Are Dieting and Dietary Inadequacy a Second Hit in the Association with Polycystic Ovary Syndrome Severity?

Comparison of dietary and physical activity behaviors in women with and without polycystic ovary syndrome: a systematic review and meta-analysis of 39 471 women

BACKGROUND

Lifestyle (dietary and/or physical activity [PA]) modification is recommended as first-line therapy to manage polycystic ovary syndrome (PCOS). Current recommendations are based on healthy lifestyle practices for the general public since evidence for unique lifestyle approaches in PCOS is limited and low quality.

OBJECTIVE AND RATIONALE

We aimed to synthesize evidence on dietary and PA behaviors between women with PCOS and those without PCOS. Primary outcomes were overall diet quality, total energy intake and total PA, and secondary outcomes included macronutrients, micronutrients, food groups, foods, glycemic indices, sedentary time and sitting levels. We conducted this work to identify any unique lifestyle behaviors in women with PCOS that could underlie the propensity of weight gain and obesity in PCOS and be targeted for precision nutrition and PA interventions. These findings could be used to inform future practice recommendations and research that more effectively address complications (weight gain, obesity, diabetes, infertility, cardiovascular disease and mental health) in this high-risk population.

SEARCH METHODS

Databases of MEDLINE, Web of Science, Scopus and CINAHL were searched until 15 February 2022 to identify observational studies documenting dietary and PA behaviors between women with PCOS and without PCOS (Controls). Studies on children, adolescents (<18 years), pregnant or menopausal-aged women (>50 years) were excluded. Data were pooled by random-effects models and expressed as (standardized) mean differences (MD) and 95% CIs. The risk of bias was assessed by the Newcastle-Ottawa scale (NOS).

OUTCOMES

Fifty-four studies (N = 39 471 participants; [n = 8736 PCOS; 30 735 Controls]) were eligible (96%; [52/54] NOS scores ≥ 7). Women with PCOS had higher cholesterol (MD: 12.78, 95% CI: 1.48 to 24.08 mg/day; P = 0.03; I2 = 19%), lower magnesium (MD: -21.46, 95% CI: -41.03 to -1.91 mg/day; P = 0.03; I2 = 76%), and a tendency for lower zinc (MD: -1.08, 95% CI: -2.19 to -0.03 mg/day; P = 0.05; I2 = 96%) intake, despite lower alcohol consumption (MD: -0.95, 95% CI: -1.67 to 0.22 g/day; P = 0.02; I2 = 0%) versus Controls. Also, women with PCOS had lower total PA (standardized mean difference: -0.38, 95% CI: -0.72 to 0.03; P = 0.03; I2 = 98%). Conversely, energy, macronutrients (carbohydrate, fat, protein, fiber), micronutrients (folic acid, iron, calcium, sodium), glycemic index and glycemic load were similar (all: P ≥ 0.06). Most eligible studies reported lower total adherence to healthy eating patterns or poorer consumption of major food groups (grains, fruits, vegetables, proteins, seeds, nuts, dairy) in women with PCOS, as described narratively since variable study methodology did not permit meta-analyses.

WIDER IMPLICATIONS

Collective evidence supports that women with PCOS have a lower overall diet quality, poorer dietary intakes (higher cholesterol, lower magnesium and zinc) and lower total PA, despite lower alcohol consumption versus those without PCOS. Considerable heterogeneity among studies reinforces the need for research to address any relative contributions of other factors (e.g. genetic, metabolic or sociodemographic) to the observed differences. These clarifications may contribute to future evidence-based guideline recommendations on monitoring and managing PCOS in the era of precision lifestyle medicine.

Effects of multidimensional life management on healthy behavior in polycystic ovary syndrome patients: A randomized controlled trial

Objective

To confirm the effects of a transtheoretical model (TTM) based on multidimensional life management on healthy behavior in patients with polycystic ovary syndrome (PCOS).

Methods

In total, eighty eligible patients were recruited from March 2021 to June 2021 and randomly assigned to either the intervention (n = 40) or control (n = 40) groups. Outcome measures include health-promoting behavior, self-efficacy, anthropometrics, and the number of unplanned outpatient admissions. Data were collected at baseline, 3, and 6 months after the intervention. The chi-square test, rank-sum test, t-test, and repeated measurement analysis of variance (ANOVA) were used to analyze the data.

