kat note: this article is loooooong but good
Journal of the American Dietetic Association
Case Problem: Dietary recommendations to combat obesity, insulin resistance, and other concerns related to polycystic ovary syndrome.
CR is an 18-year-old Hispanic woman with polycystic ovary syndrome (PCOS). PCOS is an endocrine disorder characterized by hyperandrogenism and insulin resistance. The most common symptoms include oligoamenorrhea, hirsutism, and acne. The diagnostic criteria for PCOS are controversial: there is no agreed-upon determinant for a definitive diagnosis. (See Figure for clinical profile of CR.)
CR was diagnosed at her annual physical at a school-based health center at age 17 years, when she complained of irregular menses. CR reported irregular menses since menarche at age 14 years. At the time of her exam, she had not menstruated for 4 months and reported that her last menses was a result of successful Provera challenge (medroxyprogesterone; Upjohn, Kalamazoo, Mich) by a community physician with whom she had not followed up. Provera is a synthetic progestin that, when taken orally for 10 days, can simulate the secretory stage of menstruation. A successful challenge indicates adequate estrogen levels and produces a withdrawal bleed.
Excess facial hair was noted on CR’s upper lip and chin, with acanthosis nigricans visible on her neck and waist. Acanthosis nigricans is a dark, velvety patch of skin that indicates insulin resistance. CR’s family history showed a prevalence of diabetes and hypertension. At CR’s request, a nutrition referral was made for weight loss.
At the initial nutrition assessment, CR was a poor historian; she reported skipping meals and unsuccessfully following very-low-energy diets to lose weight quickly. A 24-hour recall showed an intake of approximately 250 kcal from rice; CR expressed extreme guilt about eating what she called a “fattening food.” The dietitian interviewed CR for disordered eating characteristics and discovered that CR often ate larger-than-normal amounts of food–particularly bread and butter–in an attempt to “fill the empty hole.” She admitted to eating past the point of fullness and refused to eat with her family because she was too embarrassed about her weight.
She denied self-induced vomiting, laxative use, or the use of other compensatory mechanisms.
A review of the Food Guide Pyramid  showed that CR had poor nutrition knowledge, with many misconceptions about the energy and nutrient contents of foods. Nutrition education addressed CR’s specific questions relating to the “fattening” properties of rice and bread, the 2 staple foods in her home. CR did not exercise regularly, stating as the reason a history of asthma and shortness of breath when exerting herself.
No specific nutrition goals were set for CR at the first visit. Because of the characteristic binge-eating behaviors shown by CR, an appointment for the health center social worker was made and CR was given an invitation to participate in a nutrition group on PCOS in the health center the next day.
CR did not understand why her periods did not come every month like other girls and she did not make any connection among PCOS, her weight, and eating habits. The physicians she had seen prescribed medicine but had not provided her with any education on her diagnosis. A 1-week follow-up appointment was made to allow CR to have fasting blood drawn and analyzed for glucose and lipid levels because of the increased risk for diabetes and cardiovascular disease in women with PCOS.
CR attended the group on PCOS, led by the registered dietitian and a nurse practitioner. This particular group session reviewed the hormones involved in normal menstruation to give the participants a better understanding of how the reproductive system works. Irregular menses was described as a hormonal imbalance. Diet, exercise, stress reduction, and medications for restoring the balance of hormones were discussed.
Although the school-based health care setting allowed for weekly visits, CR did not return to the clinic for her next visit. She had attended one appointment with the social worker who discovered depression and poor school performance as a result of bereavement issues; he had recommended regular counseling to deal with these problems and her disordered eating, but CR did not return to the clinic for her laboratory tests.
After 1 month, CR returned to the clinic on her own. She understood from her physician that weight loss would help her cure her “period problem,” but she felt hopeless that she could achieve such a goal. She stated that she continued to skip meals and eat large portions of food, particularly in the evening. The dietitian discussed previous diets that CR had reported as trying unsuccessfully. Upon discussion, CR appeared to be genuinely surprised to admit that she had not been able to stay on any single diet plan for more than 3 days. After admitting to hunger pains, she agreed to try 1 week of eating more frequently, with the goal of eating 5 to 6 times per day without any dietary restrictions. A self-blinded weight check showed a 12-lb weight gain in 1 month; CR refused to meet again with the social worker, stating that she had talked instead with a different counselor in the school.
