International Lifestyle Recommendations for Polycystic Ovary … · 2019-03-27 · – Jarrett and Lujan (2017) • Included N = 22 studies with ovulation as primary outcome. •

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International Lifestyle Recommendationsfor Polycystic Ovary Syndrome (PCOS)

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2This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.

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Presentation Notes

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Brittany Y. Jarrett, PhD, RD• Postdoctoral fellow at Cornell University.• New fan of the Chicago Bears• Research Interests:

• Polycystic Ovary Syndrome• Ovarian Follicle Dynamics• Lifestyle Interventions

Today’s Presenters

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Annie W. Lin, PhD, RD, CDN• Postdoctoral fellow at Northwestern University. • Enjoys baking items with unique ingredient combinations• Research Interests:

• Diet and Physical Activity Assessments• eHealth• Patient-Clinician Communication

Today’s presenters met in graduate school at Cornell University. Both researchers studied polycystic ovary syndrome with

Dr. Marla Lujan in the Division of Nutritional Sciences.

Learning Objectives• Explain the role of nutrition and weight management

in polycystic ovary syndrome (PCOS).

• Summarize the new international evidence-based lifestyle recommendations for PCOS.– Teede et al., Human Reproduction (2018)

• Identify potential barriers to applying the lifestyle recommendations in clinical practice.

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Polling Question

Have you provided nutrition education toa woman with PCOS in the last year?

Presenter

Presentation Notes

http://www.easypolls.net/poll.html?p=5c880c34e4b064bdfdc619fe �

Background

Polycystic Ovary Syndrome (PCOS)• Complex endocrine disorder

– Affects 1 in 10 women of reproductive age globally– Accounts for 80% of cases of anovulatory infertility

• Diagnosed with 2 of 3 features:– Anovulation

• Evidence of irregular menstrual cycles

– Androgen excess• Evidence of hirsutism or• Evidence of elevated androgens

– Polycystic ovaries• Evidence of increased follicle number or• Evidence of increased ovarian size

6References: Bozdag et al. 2016; Teede et al. 2018. Image Credit: Christ et al. 2014.

Background

PCOS Complications• Linked to metabolic

disturbances– Obesity– Insulin resistance

• Imparts significant consequences on health across the lifespan

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Psychological• Anxiety• Depression• Poor quality of life

Metabolic• Metabolic syndrome• Diabetes mellitus• Cardiovascular disease

Reproductive• Infertility• Pregnancy-related risks• Endometrial cancer

References: Fauser et al. 2012.

Background

Obesity & PCOS

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Hyperinsulinemia

Obesity

Central adiposity

Ovarian dysfunction• Follicle excess• Follicle arrest and anovulation• Overproduction of androgens

Insulin resistance

Hyperandrogenism

References: Jarrett & Lujan 2017; Note: Solid lines denote direct relationships and dotted lines denote indirect relationships.

Background

Role of Lifestyle Intervention• Heralded as first-line therapy in patients with obesity

– Improves weight and metabolic abnormalities– Has unknown impact on reproductive outcomes

9References: Moran et al. 2009; Moran et al. 2011; Jarrett & Lujan 2017. Note: Dotted lines denote proposed mechanisms.

Obesity Insulin resistance Hyperinsulinemia

Hyperandrogenism Ovarian dysfunction (?)

Dietary interventionwith caloric restriction

Recap• PCOS is a complex endocrine disorder.

– Has significant effects on women’s health across the lifespan.

• Obesity is linked to the pathogenesis of PCOS.– Can worsen reproductive and metabolic features.

• Lifestyle intervention may reduce disease severity.– Likely targets obesity and insulin resistance.– Has unknown effects on menstrual cyclicity, ovulation, or fertility.

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• Includes 166 evidence-based (EBR) and clinical consensus recommendations (CCR), plus clinical practice points (CPP)– Conducted systematic reviews on prioritized questions– “…To promote consistent, evidence-based care and improve

the experience and health outcomes of women with PCOS.”

