![]() As a registered dietitian and certified diabetes educator, I'm required to complete 75 hours of continuing education (CE) every five years. Fortunately, there are many ways to fulfill this requirement, including watching webinars, attending conferences, and completing exams on nutrition-related books. Although my recertification date is more than a year away, I've been trying to complete as many CE units as I can ahead of time, including a short course on nutritional management of Polycystic Ovary Syndrome (PCOS). Although the author of the course gave a good overview of the disease and recommended avoiding refined carbohydrates, I found that several of the dietary suggestions were not particularly helpful for many women who struggle with PCOS, such as:
PCOS is one of the most common endocrine disorders among reproductive-aged women, as well as the leading cause of infertility. Instead of an egg being released from one of the follicles in the ovaries on a monthly basis as occurs in normal ovulation, a hormonal imbalance (too much luteinizing hormone and not enough follicle stimulating hormone) results in the egg failing to mature; instead, the follicle forms a small cyst. This process is repeated, and eventually the ovaries contain dozens of these cysts. Although the clinical presentation varies from person to person and some women have few symptoms, its hallmarks are insulin resistance and hyperinsulinemia. Other common features include:
Women with PCOS are more than twice as likely to meet the criteria for metabolic syndrome as those without the disorder; in fact, in one study, women between the ages of 20-39 were found to have a 4-fold to 8-fold increased prevalence of metabolic syndrome compared to women of the same ages in the general population (1). Those with both PCOS and metabolic syndrome are therefore at much higher risk for developing type 2 diabetes and cardiovascular disease. Since research has demonstrated that carbohydrate restriction improves markers of insulin resistance (IR) and other features of metabolic syndrome (2), it would seem logical to consider it an appropriate -- if not the most appropriate -- diet for PCOS. Even nonobese women with PCOS experience IR, though, and are at increased risk for progression to diabetes in the future. A small 2005 study evaluating the effects of a ketogenic diet on women with PCOS found significant improvements in fasting insulin, body weight, and hormone levels among subjects who completed the study -- including two pregnancies in women who had previously been unable to conceive (2). This is why I find it disappointing to read recommendations like those given in the PCOS course, which sound very similar to the one dietitians often make for people with diabetes. While this type of diet may work for insulin-sensitive people, it simply doesn't result in beneficial outcomes for most women with insulin resistance and hyperinsulinemia. For people with defective hormonal regulation, it can be difficult to control insulin levels and appetite when eating more than minimal amounts of carbohydrate. The authors of a recent review looking at six different diets and their effects on physiological and psychological outcomes in women with PCOS came to the following conclusion: "Weight loss should be targeted in all overweight women with PCOS through reducing caloric intake in the setting of adequate nutritional intake and healthy food choices irrespective of diet composition (4)." While the researchers noted moderate to severe bias among all the studies, I found some other issues:
The other three studies didn't look at "low-carb" diets per se but found less depression and lower triglycerides in subjects consuming higher amounts of protein and improvements in insulin sensitivity among women following a low GI diet. My point is that aside from one small study, researchers haven't attempted to investigate whether a very-low-carbohydrate diet containing adequate calories is effective in improving IR and hyperinsulinemia, promoting weight loss, and improving hormonal balance in order to reduce masculinization and facilitate ovulation. However, I've read anecdotal reports where carb restriction did improve symptoms, and at least one woman I've worked with definitely experienced benefits. There's also the spontaneous decrease in caloric intake that occurs for many, although not all, people who consume a carbohydrate-restricted diet (8). Now, I'm not claiming that low-carb diets work for everyone or that they're the only thing needed to achieve results. Certainly insulin-sensitizing medications such as metformin, stress management, exercise, support groups, and supplements play a large role in managing PCOS as well. But for the overweight woman suffering from this disorder, I don't feel that it's enough to simply encourage weight loss without providing guidance on how to do so in a sustainable way that has been shown to improve IR and insulinemia -- i.e., limiting carbs to 50 net grams per day or less. I understand that some women with PCOS may not want to follow a carb-restricted diet, and I certainly respect and support everyone's right to make dietary choices. But I believe dietitians and other healthcare professionals