What is PCOS? with Jen Funsten, MPH, RD, LDN

PCOS, or polycystic ovary syndrome, is an endocrine disorder that can cause hormone imbalances in women of reproductive age. These hormone imbalances can then cause an array of signs and symptoms including the presence of cysts on the ovaries, irregular periods, acne, hair loss, unwanted face and body hair growth (also known as hirsutism), fertility issues, weight gain, and insulin resistance1. Development of PCOS is associated with certain nutrition-related risk factors, including elevated androgen and insulin levels, overweight and obesity, physical inactivity, and poor eating habits. PCOS can then increase the risk of developing high cholesterol, high blood pressure, type 2 diabetes, depression and anxiety, sleep apnea, and endometrial cancer (2,3). The cause of PCOS is unknown, but early detection and treatment is helpful in reducing symptoms and preventing complications (1).

Nutrition Management of PCOS

Nutrition management of PCOS is aimed at preventing the development of high cholesterol, blood pressure, and type 2 diabetes. The Mediterranean Diet (MD) has been shown to decrease the risks of high cholesterol, blood pressure, and type 2 diabetes (4,5). However, I tend to think the “Mediterranean Diet” needs further clarification. People may associate this style of eating with Mediterranean cuisine, like Greek food, for example. The MD that I am referring to is not constrained to one cuisine but can rather be adapted to any cuisine. This is because the MD focuses on foods and food groups. The MD is rich in high fiber foods including fruits, vegetables, legumes, and whole grains, as well as low fat dairy products, lean meats, fish, and healthy unsaturated fats while limiting foods high in saturated fat and other highly processed foods. therefore, style of eating has also been shown to help manage depression and anxiety as well, two other conditions also associated with PCOS (6,7). I will therefore explore different considerations of the MD to manage nutrition risks of PCOS.

Carbohydrates

One common myth about people with PCOS is that they need to eliminate or restrict carbohydrates. In reality, carbohydrates are a very important component of the diet for people with PCOS. Carbohydrates provide our bodies with energy. Without carbohydrates, our bodies do not function quite as well. Some people on low carbohydrate diets may experience a “brain fog”. This is because the brain functions almost exclusively on carbohydrates, so without this form of energy, the brain does not function optimally. Many carbohydrate foods also offer additional nutritious benefits including fiber, vitamins and minerals, and an array of phytonutrients (plant nutrients that often offer health benefits).

All carbohydrates are not created equally, however. Refined carbohydrates tend to contain more simple sugars and less fiber. Because of this, refined carbohydrates can spike blood sugar more than other types of carbohydrates. Although blood sugar naturally rises and falls in response to food and hormones throughout the day, our bodies do not like large, quick changes in blood sugar, nor do they like having high blood sugar, also called hyperglycemia. Hyperglycemia triggers an immune response, leading to inflammation in the body (8). Chronic inflammation over time can then lead to other risks, including heart disease, diabetes, and even cancer (9, 10, 11). High consumption of refined carbohydrates can also influence triglyceride levels, which can impact risk of heart disease as well (12, 13). Hyperglycemia also triggers a larger insulin response, which can contribute to more insulin resistance over time (13). Since insulin resistance, type 2 diabetes, and heart disease are risk factors of PCOS, it is important for people with PCOS to be aware of refined carbohydrate consumption.

The MD, on the other hand, which incorporates carbohydrates from fruits, vegetables, whole grains, and legumes, can promote blood sugar control and prevent the development of insulin resistance and type 2 diabetes (4, 5). Therefore carbohydrates, in themselves, are not harmful for people with PCOS. People with PCOS should rather be intentional about including high fiber carbohydrate sources to reduce nutritional risks associated with PCOS. The MD encourages at least 3 servings each of fruit and vegetables each day, 3 to 6 servings per day of whole grains and starchy vegetables, and 3 servings per week of beans and legumes, while limiting snack foods and baked goods to less than 3 times per week.