• Lifestyle-related items comprise:– 1 of the 5 guideline chapters – 24 of 166 recommendations

11References: Teede et al. 2018.

Teede H, Misso M, Costello M, et al. Hum Reprod 2018; 33(9): 1602 – 1617.

“Healthy eating and regular physical activity should be recommended to achieve [or] maintain healthy weight and to optimize hormonal outcomes, general health, and quality of life across the life course.”

2018 International Evidence-Based Guideline for PCOS

Effectiveness of Lifestyle Interventions

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CCR

General population recommendations for healthy eating should be followed across the life course.

For women with PCOS and body mass index < 25 kg/m2

CCR

References: Teede et al. 2018; Jarrett, Lin, & Lujan 2019.

Multi-component lifestyle intervention should be recommended for reductions in weight and insulin resistance.


Effectiveness of Lifestyle Interventions

13References: Teede et al. 2018; Jarrett, Lin, & Lujan 2019.

EBR

“A variety of balanced dietary approaches could be recommended to reduce dietary energy intake.”

For women with PCOS and body mass index ≥ 25 kg/m2

CCR

Achievable weight loss (i.e., 5% to 10% within 6 months) yields significant clinical improvements.

CPP

Summary of Recent Systematic or Narrative Reviews

Energy-Restricted Diets in PCOS• Interventions have primarily focused on hypocaloric

diets ± physical activity in obese patients.– Moran et al. (2009)

• Androgen Excess and PCOS Society Position Statement

– Moran et al. (2011)• Cochrane Systematic Review

• Most trials have noted improvements in endocrine and metabolic status with 5% – 10% weight loss:– Adiposity– Hyperandrogenism– Insulin sensitivity

14References: Moran et al. 2009; Moran et al. 2011.


Caloric Restriction & Ovulation• Little evidence to support an impact of caloric

restriction on ovulatory cyclicity in PCOS.– Jarrett and Lujan (2017)

• Included N = 22 studies with ovulation as primary outcome.

• Findings may relate to:– Use of infrequent or surrogate measures of ovulation.– Degree of change in salient endocrine/metabolic features.

15References: Jarrett and Lujan (2017).


Macronutrient Composition & PCOS• Impact of dietary composition appears marginal.

– Moran et al. (2013)• Included N = 6 studies that provided diets with a specific composition.

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Outcome Main Findings

Anthropometric • Little to no differences in weight loss among diets.

Reproductive • Subtle differences in changes in androgens.• Improved menstrual cyclicity on low glycemic index (GI) diet.

Metabolic • Improved insulin sensitivity / lipid profiles on a low GI diet.

Psychological • Improved quality of life on all diets.• Improved depression and self-esteem on high-protein diet.

There is limited evidence that any one dietary pattern is better than another for improving health outcomes in women with PCOS.

Slide Courtesy of: Marla Lujan, PhD.

Supplement Author (Total N) Main Findings

Vitamin D± Calcium

Azadi-Yazdi 2017(N = 183)

Fang 2017(N = 502)

• Improved androgen status• Improved menstrual cyclicity• No effect on glucoregulation or lipids

Omega-3s Hajishafiee 2016(N = 298)

Sadeghi 2017(N = 145)

• Improved androgen status• No effect on insulin sensitivity

Inositol Mendoza 2017(N = 1017)

Unfer 2016(N = 496)

• No effect on infertility treatment outcomes• Decreased insulin resistance

Chromium Fazelian 2017(N = 351)

• Decreased weight• Decreased insulin resistance


Dietary Supplements for PCOS

17Slide Courtesy of: Marla Lujan, PhD


Dietary Supplements for PCOS

18Slide Courtesy of: Marla Lujan, PhD.

• Evidence is heterogeneous and still emerging.– Greater focus on general health vs. PCOS-specific outcomes– Inclusion of essential vitamins/minerals and popular supplements

• Use caution in interpreting previous studies due to:– Age– Race and ethnicity– Dose, form, bioavailability– Purpose (physiologic vs. pharmacologic)


Exercise Intervention

19References: Teede et al. 2018. Slide Courtesy of: Marla Lujan, PhD. Image Credit: https://bit.ly/2Q1eF09.

