the
growth hormone receptor. Secretion before meals stimu-
lates feeding, decreases energy expenditure and stimulates
gastric motility and acid secretion. Increased ghrelin levels
in patients with PCOS may be part of the abnormal state of
energy balance, and this abnormality is again restored
toward normal with calorie restriction and weight loss
(Norman et al. 2004).
In approaching dietary management, it is important to
take into account the calorie requirements of the indivi-
dual. The recommended daily intake for women is
summarised in Table I. Calorie requirements are higher
for women with higher body mass and, and increase in
relation to activity. It is often useful to focus initially on the
eating pattern and the macronutrient content of the diet
rather than to try to promote both healthy eating and
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weight loss too quickly. Energy deficit can be achieved
either by limiting nutrient intake or by increasing calorie
expenditure. The best approach is a combination of the
two. A daily calorie deficit of as little as 200 kcal/day will
prevent weight gain and promote weight loss in the longer
term. A deficit of 500 kcal/day is needed for the average
person to lose 0.5 kg/week, while a 1,000 kcal deficit is
needed for 1 kg weight loss/week. These deficits are often
hard to achieve in practice, which explains why many
patients find it difficult to achieve satisfactory weight loss.
There is a distinct impression, but it is not clear from
published evidence, that women with PCOS find it harder
than the average to lose weight. It is important to recognise
that improved abdominal obesity and insulin sensitivity
may occur without an overall change in body weight. In
particular, body composition of patients who exercise
regularly may change with increased lean body mass and
decreased fat mass, but no overall change in weight.
Increased lean body mass (muscle) increases resting energy
expenditure and may help improve hormonal and meta-
bolic parameters in women with PCOS. While the benefits
of modest weight loss have become more widely appre-
ciated in recent years, this should not preclude us from
aiming for as near normal body weight and composition as
possible where this is feasible. To that end, our range of
dietary options is increasing. For example, short-term meal
substitution to achieve calorie deficit is now recognized as
an option for women with PCOS (Moran et al. 2006).
Dietary fat and protein
Fat is the most energy-rich macronutrient component of
the diet containing 9 kcal/g, compared with only 4 kcal/g
for carbohydrate and protein. Furthermore, the body has a
virtually infinite capacity to store fat, particularly in
hyperinsulinaemic individuals. Experiments with fat over-
feeding suggest that fat excess decreases carbohydrate
oxidation with no apparent change in fat oxidation. When
carbohydrate is present in excess, or is inadequately
oxidised, fat deposition is increased through the process
of de novo lipogenesis. Cross-sectional studies indicate that
higher fat intake is associated with impaired insulin
sensitivity, but this relationship is mainly due to obesity
(Riccardi and Rivellese 2000; Vessby 2003). By contrast,
intervention studies showed that a reasonable increase in
total fat intake (from 20% to 40%) had no major impact on
insulin sensitivity (Riccardi ad Rivellese 2000). Hence, a
potential criticism regarding the deleterious effects of high-
protein low-carbohydrate diets on increasing fat intake may
be not applicable, at least in short-term interventions
(McAuley et al. 2005).
Increased consumption of unsaturated fatty acids has
been reported to improve insulin sensitivity in healthy
(Vessby et al. 2001), obese and type 2 diabetic subjects
(Summers et al. 2003). However, the beneficial effects of
the fat quality on insulin sensitivity were observed in
individuals with 537% of total energy intake as fat (Vessby
et al. 2001). A recent investigation (Kasim-Karakas et al.
2004) focused on a diet supplemented in polyunsaturated
fatty acids (PUFA), which have been associated with
positive health benefits in a number of studies. Adminis-
tration of diet supplements with walnuts to increase levels
of linoleic and a-linolenic acids, surprisingly increased
glucose levels, both fasting and during an oral glucose
tolerance test. One explanation might be that total fat
intake in that study was 437% (39 + 1%). There was no
change in levels of insulin or of reproductive hormones.
The longer chain PUFAs, eicosapentaenoic acid and
docosahexaenoic acid which are found in fish oil have
beneficial effects on metabolic parameters in patients with
diabetes, but specific evidence relating to PCOS is not
available at this stage. While the Mediterranean diet, rich in
monounsaturated fatty acids (MUFA), has been widely
accepted as a gold standard for healthy diets, its potential
benefits in patients with PCOS have not been documented,
although decreased features of obesity and insulin resis-
tance have been noted in Italian compared with American
patients with PCOS (Carmina 2006). Overall, dietary fat
should account for no more than 30% of the calorie
content of the diet, with a maximum of 10% of calories
coming from saturated fat. The remainder of the fat
content should be as a balanced mixture of unsaturated fat
including cooking oils and spreads. Consumption of trans-
fats unsaturated fats which, because of internal resonance
in the molecule between double bonds, behave like
unsaturated fats has been recently linked with increased
risk of anovulatory infertility (Chavarro et al. 2007).
Diets that are either low in fat or low in carbohydrate
almost inevitably deliver an increased proportion of calorie
intake as protein. Although it has been controversial, recent
evidence suggests that higher intake of protein improves the
glucose and insulin responses to a glucose load (Gannon
et al. 2003; Farnsworth et al. 2003). Higher protein intake
also increases satiety and may contribute to increasing
postprandial thermogenesis, as well as decreasing abdom-
inal fat. Adequate protein intake is important to protect
lean body mass and to increase muscle in response to
exercise. There have been recent concerns about high
intake of red meat as increased body stores of iron have
been linked to the risk of developing type 2 diabetes.
General advice is that the diet should deliver 20% of its
calories as protein, this may be increased at the expense of
other dietary components for short-term diets designed to
help the patient lose weight or improve glucose tolerance.
Dyslipidaemia in patients with PCOS is an important
determinant of long-term cardiovascular risk. This most
commonly manifests as low HDL-cholesterol but because
triglycerides are often relatively low, a full atherogenic lipid
profile is often not expressed. However, subtle abnormal-
ities including alterations in lipoprotein particle size and
increase LDL II and IV subclasses may contribute to
susceptibility to macrovascular disease (Berneis et al.
2007). Combined oral contraceptives including combina-
tions of the antiandrogenic progestogen cyproterone
Table I. Recommended calorie intake for lean adult females
Age (years)
Activity level
Sedentary Moderate Active
19 30 2,000 2,000 2,200 2,400
31 50 1,800 2,000 2,200
451 1,600 1,800 2,000 2,200
Values are based on BMI of 21.5 kg/m
2
, women with higher BMI
have greater calorie requirement. Sedentary is equivalent to just
carrying out activities of daily living. Moderately active is
equivalent to walking 1.5 3.0 miles per day at 3 4 miles per
hour. Active is equivalent to walking more than 3.0 miles per day at
that pace.
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acetate with ethinyloestradiol are often used to achieve
cycle control, decrease androgenic symptoms, to protect
the endometrium, as well as for their contraceptive action.