Fats

There are two main types of fats present in our food that we need to be conscious of: saturated fats and unsaturated fats. Trans fats are an important consideration as well, but after artificial trans fats were banned in the U.S. in 2018 for health risks, they are not as prevalent anymore (14).

Saturated fats often come from animal sources, such as red meats, processed meats, dairy products, and butter, but are also common in fried and processed foods. A Western style diet is typically high in these saturated fats and is also associated with many negative health impacts including increased risk of heart disease and type 2 diabetes (15). The American Heart Association recommends limiting saturated fat to around 10-15 grams/day (16).

On the other hand, unsaturated fats are commonly found in plants and seafood. Plant oils, such as olive oil and canola oil, avocados, nuts and seeds, beans, and many types of fish including salmon and tuna contain unsaturated fats. Many diets that were designed for health promotion, such as the DASH diet (Dietary Approaches to Stop Hypertension), the MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay), and the MD, all promote adequate consumption of these unsaturated fats. Incorporating unsaturated fats in the diet can aid in lowering cholesterol, lowering blood pressure, reducing inflammation (which may play a beneficial role in insulin resistance as well), and reducing risk of all-cause mortality (17, 18, 19). One type of unsaturated fat, omega-3s, offer additional benefits for disease prevention, promotion of mental health, and anti-inflammatory effects (20, 21, 22).

Therefore, it is important for people with PCOS to be mindful about the saturated and unsaturated fats in the diet and their impact on health.

Proteins

In large part, recommendations for protein sources for health promotion for people with PCOS aligns with the dietary fat recommendations. Leaner protein options with less saturated fats and more unsaturated fats from plant and seafood protein sources will provide benefits for people with PCOS. Beyond the fat content of different proteins, there are additional aspects of protein sources of note as well. Higher animal protein consumption creates a more acidic environment in the body, and this has been linked to more insulin resistance (23). Processed meats and red meats have also been found to be linked to certain cancers (24) and are classified by the World Health Organization as class A (carcinogenic) and class 2A (probably carcinogenic) carcinogens, respectively (25). Since people with PCOS are at a higher risk of developing endometrial cancer, reducing these types of meats would likely be beneficial.

On the other hand, incorporating plant-based proteins rich such as soybeans or other soy products has been shown to be beneficial for cardiovascular health, insulin resistance, and may play a role in preventing some cancers (26, 27, 28). Also, seafood such as salmon and tuna are rich in omega-3s, as mentioned above, which can provide benefits to cardiovascular health and insulin resistance.

For these reasons regarding dietary fat and protein, the MD encourages incorporating at least 3 servings per week of fish, 1 to 3 servings per week of poultry, 3 servings per week of low fat diary, 1 to 4 tablespoons olive oil per day, 3 servings per week of nuts and seeds, and limiting to 1 whole egg per day and 1 serving of red meat per week.

Lifestyle Factors

Sleep, stress management, and exercise are also imperative for people with PCOS. These factors are all interconnected in reducing inflammation and disease prevention. Exercise, in particular, can also improve heart health and can aid in reversing insulin resistance. High intensity exercise seems to offer the greatest benefit for people with PCOS (29). Sleep issues are common in people with PCOS, so treating this is an important part of managing PCOS as well (30).

In conclusion, establishing a balanced diet rich in high fiber foods such as fruits, vegetables, whole grains, and legumes with a variety of lean proteins, plant proteins, and seafood will provide nutritional benefit for people with PCOS. This MD pattern along with adequate sleep and exercise will help prevent high cholesterol, high blood pressure, and type 2 diabetes associated with PCOS, and can provide mental health benefits as well. Schedule an appointment with a dietitian to discuss building a nutrition plan for you to take charge of your PCOS.