Health professionals should encourage and advise the following for women with PCOS, per general population recommendations.

CCR


Exercise & PCOS• Data from exercise-specific interventions are limited.

– Include variable study designs, cohorts, and outcome measures.

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Intensity Author (Total N) Main Findings

Moderate3 – 6 months

Harrison 2011(N = 421)

• Increased sporadic ovulation• Reduced weight and insulin resistance

All intensities3 – 6 months

Hakimi & Cameron 2017(N = 341)

Conte 2015(N = 456)

• Increased sporadic ovulation• Reduced insulin resistance

• Improved quality of life and well-being

Improvements appear to occur independent of type, intensity, frequency, or duration of physical activity.

Slide Courtesy of: Marla Lujan, PhD.

“Health professionals and [patients] should be aware that women with PCOS have a higher prevalence of weight gain and obesity…with a clear need for prevention.”

CCR


Obesity & Weight Assessment

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CPP Assessment should be respectful of weight-related stigma, negative body image, and low self-esteem.

References: Teede et al. 2018; Jarrett, Lin, & Lujan 2019.

CCR “All those with PCOS should be offered regular monitoring for weight changes and excess weight.”

CPP Monitoring weight, preventing weight gain, and “encouraging evidence-based and socio-culturally appropriate healthy lifestyle [behaviors] is important in PCOS, particularly from adolescence.”


Obesity & Weight Assessment

22References: Teede et al. 2018; Jarrett, Lin, & Lujan 2019.

Jessica is a 29-year-old female patient in your clinic. For the past couple of years, her periods have been irregular and

have only happened every six months. She is now complaining of acne and excessive hair growth on her lip and chin. She also has a body mass index of 35.4 kg/m2. She has recently tried Weight Watchers and the ketogenic

diet, but describes difficulties losing weight.

Jessica’s physician suspects that she has PCOS.

Which of her features are consistent with the established diagnostic criteria for PCOS?

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Case Study

Presenter

Presentation Notes

Irregular cycles + hirsutism Irregular cycles + acne Irregular cycles + obesity Difficulty losing weight All of the above http://www.easypolls.net/poll.html?p=5c880c7fe4b064bdfdc61a0f

Jessica is a 29-year-old female patient in your clinic. For the past couple of years, her periods have been irregular and

have only happened every six months. She is now complaining of acne and excessive hair growth on her lip and chin. She also has a body mass index of 35.4 kg/m2. She has recently tried Weight Watchers and the ketogenic

diet, but describes difficulties losing weight.

Which nutrition recommendation(s) would you provide to Jessica?

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Case Study

Presenter

Presentation Notes

Follow a hypocaloric diet based on government recommendations. Aim for 5-10% weight loss over 6 months. Follow a low glycemic index and high protein diet. Continue with the ketogenic diet. Both A & B. http://www.easypolls.net/poll.html?p=5c880cd9e4b064bdfdc61a1c

Recap• New international guidelines support lifestyle as an

important component of the management of PCOS.

• Recommendations for the lifestyle management of PCOS reflect ones made in the general population.– Focus on healthy eating and physical activity behaviors.– Prioritize weight management across the lifespan.

• Assessments should be respectful of the unique physical and emotional consequences of PCOS.

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Baseline Knowledge, Behavior, and Beliefs

Usual Dietary Intake in PCOS• 8 of 17 studies identified differences in caloric intake:

• Recent focus on dietary patterns: – Those with PCOS more likely to consume Mediterranean-style diet.– Western and plant-based diet patterns associated with PCOS.

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Results (PCOS vs. Non-PCOS) Number of Studies

Total daily caloric intake N = 6



References: Lin & Lujan 2013; Cunha et al. 2018; Shahdadian et al. 2019; Zhang et al. 2018; Moran et al. 2015.