Their effect on glucose tolerance and lipid profile is
complex and controversial. It is clear that, in some
individuals, they can increase glucose intolerance and
circulating triglyceride levels (Nader and Diamanti-
Kandarakis 2007). Increased weight during oral contra-
ceptive use may also have an adverse effect on long-term
cardiovascular risk (Vrbikova et al. 2006). The dyslipidae-
mic effect of combined oral contraceptive treatment is
prevented by concurrent use of a statin drug which also
decreases the low-grade inflammation (increased C-reac-
tive protein) that often accompanies PCOS (Banaszewska
et al. 2007). A recent report also suggests that statins may
have beneficial effects on the endocrine profile in
PCOS, including decreasing circulating testosterone levels
(Duleba et al. 2006). Low circulating sex hormone binding
globulin (SHBG) has been advocated as a marker for
the dyslipidaemia associated with insulin resistance
(including PCOS) (Chen et al. 2006), although variability
in measured values might preclude its use in routine
practice (Dahan and Goldstein 2006).
Dietary carbohydrate
The glycaemic load of a diet is defined as the amount of
carbohydrate multiplied by the glycaemic index (GI).
Foods with a high GI deliver carbohydrate rapidly
following ingestion. A high glycaemic load is associated
with an increased risk of diabetes and with poor glycaemic
control in patients with established diabetes. Glycaemic
load can be decreased either by decreasing the amount of
carbohydrate (in an isocaloric diet an increased proportion
of calories are as MUFA or as protein) or by consuming
foods of lower GI. The latter has been shown to improve
insulin sensitivity, decrease post prandial hyperglycaemia,
decease triglycerides and increase HDL-cholesterol (Marsh
and Brand-Miller 2005). Apart from the fact that they have
a low GI, whole grain foods may have a specific role in
protecting against the development of diabetes. Low-
carbohydrate diets have been controversial and public
interest in these diets has preceded and, to an extent
driven, scientific interest. We have recently reviewed the
literature relating to the use of these diets in people who
have or are at risk of type 2 diabetes (Kennedy et al. 2005)
Low carbohydrate diets are effective in promoting weight
loss when used for periods up to 6 months. They are only
effective if they deliver fewer calories than are being used
(i.e., they are hypocaloric). They appear to be safe for
short-term use and, indeed, improve cardiovascular risk
profile. The diets used vary in the degree of carbohydrate
restriction. A period of relatively strict carbohydrate
restriction helps at the start of the diet, but the diet does
not have to be severely restricted in carbohydrate to be
effective. Care should be taken to limit the intake of fat,
particularly saturated fat and the diets work best when they
moderately restrict calorie intake and are used alongside a
suitable exercise programme.
Many studies with low-carbohydrate diets have been
carried out over relatively short periods of time. This
limitation has been overcome by more recent studies.
Thus, after 6 months, a greater weight loss with a low-
carbohydrate diet compared with a conventional diet has
been reported (Samaha et al. 2003; Stern et al. 2004), but
the difference between the two diets was not sustained at 12
months (Brehm et al. 2003; Foster et al. 2003). Further
investigations in obese patients demonstrated inconsistency
in terms of weight reduction after 12 months on low-
carbohydrate diets. (McAuley et al. 2005; Dansinger et al.
2005) The effects of high-protein low-carbohydrate versus
low-protein high-carbohydrate diets on PCOS have been
evaluated only in two experiments (Stamets et al. 2004;
Moran et al. 2003). Both of these studies reported no
significant differences in weight loss in terms of the
different protein content of the diets. However, these
studies were very short term (1 and 3 months, respectively).
No significant differences were observed between low-
carbohydrate and high-carbohydrate diets on fasting
insulin levels, or insulin sensitivity as assessed by homeo-
static model assessment (HOMA) (Farnsworth et al. 2003;
Layman et al. 2003; Brinkworth et al. 2004). However, a
lower postprandial insulin response was reported in
subjects consuming a low-carbohydrate diet (Farnsworth
et al. 2003; Layman et al. 2003). In one recent study
(Douglas et al. 2006), both fasting and post-challenge
insulin levels were decreased by low-carbohydrate diet.
More marked improvement in triglycerides (Samaha et al.
2003) and HDL-cholesterol (Foster et al. 2003) have been
noted with low-carbohydrate diets compared with conven-
tional diets. Other studies have reported improvements in
LDL-cholesterol particle size (Sharman et al. 2004), LDL
concentration (McAuley et al. 2005; Parker et al. 2002),
and postprandial blood-lipid profile (McAuley et al. 2005).
Low-carbohydrate diets have been associated with deleter-
ious effects on lipid profile when used long term
(Kwiterovich et al. 2003), and thus severe carbohydrate
restriction should be regarded as a short-term measure to
achieve weight loss. Recent trials confirm that restriction of
dietary carbohydrate can lead to improved adipokine levels
towards values that indicate a more normal, insulin-
sensitive state (Cardillo et al. 2006), and along with this
there is an improvement in cardiovascular risk profile
(Nordmann et al. 2006).
Regulation of appetite is complex and fluctuations in
blood glucose may play a part in stimulating appetite and
increasing energy intake. Both insulin and blood glucose
fluctuate more widely in patients with insulin resistance.
This fluctuation commonly gives rise to reactive hypogly-
caemia. For example, Altuntas et al. (2005) studied 64 lean
women with PCOS and showed that reactive hypoglycae-
mia occurred in 50% following a glucose load. The
phenomenon was associated with lower levels of androgen
and prolactin and tended to occur in women with higher
levels of b cell function. Many women with PCOS describe
carbohydrate cravings and cite this as a reason for their
difficulty in losing weight. Hypoglycaemia is known to
stimulate feeding behaviour, increasing both total food and
fat intake (Dewan 2004). Glucose sensing neurones are
present in the hypothalamus, basal ganglia, limbic system,
and nucleus tractus solitarius (Levin 2001). Glucose
responsive neurones express the components of the
sulphonylurea receptor (Kir 6.2 and SUR) and glucoki-
nase, and sense increased glucose in a manner akin to the
pancreatic b cell. Another population of glucose sensing
neurones fire in response to decreased glucose. The
components of the glucose sensing mechanism (glucoki-
nase and sulphonylurea receptor) are also present in
neurones that secrete neuropeptide Y (NPY) or pro-
opiomelanocortin (POMC), both of which are involved in
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appetite regulation. Orexins, a group of hormones that
stimulate feeding behaviour, both stimulate glucose-sensi-
tive neurones (Liu et al. 2001), and are secreted by these
neurones (Cai et al. 2005). The neurones also respond to
the potent orexigenic peptide, ghrelin (Chen et al. 2005).
Changes in feeding behaviour during the menstrual cycle
have been well documented with increased fat and total
energy intake during the luteal phase. This may relate to
increased energy requirement and loss of this cyclical
change in energy utilisation may contribute to the increase
in weight that commonly occurs following the menopause
(Reimer et al. 2005). Hyperglycaemia may also play a
direct role by stimulating release of cytokines such as TNF-
a which may be involved in the pathogenesis of insulin
resistance and hyperandrogenaemia (Gonzalez et al. 2006).
