AngelaGrassiPCOS_000

8/7/2019 AngelaGrassiPCOS_000

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Angela Grassi, MS, RD, LDN

Author of The Dietitians Guide to PolycysticOvary Syndrome, The PCOS Workbook&

PCOS Nutrition Handout Series CD

(484) 252-9028

www.PCOSnutrition.com

PCOS Through The Lifecycle

Medical Nutrition Therapy for PCOS:

Adult Diet & Fertility

Pregnancy & Lactation

Adolescence

PCOS: Background

Most common endocrinopathy in premenopausal women

Reproductive and cardiovascular features: the intersection ofsex hormones & metabolism:

Reproductive consequences

Endocrine/metabolic consequences

Cardiovascular associations

A multi-factorial, polygenic disorder with variable phenotypes

PCOS is under-diagnosed and under-treated

Multiple cardiovascular risk factors

High conversion to diabetes & metabolic syndrome

PCOS: a reproductivedisorder

Oligomenorrhea, amenorrhea

InfertilityPregnancy loss, preterm and

stillbirths

Polycystic ovaries

Endometrial carcinoma

with hirsutism, acne & weight gain

Observed Associations

Hypothyroidism

Obstructive sleep apnea

Non-alcoholic fatty liver disease

Mood disorders, especially bipolar,eating disorders

Coronary artery disease & T2DM

Metabolic syndrome
http://www.pcosnutrition.com/


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Increased prevalence ofmetabolic syndrome in PCOS

Apridonidze et al. JCEM 2005

0

1 0

2 0

3 0

4 0

5 06 0

7 0

2 0 - 2 9 3 0 - 3 9A g e

Prevalence

(%

)

N H A N E S II I

P C O S

Dietitians

may be the first health care provider to

recognize the syndrome among theirpatients.

must have the knowledge and skills torecognize and treat patients with PCOS.

Are often case managers, directing andreferring treatment options.

Multi-Disciplinary Team Approach

Dietitian

Pediatrician

Reproductiveendocrinologist/endocrinologist

Dermatologist

Therapist and/or family therapist

Patient

Pathophysiology

Hypothalamic gonadotropin releasinghormone (GnRH) pulses are abnormal LH

Insulin resistance plays a central role

endotheliumovary

hirsutism

infertility

acne

anovulationdyslipidemia

diabetes

testosterone

ovary

endothelialdysfunction

hyperinsulinemia

OverweightAcanthosis nigricans

hypertension

Sherif 2006

The Vicious Cycle of InsulinResistance

Insulin resistance

HyperinsulinemiaWeight gain


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Goals of Treatment

Regulate menstrual function, reduceandrogen and insulin levels, improvedermatological symptoms, and stabilize orreduce weight.

Prevent long-term complications Diabetes

Cardiovascular Disease

Metabolic Syndrome

Infertility

Traditional Treatment

Oral contraceptives OligomenorrheaHirsutismAcneAlopecia

Anti-androgens HirsutismAlopecia

Clomiphene Infertility

Goal: Decrease Insulin Resistance

1. Diet

2. Physical activity

3. Insulin-sensitizing medication

Metformin

Actos, Avandia

Byetta

Treatment with insulin sensitizers

improves fertility & CVD risk factors

Decrease Hyperinsulinemia

testosterone

improve endothelial function

ovulation

fertility endometrial ca

BP, lipids, glucose

Cardiovascular risk

hyperandrogenemia

Hirsutism, Acne, Alopecia

Labs To Support Diagnosis

Elevated total testosterone/DHEA-S

LH:FSH Elevated fasting glucose, HA1C

Elevated fasting insulin

Elevated insulin to glucose ratio

Frequently Observed Lab Abnormalities

Elevated TSH and thyroid peroxidaseantibodies

Elevated LFTs Elevated WBCs

Elevated C-reactive protein

Dyslipidemia

Elevated triglycerides

Decreased HDL


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Unique Challenges forWomen with PCOS

Yo-yo dieters

Intense cravings

Hypoglycemia common

Hormonal aberrations

Dermatological concerns

Higher prevalence of eating disorders

Impaired levels of ghrelin & leptin

Increased anxiety, depression, bipolar, suicide

What is the best dietcomposition ?