Presenter

Presentation Notes

Since we last published our narrative review, there are now 17 studies that examined the usual dietary intake of women with PCOS that spanned across different countries. 8 studies reported differences in daily total energy intake between women with and without PCOS, with the majority finding that women with PCOS consumed higher energy diets than women without PCOS. 9 studies found no differences in caloric intake between women with and without PCOS. Notably, two studies in the US, when using the NIH criteria, found there were no differences in daily energy intake, though these studies were limited by the enrollment of women around menopausal age and did not adjustment for potential confounders. Collectively, the mixed evidence may be attributed to variability measurements, small sample sizes, and different diagnostic criteria across studies. There has been more focus on dietary patterns in more recent studies, albeit in three that I have reviewed thus far. It appears that women with PCOS are more likely to consume healthier diet patterns. However, more studies are needed to confirm these findings. Interestingly, we have noticed a trend in the literature in which recent studies are reporting that women with PCOS did not consume more calories than those without PCOS, and are more likely to consume healthy diet. These results are promising as it suggests that the PCOS population may be interested in participating in healthy diet behaviors.

• 1 of 6 studies reported differences in PA.• Found more sedentary behavior in PCOS.

• Changes in PA in PCOS vs. Non-PCOS over time:– No differences in recent PA between groups.– In the past, women with PCOS spent less time:

• Housekeeping• Walking• Being physically active during commuting• Participating in activities of moderate intensity

– Women with PCOS spent more time sitting 5 years ago.

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Usual Physical Activity (PA) in PCOS

References: Lin & Lujan 2013; Zhang et al.2018.

Presenter

Presentation Notes

When examining physical activity, our review found that one study reported women with PCOS had longer sitting intervals, but no differences in time spent in moderate and vigorous intensity activities. I especially wanted to highlight one study that recently came out by Zhang et al. . This study was unique because the investigators examined past and recent self-reported physical activity between women with and without PCOS. Although there were no differences in recent activity between the groups - in the past, women with PCOS were less likely to participate in structured activities. Again, this is consistent with the trend that we have examined, in which recent studies support that women with PCOS are likely to adopt more healthy behaviors in present time.

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Odd

s R

atio

(95%

CI)

Exercise

Commercial Programs

Meal Replacement

Portion Size

Reduce Fat, Sugar

Low GI diet

* Significant(P < 0.05)

*

**


Weight Management Practices in PCOS

References: Moran et al. 2018. Logistic Regression: Adjusted for age, BMI, martial status, education, occupation, income, country of birth.

Presenter

Presentation Notes

The previous literature is consistent with a recent study by the Moran group in Australia. Using a longitudinal population-based study Australian women., they investigated the weight management practices of those with and without PCOS. In this figure, each weight management practice is presented on the x-axis, while the odds ratios are represented by the y-axis. Compared to those without PCOS (and accounting for age, BMI and other participant demographics), women with PCOS were more likely to consider portion sizes, reduce their fat and sugar intake, and consume a low glycemic index diet. NOTE: 7767 women who responded to the question on PCOS diagnosis in Survey 4 or 5 (‘In the last three years have you been diagnosed with or treated for polycystic ovary syndrome’) (n = 556 PCOS; n = 7211 non-PCOS)

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Diet Books

Pharma-ceuticals

Fasting Smoking Alternative PracticesHealthy

Practices

*


Weight Management Practices in PCOSO

dds

Rat

io (9

5% C

I)* Significant

(P < 0.05)

References: Moran et al. 2018. Logistic Regression: Adjusted for age, BMI, martial status, education, occupation, income, country of birth.

Presenter

Presentation Notes

Collectively, the authors found that women with PCOS were more likely to participate in alternative practices (such as use of laxatives, diuretics or diet pills, fasting or smoking) to manage their weight, which can have implications in medical nutrition therapy.

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Compared to most people your age and weight in the U.S., what would you say are your chances of getting ____?