Results

In total, sixty-six participants completed the study: 35 participants in the intervention group and 31 participants in the control group. After 6 months of intervention, the healthy behavior level of patients with PCOS increased from moderate [health-promoting lifestyle profile (HPLP)-II score of 105.37 ± 12.57] to good (156.94 ± 19.36) in the intervention group; and there was no change observed in the control group. In addition, the total self-efficacy score (p < 0.001), PCOS-related unplanned outpatient admissions (p = 0.008), waist circumference (WC) (p = 0.016), and body mass index (BMI) (p = 0.011) were found to have a significant difference in the intervention group at 6 months. Meanwhile, repeated measures analysis of variance showed a significantly greater improvement in health-promoting behavior and self-efficacy over time in the intervention group than in the control group (p < 0.001).

Conclusion

The transtheoretical model based on multidimensional life management positively affected healthy behavior, self-efficacy, the number of unplanned outpatient admissions, and anthropometrics in patients with PCOS.

Clinical Trial Registration

www.chictr.org.cn, ChiCTR2000034572.

Polycystic Ovary Syndrome: A Brain Disorder Characterized by Eating Problems Originating during Puberty and Adolescence

Polycystic ovary syndrome (PCOS) is an endocrine condition associated with reproductive and psychiatric disorders, and with obesity. Eating disorders, such as bulimia and recurrent dieting, are also linked to PCOS. They can lead to the epigenetic dysregulation of the hypothalamic-pituitary-gonadal (HPG) axis, thereby impacting on ovarian folliculogenesis. We postulate that PCOS is induced by psychological distress and episodes of overeating and/or dieting during puberty and adolescence, when body dissatisfaction and emotional distress are often present. We propose that upregulated activation of the central HPG axis during this period can be epigenetically altered by psychological stressors and by bulimia/recurrent dieting, which are common during adolescence and which can lead to PCOS. This hypothesis is based on events that occur during a largely neglected stage of female reproductive development. To date, most research into the origins of PCOS has focused on the prenatal induction of this disorder, particularly in utero androgenization and the role of anti-Müllerian hormone. Establishing causality in our peripubertal model requires prospective cohort studies from infancy. Mechanistic studies should consider the role of the gut microbiota in addition to the epigenetic regulation of (neuro) hormones. Finally, clinicians should consider the importance of underlying chronic psychological distress and eating disorders in PCOS.

Low intakes of dietary fiber and magnesium are associated with insulin resistance and hyperandrogenism in polycystic ovary syndrome: A cohort study

BACKGROUND

Women with polycystic ovary syndrome (PCOS) often have insulin resistance (IR) which may be worsened by obesity. The roles of dietary intake and activity are unclear. Our objectives were to determine whether (a) high caloric intake or inactivity explains obesity in PCOS, and (b) dietary composition is associated with PCOS phenotypes.

METHODS

Eighty-seven women with PCOS and 50 women without PCOS participated in this cohort study at a reproductive medicine center. Data collected included 3-day food and physical activity records, anthropometrics, and metabolic and hormonal assays.

RESULTS

Women with PCOS had increased body mass index (BMI) but similar caloric intake and activity to women without PCOS. There were no differences in protein, carbohydrates, fat, or glycemic load consumption, but women with PCOS consumed less fiber (medians: 19.6 vs. 24.7 g) and less magnesium (medians: 238.9 vs. 273.9 mg). In women with PCOS, those with IR consumed less fiber, less magnesium, and greater glycemic load than those without IR (medians: 18.2 vs. 22.1 g, 208.4 vs. 264.5 mg, 89.6 vs. 83.5). Fiber intake of women with PCOS was negatively correlated with IR, fasting insulin, glucose tolerance, testosterone, and dehydroepiandrosterone sulfate. Magnesium intake was negatively correlated with IR, C-reactive protein, and testosterone, but positively correlated with HDL cholesterol. Fiber intake and BMI accounted for 54.0% of the variance observed in IR.

CONCLUSIONS

Obesity in women with PCOS could not be explained by overeating or inactivity. Increasing dietary fiber and magnesium intakes may assist in reducing IR and hyperandrogenemia in women with PCOS.

Association of testosterone and antimüllerian hormone with time to pregnancy and pregnancy loss in fecund women attempting pregnancy

OBJECTIVE

To examine whether higher T and/or antimüllerian hormone (AMH) was associated with anovulation, time to pregnancy (TTP), or pregnancy loss risk among healthy, fecund women without diagnosed polycystic ovary syndrome.

DESIGN

Prospective cohort study conducted as a secondary analysis from the Effects of Aspirin in Gestation and Reproduction randomized trial.

SETTING

University medical centers.

PATIENT(S)

A total of 1,198 healthy, eumenorrheic women aged 18-40 years attempting spontaneous pregnancy with one to two prior pregnancy losses were included. Women were categorized by baseline antimüllerian hormone (AMH), as a surrogate marker of antral follicle count, and T concentrations; the highest quartile for each was "high," and below the top quartile (i.e., lower 75% of values) was "norm," forming four groups: norm T/norm AMH (n = 742), norm T/high AMH (n = 156), high T/norm AMH (n = 157), and high T/high AMH (n = 143).