Low-Fat Diets

exaggerate postprandial glycemia

increase TG, decrease HDLconcentrations

promote higher consumption of refinedcarbohydrates

Makes MBS worse

contribute to hunger, overeating, andweight gain

Meal 1 Meal 2

High-Fat,Low-Fiber

Meal(n=7)

7 day

washout

Low-Fat,High-Fiber

Meal(n=8)

Study Design

High-Fat,Low-Fiber

Meal15 Womenwith PCOS

Low-Fat,High-Fiber

Meal

Prolonged reduction in testosteronelevels after the high fat meal

0 60 120 180 240 300 360

65

60

5550

45

40

35

Time (Minutes)

High-Fat meal

Testosterone(

ng/dL)

* P


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Testosterone levels were reduced for 2

hours longer after the high fat meal

Higher levels of glucose and insulin afterthe high-fiber meal

Low vs. High Protein Diets

28 overweight or obese PCOS women

High protein (40% CHO, 30% Pro, 30% Fat) vs.Low Protein (55% CHO, 15% PRO, 30% Fat)

Both diets 1400 calories for 3 months

Weekly nutrition classes; exercise 3x/wk

Results: No significant difference was found!

Both groups lost weight, improved insulin,testosterone, menstrual function and other labs.

Moran LJ, Noakes M, Clifton M, TomlissonL, Norman RJ. Dietary composition inrestoring reproductive and metabolic physiology i n overweight women with pol ycysticovary syndrome. J ClinEndocrinol Metabol. 2003;88:812-819.

Very Low-Calorie Diets

114 obese women with PCOS

500 calories/day for 4 weeks

1,000 calories/day for 7 months

Results: 54% lost > 5% of body weight,11.8% remained at pretreatment weight;both groups showed improvements intestosterone levels.

Low GI Diets

73 obese adults without diabetes,

ages 18-35 Measured insulin levels

Lower carbohydrate (


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What is the best dietcomposition ???

For Reducing Insulin & Weight:

Lower intake of carbohydrates

Almost all whole grain, high fiber Avoidance of sweetened beverages

Spread evenly throughout the day

Eat frequently (every 3-5 hours)

Protein matching at all meals and snacks

Rich intake omega-3s

For Heart Health

Daily fat intake 35-45% of total daily calories

No more than 7% saturated fat. Transfatsshould be eliminated

Up to 20% of daily calories frommonounsaturated fatty acids, and up to 10%polyunsaturated fatty acids

Consume fatty fish 2x/week

Fish oil supplement

Plant sterols

Red wine

Protein

Lean, protein-rich foods with all meals andsnacks

Experimenting for optimal foodcombinations

Benefits of Protein

Delays postprandial response

Decreases hunger

Increases satiety Decreases ghrelin

Increases Thermic Effect of Food

Preserves LBM

Protein Intake & Fertility

Nurses Health Study-18,000 nurses Highest-protein group had 41% more ovulatory

infertility.

Women with the highest intake of animal proteinhad 39% more ovulatory infertility than thosewith the lowest.

Those who consumed the most plant-basedproteins had the lowest amount of infertility. exceptions were for eggs, dairy, and fish which were

found to increase fertility.

Chavarro J and Willett W. The Fertility Diet.


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Supplements WithInsulin-Sensitizing Properties

D - chiro inositol

Chromium

Cinnamon

N-acetyl cysteine

Alpha lipoic acid

Magnesium

Vitamin D3 Omega-3 fatty acids

Role of Exercise

3-month exercise program vs. hypocaloric diet

19 sedentary women with PCOS

SET: 25% improvement of insulin sensitivity

without weight loss.

improved fertility and menstrual cyclicity thanthose who followed a hypocaloric diet.

SET group also had greater improvements inwaist circumference and insulin resistance

despite only a smaller reduction in weight.

Barriers to Physical Activity

Size

Muscular shape

Its exercise!

The Role of The Dietitian inTreating PCOS

Empathetic, supportive, encouraging approach

Provide education on PCOS and insulinresistance

Education on healthy diet and exercise

Encourage a healthy approach to eating andexercise rather than focusing on weight loss

Assess symptom severity (including eatingdisorder behaviors)

Assess medication compliance

The Importance of NutritionCounseling for PCOS

In a study on the effects of exercise andnutritional counseling in women withPCOS, Bruner et al (2006) found thatnutritional counseling, with or withoutexercise, decreased insulin levels andimproved both metabolic and reproductiveabnormalities associated with PCOS.

