PCOS: Updates, Dietary Strategies And Lifestyle Treatments

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1 : Updates, Dietary Strategies And Lifestyle Treatments Angela Grassi, MS, RDN, LDN October 3, 2015 Disclosure Angela Grassi, MS, RDN, LDN Board Member/Advisory Panel Consultant Employee Research Support Speaker s Bureau Stock/Shareholder - none Other - Retailer: Ovasitol by Theralogix Fish oil by Nordic Natural s Learning Outcomes The participant will recognize two medical nutrition therapy guidelines used to treat. The participant will describe two challenges to proving medical nutrition therapy to women with. The participant will name two dietary supplements that may benefit women with. Medical Nutrition Therapy (MNT) Long-Term Goals: Reduce body weight if overweight Maintain weight loss after weight reduction Obtain knowledge and skills to support behavior changes Resolve metabolic syndrome Reduce risk factors for T2D and CVD Improve infertility Grassi A. Polycystic ovary syndrome. In, The Academy of Nutrition and Dietetic's Nutrition Care Manual. Chicago, IL Weight Management In Obesity and insulin resistance worsen and weight management improves reproductive, anthropometric, metabolic, and psychological aspects of. Weight management Prevention of excess weight gain, achieving modest weight loss or maintaining a reduced weight long term Applies to lean and overweight women with Lifestyle intervention primary treatment strategy in Multifactorial approach Diet And Lifestyle Factors Work Synergistically To Support Health Food Stress Management Sleep Activity Weight Management

2 Unique Challenges For Women with Yo-yo dieters Intense cravings Impaired levels of ghrelin & leptin Increased hunger? Higher prevalence obstructive sleep apnea Hypoglycemia common Dermatological concerns Higher prevalence of eating disorders Increased mood disorders Exposed to inaccurate nutrition advice WHAT IS THE BEST EATING PLAN FOR WOMEN WITH? Dietary Composition In The Treatment Of : Systematic-Review Inclusion criteria: not taking anti-obesity medications 6 Studies, 137 women Results: Subtle differences between diets Weight loss improved regardless of dietary composition : Potential Eating Plans Diet and lifestyle primary treatment approaches The optimal eating plan for is not yet determined Eating plans need to be individualized Eating plans that have shown favorable effects on weight loss and metabolic parameters in : Modifying glycemic index (GI) and glycemic load (GL) Modifying carbohydrate, fat or protein amounts Moran L. J Acad Nutr Diet. 2013;113: Grassi A. : The Dietitian s Guide Effects of Increased Protein-to-Carbohydrate Ratios Controlled, 6 mo. trial, 27 women High Protein (HP) (>40% protein,30% fat) vs. Standard Protein (SP) (<15% pro, 30% fat); no caloric restriction Monthly dietary counseling Results: HP decreased weight (7.7 vs 3.3 kg), body fat loss (6.4 vs 2.1 kg), waist circumference, glucose. No difference in lipids, hormones. Low GI For Low glycemic index (GI) vs. Conventional Diet (CD) 50% CHO, 23% protein, 27% fat 96 Overweight/obese women with, 12 months Results: Low GI had better menstrual regularity (95% vs. 63% on CD), better insulin sensitivity Those with high insulin levels had a 2-fold reduction in body fat (modest weight loss) vs. CD Sørensen LB, et al. Effects of increased dietary protein-to-carbohydrate ratios in women with polycystic ovary syndrome. Am J Clin Nutr. 2012;95(1): Marsh K et al. Effect of a low glycemic index compared with a conventional healthy diet on polycystic ovary syndrome. Am J Clin Nutr. 2010;92:83-92.