References

1. Johns Hopkins Medicine. Polycystic ovarian syndrome (PCOS). 2023. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/polycystic-ovary-syndrome-pcos
2. Daniilidis A, Dinas K. Long term health consequences of polycystic ovarian syndrome: a review analysis. Hippokratia. 2009 Apr;13(2):90-2. PMID: 19561777; PMCID: PMC2683463.
3. Ding DC, Chen W, Wang JH, Lin SZ. Association between polycystic ovarian syndrome and endometrial, ovarian, and breast cancer: A population-based cohort study in Taiwan. Medicine (Baltimore). 2018 Sep;97(39):e12608. doi: 10.1097/MD.0000000000012608. PMID: 30278576; PMCID: PMC6181615.
4. Abiemo EE, Alonso A, Nettleton JA, et al. Relationships of the Mediterranean dietary pattern with insulin resistance and diabetes incidence in the Multi-Ethnic Study of Atherosclerosis (MESA). Br J Nutr. 2013;109(8):1490-1497.
5. Barrea L, Arnone A, Annunziata G, Muscogiuri G, Laudisio D, Salzano C, Pugliese G, Colao A, Savastano S. Adherence to the Mediterranean Diet, Dietary Patterns and Body Composition in Women with Polycystic Ovary Syndrome (PCOS). Nutrients. 2019; 11(10):2278. https://doi.org/10.3390/nu11102278
6. Yin W, Löf M, Chen R, Hultman CM, Fang F, Sandin S. Mediterranean diet and depression: a population-based cohort study. Int J Behav Nutr Phys Act. 2021;18(1):153. Published 2021 Nov 27. doi:10.1186/s12966-021-01227-3
7. Gibson-Smith D, Bot M, Brouwer IA, Visser M, Giltay EJ, Penninx BWJH. Association of food groups with depression and anxiety disorders. Eur J Nutr. 2020;59(2):767-778. doi:10.1007/s00394-019-01943-4
8. Collier B, Dossett LA, May AK, Diaz JJ. Glucose control and the inflammatory response. Nutr Clin Pract. 2008;23(1):3-15. doi:10.1177/011542650802300103
9. Suetomi, Takeshi et al. “Inflammation in nonischemic heart disease: initiation by cardiomyocyte CaMKII and NLRP3 inflammasome signaling.” American journal of physiology. Heart and circulatory physiology vol. 317,5 (2019): H877-H890. doi:10.1152/ajpheart.00223.2019
10. Dandona P, Aljada A, Bandyopadhyay A. Inflammation: the link between insulin resistance, obesity and diabetes. Trends Immunol. 2004;25(1):4-7. doi:10.1016/j.it.2003.10.013
11. Grivennikov SI, Greten FR, Karin M. Immunity, inflammation, and cancer. Cell. 2010;140(6):883-899. doi:10.1016/j.cell.2010.01.025
12. Clemente-Suárez, VJ, Mielgo-Ayuso, J, Martín-Rodríguez, A, Ramos-Campo, DJ, Redondo-Flórez, L, Tornero-Aguilera, JF. (2022). The Burden of Carbohydrates in Health and Disease. Nutrients.
13. Siri-Tarino, Patty W et al. “Saturated fat, carbohydrate, and cardiovascular disease.” The American journal of clinical nutrition vol. 91,3 (2010): 502-9. doi:10.3945/ajcn.2008.26285
14. U.S. Food & Drug Administration. Trans Fat. 2023. Retrieved from https://www.fda.gov/food/food-additives-petitions/trans-fat
15. Clemente-Suárez VJ, Beltrán-Velasco AI, Redondo-Flórez L, Martín-Rodríguez A, Tornero-Aguilera JF. Global Impacts of Western Diet and Its Effects on Metabolism and Health: A Narrative Review. Nutrients. 2023;15(12):2749. Published 2023 Jun 14. doi:10.3390/nu15122749
16. American Heart Association. Saturated Fat. 2021. Retrieved from https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/saturated-fats#:~:text=AHA%20Recommendation,of%20saturated%20fat%20per%20day.