One week later, CR returned for her nutrition appointment. She had successfully eaten 3 to 4 times per day for 3 consecutive days, but felt the need for more control and requested a written meal plan. The registered dietitian worked with CR to create sample menus, encouraging a variety of food groups with a focus on whole grains, fruits, and vegetables. The final menus were inadequate in energy and calcium, but CR felt that they would give her enough structure for 1 week. The registered dietitian reinforced listening to the hunger cues that CR’s body would send her and agreed to reevaluate the diet in 1 week.
CR continued to be noncompliant with appointments, but informal visits in the hallway revealed improved eating frequency and an apparent stable weight. CR shared that she was afraid of weight-loss failure. The registered dietitian was unable to reengage CR in nutrition counseling for another 6 months. At that time, CR agreed to a revisit with the social worker, where she revealed suicidal ideations secondary to her weight and irregular menses that made her feel, as she said, “like a man.” She had not followed up with her appointments with physicians and had not menstruated in 9 months.
Nutrition reassessment showed 2 to 3 meals per day with a low intake of complex carbohydrates, inadequate in nutrients and energy. CR continued to be a poor diet historian, but she stated a decreased frequency of binges. A blinded weight check showed no change in 6 months.
CR was mostly upset by the visible signs of insulin resistance–the acanthosis nigricans on her neck and waist. The dietitian assessed CR’s knowledge of diabetes and the role of insulin in the body. CR was familiar with some concepts of diabetes management based on the experiences of family members. The dietitian expanded on the role of insulin and explained how exercise helps to improve the body’s use of insulin. She strongly encouraged CR to have her fasting blood work analyzed and to reschedule her appointment with her physician.
Anthropometric measurements were taken (see Table) and CR signed a contract to increase her activity levels using a pedometer to keep track of the number of steps she walked daily. The goal of 6,000 steps per day was set, with CR agreeing to increase the number of steps if it was too easy. Her nutrition goals were to drink 8 glasses of water per day, to eat 2 pieces of whole fruit per day, and to attempt to eat a minimum of 3 times per day. After 2 weeks, the contract indicated that CR could make changes to the plan, but CR needed to commit to the 2-week time frame.
CR had her fasting blood drawn for analysis the next day and was relieved to discover the normal results. At 2 weeks, CR had achieved the 6,000 steps per day and she reported that she felt much better and wanted to continue the program. She did not, however, want to be weighed or measured for another 2 weeks. Although she was not monitoring the exact energy or nutrient intake of CR at this point, the dietitian agreed to wait for the measurements, provided CR committed to keeping her appointments.
After 1 month had passed, CR returned and reported taking approximately 8,000 steps every day; she also had tried to increase her fiber intake and was enormously enjoying cauliflower. An unblinded weight check, conducted at CR’s request, showed an appropriate 15-lb weight loss with global decreases in anthropometric measurements (see Table). CR was happy with her progress and highly motivated to learn more about exercise, insulin resistance, and healthful eating.
CR had been seeing the social worker biweekly and reported improved body acceptance, but she continued to be amenorrheic (because of the PCOS). The weight loss gave her improved confidence and she visited a gynecologist who provided her with education regarding the use of oral contraceptives to regulate her periods. CR had never been sexually active and was concerned about using the pills; she opted for Provera withdrawal bleeds every 3 months.
When CR started a new job, she reported that although she liked using the pedometer to monitor her improvements in her activity levels, she felt that she did not have enough time every day to continue the 8,000 steps. She and the registered dietitian developed an at-home workout using Dyna Bands (Fitness Wholesale, Stow, Ohio), a form of resistance training that could be used in conjunction with the pedometer program. At her 1-month measurements, she was thrilled to see that her modified diet and exercise program was continuing to work; she lost an additional 9 lbs and continued to show decreased body measurements. She continued to eat 3 to 4 times per day with a salad at 1 meal and 1 piece of whole fruit per day.
At her most recent visit, CR told the dietitian that she would like to have a baby in the future. For now, however, she had decided to start the birth control pills even though she planned to remain sexually inactive. She was present at the birth of her cousin’s baby 1 week earlier and was extremely relieved to know that different treatment options exist for women with fertility problems and PCOS, The dietitian was able to provide positive reinforcement for the health decisions that CR has been making. After CR returned for her third measurement, she was to begin a prescription of oral contraceptives.
