Carolynn Francavilla Brown, MD, FOMA

Family Medicine and Obesity Medicine

Green Mountain Partners for Health and Colorado Weight Care

DoctorFrancavilla@gmail.com

Thinking Like an Obesity Physician: Nutrition and Weight Loss Strategies for PCOS

Nutrition and Weight Loss Strategies for PCOS

Goals

Feel comfortable offering brief but focused nutrition counseling to women with PCOS

Understand appropriate weight loss goals for PCOS

Be aware of pros and cons of popular diet strategies

Nutrition and Weight Loss Strategies in PCOS

Pillars of Obesity Management

What does an obesity physician do?

Identify Underlying Causes of Obesity Utilize Medications Advise Exercise Nutrition Counseling Behavior Modification

Obesity Treatment

Relationship of PCOS and Obesity

PCOS is a heterogenous disease state with different phenotypes

PCOS has different criteria by different expert groups

Underlying Causes

ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome. (2018). Obstetrics & Gynecology, 131(6),158.

Relationship of PCOS and Obesity Overweight or obesity affects approximately

60–80% of PCOS patients Approximately 70% of women with PCOS have

insulin resistance Women with PCOS who have obesity or are

lean both show increased incidence of insulin resistance

Identifying insulin resistance: A1C, fasting glucose, glucose tolerance test (75g 2 hourglucose tolerance test), HOMA-IR (fasting glucose to insulin ratio), acanthosis nigricans on exam

Underlying Causes

R. Azziz, L. A. Sanchez, E. S. Knochenhauer et al., “Androgen excess in women: experience with over 1000 consecutivepatients,” Journal of Clinical Endocrinology and Metabolism, vol. 89, no. 2, pp. 453–462, 2004.Deugarte, C., Bartolucci, A., & Azziz, R. (2005). Prevalence of insulin resistance in the polycystic ovary syndrome using the homeostasis model assessment. Fertility and Sterility, 83(5), 1454–1460. doi: 10.1016/j.fertnstert.2004.11.070

Goals of Weight Loss in PCOS

Many women with PCOS have improvement in cycles, fertility and insulin resistance from modest weight loss, but not all.

What should be the weight loss goal?5-10% weight loss

If symptoms have not been reduced with a 10% weight loss, additional weight loss is unlikely to improve symptoms and other treatment modalities should be maximized.

Prevent weight gain for women at normal weight with PCOS

Underlying Causes

Guzick, D. S., Wing, R., Smith, D., Berga, S. L., & Winters, S. J. (1994). Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertility and Sterility, 61(4), 598–604. doi: 10.1016/s0015-0282(16)56632-1Huber-Buchholz, M.-M. (1999). Restoration of Reproductive Potential by Lifestyle Modification in Obese Polycystic Ovary Syndrome: Role of Insulin Sensitivity and Luteinizing Hormone. Journal of Clinical Endocrinology & Metabolism, 84(4), 1470–1474. doi: 10.1210/jc.84.4.1470

Underlying Causes

Why is weight loss (and maintenance) so hard?Adaptive thermogenesis

Ø Decreased energy expenditure with weight lossØ Most studies show it does not fully restore to normal with weight regainØ Maintenance of a 10% or greater reduction in body weight in lean or obese

individuals is accompanied by an approximate 20%-25% decline in 24-hour energy expenditure

This decrease in weight maintenance calories is 10–15% below what is predicted solely on the basis of alterations in fat and lean mass

Biggest Loser Study. Mean RMR after 6 years was ~500 kcal/d lower than expected based on the measured body composition changes and the increased age of the subjects

Increase appetite Increased Ghrelin, PYY, CCK, Amylin (hunger signals) with weight loss=hunger which

resolves with weight loss Leptin (fullness signal) decreases It’s not WILL POWER!

Int J Obes (Lond). 2010 October ; 34(0 1): S47–S55. doi:10.1038/ijo.2010.184Obesity (Silver Spring). 2016 August ; 24(8): 1612–1619. doi:10.1002/oby.21538.