3 DASH Diet For Randomized-controlled trial 48 women with, 8 weeks duration DASH & control diet consisted of 52% carbohydrates, 18% proteins, 30% total fats Results: DASH diet significantly reduced insulin, CRP levels, reductions in waist & hip circumference measurements Anti-Inflammatory/Mediterranean Diet For 100 overweight & obese Women, 12 weeks Reduced calorie, 5 small meals 25% proteins, 25% fat, and 50% carbohydrates Moderate to high fiber Emphasis on fish (2x/week), legumes, low-fat dairy Limited chicken, red meat, added sugars 5 cups of green tea daily Asemi Z, Esmaillzadeh A.DASH Diet, Insulin Resistance, and Serum hs-crp in Polycystic Ovary Syndrome: A Randomized Controlled Clinical Trial. Horm Metab Res Salama A et al. N Am J Med Sci Jul; 7(7): Asemi Z, Esmaillzadeh A.DASH Diet, Insulin Resistance, and Serum hs-crp in Polycystic Ovary Syndrome: A Randomized Controlled Clinical Trial. Horm Metab Res Results Mean weight loss 7.2%, WC 6.6%, BFP 9.2%, VFA 21.7% T Chol 8.9%, TG 18.02%, LDL 10.6% FBG 5.15%, BP 4.3/2.7 mmhg CRP 35%, SSA 38.25% 63% regain of menstrual cyclicity; 12% spontaneous pregnancy rate Salama A et al. N Am J Med Sci Jul; 7(7): Differential Effects Of PUFAs And MUFAs In Randomized trial 31 women, 6 weeks Walnuts (PUFAs) or Almonds (MUFAs); total 31 g fat daily Results: No change in weight Both nuts increased insulin response by 26% and decreased HA1C from 5.7% to 5.5% Both nuts reduced androgens, LDL Kalgaonkar S et al. Eur J Clin Nutr. 2011;65(3): Benefits Of Fish Oil Improves: TG levels Non-alcoholic fatty liver disease Fertility Depression Skin and hair health Maintains cardiovascular health Decreases inflammation Supports a healthy pregnancy Recommended amount: 1 to 4 grams daily Fish Oil And 45 non-obese women with : 1,500 mg of omega-3 for 6 months Reductions: BMI, testosterone, & insulin levels; improvements in LH & SHBG levels Oner et al. J Obstet Gynaecol. 2013;33(3): Double-blind RCT overweight women: 4 g/day of fish oil for 2 months Reductions: glucose, insulin, triglycerides, LDL Increased HDL Mohammadi E et al. Asia Pacific J Clin Nut. 2012;21(4):

4 : Helpful Eating Strategies Reduce intake of carbohydrates Emphasize low GI, high fiber carbohydrates Avoid sugary and refined foods Spread carbohydrates evenly throughout the day Emphasize protein with all meals and snacks Emphasize antioxidant rich-diet Fats: emphasize omega-3 fats, limit saturated Supplements With Insulin-Sensitizing Properties In N-acetyl cysteine (NAC) Vitamin D Inositol (Myo and d-chiro inositol) Grassi A. : The Dietitian s Guide Grassi A, Mattei S. The Workbook: Your Guide to Complete Physical and Emotional Health N-Acetylcysteine (NAC) What is it? Antioxidant and amino acid Derivative of L-cysteine, a precursor to glutathione Purported use: insulin resistance, infertility, inflammation, androgen-lowering, dyslipidemia, bronchitis, immune support Recommended dosage: 1.6 to 3 g/day Side effects: minimal NAC & 100 women with ; Prospective trial Metformin (500 mg three times daily) or NAC (600 mg three times daily) for 24 weeks Both treatments equally resulted in a significant decrease in BMI, hirsutism, fasting insulin, free testosterone and menstrual irregularity NAC led to a significant decrease in total cholesterol and LDL levels Oner G et al. European journal of obstetrics, gynecology, and reproductive biology. Nov 2011;159(1): Vitamin D: Metabolic Risk Factors In Studies in show an inverse relationship between vitamin D & metabolic risk factors (insulin resistance, BMI, triglycerides, HDL) Overweight women with who were vitamin D deficient & supplemented with vitamin D for 8 weeks saw improvements in insulin, triglycerides, & cholesterol levels. Asemi Z et al. Clin Nutr. 2014;14:S Supplementing with vitamin D & calcium for 3 months significantly reduced testosterone & blood pressure in women with. Pal L et al. Gynecol Endocrinol. 2012;28(12): Vitamin D, And Infertility Infertile women had improvements in menstrual regularity after 3 months of supplementation with 1,000 milligrams of calcium and 400 IU daily of vitamin D. Rashidi B et al. Taiwanese J Obstetrics & Gynecology. 2009;48: Infertile women with who underwent clomid stimulation had more mature follicles and were more likely to get pregnant when they had had higher vitamin D levels. Ott J et al. European J Endocrinol. 2012;166(5):