(1.) Food Guide Pyramid: A Guide to Daily Food Choices. Washington, DC: US Dept of Agriculture, Human Nutrition Information Service: 1992. Home and Garden Bulletin No. 232.
Polycystic ovary syndrome (PCOS) usually begins in adolescence, although it is difficult to predict whether the symptoms of the syndrome will persist in adulthood or self-correct [1,2]. The characteristic symptoms of PCOS–irregular menses, insulin resistance, overweight or obesity, and hyperandrogenism –are similar in both adolescence and adulthood; however, overweight is less common during adolescence . Both age groups tend to have android body types, with waist-to-hip ratios greater than 0.8, even in the presence of normal body mass index .
The unique insulin resistance seen in women with PCOS increases the risk of cardiovascular disease independent of obesity, type 2 diabetes mellitus, and reproductive cancers . Women with PCOS need to be educated about and understand the health implications of the syndrome. Appropriate health-related screenings–including lipid analysis, glucose tolerance tests, and regular checkups with a gynecologist–should be part of the care plan for all women with PCOS.
The diagnosis of PCOS is based on clinical signs and symptoms of hyperandrogenism in the presence of menstrual irregularities after excluding other possible causes (ie, nonclassic congenital adrenal hyperplasia, Cushing’s syndrome, and hyperprolactinemia) . An ultrasound showing ovarian cysts is not necessary to make a diagnosis . Symptoms of high androgen levels may include male balding patterns; excessive hair growth on the face, chest, and/or back; oiliness of the skin; and cystic acne. As a diagnostic measure, an elevated ratio of luteinizing hormone to follicle-stimulating hormone is insensitive, failing to detect PCOS in at least 50% of women with the syndrome. Elevated total testosterone levels or the free androgen index are better measurements that are more accurate, diagnosing even women without visible signs of elevated androgens .
Eating disorders and body image problems can also begin in adolescence. Women with PCOS are often instructed to lose weight by their physician but are given very little, if any, guidance on safe dieting practices. PCOS has been associated with a higher incidence of disordered eating; binge eating and fasting are the most common behaviors . The extreme variations in energy intake of these behaviors may contribute to or exacerbate the insulin resistance that is found in both overweight and lean women with PCOS . All women with PCOS should be screened for disordered eating behaviors before beginning weight-loss treatment, and interdisciplinary referrals should be made as appropriate.
Thirty-one percent of women with PCOS have impaired glucose tolerance and 7.5% to 16% have type 2 diabetes mellitus. Because of the association among PCOS, insulin, and diabetes, women with PCOS commonly attempt to follow low-carbohydrate or no-carbohydrate diets. There is no consensus however, on how to treat insulin resistance or how to prevent the onset of type 2 diabetes. The American Dietetic Association and the American Diabetes Association both support individualized dietary treatment. They recommend that for people with type 2 diabetes or with insulin resistance, the majority of energy intake should be divided between monounsaturated fats and carbohydrates to provide 60% to 70% of total daily energy needs. This division of energy provides a higher intake of energy as fat than most women with disordered eating would consider on their own.
Weight loss has been the major recommendation by physicians for women with PCOS. Lifestyle modifications including stress reduction, exercise, and group support, along with a decrease in total energy intake, have had positive results . A weight decrease of only 5% of total body weight is associated with decreased insulin levels, improved menstrual function, reduced hirsutism and acne, and lower free testosterone levels [2,11-12]. Exercise has been shown to improve use of insulin and can support dietary interventions to promote weight loss ; it is important that the exercise program chosen is enjoyable for the client. A combination of diet and exercise improves the sustainability of the interventions .
Physicians commonly prescribe oral contraceptives for women with PCOS to regulate menstruation, to prevent endometrial buildup, and to decrease ovarian androgen production . In women with insulin resistance, long-term use of oral contraceptives may increase the odds of developing impaired glucose tolerance or type 2 diabetes, but sufficient long-term studies specific to PCOS are not available . A Provera withdrawal bleed once every 3 months can also be used for high-risk patients or for those who are opposed to the use of oral contraceptives because of religious, cultural, or personal reasons.