Anti-Obesity Medications Phentermine (and other sympathomimetic

amines) Orlistat Naltrexone/Bupropion ER (Contrave) Phentermine/Topiramate ER (Belviq) Liraglutide (Saxenda)

Current recommendations to use medications LONG TERM as neededShould achieve a 5% weight loss by 12 weeks of medication

Medications

Metformin

Not a first line for hirsutism, anovulation, or fertility

Utilized frequently for treatment of insulin resistance and obesity, so consider if either of these is present

Helps insulin resistance, weight ovulation, improvement of symptoms

Dose 1500-2000mg daily

Medications

Neil F. Goodman, Rhoda H. Cobin, Walter Futterweit, Jennifer S. Glueck, Richard S. Legro, and Enrico Carmina (2015) AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, AMERICAN COLLEGE OF ENDOCRINOLOGY, AND ANDROGEN EXCESS AND PCOS SOCIETY DISEASE STATE CLINICAL REVIEW: GUIDE TO THE BEST PRACTICES IN THE EVALUATION AND TREATMENT OF POLYCYSTIC OVARY SYNDROME - PART 2. Endocrine Practice: December 2015, Vol. 21, No. 12, pp. 1415-1426

Exercise and PCOS

Guidelines for everyone 150-300 minutes a week of moderate intensity physical activity

Patients who lose weight and keep it off are exercising and average of 60 minutes a day, with the most common exercise being walking

Create an “Exercise Prescription” Any movement is good for health

Exercise

Physical Activity Guidelines for Americans, 2nd Editions. Accessed at: https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdfNational Weight Control Registry Retrieved from http://www.nwcr.ws/Research/default.htm

https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdfhttp://www.nwcr.ws/Research/default.htm

General Approaches to Dietary AdviceAsk permission to discuss weight-Consider if patient has or had an eating disorder (ED)-Screening tools- EDDS, EAT, QEWP-R, BEDS7. -“Are there times when you feel like you eat out of control?”-If concern for ED If present refer to therapist, psychiatrist or obesity specialist that you know is comfortable with ED.

Nutrition

General Approaches to Dietary Advice Find out what they are currently eating-24 hour recall-“Typical day”-Food journal

Why?-Low hanging fruit like sweet drinks, alcohol, snacks, sweets, fastfood, restaurant food-Preferences- eating pattern, homemade food, restaurant food, packaged food-Lack of patient confidence if you tell them to do what they are already doing-Already eating pretty healthy? Is there binge eating present? Do you need to consider a medication or step up care to someone else like and obesity physician or RD

Nutrition

General Approaches to Dietary Advice

What is a calorie?

Nutrition

There is no good evidence that one type of diet is superior to another for women with

PCOS

Nutrition

Mediterranean Diet

Summary: pattern of eating high in fruits, vegetables, whole grains, beans, nuts, and seeds, olive oil, and moderate wine consumption. It generally includes low to moderate amounts of fish, poultry, and dairy products, with little red meat.

Pros:• Better studied than

most diets• Improved overall

mortality, CVD, cancer, Alzheimer’s, Parkinsons

Cons:• No specific

“Mediterranean Diet”, really a pattern of eating associated with health

• In of itself does not lead to weight loss, need calorie goal to with it

Adherence to Mediterranean diet and health status: meta-analysis.Sofi. BMJ (Clinical research ed.) Volume: 337 (2008) ISSN: 0959-8138 Online ISSN: 1756-1833

Plant Based Diet

Summary: (Vegan, Lacto-Ovo Vegeterian, Lacto Vegeterian)Avoidance of Beef, lamb, poultry, seafoods. May avoid eggs or dairy.

Pros:• Appears to be

cardio-protective• May reduce risk of

cancers

Cons:• Long-term effects of diet

are difficult to separate from those associated with a vegetarian diet like regular exercise, avoidance of tobacco and alcohol products

• Without calorie or macronutrient goals may not lead to weight loss

• Many plant-based foods favored by average person are also high glycemic (potato, rice, pasta, chips, crackers, tortillas)

• Deficiencies in b12, vit D and omega 3s if not supplemented

Rao, V., & Al-Weshahy, A. (2008). Plant-based diets and control of lipids and coronary heart disease risk. Current Atherosclerosis Reports, 10(6), 478–485. doi: 10.1007/s11883-008-0075-2

Ketogenic Diet

Summary: Diet very low in carbohydrates, leading body to burn fat as a fuel source producing ketones as a result

Pros:• Rules of diet are

clear- limit carbs to 20-40g daily (depending on protocol)

• Getting into ketosis suppresses appetite making it easier to stick to

• Improved insulin resistance quickly

Cons:• Often high in saturated

fat, red meat (though does not have to be)

• Long term adherence• Weigh regain when

diet is stopped

Paleolithic Diet

Summary: based upon presumed dietary pattern in the PaleolithicPeriod excludes grains, legumes, dairy, and ultra-processed foods.