who work with women who struggle with PCOS should present a low-carb diet as an option rather than insist that everyone consume "a minimum of 130 grams of carbohydrate per day." Unless you have lived with PCOS, diabetes, or metabolic syndrome and tried carbohydrate restriction, it's impossible to understand what an impact making this type of change could have on your health and quality of life. * Please speak with your doctor or health care provider prior to making any changes to your diet. References: 1. Apridonidze T, et al. Prevalence and Characteristics of the Metabolic Syndrome in Women with Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2005 Apr;90(4):1929-35 2. Volek JS, Feinman RD.Carbohydrate restriction improves features of the Metabolic Syndrome. Metabolic Syndrome may be defined by the response to carbohydrate restriction. Nutr Metab(Lond) 2005 ;2:31 3. Mavropoulos JC, et al. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: A pilot study. Nutrition & Metabolism. 2005;2:35 4. Moran IJ, et al. Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines. J Acad Nutr Diet. 2013 Apr;113(4):520-45 5. Douglas CC, et al. Role of diet in the treatment of polycystic ovary syndrome. Fertil Steril.2006; 85(3):679-688 6. Stamets K, et al. A randomized trial of the effects of two types of short-term hypocaloric diets on weight loss in women with polycystic ovary syndrome. Fertil Steril. 2004;81(3):630-637 7. Moran LJ, et al. Short-term meal replacements followed by dietary macronutrient restriction enhance weight loss in polycystic ovary syndrome. Am J Clin Nutr. 2006;84(1):77-87 8. Westman EC, et al. Low carbohydrate nutrition and metabolism. Am J Clin Nutr.August 2007; 86(2):276-284
33 Comments
Vicki
2/26/2015 12:16:02 pm
Franziska, what about a moderate carbohydrate diet like what is usually recommended of pairing a carb and protein (like the IR Diet) for PCOS?
Reply
2/28/2015 09:20:35 am
Hi Vicki,
Reply
Gerri
2/27/2015 12:27:46 pm
If only other health professionals shared your respect for individual choice & actually presented options. No end to the propaganda for whole grains & high carb meals.
Reply
2/28/2015 09:21:43 am
Thank you so much for your very kind words of support, Gerri!
Reply
Franziska, another very balanced and thought out post for all to read. I am in total agreement with the earlier comment from Gerri "respect for individual choice & actually presented options". People / patients deserve to be given all the options, all the choices ..... they can then make fully informed decisions.
Reply
2/28/2015 09:48:21 pm
Sincere thanks for the nice feedback and your continued support, Jan! Appreciate your insight.
Reply
3/2/2015 05:02:12 am
This is an excellent post Franziska. You presented it in a balanced and thorough manner.
Reply
3/2/2015 06:20:26 am
Thanks so much for your comments and for sharing my article with your PCOS patients, Sam! So glad you recommend carb restriction for all of them :)
Reply
Janknitz
3/6/2015 04:25:19 am
I am a woman with PCOS. I was thin until we monkeyed with my hormones for three years of infertility treatment. I finally conceived my first child after IVF and continued to gain a lot of weight from there.
Reply
3/6/2015 07:18:06 am
Thanks so much for sharing your story and your daughter's as well, Janknitz. I'm thrilled to hear that you resumed ovulating after switching to low carb and starting metformin, and that you were able to have more children. Two women reported the same thing on my Facebook page shortly after I published this article.
Reply
granny gibson
3/7/2015 12:25:16 am
Great post! I have had PCOS since puberty, with all the associated conditions. When I was in my late twenties I joined a program that advised a low carb diet (not labled as such) and I lost almost 100 pounds. My doctors were amazed when I became pregnant and had a healthy baby.
Reply
3/7/2015 02:47:55 am
Thank you so much for your very nice feedback and for sharing your story, GG! Congratulations for losing nearly 100 pounds and keep it off for more than 30 years! I'm also very happy to hear that you were able to get pregnant and delivered a healthy baby.
Reply
granny gibson
3/7/2015 10:49:25 pm
I actually did not keep it off, Franziska. When I married a man with a three-meals-a-day regimen and a sweet tooth, I gained it all back and more. Losing it again was much more difficult and menopause made it worse. I'm still 50 pounds from where I'd like to be despite low carb, minimally processed food and regular exercise. Being hypothyroid and T2 diabetic doesn't help either. Still working on it, though! Hubby and I eat two different menus, with only meat and vegetables in common. ;) 3/8/2015 12:11:49 am
Sorry to hear you experienced weight regain, but it sounds like you were able to get back on track with LC :) It can be hard when your spouse eats differently than you do. I'm rooting for you to keep losing until you reach your goal!
Reply
Andrea
3/27/2015 05:55:52 am
I just found your website today. I love to see support for low carbing in the nutrition field. I have PCOS and have changed my lifestyle to low carb because it gives me the best results. Fortunately my doctors support low carbing too. Very informative site. Thank you!