Some women with PCOS can benefit from the use of insulin sensitizing medications as well. A fasting glucose-to-insulin ratio is useful in identifying the women with PCOS who would be most likely to benefit from these medications. A ratio value of less than 4.5 is considered abnormal . Several studies using metformin show reduced hyperinsulinemia and hyperandrogenemia, independent of changes in body weight [7,14]. The long-term effects of metformin on women with PCOS are not known, however, and dietary intervention should remain the first line of treatment for many women. Troglitazone–another insulin sensitizer shown to be effective in the treatment of PCOS –was taken off the market by the US Food and Drug Administration in March 2000 because it effected liver complications. It is important to remember that diet and exercise interventions are the least expensive, least invasive, and safest way to control overweight and/or hyperinsulinemla .
Nutrition therapy should be an important intervention for women with PCOS. Because modifications in diet, exercise, and disordered eating behaviors can improve the symptoms of PCOS in many women, dietetics professionals can play an important role in women’s health.
(1.) Apter A. How possible is the prevention of PCOS development in adolescent patients with early onset of hyperandrogenism? J Endocrinol Invest. 1998:613-617.
(2.) Legro RS, Dunaif A. Menstrual disorders in insulin resistant states. Diabetes Spectr. 1997:10:185-190.
(3.) Cortett-Rudelli C, Dewailly D. How actual is the dietary treatment in overweight patients with PCOS? J Endocrinol invest 1998;21:636-640.
(4.) Mather KJ, Kwan F, Corenblum B. Hyperinsulinemia in polycystic ovary syndrome correlates with cardiovascular risk independent of obesity. Fertil Steril. 2000:73:150-156.
(5.) Legro RS. Polycystic ovary syndrome: current and future treatment paradigms. Am J Obstet Gynecol. 1998:179[suppl]:S101-S108.
(6.) McCluskey S. Evans C, Lacey JH, Pearce JM, Jacobs H. Polycystic ovary syndrome and bulimia. Fertil Steril. 1991:55:287-291.
(7.) Ehrman DA. Attenuation of hyperinsulinemia in polycystic ovary syndrome: what are the options? J Endocrinol Invest. 1998:21:632-635.
(8.) American Diabetes Association. Type 2 diabetes in children and adolescents. Pediatrics. 2000;105:671-680.
(9.) Concensus Development Conference on Insulin Resistance. 5-6 November 1997. American Diabetes Association. Diabetes Care. 1998;21:310-314.
(10.) Lipkin E. New strategies for the treatment of type 2 diabetes. J Am Diet Assoc. 1999;99:329-334.
(11.) Huber Buchholz MM, Carey DGP, Norman RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab. 1999:84:1470-1474.
(12.) Galletly C, Clark A, Tomlinson L, Blaney F. Improved pregnancy rates for obese, infertile women following a group treatment program. Gen Hosp Psych. 1996192-195.
(13.) Legro RS, Finegood D, Dunaif A. A fasting insulin to glucose ratio is a useful measure of insulin sensitivity in women with PCOS. J Clin Endocrinol Metab. 1998:83:2694-2698.
(14.) Moghetti P. Castello R, Negri C, Tosi F, Caputo M, Anolin G, Muggeo M. Metformin effects on clinical features, endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary syndrome: a randomized, double-blind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. J Clin Endocrinal Metab. 2000:85:139-146.
Kathy Scalzo, MA, RD, works with adolescents with PCOS in a school-based health center in Brooklyn, NY. She is a member of the Women and Reproductive Nutrition dietetic practice group (DPG) and the Sports and Cardiovascular Nutrition DPG.
PCOS is a common endocrine disorder that often goes undiagnosed. Exactly how and why the syndrome develops is not quite clear; however, the cause is believed to be genetic . The major biochemical abnormality present in the majority of women with PCOS is hyperinsulinemia. Hyperinsulinemia leads to ovarian and adrenal overproduction of male hormones, causing any or all of the following symptoms: erratic menstrual periods, infertility, acne, hirsutism, and alopecia. Hyperinsulinemia can also cause abnormal lipid metabolism (elevated low-density lipoprotein and triglyceride levels and decreased high-density lipoprotein levels [HDL]) and abnormal clotting factors, thus increasing the risk of heart disease . In addition, women with PCOS have increased risk of hypertension and type 2 diabetes mellitus .
