Lifestyle interventions are a top priority for women with polycystic ovary syndrome

• Lifestyle modification, the first-line treatment for PCOS, can significantly improve both metabolic and reproductive features.
• Multicomponent lifestyle modification is most effective – focus on weight gain prevention, achievable weight loss and sustained healthy lifestyle behaviours.
• In women who are overweight, weight loss of 5–10 per cent produces significant clinical improvement.
• Base dietary advice around general healthy eating recommendations tailored to individual goals and food preferences.
• Anxiety, depression, body-image concerns and eating disorders are prevalent in women with PCOS.

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Depression and anxiety are likely to…impact on the ability to make lifestyle changes

Polycystic ovary syndrome is a complex metabolic disorder in women of reproductive age. It increases the risk of chronic disorders such as type 2 diabetes, hypertension, dyslipidaemia and cardiovascular disease, as well as breast and endometrial cancer.

The current understanding of the pathophysiology of PCOS suggests that insulin resistance plays an important role in many of its symptoms. Insulin resistance is present irrespective of weight and affects both lean and overweight women with PCOS; it is further exacerbated by being overweight or obese. It is estimated insulin resistance occurs in 50–80 per cent of women with PCOS and up to 80 per cent of women with PCOS concomitant with being overweight or obese.

Lifestyle modification is the first-line treatment in the management of PCOS.

International evidence-based guidelines for the assessment and management of PCOS were released in 2018, confirming diet and lifestyle modification as first-line therapy. The recommendations advise weight management for all women with PCOS, including weight loss for women who are over¬weight or obese, and the prevention of weight gain for women within a healthy weight range.^1,2

The good news is a modest and achievable weight loss of 5–10 per cent produces significant clinical benefit, such as improved insulin sensitivity, reduction in androgen levels, improved hirsutism and acne, menstrual regulation, resto¬ration of ovulation and increased fertility.

Many women with PCOS report they gain weight easily, but studies confirm lifestyle interventions are as effective in women with PCOS as in women without PCOS. Studies have shown that behavioural-change techniques (eg, self-monitoring, relapse prevention, mindful eating) in combination with diet and exercise interventions increase weight loss over diet and/or physical activity alone.

Monitoring of weight and continued contact after treatment (face-to-face or via telephone) also improve weight-loss maintenance. Tailored lifestyle advice that accounts for patients’ personal goals, existing dietary intake and physical activity levels is critical for the successful adoption and sustainability of lifestyle changes.

A healthy, balanced diet should be followed for all women with PCOS. Currently, there is no evidence to support one specific dietary type.

Dietary recommendations should consider any risk factors, including glucose intolerance, dyslipidaemia and hypertension. The delivery of consistent evidence-based nutrition messages based on general recommendations for healthy eating and weight management is suggested (see Ministry of Health guidelines, https://tinyurl.com/MoHguides).

Dietary strategies for the prevention of diabetes and cardiovascular disease could be considered, as well as optimal preconception and pregnancy nutrition where relevant.

To achieve weight loss in those with a BMI ≥25kg/m2, a reduction in overall total energy (calorie) intake has been shown to be more successful than following any one diet. Dietary changes should be tailored to food preferences, allowing for a flexible and individual approach to reducing energy intake and avoiding unduly restrictive and nutritionally unbalanced diets. Consider referral to a dietitian where appropriate.

Below is a summary of suggested dietary guidelines:

• Avoid or limit energy-dense foods high in sugar, salt and unhealthy fats as well as sugary drinks.
• Reduce saturated fats (eg, red meat and processed meats) as there is evidence increased saturated fat worsens insulin resistance and is pro-inflammatory. Choose lean meat, chicken and fish, aiming for two servings of oily fish per week for omega-3 fatty acid intake.
• Choose high-fibre foods, such as vegetables, fruit, minimally processed grains, nuts, seeds and legumes, due to the benefits of fibre on improving insulin sensitivity and satiety.
• Choose moderate amounts of healthy carbohydrates (minimally processed grains and starchy vegetables) and lean protein (chicken, fish, lean red meat) with a focus on plenty of vegetables. Use the healthy plate model to help guide portion control: half a plate of vegetables, quarter of a plate of lean protein, and quarter of a plate of healthy carbohydrates.
• Aim for small regular meals with or without snacks spread over the day. There is evidence that spreading meals over the day helps to reduce postprandial glucose and insulin spikes.
• Encourage small and achievable dietary changes rather than short-term fad diets or changes that can’t be maintained.

The latest international guidelines for PCOS recommend health professionals encourage and advise the following physical activity:^1,2

For women with PCOS who want to prevent weight gain and maintain health – aim for at least 150 minutes per week of moderate-intensity physical activity (puffed but can still easily talk), especially in those with BMI ≥25kg/m2 given the metabolic risks of PCOS and the long-term metabolic benefits of exercise; or 75 minutes per week of vigorous-intensity exercise; or an equivalent combination of both, including muscle-strengthening exercise on two non-consecutive days per week.

Physical activity should be performed in at least 10-minute bouts or around 1000 steps, aiming to achieve at least 30 minutes on most days.

In adolescents, aim for at least 60 minutes of moderate to vigorous-intensity physical activity daily, including exercises that strengthen muscles and bone at least three times weekly.

For women aiming to lose weight, for prevention of weight re-gain and for greater health benefits – a minimum of 250 minutes per week of moderate-intensity exercise; or 150 minutes per week of vigorous-intensity exercise; or an equivalent combination of both, including muscle-strengthening exercise on two non-consecutive days per week.

Physical activity can be structured or incidental (daily life). Encourage opportunistic activity, such as taking the stairs, parking the car further away, and walking to the shops rather than driving. Minimise sedentary, screen and sitting time as research shows prolonged sitting increases diabetes risk. Where appropriate, referral to local programmes such as Green Prescription (https://tinyurl.com/Rxgreen) should be considered.

Research shows that negative body image is more prevalent in women with PCOS. Further, a higher incidence of anxiety (35–55 per cent versus 18 per cent in women in the general population) and depression (28–64 per cent versus 7–8 per cent in women in the general population) is present in women with PCOS, even after controlling for weight.

Depression and anxiety are likely to reduce quality of life and increase risk of disordered eating, and impact on the ability to make lifestyle changes. One study found that 21 per cent of women with PCOS had some form of eating disorder; of those, 62 per cent had major depression and 41 per cent anxiety.

Practitioners are recommended to screen their PCOS patients for anxiety, depression and eating disorders, and refer them to appropriate services as required. It is important to be very aware of any previous history of disordered eating before giving diet and lifestyle recommendations.

Research shows that lack of sleep worsens insulin sensitivity, increases blood pressure, and is associated with weight gain. There is also a high prevalence of sleep apnoea in women with PCOS. Ask about sleep and discuss sleep hygiene techniques as required. Seven to eight hours of sleep is recommended each night.

Stress increases blood glucose and insulin levels, and it can also lead to emotional eating and weight gain. Discuss strategies to manage and reduce stress. Where complex issues arise, consider referral to a suitably trained health professional.

Useful resources are free to download from the Monash University website for both health professionals (https://tinyurl.com/PCOS-tools) and women (https://tinyurl.com/PCOS-women). These include a suite of tools for GPs and an evidenced-based PCOS app (AskPCOS).

Sarah Munn is a registered dietitian at Dietary Specialists private practice in Christchurch

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