    Perelman D, Coghlan N, Lamendola C, Carter S, Abbasi F, McLaughlin T. Substituting poly- and mono-unsaturated fat for dietary carbohydrate reduces hyperinsulinemia in women with polycystic ovary syndrome. Gynecol Endocrinol. 2017;33(4):324-327. doi:10.1080/09513590.2016.1259407
17. Ricci C, Baumgartner J, Zec M, Kruger HS, Smuts CM. Type of dietary fat intakes in relation to all-cause and cause-specific mortality in US adults: an iso-energetic substitution analysis from the American National Health and Nutrition Examination Survey linked to the US mortality registry. British Journal of Nutrition. 2018;119(4):456-463.
18. Delarue J, LeFoll C, Corporeau C, Lucas D. N-3 long chain polyunsaturated fatty acids: a nutritional tool to prevent insulin resistance associated to type 2 diabetes and obesity?. Reprod Nutr Dev. 2004;44(3):289-299. doi:10.1051/rnd:2004033
19. Manuelli M, Della Guardia L, Cena H. Enriching Diet with n-3 PUFAs to Help Prevent Cardiovascular Diseases in Healthy Adults: Results from Clinical Trials. International Journal of Molecular Sciences. 2017; 18(7):1552. https://doi.org/10.3390/ijms18071552
20. DiNicolantonio JJ, O’Keefe JH. The Importance of Marine Omega-3s for Brain Development and the Prevention and Treatment of Behavior, Mood, and Other Brain Disorders. Nutrients. 2020;12(8):2333. Published 2020 Aug 4. doi:10.3390/nu12082333
21. Yang K, Zeng L, Bao T, Ge J. Effectiveness of Omega-3 fatty acid for polycystic ovary syndrome: a systematic review and meta-analysis. Reprod Biol Endocrinol. 2018;16(1):27. Published 2018 Mar 27. doi:10.1186/s12958-018-0346-x
22. Della Guardia L, Thomas MA, Cena H. Insulin Sensitivity and Glucose Homeostasis Can Be Influenced by Metabolic Acid Load. Nutrients. 2018; 10(5):618. https://doi.org/10.3390/nu10050618
23. Farvid MS, Sidahmed E, Spence ND, Mante Angua K, Rosner BA, Barnett JB. Consumption of red meat and processed meat and cancer incidence: a systematic review and meta-analysis of prospective studies. Eur J Epidemiol. 2021;36(9):937-951. doi:10.1007/s10654-021-00741-9
24. World Health Organization. Cancer: Carcinogenicity of the consumption of red meat and processed meat. 2015. Retrieved from https://www.who.int/news-room/questions-and-answers/item/cancer-carcinogenicity-of-the-consumption-of-red-meat-and-processed-meat
25. Mudryj AN, Yu N, Aukema HM. Nutritional and health benefits of pulses. Appl Physiol Nutr Metab. 2014 Nov;39(11):1197-204. doi: 10.1139/apnm-2013-0557. Epub 2014 Jun 13. PMID: 25061763.
26. Chatterjee C, Gleddie S, Xiao C-W. Soybean Bioactive Peptides and Their Functional Properties. Nutrients. 2018; 10(9):1211. https://doi.org/10.3390/nu10091211
27. Ramdath DD, Padhi EM, Sarfaraz S, Renwick S, Duncan AM. Beyond the Cholesterol-Lowering Effect of Soy Protein: A Review of the Effects of Dietary Soy and Its Constituents on Risk Factors for Cardiovascular Disease. Nutrients. 2017 Mar 24;9(4):324. doi: 10.3390/nu9040324. PMID: 28338639; PMCID: PMC5409663.
28. Patten RK, Boyle RA, Moholdt T, et al. Exercise Interventions in Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis. Front Physiol. 2020;11:606. Published 2020 Jul 7. doi:10.3389/fphys.2020.00606
29. Szczuko M, Kikut J, Szczuko U, et al. Nutrition Strategy and Life Style in Polycystic Ovary Syndrome-Narrative Review. Nutrients. 2021;13(7):2452. Published 2021 Jul 18. doi:10.3390/nu13072452