lifestyle management of pcos by dr shashwat jani

Approaches to Lifestyle Management In PCOS

Dr Shashwat K. Jani.M.S. ( Gynec )

Diploma in Endoscopy. Consultant Assistant Professor,

Smt. N.H.L. Medical College.Sheth V. S. General Hospital, Ahmedabad.

( M ) : 99099 44160.E- mail : [email protected]

Polycystic Ovary Syndrome (PCOS) is one of the most common endocrinopathy affecting women.

It has an unknown etiology and is recognized as a heterogeneous disorder that results in overproduction of androgens, primarily from the ovary, and is associated with insulin resistance (IR).

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OBESITY, PCOS & INFERTILITY

Obesity has substantial effects on manifestations of PCOS.

35-50% of women with PCOS are obese. 50% of overweight women have PCOS. Obesity plays a significant role in

determining the severity of clinical manifestations and metabolic disorder.

Significant increase in infertility and menstrual irregularities with BMI > 30 kg/m2.


OBESITY, PCOS ANDINFERTILITY…

Obesity augments the metabolic disorder prevalent in PCOS leading to:

- Oligomenorrhoea. - Chronic anovulation. - Lower pregnancy rates. - Higher miscarriage rates. - Increased obstetric complications.


OBESITY,PCOS ANDINFERTILITY…

Obese PCOS women have : - More marked hyperinsulinemia - Insulin resistance - Relative hyperglycemia - Lower SHBG levels - Higher levels of total and free testosterone and DHEAS - Decreased GH pulse amplitude - Increased LH pulse frequency - Attenuated LH pulse amplitude

ALL THESE LEAD TO ANOVULATION AND INFERTILITYMay 1, 2023 Dr Shashwat Jani.

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Obesity may have a marked impact on both the development and progression of the PCOS.

A high proportion of women with PCOS are obese. Regardless of the degree of obesity, women with PCOS are more likely to have central (abdominal) distribution of body fat, which is associated with insulin resistance and hyperandrogenaemia.

PCOS is not only a reproductive disorder, but is also associated with significant increase in metabolic aberrations and cardiovascular risk factors.


Prevalence3 to 20 %

70% undiagnosed

Reproductive Symptoms of PCOS

Anovulation Subfertility

Hyperandrogenism

Lifestyle ChangesDietExerciseWeight LossBehavioral ChangesSmoking cessation


DIET


#1: Cut Down on Calories, Especially in the Evening

• Studies have also shown that a calorie-restricted diet may help normalize hormones, induce ovulation, and treat infertility.

• Most health professionals recommend creating a caloric deficit of 3,500 to 7,000 per week for healthy and successful weight loss.


• It is generally recommended to spread the calories throughout the day by having 5-6 small meals.

• This will keep the metabolism humming and reduce cravings for sweets and starches.

(Very common among women with PCOS).


#2: Favor Monounsaturated Fats

• Monounsaturated fats in nuts help fight insulin resistance associated with PCOS.


#3: Choose Low-GI Carbs• Low-GI carbs, which take much longer to

digest, cause only a small, slow rise in the blood glucose and insulin levels.

• In addition, low-GI foods reduce cravings as they provide the body with a slow, steady supply of energy.

• Most non-starchy vegetables, legumes and fruit have a low GI rating while most refined carbohydrate-rich foods are rated high on the Glycemic Index.


#4: Load on B vitamins• The B vitamins in sunflower seeds can help beat PCOS

symptoms.• Vitamin B2 helps convert dietary fat, protein and

carbohydrates into energy. • Vitamin B3 helps maintain normal blood sugar levels.• Vitamins B5 helps with weight loss due to its ability to control

fat metabolism. • Vitamin B6 plays a critical role in maintaining a woman’s

hormonal balance and fertility. It is also needed for proper absorption of zinc in the intestines.

• In addition, vitamins B2, B3, and B6 are essential for normal thyroid function and metabolism, and can thus help reduce excess body weight.


#5: Ensure a Sufficient Intake of Calcium and Vitamin D

• Calcium plays an important role in egg maturation and follicle development in the ovaries.

• Vitamin D is essential for promoting calcium absorption from food in the intestines.

• In addition, low levels of vitamin D and have been associated with other problems related to PCOS, including infertility, weight gain, and insulin resistance.


#6: Consume Foods Rich in Zinc

• Zinc can exert beneficial effects on at least two common conditions associated with PCOS: Acne and Obesity.