Fluctuations in blood glucose may thus arise from the
changes that occur in PCOS but may also contribute to
development of these changes through altered feeding
behaviour, body composition and insulin responses.
Eating pattern
The importance of frequency and regularity of eating
patterns is often neglected. There has been, in recent years,
a move away from regular and social eating patterns to
more irregular eating with increased consumption of
convenience and energy-dense snack foods (Harnack
et al. 2000). There has been surprisingly little research on
the influence of eating pattern on metabolic parameters but
available evidence suggests that it may be an important
determinant of overall nutrient intake and may, to an
extent, govern the metabolic response to food. In a study of
nearly 16,000 adults (Kerver et al. 2006), meal and snack
patterns were good markers for overall nutrient intake.
Those who ate frequently during the day had higher intakes
of carbohydrate, fibre, and a range of micronutrients.
Those who ate less frequently had higher intakes of fat,
cholesterol, protein and sodium. Lower micronutrient
intake was associated with skipping breakfast. Our recent
experiments on lean (Farshchi et al. 2004a,b) and obese
(Farshchi et al. 2005a) women showed that a regular meal
frequency leads to higher postprandial energy expenditure,
lower energy intake and improved impaired insulin
sensitivity compared with irregular eating in 2-week
interventions. In a further study (Farshchi et al. 2005b),
breakfast consumption was associated with a lower energy
intake and improved insulin sensitivity compared with
breakfast omission. If such effects seen after only 2 weeks of
irregular eating or omitting breakfast are sustained in the
long term, they could lead to weight gain and thus
contribute to the development of obesity. Chapelot et al.
(2006) have confirmed that less frequent major eating
episodes may lead to increased fat mass and increased
levels of leptin. The optimal frequency of food intake has
yet to be determined, but a regular pattern with low intake
from snacks seems to be desirable. Ghrelin levels increase
in response to anticipation of food (Drazen et al. 2006),
and this response is learned. Since this and other orexigenic
hormones increase energy intake and decrease energy
expenditure, there is a strong argument for regular but
not too frequent eating episodes in individuals who wish to
control or lose weight. The importance of breakfast may
not just relate to the distribution of energy intake and
thermic response to food. Individuals who missed breakfast
in the Go¨ teburg Adolescence Study (Sjoberg et al. 2003)
were more likely to smoke, drink alcohol, eat more
carbohydrate and have decreased micronutrient intake.
Although further long-term studies in obese and PCOS are
required, it appears that regular eating including breakfast
can help in weight management and also improve insulin
sensitivity.
Exercise and PCOS
There is a surprisingly scant literature on the role of
exercise in managing patients with PCOS. What we know,
and what we recommend, must therefore come largely
from studies involving non-PCOS subjects. We currently
recommend 30 min of exercise on at least 5 days of the
week to maintain weight, and for healthy lifestyle. Recent
studies showed that 60 75 min of moderate-to-high
intensity of physical activity promotes a greater long-term
(12 18 months) weight loss compared with the conven-
tional recommendation for optimum health (Jeffery et al.
2003; Jakicic et al., 2003). Accumulation of exercise in
frequent short periods of physical activity appears to have
similar influence in long-term weight loss programmes.
Activity related to daily living and leisure time activity is an
important determinant of body weight but not of the
response to weight management programmes. A realistic
approach to exercise depends on the assessment of the
patient’s current exercise habits, preferences regarding type
of exercise, and inclination to undertake exercise. The
following options for exercise should be discussed with the
patient:
. Aerobic exercise. This is important for cardiovascular
fitness and to increase energy expenditure as part of a
weight loss programme. It is important to recognise
that the overweight and unfit patient may have limited
capacity for aerobic exercise
. Exercises to increase suppleness and flexibility.
Although they may not greatly increase calorie ex-
penditure, such exercises may increase engagement
with an exercise programme, decrease risk of injury
with exercise, and promote a sense of well-being
. Endurance exercise. For patients who cannot manage
high-intensity exercise, prolonged lower level activity is
an appropriate way to gain fitness and to increase
energy expenditure. Walking with a pedometer can be a
very useful approach to begin to increase energy
expenditure.
. Resistance training. Increasing muscle strength and
mass with weight training has been neglected as a
means of improving function and body composition
until recently. The high metabolic rate of muscle means
that muscle mass is an important determinant of resting
energy expenditure and resistance training is now
regarded as a highly acceptable way to influence weight,
body composition, and insulin sensitivity (Poehlman
et al. 2000; Borg et al. 2002).
Drug therapy
Pharmacological treatment should obviously only be
considered as an adjunct to lifestyle management, and
only when the latter has been shown not to have controlled
symptoms and signs on its own. However, the benefits
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which accrue when insulin sensitivity is improved with drug
therapy can be useful to demonstrate what could be
achieved with sustained lifestyle interventions. Also, there
is increasing evidence that drug treatments to improve
insulin sensitivity are a useful adjunct to lifestyle interven-
tions. Specific aspects of PCOS such as menstrual
irregularity, anovulatory infertility and hirsutism may
require specific treatment. For many patients, the greatest
symptomatic relief, as well as improved long-term prog-
nosis, could be gained by dealing with the underlying
causes of the condition insulin resistance and overweight/
obesity. These two aspects can be treated separately with
modern drugs, and both the patient and the clinician
should be informed about the likely benefits and limitations
of each.
Management of insulin resistance is with metformin, a
biguanide drug, or with the thiazolidinediones (rosiglita-
zone or pioglitazone) which are agonists at the peroxisome
proliferator activator receptor-g (PPARg) receptor. Use of
these drugs should be considered at an earlier stage in
patients who have impaired fasting glucose or impaired
glucose tolerance to prevent or delay progression to type 2
diabetes, and in patients who have developed diabetes to
improve diabetic control. Metformin is extensively used in
patients with PCOS, not only because of its effects on
glucose homeostasis, but also because by decreasing insulin
resistance it leads to favourable changes in androgens and
gonadotrophins (Checa et al. 2005). The latter has proved
to be useful in restoring ovulatory function and thus fertility,
either used alone or in combination with clomiphene
citrate. This effect of metformin is not necessarily confined
to women who are either overweight or who have overt
insulin resistance (Goldenberg et al. 2005). Metformin does
not promote weight loss. Metformin added to a hypocaloric
diet may decrease some of the features of abdominal obesity
specifically decreased leptin levels consistent with the loss
of visceral fat which may contribute to improvement in a
number of features of PCOS (Pasquali et al. 2000; Tang
et al. 2006). The drug is usually well tolerated, although up
to 30% of patients may experience gastrointestinal side-
effects. Lactic acidosis is a very rare side effect but
sufficiently serious to warrant the drug not being used in
patients with cardiac, renal or hepatic failure. One of the
difficulties in using metformin or other insulin sensitising
drugs for PCOS is the lack of a readily available marker to
document successful treatment or to guide dosage. Recent
evidence suggests that the combination of metformin and
lifestyle intervention has sustained beneficial effects on
weight maintenance and cardiovascular risk profile that
might last for up to four years (Glueck et al. 2006;
Gambineri et al. 2006). In addition to affording some
protection from macrovascular damage, use of metformin
with suitable lifestyle advice has been shown to improve
microvascular function (Topcu et al. 2006; Alexandraki
et al. 2006). The drug has been shown to decrease systemic
levels of advanced glycation end products (AGEs) which
contribute to vascular and renal complications of insulin
resistant states (Diamanti-Kandarakis et al. 2007). As
confidence with use of metformin in PCOS grows, and as
scientific evidence supporting its use accumulates, the drug
is increasingly being used in younger patients, including
adolescents, with PCOS (De Leo et al. 2006; Mastorakos
et al. 2006; Glueck et al. 2006).