The Nutrition Assessment

Screen any woman for PCOS Provide appropriate referral information

Screen for distorted eating

Review lab results Assess diet

Educate patient and parents about PCOS Insulin resistance Connection to symptoms Long-term risks Role of diet and exercise

Assess readiness for change


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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, nauseous, orirritability that gets better when you eat?

Have you ever been told by your physician or healthcareprovider that you have any abnormal lab values?

Can you tell me about any excessive body hair thatyouve dealt with?

Do you have dry/rough elbows, skin tags, or any darkpatches that look dirty on your body?

Does anyone in your family have polycystic ovarysyndrome?

From The Dietitians Guide to Polycystic Ovary Syndromeby Angela Grassi

Questions to ask a patientsuspected of PCOS: Tools

Food records

Mindful eating exercises

Food models and labels

Handouts

How food affects insulinlevels

Food exchanges

Managing hypoglycemia

Scale vs. waistcircumference

Lab results

PCOS in Pregnancy

Higher risk for:

Gestational diabetes

-GDM ~ 3.5% in general population

-GDM in PCOS estimated to be 20-50%

-Early OGTT

Miscarriage

Neonatal intensive care stays

Other Concerns in Pregnancy

Multiple babies

Food fears

Emotional Concerns

Weight gain

Body image issues

PCOS & Pregnancy

Should be considered a state of GDM:

-Moderate intake of carbohydrates

-Even distribution of carbohydrates-Protein matching

Daily exercise, preferably after meals

Patient education of risks

Appropriate weight gain

Metformin in Pregnancy

10-fold reduction inGDM using metformin

Glueck 1992 FertilSteril

Metformin decreasedmiscarriage Jacubovitz 2002

JCEM


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Unique Concerns:PCOS & Lactation

Insufficient milk

production

Failure of breast

tissue to develop

Insulin resistance

Adherence due to

size

Overabundance of

milk production

Guidelines To Establish AdequateMilk Supply in PCOS:

Pump after feedings for 10-15 minutes on

each breast in the first 2 weeks of initiatingnursing

Frequent feedings with full drainage

Adequate diet and fluid intake

Extra breast stimulation by frequentnursing or pumping sessions is crucial

Resources prior to birth

Safety: Metformin & Lactation

61 nursing infants and 50 formula fed infants

born to mothers with PCOS

took an average of 2.55 grams of Metformin per

day throughout pregnancy and lactation

Infants followed birth-6 mo.

Metformin had no adverse health risks in

regards to growth or motor-social development.

Glueck C et al. J Pediatr2006;148:628-32.

PCOS in Adolescence

Adolescence is the most vulnerable and

influential stage of PCOS.

It is in adolescence when symptoms of PCOS

first start to present themselves.

Changes can be made to diet and lifestyle thatcould prevent the worsening of symptoms later

in life and prevent the onset of many health

complications.

Obstacles Affecting Treatment

Proper diagnosis/ Lab profile

Patient readiness

Mental status Anxiety, Depression, Eating disorders

Social involvement

Family involvement

Resistance to exercise

In Summary

PCOS is a very complex, under-treated andunder-recognized epidemic

Early detection and treatment are key

Diet plays an important role in the treatment of

PCOS

RDs can offer lifestyle counseling on weight loss

and diet to improve insulin resistance to reducethe risk of chronic disease within the PCOSpopulation


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PCOS Resources www.PCOSnutrition.com

FREE PCOS nutrition tipsnewsletter, articles, resources

PCOS Nutrition Handout Series CD The Dietitians Guide to PCOSwith

Self-Study Course

PCOS Handouts on CD

The PCOS Workbook

www.youngwomenshealth.org Great resources for Teens with

PCOS Sample meal plans, articles,

information

www.PCOsupport.org Professional database

www.soulcysters.net

www.ProjectPCOS.org Latest PCOS news Information, tips, articles

QUESTIONS? COMMENTS?

THANK YOU!
http://www.projectpcos.org/http://www.soulcysters.net/http://www.pcosupport.org/http://www.youngwomenshealth.org/http://www.pcosnutrition.com/

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AngelaGrassiPCOS_000