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Anovulation, pregnancy incidence, TTP, and pregnancy loss incidence.

RESULT(S)

Women with high T/high AMH had a greater anovulation risk (risk ratio 1.58, 95% confidence interval 1.13-2.22) compared with women with norm T/norm AMH, but with imprecise differences in incidence of pregnancy, TTP, or pregnancy loss.

CONCLUSION(S)

Women with higher T and AMH had more frequent anovulatory cycles but with marginal impacts on TTP or pregnancy loss. A continuum of mild inefficiency in reproductive function may be related to higher T and AMH, including in fecund women with normal menstrual cycles and no clinical diagnosis of polycystic ovary syndrome, but with unclear effects on fecundability and pregnancy loss.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00467363.

Dietary patterns and the phenotype of polycystic ovary syndrome: the chance of ongoing pregnancy

Polycystic ovary syndrome (PCOS) is generally considered a complex disorder caused by interactions between genetic and environmental factors. In a sub-cohort of women with PCOS visiting the preconception outpatient clinic of a tertiary hospital with follow-up in a periconception cohort, we identified specific dietary patterns and adherence in patients with PCOS with and without hyperandrogenism and the chance of ongoing pregnancy. Food frequency questionnaires were available from 55 patients diagnosed with PCOS during follow-up in routine clinical practice, including 25 with hyperandrogenism and 30 without hyperandrogenism. Strong adherence to the healthy dietary pattern was inversely associated with the hyperandrogenic PCOS phenotype (Adjusted OR 0.27; 95% CI 0.07 to 0.99). In women with PCOS overall, a strong adherence to the healthy dietary pattern showed a three-fold higher chance of ongoing pregnancy (adjusted OR 3.38; 95% CI 1.01 to 11.36) and an association with anti-Müllerian hormone concentration (β -0.569 µg/L; 95% CI -0.97 to -0.17). The effect of this dietary pattern on the chance of ongoing pregnancy and AMH suggests causality, which needs further investigation in prospective studies in the general population.

A three-component cognitive behavioural lifestyle program for preconceptional weight-loss in women with polycystic ovary syndrome (PCOS): a protocol for a randomized controlled trial

Background

Obesity in women with polycystic ovary syndrome (PCOS) negatively affects all clinical features, and a 5 to 10% weight loss has shown promising results on reproductive, metabolic and psychological level. Incorporating a healthy diet, increasing physical activity and changing dysfunctional thought patterns in women with PCOS are key points in losing weight. The biggest challenge in weight management programs is to achieve a reasonable and sustainable weight loss. The aim of this study is to explore whether Cognitive Behavioural Therapy (CBT) by a mental health professional, working in a multidisciplinary team with a dietician and a physical therapist (a three-component intervention), is more effective for weight loss in the long term, within 12 months. We will also explore whether mobile phone applications are effective in supporting behavioural change and sustainable weight loss.

Methods

The present study is a longitudinal randomized controlled trial (RCT) to study the effectiveness of a three-component 1-year cognitive-behavioural lifestyle intervention in overweight/obese women with PCOS. A total of 210 participants are randomly assigned to three groups: 1) CBT provided by the multidisciplinary team or; 2) CBT provided by the multidisciplinary team and Short Message Service (SMS) or; 3) usual care: encourage weight loss through publicly available services (control group). The primary aim of the 12-month intervention is to explore whether a three-component 1-year cognitive-behavioural lifestyle intervention is effective to decrease weight, when compared to usual care. Secondary outcomes include: the effect of the intervention on the PCOS phenotype, waist circumference, waist to hip ratio, ovulation rates, total testosterone, SHBG, free androgen index (FAI), AMH, hirsutism, acne, fasting glucose, blood pressure and all psychological parameters. Additionally, we assessed time to pregnancy, ongoing pregnancies, clinical pregnancies, miscarriages and birth weight.

All outcome variables are measured at the start of the study, and again at 3 months, 6 months, nine months and 12 months.

Discussion

We expect that CBT provided by a multidisciplinary team, especially combined with SMS, is effective in developing a healthy lifestyle and achieving a long-term weight loss in women with PCOS. Losing 5– 10% body weight improves various PCOS characteristics. Consequently, we expect to show that CBT provided by a multidisciplinary team improves reproductive and metabolic outcomes, as well as quality of life, while at the same time being cost-effective.

Trial registration

Registered at the Netherlands National Trial Register with number NTR2450 on August 2nd, 2010.