1 = Much lower than average; 3 = Same; 5 = Much higher than average

β = 0.83 (0.11)P < 0.01

β = 1.25 (0.11)P < 0.01

β = 0.89 (0.11)P < 0.01

β = 1.05 (0.09)P < 0.01


Beliefs in PCOS: Perceived Susceptibility

References: Lin et al. 2018. Raw Data: Mean ± SD. Multiple Linear Regression: Adjusted for age, BMI, education.

Presenter

Presentation Notes

But what beliefs are driving these behaviors? Our research group examined the health-related beliefs of women with PCOS and compared their responses against a comparison group without PCOS. In this figure, PCOS-related health outcomes are presented on the x-axis, while the 5-point response scale is presented on the y-axis. We found that women with PCOS reported they were at higher risk of CVD, diabetes, endometrial cancer, and weight gain than the average US resident of similar age and weight. When compared to women without PCOS, the PCOS group reported feeling more susceptible for heart disease, diabetes, endometrial cancer, and weight gain.

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There’s a lot I can do to prevent getting __________.

1 = Disagree; 3 = Neutral; 5 = Agree


Beliefs in PCOS: Disease Prevention


β = -0.19 (0.09)P = 0.04

β = -0.44 (0.10)P < 0.01

Presenter

Presentation Notes

Women with PCOS also were likely to somewhat agree that heart disease, diabetes and weight gain were preventable, but these findings were not reflected with endometrial cancer and infertility. Although the PCOS group reported poorer perceived control over cardiovascular disease and weight gain than the comparison group, this pattern was not observed for endometrial cancer and infertility as evidenced by the regression models (after adjusting for age, BMI and education. The result with diabetes was trending.

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A healthy diet will reduce my risk of __________.

1 = Disagree; 3 = Neutral; 5 = Agree




β = -0.19 (0.09)P = 0.03

Presenter

Presentation Notes

A similar trend was observed with healthy diet where women were more likely to believe a healthy diet and PA were able to reduce CVD, diabetes and weight gain.

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It is important for me to meet government __________ recommendations.




1 = Disagree; 5 = Agree

β = 0.38 (0.13)P < 0.01

Presenter

Presentation Notes

Although women with PCOS are more likely to participate in healthy behaviors, it does not appear that they place great importance in meeting government recommendations for dietary and physical activity. However, women with PCOS did place greater importance on meeting physical activity recommendations than women without PCOS.

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Please select how confident you are in your ability to do the following for the next month.


Self-Efficacy of Diet Behaviors


1 = Cannot do; 5 = Certainly can do

Presenter

Presentation Notes

When examining the self-efficacy of women with PCOS, they were confident in their ability to incorporate government recommendations, especially aimed at weight loss. Although women with PCOS did not score as confidently on items related to resisting cues, mean scores fell between “possibly can do” and “mostly can do.” No significant differences were observed in self-efficacy scores between women with and without PCOS in either the unadjusted or adjusted models.

• Recent studies have shown no differences in dietary intake or physical activity between women with and without PCOS.– Women with PCOS may be consuming higher quality diets. – They are confident they can perform healthy diet behaviors.

• Women with PCOS are less certain that healthy diet and physical activity can prevent weight gain.

• Women with PCOS place greater importance on physical activity recommendations than controls.– Potential area of encouragement.

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Recap

Presenter

Presentation Notes

Overall, recent studies have shown no differences in diet and physical activity between women with and without PCOS. However, the data are from cross-sectional studies. The Zhang et al article leads us to wonder, is there a critical period of time where a healthy diet and increased physical activity will have a greater impact on reproductive function? Duration might also have an impact? Further, although women with PCOS does believe a healthy diet and increased physical activity will ameliorate their risk for PCOS-related health outcomes, they are less certain that it can prevent weight gain. Something to highlight is that their definition of a healthy diet may not reflect those from the dietary guidelines for Americans, which is reflected by their higher likelihood to practice alternative approaches to manage their weight. Interestingly, women with PCOS place greater importance on the 2008 physical activity guidelines, which could serve as a potential area to target when providing weight loss strategies.