Because of the pivotal role of hyperinsulinemia in PCOS and the increased risks of serious, long-term complications, counseling on diet and exercise should be key components in the overall treatment plan of a woman with PCOS. The following components for a treatment plan are necessary:
* Maintain an empathetic approach. It is not uncommon for women with PCOS to be embarrassed and frustrated regarding their symptoms.
* Promote education on insulin resistance to provide patients with an understanding of why the symptoms are occurring as well as why the risks of heart disease and diabetes are increased. Knowledge is empowerment. Help promote an understanding of the role that diet and exercise can play in controlling insulin levels.
* The typical low-fat, high-carbohydrate diet may not be the best choice for a person with insulin resistance. Studies have shown that a lower-carbohydrate, higher- monounsaturated-fat diet can lower insulin levels and improve lipid profile more effectively than can a low-fat, high-carbohydrate diet .
In my experience, most women with PCOS have better success in losing weight on a lower glycemic index diet. This diet emphasizes fibrous vegetables and legumes rather than simple carbohydrates and starches made from refined flour, and contains a little more lean protein and fat (mainly from unsaturated fat) than does the standard high-carbohydrate diet. Although a diet based on the Food Guide Pyramid, with emphasis on whole grains, may promote weight loss for some women with PCOS, it may be too high in carbohydrates for others and therefore may not promote weight loss. Each diet should be tailored to the individual. A patient might want to start with the Food Pyramid and, if weight loss does not occur despite the reduced energy intake and exercise program, then a reduction in carbohydrate content and an increase in unsaturated fat and lean protein would be the next step.
In addition to symptoms present at initial appointment, dietetics professionals should explore:
* Blood analysis The following laboratory tests for blood analysis have been useful in my nutrition assessments:
– Lipid profile; these laboratory analyses are important because of the increased risk of heart disease.
– Fasting blood glucose; women with PCOS have an increased risk of type 2 diabetes.
– Fasting insulin levels–or a more effective 2-hour glucose tolerance test–with measurements of glucose and insulin levels before and after a 75-g glucose load can be helpful in assessing insulin resistance. There is an increased incidence of abnormal glucose tolerance tests in 40% of obese women with PCOS and in 10% of normal-weight women with PCOS .
* Medications Common medications include birth control pills, antiandrogens such as spironolactone and insulin-sensitizing agents such as metformin. In obese women, metformin may improve menstrual irregularity as well as enhance weight reduction ; however, it should be stressed that diet and exercise are recommended before starting insulin-sensitizing medications. Even when administering these medications, diet and exercise should be part of the treatment plan.
Education on PCOS
The knowledge base of the patient regarding P005 should dictate the direction of the initial appointment. In this case, CR obviously knows she has this diagnosis, but she may not know how common the syndrome is or why the symptoms are occurring. The patient should be told that PCOS is common: 5% to 10% of all women of reproductive age have PCOS . Many women with PCOS think that they are alone and that they are somehow unfeminine. It can be somewhat reassuring when they discover that the syndrome is common and the reasons the symptoms present. I would also address the issue of obesity. CR is obviously upset regarding her weight. Again, I would let her know that she is not alone. Fifty to 60% of women with PCOS are obese, compared with 35% of women without PCOS. One theory suggests that the high levels of insulin promote fat storage .
Not only is excess body fat upsetting for women, but being 35% to 40% over ideal body weight can decrease insulin sensitivity by 30% to 40%. However, it should be noted that although insulin resistance is more common in obese women, it can occur in lean women with PCOS as well. Patients should be reassured that weight loss is possible with the proper diet and exercise plan. Even losing 5% to 7% of body weight can reduce androgen levels, reduce insulin levels, and frequently improve skin appearance and regularity of the menstrual cycle.
Insulin resistance should be incorporated into the patient-education portion of the session. I would keep the explanation simple, but my goals would be for her to understand the role of insulin in the body; that the type and quantity of foods play a role in the amount of insulin secreted; and that the goal is for her body to secrete less insulin and, therefore, certain foods such as simple sugars and refined starches should be limited.
