Perplexing polycystic ovary syndrome
Health-care team applauds client who worked through lifestyle, diet changes
By Susie Langley
Maura is a 31-year-old married professional referred for infertility and polycystic ovary syndrome (PCOS), a metabolic syndrome characterized by hyper andro genism (hirsutism and acne), menstrual irregularities and insulin resistance.
On her first visit, Maura was highly anxious about her pending pregnancy test results since she had already experienced two miscarriages. Feeling depressed and unattractive, she tearfully exclaimed: “I do not want to get diabetes like my mother!”
Her mother, who also has PCOS, suffers from severe psoriatic arthritis and anemia. Maura noted a medical history of iron deficiency anemia and juvenile arthritis, which has been in remission for several years. She also had borderline high blood sugar and high blood pressure. Her fertility specialist prescribed metformin to improve her insulin resistance and fertility status and to lower elevated blood sugar, testosterone, prolactin and luteinizing hormone to follicle stimulating hormone ratio, commonly seen in PCOS.
The nutrition assessment revealed a history of chronic dieting without lasting weight loss. Four years earlier she had lost 40 lbs (18 kg)—down to 160 lbs (72 kg)—on the Bernstein Diet (800 Kcal, low carbohydrate with B vitamin injections) but regained this weight and more (up to 240 lbs, or 108 kg) over the past two years.
Searching the Internet, Maura found an infertility help group advocating “the insulin control diet.” Thinking this might improve her chances for pregnancy, she wanted to try this high-protein, low-carbohydrate approach again, until she learned the diet was based on Dr. Atkin’s New Diet Revolution. She recalled her intense craving for sweets on similar fad diets and the ensuing guilt and poor self-esteem that followed her binges. Physical activity had not been a high priority in her stressful lifestyle, though she did enjoy walking her dog.
Maura’s food diary reflected a chaotic eating pattern—meal skipping, restrictive eating and bingeing. Further, she only ate with her husband on weekends due to his late-night work schedule. Thus, she was not motivated to prepare balanced meals for herself.
She chose mainly fast foods such as burgers and fries when out with friends or salty, highly refined convenience foods like instant noodle soups, pastas, mashed potatoes and low-fat commercial cookies and crackers with a high glycemic index at home. Fibre from whole grains, fresh vegetables, fruits and legumes was lacking and she did not consistently eat enough protein (lean red meat, poultry, fish, lower-fat dairy products) at daily meals. She also did not get enough beneficial monounsaturated and omega-3 fats because of her low-fat approach to weight loss. She supplemented her diet with an iron and folic acid supplement and occasionally took one or two calcium carbonate tablets.
PCOS is one of the most common causes of infertility and affects 5% to 10% of premenopausal women. The actual presence of polycystic ovaries is not essential for a positive diagnosis. However, polycystic ovaries are due to incomplete development or failure to ovulate, so are often seen in women recovering from anorexia nervosa or bulimia. Although obesity is a common characteristic, only 35% to 50% of PCOS women are obese.
PCOS is not unlike Syndrome X, where the “apple shape,” insulin resistance, glucose intolerance and hypertension are markers. PCOS women often have a waist to hip ratio greater than 0.8. Excess weight gain in these women further contributes to insulin resistance, making weight loss extremely difficult without regular physical activity. In fact, lack of physical activity is said to exacerbate this syndrome.
According to Dr. Jean-Patrice Baillergeon, at the University of Sherbrooke, the primary treatment of obese PCOS patients is weight loss. He says “a 5% weight loss in infertile, obese patients (BMI>27) results in a 70% rate of spontaneous conception and a 40% reduction in hirsutism.” Others have stated that losing as little as 5% to 10% of weight via regular physical activity plus a balanced, individualized meal plan can improve chances for pregnancy.
Dr. Sheila Laredo, of Sunnybrook and Women’s College Health Sciences Centre in Toronto, is conducting a study to determine whether lifestyle factors such as the addition of exercise to a healthy diet can improve ovulation rates in women with PCOS. Dr. Laredo adds: “We also wish to determine whether exercise can benefit these women with respect to blood pressure, cholesterol, excessive hair growth, body weight and body fat.” (Women interested in participating in this study can call (416) 351-2536 for information.)
Whenever possible, lifestyle counselling including stress and anxiety management, regular and enjoyable physical activity along with a non-diet approach to weight loss should be promoted by the entire health-care team. A dietitian often plays an important role, since PCOS women are potentially at a higher risk for heart disease, type 2 diabetes, hypertension and possibly endometrial cancer. Individualized dietary counselling and education on cardiovascular risk factors, hyperlipidemia, obesity, disordered eating, glucose intolerance, high blood pressure with promotion of regular physical activity are key. Cigarette smoking should be strongly discouraged due to exacerbation of the increased risk for atherosclerosis and aggravation of insulin resistance.
There is no consensus on dietary management for PCOS. But the main message is clear—diets don’t work. Many dietetic and diabetic professionals promote carbohydrate controlled menus with more fibre from whole or unprocessed grains, fresh vegetables, fruits and legumes, with special emphasis on using more monounsaturated fats (olive, canola and peanut oils, avocado, walnuts, flaxseeds). Moderate to slightly higher amounts of lean proteins (for satiety and glycemic control) can also be helpful for some.
Encouraging lower glycemic index (GI) foods may assist appetite control, but probably should not be enforced in the strictest sense—since we consume mixed meals, not just single foods. Mixing a high GI food with some protein and fat will produce a different GI for the whole meal. Combining unrefined or unprocessed grains and vegetables with lean proteins, and encouraging a little more of the beneficial fats —monounsaturated fats and omega-3 fats (salmon, canola oil, soybean and flaxseed oils and walnuts) can be a positive approach to health, enjoyment of food and prevention of chronic diseases.
Once Maura started putting some structure in her meal pattern—with more fibre and protein—she did not crave as many sweets or refined snacks. Even though there were only modest changes in weight, her parameters improved. She had tapered her soft drinks and increased her calcium from dairy foods. She was still afraid to incorporate even healthy fats in her diet but agreed to give it a try. Her positive pregnancy test was a strong motivator to eat regular meals and snacks, since there was the possibility of gestational diabetes. She began a regular walking program that also included walking her dog. The health-care team is cheering her on with continued support for lifestyle changes and education about this perplexing syndrome.
—Susie Langley is a Toronto clinical dietitian.