There is increasing evidence for the use of thiazolidine-
diones in patients with PCOS. Side-effects include weight
gain, peripheral oedema, anaemia and changes in liver
tests. Rosiglitazone has been shown to improve glucose
tolerance and insulin sensitivity in patients with PCOS,
although it does not necessarily produce marked improve-
ment in other endocrine parameters (Belli et al. 2004). In a
head-to-head study with metformin, rosiglitazone was
reported to be more useful where the features were
predominantly those of insulin resistance, while metformin
additionally ameliorates features of a high androgen state
(Mitkov et al. 2006). It may, however, usefully be
combined with oestrogen and/or antiandrogen treatment
to produce benefits in features related to insulin resistance
and hyperandrogenaemia (Lemay et al. 2006). Pioglitazone
tends to have more marked beneficial effect on cardiovas-
cular risk factors, and may be beneficial in insulin-resistant
patients who fail to respond to metformin (Glueck et al.
2003; Glintborg et al. 2006). The drug may be used singly
or in combination with metformin. Increased weight with
the glitazone drugs relates to increased subcutaneous fat
which is due to the drugs increasing fat cell differentiation
and growth in fat depots that do not contribute, or have a
beneficial effect on, cardiovascular risk. The resultant
decrease in circulating triglycerides and non-esterified fatty
acids contributes to improved insulin sensitivity but has no
influence on the overall body composition and energy
expenditure (Smith et al. 2005). Decreased adiponectin
and increased resistin are features of PCOS and insulin
resistance (Gulcelik et al. 2006; Escobar-Morreale et al.
2006), and these features are partly normalised during
treatment with thiazolidinediones (Majuri et al. 2007).
Additionally, these drugs can decrease some of the changes
found in association with non-alcoholic steatohepatitis
(NASH) and low-grade inflammation (Rautio et al. 2007).
Modern drugs to assist with weight loss and maintenance
are certainly effective in some patients, and appear to be
safe if used within guidelines. Orlistat is a gastrointestinal
lipase inhibitor that decreases absorption of ingested fat by
up to 30%. Although its use leads to gastrointestinal side-
effects in up to one-third of cases, it appears to be a very
safe drug and is now widely used in treatment of PCOS.
The beneficial effect on insulin resistance and in decreasing
androgen levels is equivalent to that achieved by metformin
(Jayagopal et al. 2005). Advanced glycation end-products
are reactive molecules produced by glycation of proteins
and lipids, and are involved in pathogenesis of diabetic
complications. Orlistat may decrease assimilation of these
products for the diet (Diamanti-Kandarakis et al. 2006).
Sibutramine is a centrally-acting inhibitor of serotonin
and noradrenaline uptake. It is marginally more effective
than orlistat as a weight-controlling drug but its use is
limited to 1 2 years since it consistently increases pulse
rate and blood pressure. It should not be used in patients
with uncontrolled hypertension. Used in patients with
PCOS, sibutramine improves glucose tolerance and
decreases androgen levels (Sabuncu et al. 2003; Filippatos
et al. 2005). It also decreases levels of leptin and resistin
and increases adiponectin, all of which are associated with
improved insulin sensitivity and decreased risk of type 2
diabetes (Karabacak et al. 2004). Other drugs to assist
with weight control are in development. The most
immediately promising of these is rimonabant, an
inhibitor of the cannabinoid-1 receptor (CB-1). This
drug has been shown in extensive trials, both in Europe
and North America, to promote weight loss and
improvement in cardiovascular risk profiles in overweight
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patients (Van Gaal et al. 2005; Despres et al. 2005; Pi-
Sunyer et al. 2006). Although there is no specific evidence
relating to PCOS at present, there is every reason to
believe that Rimonabant will prove useful in this condi-
tion. There is a distinct possibility that weight manage-
ment drugs will not only prove useful overall, but that
specific agents might be selected to match the underlying
problem with calorie intake and that these drugs may be
useful singly or in combination with other drugs to treat
the features or natural history of PCOS. There are no
specific data at present relating to the role of bariatric
surgery in managing patients with PCOS. While surgi-
cally-induced weight loss clearly may restore fertility and
improve cardiovascular risk profile, potential risks have to
be considered carefully (Merhi 2007).
Conclusions
PCOS is a complex disorder due, in part but not
exclusively to, insulin resistance and overweight. In
practice, its management is often not entirely satisfactory
from the patient’s point of view. Treatment of PCOS
may be divided as follows: (1) Attention to lifestyle
factors including diet and exercise. (2) Management of
specific aspects such as menstrual irregularity, anovula-
tory infertility, and hirsutism. (3) Dietary and exercise
interventions to promote weight loss and improve glucose
tolerance. (4) Pharmacological interventions to improve
insulin sensitivity or to assist with weight loss. A scheme
for management of the overweight or insulin resistant
patient with PCOS is proposed in Figure 1. Although
Figure 1. Approach to the patient with PCOS.
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there has been a general increased interest in the role of
lifestyle modification to favourably alter the clinical
features of PCOS, much of what has been learned is
by inference from the non-PCOS population. There is
relatively little specific information on nutritional recom-
mendations for patients with PCOS (Stein 2006; Hoeger
2006). The focus, to date, has been on the macronu-
trient components of the diet. Evidence is beginning to
emerge that micronutrients are also important. Thus,
there may be benefits to supplementation with omega-3
fatty acids and antioxidants (Stein 2006), and low
vitamin D levels in some patients may contribute to
the metabolic features of the syndrome (Hahn et al.
2006). Some early evidence supports non-pharmacologi-
cal treatment including herb and nutritional supplements
(Dennehy 2006; Westphal et al. 2006).
As PCOS is principally a disease of over-nutrition, the
primary management in most cases should centre on a
nutritional approach. Based on published information
summarised in this review, certain recommendations can
be made about diet and exercise in patients with PCOS.
These are summarised in Table II. An approach which
deals with the fundamental problem in PCOS will help to
improve the multiple facts of the disease and to protect the
patient from the long-term consequences including, type 2
diabetes and cardiovascular disease. A rational approach to
lifestyle management in PCOS will help the practitioner
engage with the patient, and allow both practitioner and
patient to approach this complex disorder in a rational
manner. PCOS is largely a disease of lifestyle. As it
becoming more commonly diagnosed, it is mandatory for
health professionals dealing with PCOS patients to have
some knowledge of how lifestyle factors influence the
disorder and how they may be changed to alter prognosis
without an undue reliance on the short-term use of
pharmacological treatments.