Education on a Healthful Diet
To address unhealthful diet practices, setting goals during the initial session for the patient to accomplish by the next visit would be helpful. Some goals that could be of benefit to CR include:
* Eat something for breakfast, lunch, and dinner. Based on her food preferences, I would write down a few suggestions for sample meals and snacks. The suggestions would be very basic (ie, a bowl of cereal, low-fat milk and juice, or a banana for breakfast; a sandwich and a piece of fruit for lunch; and a piece of chicken, a cup of rice and beans, and a vegetable for dinner).
* Try to eat more vegetables and smaller portions of starch. I would write down some suggestions for CR’s mother: serve vegetables at each meal (salad and/or cooked vegetable), serve smaller portions of starch, and cook with as little oil as possible.
I would not suggest that CR weigh or measure foods or keep food records so she would not feel overwhelmed. I would stress to the patient that we are looking for improvement, not perfection. If she is able to meet only a few of her goals, that is still a success. I would encourage a weigh-in; however, I would make it optional. In the case study, it was reported that CR agreed to be weighed, but did not want to see her weight.
Follow-up Session #1
My goals for the first follow-up visit would be:
* To evaluate progress with the initial goals;
* To continue educating on a healthful diet;
* To review how different foods affect blood sugar levels and insulin levels;
* To educate on the importance of exercise to facilitate weight loss and increased insulin sensitivity; and
* To set additional goals
Progress In the case it is reported that CR returned for a follow-up appointment 5 weeks after her initial consultation. She reported that she was able to eat more frequently on some days but not all. It appeared that she felt better on the days when she ate more frequently and subsequently had fewer urges to overeat. I would reinforce the concept of eating moderate sized portions of foods several times per day instead of 1 to 2 large meals.
Education I would spend most of the second session instructing on a healthful, balanced diet, reviewing the food groups and providing basic information on energy content of foods. I would stress the importance of trying to select higher-fiber, unprocessed carbohydrates rather than refined or high-sugar carbohydrates, and would review how the types and portion sizes of these foods affect blood sugar levels, which will ultimately affect insulin levels. I would use food models to explain portion sizes. In view of the increased risk of heart disease, I would review the different types of fats and encourage selection of foods containing unsaturated fat, preferably monounsaturated fat, instead of saturated and trans fatty acids. I would explain a “balanced” meal and would encourage inclusion of some lean protein and unsaturated fat in the diet along with starches and vegetables.
Because exercise can aid in weight control as well as improve insulin sensitivity, I would help CR find a form of exercise that she might enjoy as well as one in which, realistically, she could participate and succeed.
I would end the session by assisting CR in planning balanced meals that would fit into her lifestyle. I would set the following goals:
1. Continue to try to eat 3 meals per day with a snack between lunch and dinner.
2. Limit foods high in sugar
3. Select starches that are higher in fiber, such as whole grain cereal, rice and beans, or 7-grain bread, rather than refined cereals, white rice, and white bread.
4. Include a little heart-healthy fat, such as olive oil or peanut butter, and lean protein at each meal.
5. Eat at least one serving of fruit and at least one serving of vegetables each day.
6. Start to walk for exercise at least 20 minutes per day, 4 times per week.
Follow-up Session #2
My goals for the second follow-up visit would be:
* To evaluate on goals set at previous session;
* To provide support and encouragement; and
* To emphasize the importance of keeping scheduled appointments.
If the patient proves to be noncompliant in keeping appointments with me or other involved health care professionals–such as the social worker or physician–I would provide her with support and reinforce the importance of keeping appointments. I would again let her know that if she keeps her appointments, her chances of losing weight will be much greater and, ultimately, by losing weight and exercising regularly, it is highly likely that her symptoms will be decreased. I would let her know that even if the symptoms remain, there are medications such as birth control pills, antiandrogens, and insulin sensitizing agents that may be able to help her symptoms.
No new goals would be set at the end of the second follow-up. Instead, I would review the goals set at the last nutrition session.
Follow-up Session #3
My goals for the third follow-up visit would be:
* To evaluate on the goals set at the second follow-up session;
* To increase variety in the diet and exercise program; and
* To encourage the patient to take on a more assertive role in meal planning.