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Barriers to PCOS-Related Care

Visits with Healthcare Providers

References: Jarrett, Lin, & Lujan 2019. Note: Categories in figure are not mutually exclusive.

Presenter

Presentation Notes

But we started to wonder, who had more opportunity to provide weight loss counseling? When we went back to our data, out of 134 women with PCOS, only 8 women visited a dietitian for PCOS-related care.

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Visits with Healthcare Providers

References: Jarrett, Lin, & Lujan 2019. Note: Categories in figure are not mutually exclusive.

Presenter

Presentation Notes

By far, most of the women with PCOS visited a primary care physician, a specialist, and/or a nurse practitioner or physician assistant.

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β = 0.30 (0.13), P = 0.02

1 = Never; 3 = Sometimes; 5 = Always


Provider Support for PCOS


Presenter

Presentation Notes

Social support items were asked about healthcare providers (which included all types of physicians, nurse practitioners, and physician assistants). Response options on items related to social support ranged from ‘never’ to ‘always’ with higher scores indicating greater frequency. The PCOS group reported that they usually received general health advice (informational support) from healthcare providers, but did not usually receive specific information on nutrition and PCOS. Interestingly, though women with PCOS reported that they rarely had negative encounters with their healthcare providers, yet were only sometimes satisfied with the emotional support provided during their medical care. The limited satisfaction may be attributed to the patients’ inability to usually relax and discuss their health concerns with their healthcare providers, as well as the patients’ perception that they only sometimes were provided encouragement about their health. When examining differences in perceptions of social support by mixed models, the PCOS group reported that their healthcare providers argued with them more frequently about health-related issues than the comparison group.

• Limited access to nutrition services– Limited physician referrals to RDs– Limited insurance coverage

• Inadequacy of nutrition care for PCOS– Only 11% of patients with PCOS have reported being satisfied

with the support that they received for making lifestyle changes.– Most rely on information from unregulated sources.

• Failure to tailor care to the unique concerns of PCOS

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Barriers to Implementing the New International Guidelines for PCOS

References: Jarrett, Lin, & Lujan 2019; Lin et al. 2018; Gibson-Helm et al. 2017; Tomlinson et al. 2017.

Presenter

Presentation Notes

Based on the data, we identified three barriers to implementing these new international guidelines for PCOS. The first barrier includes limited access to nutrition services, particularly due to the medical infrastructure. Studies have shown that physicians often function as sole providers of weight loss counseling in primary care settings yet report having limited confidence in sharing weight management information with patients. This issue is exacerbated by the limited insurance coverage for medical nutrition therapy. The second barrier is inadequate nutrition care for PCOS. Less than 1/4th of PCOS patients are satisfied with the support they received while making lifestyle changes, and often rely on sources that are unregulated. The third barrier, and one that we have seen through the presentation, is that care is not tailored to the unique considerations associated with PCOS. Women with PCOS feel this condition increases their risk for health complications, and thus, it makes sense that they feel government recommendations suited for the general American may not be helpful for them.

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Discussion Question

What are some strategies to increase the provision of tailored, evidence-based nutrition information to

patients with PCOS?

What are some strategies to increase physician referrals to nutrition experts for PCOS?

Presenter

Presentation Notes

So this leads us to the discussion question, what strategies do or would you use to provide tailored, evidence-based nutrition information to patients with PCOS? Also, how do we get physician buy-in to encourage referrals to dietitians? What are some strategies you would use to increase physician referrals to nutrition experts for PCOS?

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Proposed Solutions to Barriers in PCOS-Related Nutrition Care

References: Jarrett, Lin, & Lujan 2019.

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Translation of the PCOS Guideline

References: Teede et al. 2018.