#7: Eat Plenty of Foods That Contain Magnesium

• Research indicates that there is a strong link between magnesium deficiency and insulin resistance associated with PCOS.

• Magnesium appears to be the most common micronutrient found to be depleted in insulin resistant people and diabetes patients.


#8: Eat Foods That Contain Chromium

• Chromium is a component of the glucose tolerance factor (GTF) which helps maintain normal blood glucose levels by making insulin more efficient.

• This will fight insulin resistance which is often associated with PCOS.

• Furthermore, chromium promotes weight loss due to its ability to help control cravings, reduce hunger, and control fat in the blood.


• Good dietary sources of chromium include onions, romaine lettuce, tomatoes, whole grains, and potatoes.

• People who consume lots of coffee, tea, or sugar have an elevated risk of being deficient in chromium.


Healthy Living Guidelines

Dr Shashwat Jani. 99099 44160.

Minimize whole fat dairy products, such as butter and whole milk

Cholesterol should be less than 300 mg daily

Use low fat cooking methods: baking, broiling, grilling, boiling, rather than breading, frying

Use liquid vegetable oilMay 1, 2023 27

Optimal meal patterns• Eating small , frequent meals, and snacks not

only decreases food cravings , but it also provides steady flux of energy & helps prevent low blood sugar.

• Consume breakfast within 1 hr of walking• Snack 2 -3 hr later • Eat lunch 2 hr later• Another snack 2 – 3 hr later• Dinner 2 hr later


SMALL CHANGES MAKE A BIG DIFFERENCE


LIFESTYLE MODIFICATIONS

• Weight reduction includes a combination of caloric restriction, increased physical activity and behaviour modification.


Effects of Weight Loss

Even a 5% loss of body weight will reduce insulin resistance and circulating androgens, resulting in spontaneous ovulation and relief of symptoms.


Effects of Weight Loss• Weight loss (5-10% over 6 months) is effective in

re-establishing ovarian function in > 50% of obese PCOS women.Study Weight loss Outcomes1995 6.3 kg 12 out of 13 + ovulations

11 out of 13 + pregnantHollman 1996 5.6 kg 80% ovulation rate

29% pregnancyandrostenedione, insulintestosterone, estradiol

Huber-Buckholz 1999

6.3 kg (2-5% loss)

9 out of 15 + ovulations2 out of 15 + pregnant

Hoeger 2004 6.8% loss 30% increased ovulation Decreased hirsutism score


Women with WHO group II anovulatory infertility with PCOS who have a BMI of 30 or over must lose weight. Inform them that this alone may restore ovulation, improve their response to ovulation induction agents, and have a positive impact on pregnancy outcomes

Life style managementof Weight Reduction

(NICE 2013)May 1, 2023 Dr Shashwat Jani.

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Screening for cardiovascular risksWomen with PCOS should be

screened for cardiovascular risk by determination of CVD risk factors (obesity, lack of physical activity,

cigarette smoking, family history of type II diabetes, dyslipidaemia, hypertension, impaired glucose

tolerance, type II diabetes)They should be strongly warned

against smoking.

American College of Obstetrics and Gynecology. ACOG Practice Bulletin No. 41: Polycystic Ovary Syndrome. Obstetrics & Gynecology. 2002;100(6):1389-402.

PCOS Exercise Recommendations


Section 5. Lifestyle Management In PCOS

• 5.1a Lifestyle management (single or combined approaches of diet, exercise and/or behavioral interventions) for weight loss, prevention of weight gain, or for general health benefits should be recommended in women with polycystic ovary syndrome. — level B

• 5.2a Lifestyle management targeting weight loss (in women with a body mass index ≥25kg/m2 [overweight]) and prevention of weight gain (in women with a body mass index < 25 kg/m2 [lean]) should include both reduced dietary energy (caloric) intake and exercise and should be first-line therapy for all women with polycystic ovary syndrome. — level C

• 5.5a Exercise participation of at least 150 minutes per week should be recommended to all women with polycystic ovary syndrome, especially those with a body mass index ≥25 kg/m2 (overweight), given the metabolic risks of polycystic ovary syndrome and the long-term metabolic benefits of exercise. Of this, 90 minutes per week should be aerobic activity at moderate to high intensity (60%–90% of maximum heart rate) to optimize clinical outcomes. — level D

Treatment Focus:Reduce insulin resistanceImprove metabolic featuresImprove reproductive functionImprove body image and mood