Pros:• Limits processed

food• Encourages

vegetables and fruit

Cons:• Lots of paleo “junk

food” and processed food available now

• Not calorie restricted-so doesn’t always lead to weight loss

Meal Replacement Programs

Summary: (Optavia, Nutrisystem, Optifast, etc) Pre-made meals, protein bars and shakes make up majority of calories

Pros:• Strong structure• Easy• High protein,

calorie controlled• Weight loss very

likely to occur if program is followed

Cons:• Transition to more “real

food” can be a challenge, can lead to yo-yo dieting

• Highly processed food

Intermittent Fasting

Summary: Caloric intake is limited to part of the day. Recommend fasts start at 14-16 hours and sometime extend to 72 or more hours.

Pros:• Eating less often

exposes patient to less insulin

• Appears to reduce diabetes, heart disease, cancer an neurodegenerative disease

• May limit total calories eaten per day

Cons:• Can worsen poor

eating patterns, over eating in eating window

• Still need guidelines of what can be eaten

Cabo, R. D., & Mattson, M. P. (2019). Effects of Intermittent Fasting on Health, Aging, and Disease. New England Journal of Medicine, 381(26), 2541–2551. doi: 10.1056/nejmra1905136

Nutrition SummaryWhat do these plans have in common?o Increasing vegetables and produceo Structure- reduce calories or

carbohydrateso Decreasing processed foods

Nutrition

If you have 5 minutes or less to discuss nutritionThe best diet for weight loss is the one a patient will stick to!

What fits with the patient’s lifestyle, culture, interests and experience

The physical and psychological tendencies Plants are good for you! But too much fruit does not help with weight

loss, eat more veggies- 1 serving of fruit a day For most plans give a calorie goal- 1200 is a

reasonable target for most women, can use an online calculator to help patients set a goal

Nutrition

Source:Bays HE, McCarthy W, Christensen S, Wells S, Long J, Shah NN, Primack C. Obesity Algorithm eBook, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2019. https://obesitymedicine.org/obesity-algorithm/ (Accessed January 28, 2020)

If you have 5 minutes or less to discuss nutrition

Nutrition

Calorie Goal:

If you have 5 minutes or less to discuss nutrition

Nutrition

Protein Fat Carbs

MeatBreadGrains-Wheat-Rice-Corn-Oats

ButterEgg White Egg yolkSoySome dairy (greek yogurt, cottage cheese)Protein shakes and bars

OilsNutsAvocado

Fat on meat

CrackersChipsPotatoSweetsDessertsFruit

Cheese

Veggies

General Approaches to Behavior Change Stimulus Control: portion control, limiting

snacking/grazing, removing trigger foods Cognitive Restructuring: realistic weight goals

and body image, change relationship with foods, let go of all or nothing mentality

Self- Monitoring: logging (apps like myfitnesspal or loseit, pen and paper)

Support/Accountability: therapist, obesity physician, personal trainer, support group, structured program (weight watchers, etc)

Behavior Change

Source:Bays HE, McCarthy W, Christensen S, Wells S, Long J, Shah NN, Primack C. Obesity Algorithm eBook, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2019. https://obesitymedicine.org/obesity-algorithm/ (Accessed January 28, 2020)

Bariatric Surgery Requirements BMI ≥ 40, or more than 100 pounds overweight BMI ≥ 35 and at least one or more obesity-

related co-morbidities such as type II diabetes, hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.

Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts. (usually 3-6 months for insurance purposes)

Bariatric Surgery

Who is a Candidate for Bariatric Surgery?: Patients: ASMBS. (n.d.). Retrieved February 22, 2020, from https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery

Escobar-Morreale, H. F., Botella-Carretero, J. I., Álvarez-Blasco, F., Sancho, J., & Millán, J. L. S. (2005). The Polycystic Ovary Syndrome Associated with Morbid Obesity May Resolve after Weight Loss Induced by Bariatric Surgery. The Journal of Clinical Endocrinology & Metabolism, 90(12), 6364–6369. doi: 10.1210/jc.2005-1490

https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery

Billing for Obesity Counseling Can add code 99401 for 15 minutes of

nutrition counseling for obesity in addition to your E&M code for management at visit

Modifier 25 on E&M Code (i.e. 99214) Document what you spent the 15 minutes

counseling on Some suggest a “separate note” to

document this

Billing

Summary✭60-80% of women with PCOS have

overweight or obesity✭Obesity is a risk factor for diabetes, heart

disease, cancer and other disease states✭Treatment of weight in women with PCOS

can improve PCOS symptoms✭A 5-10% weight loss often improves PCOS

symptoms in addition to reducing disease risks from obesity

✭The best diet is the diet a patient can stick with!

Summary