• Tools for Patients– Evidence-based app (AskPCOS)

• Tools for Providers– Question prompts– Health literacy enhancing tools– Accredited courses– Webinars with international expert panels– e-Health information resources

https://www.monash.edu/medicine/sphpm/mchri/pcos

Conclusions• PCOS is linked to lifelong metabolic complications.

– Weight management is key.

• International evidence-based guidelines support lifestyle management in all women with PCOS –regardless of weight.– Interventions should be multicomponent and individualized,

and reflect government recommendations for healthy eating and physical activity.

• Providers should work to address barriers to effective nutrition care for women with PCOS.– Tailor nutrition counseling to unique concerns of PCOS.– Increase physician referrals to registered dietitians for PCOS.

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AcknowledgmentsLujan Research Group• Marla Lujan, PhD• Heidi Vanden Brink, MSc, RDMS

Cornell Faculty, Staff, and Students• Pat Cassano, PhD• Jamie Dollahite, PhD• Jeffery Sobal, PhD• Kevin Klatt, PhD

University of Rochester• Kathleen Hoeger, MD

Study Participants

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Funding• Cornell University

– Division of Nutritional Sciences– CALS Alumni Association– CHE Alumni Association

• National Institutes of Health– T32-DK007158 (B.Y.J.)– T32-CA193193 (A.W.L.)

ReferencesBozdag G., Mumusoglu S., Zengin D., et al. The prevalence and phenotypic features of polycystic ovary syndrome: a systematic reviewand meta-analysis. Hum Reprod. 2016; 31(12); 2841–2855.

Christ J., Willis A., Brooks E., et al. Follicle number, not assessments of the ovarian stroma, represents the best ultrasonographic markerof polycystic ovary syndrome. Fertil Steril. 2014; 101(1): 280–287.

Fauser B., Tarlatzis B., Rebar R., et al. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the AmsterdamESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012; 97(1): 28–38.

Gibson-Helm M., Teede H., Dunaif A., et al. Delayed diagnosis and a lack of information associated with dissatisfaction in women withpolycystic ovary syndrome. J Clin Endocrinol Metab. 2017; 102(2): 604–612.

Jarrett B., Lujan M. Impact of hypocaloric dietary intervention on ovulation in obese women with PCOS. Reproduction. 2016; 156(1): R15–R27.

Jarrett B., Lin A., Lujan M. A Commentary on the New Evidence-Based Lifestyle Recommendations for Patients with Polycystic OvarySyndrome and Potential Barriers to Their Implementation in the United States. J Acad Nutr Diet. 2019; 119(2): 205–210.

Lin AW, Dollahite JS, Sobal J, Lujan ME. Health-related knowledge, beliefs and self-efficacy in women with polycystic ovary syndrome.Hum Reprod. 2018; 33:91-100

Lin AW, Bergomi E, Dollahite JS, Sobal J, Hoeger KM, Lujan ME. Trust in physicians and medical experience beliefs differ between womenwith and without polycystic ovary syndrome. J Endocr Soc. 2018;2(9):1001-1009.

Moran LJ, Pasquali R, Teede HJ, et al. Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excessand Polycystic Ovary Syndrome Society. Fertil Steril. 2009; 92(6): 1966–1982.

Moran LJ, Hutchison SK, Norman RJ, et al. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev.2011; CD007506.

Moran LJ, Brown WJ, McNaughton SA, et al. Weight management practices associated with PCOS and their relationships with diet andphysical activity. Hum Reprod. 2017; 32(3):669-678.

Teede H., Misso M., Costello M., et al, Recommendations from the International Evidence-based Guideline for the Assessment andManagement of Polycystic Ovary Syndrome. Hum Reprod. 2018; 33: 1602–1618

Tomlinson J., Pinkney J., Adams L., et al, The diagnosis and lived experience of polycystic ovary syndrome: A qualitative study. J AdvNurs. 2017; 73: 2318–2326.

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49This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.

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Documents

International Lifestyle Recommendations for Polycystic Ovary … · 2019-03-27 · – Jarrett and Lujan (2017) • Included N = 22 studies with ovulation as primary outcome. •