Research Findings Since 2011

Improved body composition

Restored insulin sensitivity

Enhanced adipose tissue lipolysis

Improved depression


Improved Body Composition

• 24 women with PCOS – 12 in aerobic exercise group, 12 in control group

• Intervention: 12 weeks of moderate level (60 to 70% of maximum heart rate) aerobic exercise for 60 min., 3 times/week

• Results: significant improvements in body composition measures - BMI, WHR, body fat percentage, body fat mass


Restored Insulin Sensitivity• Control and PCOS rats were

treated with vehicle or resveratrol, while another group of PCOS rats were allowed to exercise freely for 5 weeks

• “We have shown that 5-6 weeks of resveratrol treatment did not improve insulin sensitivity in DHT-induced PCOS rats, but exercise restored insulin sensitivity to a similar level as in control rats.”

• “Physical exercise also had beneficial effects on fat mass, adipocyte size, and estrus cyclicity.”


Enhanced Adipose Tissue Lipolysis• 8 women with PCOS and 8 normal-

cycle women matched for BMI, age, and percent body fat

• Intervention: 16-week progressive moderate intensity (55% VO2max) aerobic exercise-training program

• “Alterations were seen in the gene expression in the adipose tissue following exercise”

• “Lipase expression is increased following exercise training with no decreases in circulating concentrations of total testosterone or free androgen index, perhaps indicating that aerobic exercise can increase adipose tissue lipolysis despite altering testosterone expression.”


Improved Depression• 153 women with PCOS and 64

women without PCOS aged 18-50 years

• Completed a questionnaire including the Hospital Anxiety and Depression Scale and a survey regarding levels of physical activity, physical activity barriers, motivators and supports

• “Physical activity is associated with lower depression in women with PCOS”


Writing The Exercise Prescription

FITT - VP• Frequency: 5 days a week• Intensity: moderate• Type: aerobic exercise• Time: 30 minutes/day• Volume: F x I x T = 150 minutes/week,

moderate intensity• Progression: start low, go slow


Exercise As Punishment…!!!

Long-term adherence is based on enjoyment

Patient should never be sore or in pain

But she should be challenged

A challenge is encouraging , engaging and rewarding; it increases enjoyment .

Start low and go slow


Get Started

ZumbaPilatesYogaAerobicsCyclingWalkingSwimming


Obstructive Sleep Apnea (OSA)

Women diagnosed with PCOS should be asked about the symptoms of OSA (snoring, daytime fatigue/somnolence) and offered investigation and treatment if indicated.

Fogel RB, Malhotra A, Pillar G, Pittman SD, Dunaif A, White DP. Increased prevalence of obstructive sleep apnea syndrome in obese women with polycystic ovary syndrome. J Clin Endocrinol Metab.

2001;86(3):1175-80.

Gopal M, Duntley S, Uhles M, Attarian H. The role of obesity in the increased prevalence of obstructive sleep apnea syndrome in patients with polycystic ovarian syndrome. Sleep Med. 2002;3(5):401-4.

Psychological assessment and intervention

Every study of PCOS has shown a higher risk of depression, anxiety and

worsened quality of life in this condition.

Practitioners must investigate the presence of mental distress and include treatment of this in the

management plan.

Deeks AA, Gibson-Helm ME, Paul E, Teede HJ. Is having polycystic ovary syndrome a predictor of poor psychological function including anxiety and

depression? Hum Reprod. 2011;26(6):1399-407.

Articles in news papers and magazinesTV showsClasses to teenage school children by expertsMedical conferences to educate doctors, paramedicsPCOS awareness associations in every country with

regular activitiesGood blogs by expertsSocial media postings – targetting next generation

possible by face book , instagram, whatsappWebsites for informationComedy shows , memes with this theme of pcos .

Target population likes humour.May 1, 2023 Dr Shashwat Jani.

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Target Population

• Mothers- include Healthy eating and exercise part of ANC .

• Schools - add these in curriculam, add cooking classes

• Schools – experts can take classes • Schools – to reduce sitting hours , increase activities • Teenagers – catch them early before it is too late• Infertility patients


Take Home Message


Obesity & sedentary lifestyle in PCOS is associated with anovulation & failure of infertility treatment.

Lifestyle modifications ( weight loss & exercise ) prior to infertility treatment improves ovulation rates & are recommended as first line treatment.


The best diet & exercise regimens are unknown , but a caloric restriction & increased physical activity are recommended.

The ideal amount of weight loss is unknown, but a 5 % decrease in body weight might be clinically meaningful.


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Thank you

lifestyle management of pcos by dr shashwat jani

Health & Medicine