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1. Daily energy requirement of 2,000 2,400 kcal for patient of average build who is not too active. Avoid restricting this too much to
start with.
2. Exercise regularly: 30 min of moderate exercise daily will help to maintain body weight. More prolonged or vigorous exercise may
be needed to produce weight loss.
3. Eat no more than 30% of daily calories as fat, restricting saturated fat to 510% total calories. Use low fat spreads and dairy
products.
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glycaemic index (GI) foods, those high in fibre and wholegrain foods.
5. Diet of higher protein content may improve satiety and insulin sensitivity. Start with 20% of daily energy as protein, but this may be
increased by substituting for carbohydrate in those who have difficulty controlling eating or maintaining weight.
6. Avoid too much red meat. Eat oily fish at least once per week to supply long-chain essential fatty acids (omega-3, polyunsaturated
fatty acids).
7. Eat at least five portions of fruit or vegetable per day. This promotes satiety, supplies fibre and maintains the micronutrient content
of the diet.
8. Eat regularly and focus food intake on three (maximum four) meals per day. Breakfast is an important meal.
9. Avoid calorie-dense snacks as they promote hyperinsulinaemia and drive hunger. Make sure that drinks are counted in daily
calorie intake estimated fruit juices and alcoholic drinks are often forgotten but are rich in calories and carbohydrates.
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intake or increased utilisation will lead to 5% weight loss in 6 months for many. A 500 kcal per day energy deficit usually equates
to weight loss of up to 0.5 kg/week.
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... As increasing studies focus on the roles of physical activities in human health, the evidence showed that in the management of PCOS, exercise activities would help female patients gain benefits, and this view is becoming accepted among doctors and patients (36,37). When considering the appropriate exercise activities to alleviate the symptom of PCOS, it is always puzzling how to set the appropriate exercise intensity and frequency. ...
... Some studies reported that once the intake of carbohydrates is less than 45% of the total daily calories, the low-carbohydrate diet might be helpful to decrease the body mass index as well as the serum levels of total cholesterol in PCOS subjects (41). Furthermore, studies indicate that maintaining the low-carbohydrate diet for more than 1 month could significantly increase the levels of follicle-stimulating hormone and sex-hormone-binding globulin (36). Even though some evidence indicates the effect of the lowcarbohydrate diet on PCOS, the definitive mechanisms to explain the relationship are still unclear. ...
Article
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Polycystic ovary syndrome (PCOS) is defined as a kind of endocrine and metabolic disorder that affects female individuals of reproductive age. Lifestyle modifications, including diet modifications, exercise, and behavioral modification, appear to alleviate the metabolic dysfunction and improve the reproductive disorders of PCOS patients (particularly in obese women). Therefore, lifestyle modifications have been gradually acknowledged as the first-line management for PCOS, especially in obese patients with PCOS. However, the mechanism of lifestyle modifications in PCOS, the appropriate composition of diet modifications, and the applicable type of exercise modifications for specific female populations are rarely reported. We conducted a systematic review and enrolled 10 randomized controlled trials for inclusion in a certain selection. In this review, we summarized the existing research on lifestyle modifications in PCOS. We aimed to illustrate the relationship between lifestyle modifications and PCOS (referring to hyperandrogenism, insulin resistance as well as obesity) and also considered the priorities for future research. These results might be an invaluable tool to serve as a guide in lifestyle modifications as the intervention for PCOS and other related endocrine disorders.
... Lifestyle factors also help in overcoming the risk for co-morbid diseases related with PCOD like heart disease, diabetes, and endometrial cancer (Hoeger et al., 2007). Farshchi (2007) reported that "use of drugs to either improve insulin sensitivity or to promote weight loss are justified as a short-term measure, and are most likely to be beneficial when used early in combination with diet and exercise". Ogbuji, 2010 reported that young women adults with menstrual problems have lack of awareness about the food digestion, calorie count, metabolism rate, fat consumption etc.So, education and encouragement need to be given for girls with PCOS to perform suggested physical activity each day. ...
... Spiritual therapy is a cognitive knowledge that affects a person's ability to control his/her negative emotion using religious understanding (Chiesa &Serretti., 2009;Fjorback et al., 2011). Researchers have documented that intermittent fasting can help in recovering from PCOS symptoms (Farshchi et al.,2007).In the intervention group, levels of Serum cortisol and nor-adrenaline were significantly lesser than the levels at the starting of Ramadan in comparison to control group. It means that in females with PCOS, Ramadan fasting reduces stress neurohormones, Zangeneh et al. (2015). ...
Article
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Polycystic ovary syndrome (PCOS) is one of the most prevalent disorders in women which influence their endocrine and metabolic functioning. It causes physical and psychological issues which are responsible for causing disturbances in daily life of women. Apart from genetics, stress, anxiety, obesity, and sedentary life style are among several factors that contribute to this disease. Hence, the treatment must target all these factors. Yoga, diet, exercises and therapies like mindfulness based cognitive therapy (MBCT) have significant effects on management of symptoms of PCOS. Assessment of the overall health of women can assist in the treatment programme and integral plans can be designed to deal with the problem. The purpose of this qualitative study is to assess different treatment outcomes which can help the women suffering from PCOS, health experts, and mental health workers in understanding, management and treatment of this disease from a holistic point of view. This could further enhance the well-being and overall living pattern of the women.
... Responses from the participants were scored using a model answer key. A score of "one" or "zero" was awarded for each correct or incorrect answer, respectively, and the sum total for each participant was expressed as the "awareness score" described on an ordinal scale as follows: fair (10 or less), moderate (11)(12)(13)(14)(15)(16)(17) and good (18)(19)(20)(21)(22)(23)(24)(25). ...
... PCOS is a chronic multisystem disorder with considerable variation in symptom expression. Lifestyle change and nutritional management remain the first line of management for all, even in women with a lean PCOS phenotype, as there is a strong association between abdominal obesity and insulin resistance in women with PCOS who are not markedly overweight (17). Lifestyle change is multifactorial and includes goal setting, self-monitoring, stimulus control, slower eating, reinforcing changes, and prevention of relapse to optimise physical and emotional health in women (18). ...
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Objective: To evaluate the role of an online, video-based, structured, educational module in increasing awareness in women with polycystic ovary syndrome (PCOS). Material and methods: Patients with PCOS were assessed for baseline awareness about PCOS, quantified as “awareness score”, using a validated questionnaire. Topics assessed included factual and conceptual knowledge of the disease and awareness of behaviour-related lifestyle modification and therapy compliance in PCOS. An educational video module was shown to the participants which covered normal menstrual physiology, symptomatology, pathophysiology and natural history of PCOS, a comparative animation of healthy versus unhealthy lifestyle, indications of pharmacological intervention, and role of treatment adherence. The questionnaire was re-administered after exposure to the educational module, and effectiveness of the teaching method was evaluated by comparing pre and post test scores. Results: The total number of subjects was 41. Baseline knowledge was “fair” in 17.1%, “moderate” in 48.8% and “good” in 34.1%. Significant increase in awareness scores was noted among participants regarding PCOS after exposure to the learning module from 15.09±4.31 to 18.60±3.85 (p<0.00001) with a large effect size (Cohen’s d=0.85). Most (48.8%) of the respondents had baseline awareness in the “moderate” range (scores between; 11-17) whereas post intervention scores improved to the “good” category for 63.4% of the women. Conclusion: The educational module was effective in significantly increasing knowledge about PCOS. Patient education is likely to help reinforce the message about lifestyle modification and continued compliance and may aid in promoting a patient-driven healthcare model in PCOS.