Reply
3/27/2015 10:12:30 pm
Thanks so much for your comments and nice feedback, Andrea! I'm so glad you've found that carb restriction helps manage your PCOS. Also great to have a doctor who understands the benefits of LC. I wish you all the best!
Reply
Suzy Q
7/27/2015 06:47:25 pm
Very good column. I actually came here searching whether there was any information available about the effect of a ketogenic diet on PCOS.
Reply
7/27/2015 10:46:38 pm
Thank you so much for the nice feedback and for sharing your own story, Suzy! I'm so happy to hear that you experienced benefits beyond weight loss with low carb, including hormonal regulation, as evidenced by monthly periods. Keep up the great work!
Reply
Suzy Q
7/27/2015 11:15:17 pm
Oh, I definitely will. I actually had a stress induced cheat night the day before yesterday, and today am paying the price with obvious low blood sugar levels - I keep getting woozy, which is very inconvenient when caring for two toddlers. 7/28/2015 12:53:33 am
Sounds like a good strategy! Best of luck with everything!
Reply
There is another interesting piece of information about the link between diet and PCOS. According to research, eating a big breakfast and a small dinner can cause a drop in testosterone levels and insulin resistance by at least 50%. Of course you need to do it consistently. Just try to eat the majority of your calories early in the day.
Reply
7/5/2016 07:37:28 am
Thanks for your comments, Kate! Changing the distribution of calories during the day can indeed be helpful as well. On the other hand, carbohydrate restriction can help keep hunger levels under control by maintaining stable blood glucose levels, making it a very sustainable way of eating for many. I've certainly experienced this over the past 5.5 years of following a low-carb diet where I eat roughly the same amount of calories and carbs at each meal.
Reply
lbd
8/24/2016 03:57:52 am
Meanwhile in Last century Australia... The DAA still have their head in the sand...
Reply
Jennet Scarborough
10/11/2016 06:55:45 pm
I was diagnosed with PCOS when i was 19 (i'm 36 now) and have always had irregular periods except while on the pill. For at least the last 10-12 years i have had 1-2 periods a year max, many years i didn't have any. During this time i have also suffered hirsutism. Within the last year i have started to develop male pattern baldness, with a receding hairline.
Reply
10/12/2016 04:56:06 am
Thanks so much for sharing your story, including the encouraging changes you've seen after following a ketogenic diet for two months! I'm so happy to hear this. I think an 8-lb loss so far is great, but clearly being in ketosis is having powerful effects on hormonal regulation. Congratulations on restarting your cycle and the early hair growth! Keep up the great work :) - Franziska
Reply
It is good to read this well thought out and researched article. My daughter was diagnosed with PCOS in high school and she struggles with weight gain and the hormonal acne. Even before she diagnosed, we felt something was different based on other girls her age. I tried to keep her on a low carb diet, but that is so hard to maintain with a child. And as an adult she resents that I did and says it set her up for "food issue". She is in grad school and very sedentary and puts on weight very quickly due to low activity, poor diet, binge eating, alcohol intake, etc. (all of this she shares with me). We have paid for personal trainers (at her request) and provided more funds for healthy food purchases as a student, all to no avail. I worry so much about her self esteem, happiness, and more importantly heart disease. She has an appointment soon with a dietitian soon and I pray that she has your same professional opinion of low carb diets and PCOS. What is your opinion of alcohol intake and PCOS? I have no problem with alcohol in general, but consider it empty calories and have heard it lowers metabolism. I try to stay away from it as I have hypothyroidism.
Reply
2/26/2017 07:30:11 am
Thanks for your comments and for sharing your daughter's story, Ingrid. I'm so sorry to hear that she continues struggling with weight gain and other PCOS-related symptoms. I don't know of any particular contraindications for alcohol intake with PCOS, but I agree that it is essentially empty calories. In addition, it may increase storage of abdominal fat and can lead to overeating by clouding judgment and resolve. I wish your daughter the very best of luck in getting her eating under control in order to improve her health and overall quality of life. - Franziska
Reply
Jayne
8/5/2017 05:41:57 am
Fantastic article. Not that I ever was diagnosed w PCOS, but irregular, heavy periods, enormous weight gain at puberty, etc, makes it seem likely to have been the case. Fast forward to my childbearing years, overweight w those heavy irregular periods and my husband and I simply not having any luck conceiving.
Reply
8/6/2017 06:42:34 am
Hi Jayne,
Reply
Ella
3/8/2018 05:09:09 pm
Thank you for this incredible article. You are a blessing to the low carb community.
Reply
Your comment will be posted after it is approved.
Leave a Reply. |
Author
Franziska Spritzler, RD, CDE Categories
All
Archives
July 2019
|