5 Myo-Inositol (MYO) AND D-Chiro-Inositol (DCI) What is it? Relatives of the B complex vitamins; found in foods (fruits, beans, cereals, buckwheat, etc) Inositol-phosphoglycan (IPG) mediators secondary messengers regulates activities of hormones including FSH, TSH and insulin Purposed uses: insulin resistance, dyslipidemia, androgen-lowering, infertility, hypertension, weight loss, reducing gestational diabetes risk, and improving egg quality in Recommended dosage: 2 to 4 g/day Side effects: Hypoglycemia MYO Improves Metabolic Factors in 2 g/day of MYO for 6 months resulted in significant weight loss and improved HDL and LDL levels Venturella R et al. Minerva ginecologica. 2012;64(3): Results of 2, double-blind, placebo-controlled RCTs showed MYO (4 g/day) in : increased HDL levels & resulted in significant weight loss Decreased insulin, triglycerides, testosterone, and blood pressure Costantino D et al. Europ review med pharm sci. 2009;13(2): Gerli S et al..europ rev med pharm sci. 2007;11(5): Combined, MYO and DCI in 40:1 ratio was more effective in improving metabolic parameters compared with MYO alone Nordio M et al. Europ rev med pharmacol sci. 2012;16(5): Myoinositol Versus Metformin: Fertility RCT 120 women 1500 mg Metformin vs 4 g MYO mcg folic acid Results: Metformin: 50% restored ovulation, 18% conceived 42 pts received MET+ FSH: 26% conceived Total pregnancy rate MET and MET+FSH: 36% Myoinositol: 65% restored ovulation, 30% conceived 38 pts received MYO+FSH: 29% conceived Total pregnancy rate MYO and MYO+FSH: 48% Raffone E, et al. Gynecol Endocrinol. 2010;26(4): Copyright 2015 Mark Perloe, MD Myo And D-Chiro Inositol Versus Metformin 128 women with Case-controlled, 3 month 1500 mg metformin or myo + d-chiro inositol Myo + DCI showed significantly better results in weight reduction, ovulation, and pregnancy rates (46.7 vs.11.2%) than Metformin Hamid A et al. Evidence-Based Women s Health Journal. 2015;5(3): The Role Of The Dietitian In Treating Provide empathetic, supportive, encouraging approach Provide education on and insulin resistance Provide education and support on healthy diet, supplements, sleep, stress, and exercise Encourage a healthy, sustainable approach to eating and exercise rather than focusing on weight loss Assess symptom severity (including eating disorder behaviors) Assess medication and supplement compliance Questions To Ask A Patient Suspected Of : Tell me what your periods are like. Are they heavy, irregular, absent, etc.? What types of foods do you crave and when do you crave them? Do you ever feel lightheaded, dizzy, or nauseous which improves when you eat? Have you ever been told by your physician or healthcare provider that you have any abnormal lab values? Can you tell me about any excessive body hair that you ve dealt with? Do you have dry/rough elbows, skin tags, or any dark patches that look dirty on your body? Does anyone in your family have polycystic ovary syndrome? Grassi A. : The Dietitian s Guide.

6 Tools Food records Mindful eating exercises Food models and labels Educational handouts Scale Waist circumference measurements Lab results Practice Applications An underdiagnosed and undertreated epidemic With age, higher risk for T2D, Metabolic Syndrome, CVD Prevention and early diagnosis are key! Diet and lifestyle are primary treatment approach Treatment is individualized and may involve a combination of healthy eating, lifestyle changes, supplements, and insulin sensitizers Dietitians play an important role in the treatment of To Learn More Nutrition Center (nutrition.com) : The Dietitian s Guide with Self-Study Course (CEUs for RD/nurses) The Workbook: Your Guide to Complete Physical and Emotional Health The Nutrition Center Cookbook Georgia Reproductive Specialists (IVF.com) Androgen Excess & Society (ae-society.org) American Society of Reproductive Medicine (ASRM.org) Challenge (challenge.org) Professional podcasts, information Online community Annual symposium