... Due to the relationship between increased insulin levels and androgens, the treatment of hyperinsulinemia with pharmacological and nonpharmacological approaches is essential, notwithstanding the preclinical effects of high insulin levels and predisposition to diabetes. Insulin resistance has also been implicated in cravings for carbohydrates and subsequently overeating, binge pattern eating, and weight gain [24,25]. is has the potential to have confounding effects on the overall risk of hyperinsulinemia, subsequent diabetes, and cardiovascular disease. Obesity in PCOS is a key driver of deranged cardiometabolic parameters including insulin resistance, hyperandrogenism, and dyslipidaemia. ...
Article
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Results: 2662 papers were identified with 37 selected for full-text review and one paper meeting criteria for inclusion. Ramadan fasting was the only time-restricted eating regimen trialled in this population with no strong evidence of a significant effect on insulin levels. Conclusion: As the systematic review retrieved only one study investigating time-restricted eating to reduce insulin in patients with PCOS, there is no evidence to suggest that this intervention is effective. From the narrative review, based on studies in other patient groups, time-restricted eating could improve insulin resistance in those with PCOS; however, well-designed studies are required before this intervention can be recommended.
... As the number of antral follicles in the left ovary and number of antral follicles in the right ovary are used in the diagnosis of PCOS, the significant differences in these variables between the 2 groups were significant. Finally, age and diet habits were found to be important factors for PCOS [32,33]. ...
Article
Full-text available
Background Artificial intelligence and digital health care have substantially advanced to improve and enhance medical diagnosis and treatment during the prolonged period of the COVID-19 global pandemic. In this study, we discuss the development of prediction models for the self-diagnosis of polycystic ovary syndrome (PCOS) using machine learning techniques. Objective We aim to develop self-diagnostic prediction models for PCOS in potential patients and clinical providers. For potential patients, the prediction is based only on noninvasive measures such as anthropomorphic measures, symptoms, age, and other lifestyle factors so that the proposed prediction tool can be conveniently used without any laboratory or ultrasound test results. For clinical providers who can access patients’ medical test results, prediction models using all predictor variables can be adopted to help health providers diagnose patients with PCOS. We compare both prediction models using various error metrics. We call the former model the patient model and the latter, the provider model throughout this paper. Methods In this retrospective study, a publicly available data set of 541 women’s health information collected from 10 different hospitals in Kerala, India, including PCOS status, was acquired and used for analysis. We adopted the CatBoost method for classification, K-fold cross-validation for estimating the performance of models, and SHAP (Shapley Additive Explanations) values to explain the importance of each variable. In our subgroup study, we used k-means clustering and Principal Component Analysis to split the data set into 2 distinct BMI subgroups and compared the prediction results as well as the feature importance between the 2 subgroups. Results We achieved 81% to 82.5% prediction accuracy of PCOS status without any invasive measures in the patient models and achieved 87.5% to 90.1% prediction accuracy using both noninvasive and invasive predictor variables in the provider models. Among noninvasive measures, variables including acanthosis nigricans, acne, hirsutism, irregular menstrual cycle, length of menstrual cycle, weight gain, fast food consumption, and age were more important in the models. In medical test results, the numbers of follicles in the right and left ovaries and anti-Müllerian hormone were ranked highly in feature importance. We also reported more detailed results in a subgroup study. Conclusions The proposed prediction models are ultimately expected to serve as a convenient digital platform with which users can acquire pre- or self-diagnosis and counsel for the risk of PCOS, with or without obtaining medical test results. It will enable women to conveniently access the platform at home without delay before they seek further medical care. Clinical providers can also use the proposed prediction tool to help diagnose PCOS in women.
... A number of dietary compositions have been investigated for PCOS, with recent studies recommending macronutrient intake. Fat restriction to 30% of total calories, less intake of high GI (Glycemic index) carbohydrate, calorie intake distribution between several meals per day with low intake from snacks and drinks should be given a thought [141]. The pilot study by Mavropoulos et al., reported that the intake of low carbohydrate, ketogenic diet (LCKD) resulted in significant reduction in weight, free testosterone, LH/FSH ratio, and fasting insulin in women with obesity and PCOS [142]. ...
Article
Full-text available
Polycystic ovary syndrome (PCOS), the most common endocrinopathy in women is characterized by polycystic ovaries, chronic anovulation and hyperandrogenism. The treatment in PCOS is mainly symptomatic and involves lifestyle interventions and medications such as Metformin, Oral contraceptives and Antiandrogens. However, the management of PCOS is challenging and current interventions are not able to deal with outcomes of this syndrome. This review encompasses latest pharmacotherapeutic and non-pharmacotherapeutic interventions currently in use to tackle various symptomatic contentions in PCOS. Our focus has been mainly on novel therapeutic modalities for treatment/management of PCOS, like use of newer insulin sensitizers viz., Inositols, Glucagon-like peptide-1(GLP-1) agonists, Dipeptidyl pepdidase-4 (DPP-4) inhibitors, and sodium-glucose transport protein 2 (SGLT2) inhibitors. Also, evidence suggesting the use of vitamin D, statins, and Letrozole as emerging therapies in PCOS have been summarized in this review. Additionally, novel cosmetic techniques like electrolysis, laser and use of topically applied eflornithine to tackle the most distressing feature of facial hirsutism associated with PCOS, non-pharmacological therapy like acupuncture and the role of herbal medicine in PCOS management have also been discussed.
Chapter
A obra intitulada “Aspectos conceituais e metodológicos voltados para a área da saúde vol. 01”, publicada pela Brazilian Journals Publicações de Periódicos e Editora, apresenta um conjunto de trinta e três capítulos que apresentam diversas temáticas do conhecimento da área da saúde. Entre eles, um estudo com objetivo de investigar os sintomas de ansiedade e depressão, e a imagem corporal em obesos submetidos à cirurgia bariátrica e metabólica. Outro com intuito de esclarecer a população sobre os fatores de risco para as DCVs, esclarecer sobre o potencial deletério dessas doenças e promover a saúde incentivando adoção de hábitos de vida saudáveis. Assim como uma pesquisa com o propósito de caracterizar a relação entre hábitos de vida, prevalência de DCNT, polifarmácia e interações medicamentosas em pacientes adultos/idosos pós Acidente Vascular Cerebral em atendimento fonoaudiológico em uma clínica escola. Também uma revisão sobre os efeitos psicológicos oriundos do uso de compostos psicoativos da maconha durante o período gestacional e de lactação, acometendo crianças e adolescentes. Além disso um estudo com finalidade de identificar na literatura a existência de estudos primários e secundários que avaliem a eficácia da Restruturação Cognitiva no contexto da redução do abuso de álcool. Juntamente, uma avaliação das evidências científicas acerca dos aspectos nutricionais envolvendo a patogênese e as abordagens terapêuticas multidisciplinares nas doenças inflamatórias intestinais. Além do mais, uma pesquisa afim de construir e validar o Instrumento de Rastreio para Sintomas de Ansiedade Gestacional. Finalizando com uma revisão sobre epilepsia, compreendendo-a em sua totalidade, do diagnóstico ao tratamento. Entre outros diversos assuntos. Agradecemos os autores que contribuíram com empenho e dedicação na construção dessa obra e esperamos que a mesma auxilie no debate e discussão dos temas aqui tratados. Boa leitura.