CR became compliant in keeping appointments and returned for her nutrition appointment 1 month after the second follow-up appointment. As reported in the case study, she lost 15 lbs after the initial weigh-in and appeared to be very encouraged and motivated to continue on her diet and exercise program. She met several of the goals set at her previous appointment: she was walking for 30 minutes 4 times per week, she increased her intake of vegetables, and she was eating smaller portions. Aside from weight loss, she expressed an interest in toning her body. I would educate CR on the different types of exercise, resistance training, and aerobic exercise, and review the benefits of both. Because she was already speed-walking, I would discuss ways she could incorporate resistance training. I would recommend that she use an instructional weight-training video that would call for CR to purchase 5-lb handweights. I would suggest that CR use the videotape 3 times per week.
For many years, PCOS has been misdiagnosed. It has only been in the recent past that there has been an increased awareness about the seriousness of this condition. As dietetics professionals, it is important that we become knowledgable about this condition so that we can educate patients on insulin resistance and the effects of hyperinsulinemia, and to be able to provide dietary recommendations to women with PCOS.
The following are some dietary recommendations that I share with my patients who have PCOS:
The bottom line is that you need to find a diet that works for you and one that you can live with.
* Select whole-grain starches instead of processed, refined starches. Foods high in fiber will cause a slower rise in blood sugar levels. Restrict foods high in sugar such as sweetened beverages and sweet desserts. Check food labels on fat-free desserts, as many are loaded with sugar.
* Include a lean protein as well as a heart-healthy fat at each meal. This will slow the rise in blood sugar levels.
* Avoid diets that promote ketosis.
* Space out the consumption of carbohydrates throughout the day. This will cause less of rise in blood sugar and insulin peak levels, compared with eating all carbohydrates at one meal.
* Consume vitamin/mineral supplements, such as:
– Calcium 1,000 mg to 1,500 mg (take 2 to 3500-mg pills per day; be sure to ingest the pills at different times during the day to enhance absorption).
– Multivitamnin with minerals (make sure it contains 400 [micro]g folic acid if trying to get pregnant)
* For heart health, limit foods high in saturated and trans fats (eg, fatty red meats, whole milk, butter and stick margarine, chicken skin, fried foods, and rich desserts). Select mainly monounsaturated fats (ie, olive oil, canola oil, nuts) and n-3 fats (fatty fish such as salmon and bluefish, flaxseed, nuts), as these fats are heart healthy.
* Exercise on a regular basis. The benefits of aerobic exercise include: burns energy and aids in weight control; lowers blood pressure; raises HDL cholesterol levels; and may improve insulin resistance (proven in type 2 diabetics). Some benefits of resistance training are that it builds lean mass which will speed metabolism and it helps prevent osteoporosis
(1.) Reaven GM. Role of insulin resistance in human disease. Diabetes. 1988:37:1595-1607.
(2.) Kidson W. Polycystic ovary syndrome: a new direction in treatment. BMJ [serial online] 1998:169:537-540. Available at: http://www.mja.com.au/public/issues/nov16/kidson/kidson/html. Accessed June 1, 2000.
(3.) Reaven GM, Olefsky JM. Increased plasma glucose and insulin response to high carbohydrate feeding in normal subjects. J Clin Endocrinol Metab. 1974;38:151-154.
(4.) Legro R, Kunselman A, Dodson W, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab. 1999;84:165-169.
Martha McKittrick, RD, CDE, is a registered dietitian and certified diabetes educator at The New York Presbyterian Hospital and in private practice where she specializes in weight control, hyperlipidemia, PCOS, and diabetes. She is on the medical advisory board for the Polycystic Ovary Syndrome Association (PCOSA) and is on the editorial advisory board for PCOS Pavilion of OBGYAL NET. She lectured on diet and PCOS at the PCOSA conference in San Diego, Calif, in June 2000.
Weight (lbs) 230
Height (in) 62 1/4
Body mass index 43
Luteinizing hormone: follicle-stimulating hormone 2.8
Acanthosis nigricans yes
FIG. Clinical profile for CR, an 18-year-old with polycystic ovary syndrome [a]
(a.) Note: thyroid and prolactin levels within normal limits
COPYRIGHT 2000 American Dietetic Association
in association with The Gale Group and LookSmart. COPYRIGHT 2001 Gale Group