Article
A síndrome dos ovários policísticos (SOP) é um distúrbio multifatorial que ocorre em mulheres. Mudanças no estilo de vida, especialmente nos hábitos alimentares podem ter um papel no aumento da prevalência da SOP. Este estudo teve por objetivo investigar a associação da mudança de estilo de vida e padrão alimentar na SOP utilizando-se de revisão de literatura exploratória em artigos de língua inglesa. Por meio dos dados encontrados observa-se que mudanças no estilo de vida de mulheres com SOP precisam ser implementadas, visto que obesidade e resistência à insulina estão fortemente implicadas em sua etiologia e a redução desses fatores de risco devem ser o foco central do tratamento. O qual deve priorizar em uma reeducação alimentar e perda de peso, se necessário. Para assim, uma redução na resistência à insulina e na restauração da ovulação e fertilidade, sendo fundamental um acompanhamento de um nutricionista para auxiliar no processo.
Article
Dietary fiber is getting attention these days due to its tendency to improve the reproductive performance in human beings. Sodium alginate (SA) is one of the natural dietary fibers. The present study aimed to evaluate the effect of SA on serum insulin, blood sugar, lipid profile, estrogen and testosterone in polycystic (PCOS) females. A single in vivo trial was conducted on thirty adult PCOS females (25 ± 5 years old) with a body mass index (BMI) of 27.5 ± 3.5 kg m-2. Blood samples of all PCOS females were drawn for the initial biochemical analysis and considered as the negative control (NC). A complete randomized design was used to divide the NC group into three equal subgroups (n = 9) i.e. SA3: with 0.03 g; SA6: with 0.06 g per kg body weight per day of sodium alginate; the positive control (PC): metformin 500 mg day-1 for 60 days (two months). A significant reduction (p < 0.05) in the body weight, BMI, blood sugar, serum insulin, lipids and testosterone was observed, while a significant incremental effect (p < 0.05) was observed in the high-density lipoprotein level. The percentages of some physical parameters were also improved like obesity, menstrual cycle, physical activity, psychological issues and hirsutism. Therefore, the study concluded that SA exhibited therapeutic potential for weight management and the improvement of serum testosterone in PCOS females.
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A obra intitulada “Aspectos conceituais e metodológicos voltados para a área da saúde vol. 01”, publicada pela Brazilian Journals Publicações de Periódicos e Editora, apresenta um conjunto de trinta e dois capítulos que apresentam diversas temáticas do conhecimento da área da saúde. Entre eles, um estudo com objetivo de investigar os sintomas de ansiedade e depressão, e a imagem corporal em obesos submetidos à cirurgia bariátrica e metabólica. Outro com intuito de esclarecer a população sobre os fatores de risco para as DCVs, esclarecer sobre o potencial deletério dessas doenças e promover a saúde incentivando adoção de hábitos de vida saudáveis. Assim como uma pesquisa com o propósito de caracterizar a relação entre hábitos de vida, prevalência de DCNT, polifarmácia e interações medicamentosas em pacientes adultos/idosos pós Acidente Vascular Cerebral em atendimento fonoaudiológico em uma clínica escola. Também uma revisão sobre os efeitos psicológicos oriundos do uso de compostos psicoativos da maconha durante o período gestacional e de lactação, acometendo crianças e adolescentes. Além disso um estudo com finalidade de identificar na literatura a existência de estudos primários e secundários que avaliem a eficácia da Restruturação Cognitiva no contexto da redução do abuso de álcool. Juntamente, uma avaliação das evidências científicas acerca dos aspectos nutricionais envolvendo a patogênese e as abordagens terapêuticas multidisciplinares nas doenças inflamatórias intestinais. Além do mais, uma pesquisa afim de construir e validar o Instrumento de Rastreio para Sintomas de Ansiedade Gestacional. Finalizando com uma revisão sobre epilepsia, compreendendo-a em sua totalidade, do diagnóstico ao tratamento. Entre outros diversos assuntos. Agradecemos os autores que contribuíram com empenho e dedicação na construção dessa obra e esperamos que a mesma auxilie no debate e discussão dos temas aqui tratados. Boa leitura.
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Polycystic ovary syndrome (PCOS) is a common endocrine disorder, affecting women in reproductive age, characterized by chronic anovulation and hyperandrogenism. The etiology of PCOS is still unknown. However, several studies have suggested that insulin resistance plays an important role in the pathogenesis of the syndrome. As a consequence of insulin-resistance, women affected by PCOS often present abnormalities of glucose metabolism and lipid profile, and have an increased risk of type 2 diabetes and cardiovascular disease over-time. Besides insulin-resistance, it has been demonstrated that some of these women also have alterations in beta-cell-function. Both disorders (insulin-resistance and beta-cell-dysfunction) are recognized as major risk factors for the development of type 2 diabetes. Long-term studies, evaluating the glucose-insulin system in women affected by PCOS, have shown a higher incidence of glucose intolerance, including both impaired glucose tolerance and type 2 diabetes, compared to age and weight matched control populations. The risk of glucose intolerance among PCOS subjects seems to be approximately 5 to 10 fold higher than normal and appears not limited to a single ethnic group. Moreover, the onset of glucose intolerance in PCOS women has been reported to occur at an earlier age than in the normal population (approximately by the 3rd-4th decade of life). However, other risk factors such as obesity, a positive family history of type 2 diabetes and hyperandrogenism may contribute to increasing the diabetes risk in PCOS.
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Background: A previous paper reported the 6-month comparison of weight loss and metabolic changes in obese adults randomly assigned to either a low-carbohydrate diet or a conventional weight loss diet. Objective: To review the 1-year outcomes between these diets. Design: Randomized trial. Setting: Philadelphia Veterans Affairs Medical Center. Participants: 132 obese adults with a body mass index of 35 kg/m 2 or greater; 83% had diabetes or the metabolic syndrome. Intervention: Participants received counseling to either restrict carbohydrate intake to <30 g per day (low-carbohydrate diet) or to restrict caloric intake by 500 calories per day with <30% of calories from fat (conventional diet). Measurements: Changes in weight, lipid levels, glycemic control, and insulin sensitivity. Results: By 1 year, mean (±SD) weight change for persons on the low-carbohydrate diet was -5.1 ± 8.7 kg compared with -3.1 ± 8.4 kg for persons on the conventional diet. Differences between groups were not significant (-1.9 kg [95% Cl, -4.9 to 1.0 kg]; P = 0.20). For persons on the low-carbohydrate diet, triglyceride levels decreased more (P = 0.044) and high-density lipoprotein cholesterol levels decreased less (P = 0.025). As seen in the small group of persons with diabetes (n = 54) and after adjustment for covariates, hemoglobin A 1c levels improved more for persons on the low-carbohydrate diet These more favorable metabolic responses to a low-carbohydrate diet remained significant after adjustment for weight loss differences. Changes in other lipids or insulin sensitivity did not differ between groups. Limitations: These findings are limited by a high dropout rate (34%) and by suboptimal dietary adherence of the enrolled persons. Conclusion: Participants on a low-carbohydrate diet had more favorable overall outcomes at 1 year than did those on a conventional diet. Weight loss was similar between groups, but effects on atherogenic dyslipidemia and glycemic control were still more favorable with a low-carbohydrate diet after adjustment for differences in weight loss.
Article
BACKGROUND: A high proportion of infertile patients have polycystic ovarian syndrome (PCOS) with a reportedly greater risk of spontaneous abortion. Because of the close link between PCOS and obesity and the independent association of obesity with poor pregnancy outcomes, it is important to distinguish the possible confounding effect of body mass index (BMI) or other variables from that of PCOS. This study aims to determine the effect of PCOS status on the risk of spontaneous abortion with adjustment for body mass and several other confounding factors in a large cohort of pregnant infertile women. METHODS: The patients (n = 1018) were treated in a tertiary infertility centre. Their PCOS status was determined by standard criteria and their BMI had been taken less than 1 year before the pregnancy. Patients whose PCOS status or BMI measurements were not assessed were excluded. Student's t-test or χ2 test were used to test the difference between the PCOS and non-PCOS groups while a multivariate logistical regression model was used to assess the effect of PCOS, BMI and other confounding factors. RESULTS: Overall, the incidence of PCOS was 37% in this cohort. The overall incidence of spontaneous abortion in the study population was 21%. Univariate analysis showed that women with PCOS had a significantly greater risk of spontaneous abortion compared with non-PCOS women (25 versus 18%, P < 0.01). However, using multivariate logistic regression analysis this effect was reduced to a non-significant level [odds ratio (OR) = 1.10, 95% confidence interval (CI) 0.85–1.36] after adjusting for obesity and patients/treatment combination factor, and to nil after adjusting for all confounding factors considered in this study (OR = 0.98, 95% CI 0.75–1.28). CONCLUSION: The results of this study suggest that the higher risk of spontaneous abortion observed in women with PCOS is likely to be due to their high prevalence of obesity and the type of treatment they receive.
Article
Polycystic ovary syndrome (PCOS) is a very common disorder affecting 5–10% of women of reproductive age. The pivotal endocrine abnormalities of this syndrome are insulin resistance and ovarian and, to a lesser degree, adrenal hypersensitivity to hormonal stimulation. PCOS may manifest itself as early as the first decade of life by premature pubarche or menarche. Oligoamenorrhea in the first postpubarchal years, although very common, may be an early symptom of PCOS, especially in overweight girls with hirsutism or acne. Girls with low birth weight as well as a family history of diabetes mellitus or premature cardiovascular disease are at high risk for developing PCOS. Circulating bioavailable testosterone levels are usually elevated, while total testosterone may be normal due to low levels of sex hormone-binding globulin. The typical sonographic appearance of PCOS ovaries consists of high ovarian volume (>10mL) and the presence of 12 or more follicles in each ovary measuring 2–9mm in diameter. However, this finding is not specific, since it may occur in >20% of healthy girls. The therapeutic goals in adolescents with PCOS is first to restore bodyweight and menses and to reduce the signs of hyperandrogenism. The reduction of bodyweight in this young age group may require the collaboration of the pediatrician, dietitian, and psychotherapist. The adolescent should be urged to adopt a healthy lifestyle with the aim to maintain a normal body mass index throughout adolescence and adult life. The choice of medical therapy depends on the clinical presentation. Oral contraceptives are a good option when acne and hirsutism are the principal complaints. Adolescents with isolated cycle irregularity may be placed on a cyclical progestin regimen to induce withdrawal bleeding. Metformin, by decreasing insulin resistance, alleviates many of the hormonal disturbances and restores menses in a considerable proportion of patients. It may be used alone or in combination with oral contraceptives. Independently of medical treatment, restoration and maintenance of bodyweight within normal range is of paramount importance.
Article
Context: The scarcity of data addressing the health effects of popular diets is an important public health concern, especially since patients and physicians are interested in using popular diets as individualized eating strategies for disease prevention. Objective: To assess adherence rates and the effectiveness of 4 popular diets (Atkins, Zone, Weight Watchers, and Ornish) for weight loss and cardiac risk factor reduction. Design, Setting, and Participants: A single-center randomized trial at an academic medical center in Boston, Mass, of overweight or obese (body mass index: mean, 35; range, 27-42) adults aged 22 to 72 years with known hypertension, dyslipidemia, or fasting hyperglycemia. Participants were enrolled starting July 18, 2000, and randomized to 4 popular diet groups until January 24, 2002. Intervention: A total of 160 participants were randomly assigned to either Atkins (carbohydrate restriction, n=40). Zone (macronutrient balance, n=40), Weight Watchers (calorie restriction, n=40), or Ornish (fat restriction, n=40) diet groups. After 2 months of maximum effort, participants selected their own levels of dietary adherence. Main Outcome Measures: One-year changes in baseline weight and cardiac risk factors, and self-selected dietary adherence rates per self-report. Results: Assuming no change from baseline for participants who discontinued the study, mean (SD) weight loss at 1 year was 2.1 (4.8) kg for Atkins (21 [53 %] of 40 participants completed, P=.009), 3.2 (6.0) kg for Zone (26 [65%] of 40 completed, P=.002), 3.0 (4.9) kg for Weight Watchers (26 [65%] of 40 completed, P<.001), and 3.3 (7.3) kg for Ornish (20 [50%] of 40 completed, P=.007). Greater effects were observed in study completers. Each diet significantly reduced the low-density lipoprotein/high-density lipoprotein (HDL) cholesterol ratio by approximately 10% (all P<.05), with no significant effects on blood pressure or glucose at 1 year. Amount of weight loss was associated with self-reported dietary adherence level (r=0.60; P<.001) but not with diet type (r=0.07; P= .40). For each diet, decreasing levels of total/HDL cholesterol, C-reactive protein, and insulin were significantly associated with weight loss (mean r=0.36, 0.37, and 0.39, respectively) with no significant difference between diets (P= .48, P= .57, P= .31, respectively). Conclusions: Each popular diet modestly reduced body weight and several cardiac risk factors at 1 year. Overall dietary adherence rates were low, although increased adherence was associated with greater weight loss and cardiac risk factor reductions for each diet group.