Accepted Manuscript

Title: Nutritional management in women with polycystic

ovary syndrome: A review study

Authors: Zeinab Faghfoori, Siavash Fazelian, Mahdi

Shadnoush, Reza Goodarzi

PII: S1871-4021(17)30011-5
DOI: http://dx.doi.org/doi:10.1016/j.dsx.2017.03.030
Reference: DSX 736

To appear in: Diabetes & Metabolic Syndrome: Clinical Research & Reviews

Please cite this article as: Faghfoori Zeinab, Fazelian Siavash, Shadnoush Mahdi,
Goodarzi Reza.Nutritional management in women with polycystic ovary syndrome:
A review study.Diabetes and Metabolic Syndrome: Clinical Research and Reviews
http://dx.doi.org/10.1016/j.dsx.2017.03.030

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Nutritional management in women with polycystic ovary syndrome:
A review study

Nutritional management in women with polycystic ovary syndrome:

A review study

Zeinab Faghfoori1, Siavash Fazelian 2, Mahdi shadnoush3, Reza Goodarzi 4*

1
Associate Professor, Food (Salt) Safety Research Center, School of Nutrition And Food
Sciences, Semnan University of Medical Sciences, Semnan, Iran
2
Songhor Healthcare Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
3
Ph.D. of Nutrition, Semnan University of Medical Sciences, Semnan, Iran
4
Corresponding Author: Msc In Nutrition, Imam Hospital of Borujerd, Lorestan University of
Medical Sciences, Khorram -Abad, Iran.
Phone:+986642503054 Email : Goodarzi121@Yahoo.Com
Abstract
Polycystic ovary syndrome (PCOS) is endocrine disorder in women of reproductive age, which leads to
reproductive, hormonal and metabolic abnormalities. Due to the presence of insulin resistance, PCOS increases the
risk of chronic diseases like type 2 diabetes, hypertension, lipid disorders, cardiovascular diseases and malignancies
such as breast and endometrial cancer. The actual cause of this syndrome is unknown but environmental factors such
as dietary habits play an important role in prevention and treatment and lifestyle modifications are the most
important therapeutic strategies in these patients. The approach of the diet therapy in these patients must be to reach
specific goals such as improving insulin resistance, metabolic and reproductive functions that will be possible
through the design of low-calorie diet to achieve weight loss or maintaining a healthy weight, limit the intake of
simple sugars and refined carbohydrates and intake foods with a low glycemic index, reduction of saturated and
trans fatty acids and attention to possible deficiencies such as vitamin D, chromium and omega-3. Given the
prevalence of overweight and obesity and insulin resistance, a relatively low reduction in weight, about 5%, can
improve problems such as insulin resistance, high levels of androgens, reproductive system dysfunctions and
fertility in these women.

Key words: polycystic ovary syndrome, Insulin resistance, Obesity, Nutritional management, Life style
modification
Introduction

Polycystic ovary syndrome (PCOS) is the most common endocrine system disorder in women of

reproductive age, which appears as a set of symptoms and disorders with mild to severe protests

in the functioning of reproductive, hormonal and metabolic systems (1).

This syndrome is characterized by irregular menstruation, polycystic ovaries and

hyperandrogenism, insulin resistance, and obesity that is observed in 5 to 20 percent of women

depending on the diagnostic criteria used (2).

Symptoms of this syndrome include the endocrine system and reproductive signs which occur in

the shape of amenorrhea or oligomenorrhea, hirsutism, obesity, acne, male pattern hair loss and

reproductive disorders. This syndrome also increases the risk of diseases like type 2 diabetes,

hypertension, lipid disorders, cardiovascular diseases and malignancies, such as breast and

endometrial cancer (3).

The actual cause of PCOS is unknown and probably stems from a combination of factors such as

genetic factors, exposure to high levels of androgen prenatally, epigenetic factors and

environmental factors. Various environmental factors play a fundamental role in the occurrence

and treatment of this syndrome, among which dietary pattern, physical activity, smoking and

stress could be pointed out (6-4).

Most women with polycystic ovary syndrome, regardless of weight, have resistance to insulin.

For this reason, changes in lifestyle that lead to improvements in insulin sensitivity should be

considered as the first-line therapy in this syndrome, especially in cases where there is the

problem of excess weight and obesity (7).

In spite of the prevailing belief of the necessity to modify lifestyle factors, comprehensive

information on nutritional recommendations for women with polycystic ovary syndrome is not
available. That being the case of conducting the present review study aiming at the provision of

recommendations for the nutritional management in women with polycystic ovary syndrome.

Obesity and weight loss in polycystic ovary syndrome

There is a close connection between PCOS and obesity, in a way that the mean of obese patients

with polycystic ovary syndrome is higher than the mean of obesity among healthy women.

Studies have shown that, approximately, 60-40 percent of PCO cases are overweight or obese.

Obesity, especially abdominal obesity in adolescence and adulthood, and weight gain in puberty

are predictor of hirsutism and menstrual disorders in this syndrome. In fact, it seems that obesity

in many cases makes the hidden syndrome clinically apparent in susceptible women (8).

Some studies also have reported an increase in visceral adipose tissue and central obesity even in

lean women with PCOS, compared to the healthy control group. Obesity may increase the risk of

certain PCOS features such as increased levels of androgens, hirsutism, infertility, and pregnancy

complications, such as preeclampsia and gestational diabetes. Moreover, the obesity associated

with insulin resistance increases the risk of cardiovascular diseases and type 2 diabetes in women

(9).

Several studies have reported the positive effects of 5 -10 percent weight loss on reducing the

risk factors for cardiovascular disease, type 2 diabetes, endocrine and reproductive parameters in

polycystic ovary syndrome (12-10). Women suffering from PCOS often complain about the lack

of, or slow rate of weight loss in spite of a low-calorie diet; however, other studies have not

confirmed these findings (13, 14). Although Georgopoulos et al. found that women with PCOS,

with or without resistance to insulin, have a lower basal metabolic rate compared to healthy

women (15).

Disorderliness in appetite regulation is also observed among these women that may cause some

problems with weight control. Levels of ghrelin and cholecystokinin, hormones which play
essential roles in regulating appetite, are also impaired in these patients (19-16). In one study,

overweight women with PCOS, experienced increased hunger after eating a balanced meal, and

their experience was observed before and after weight loss (17). The success in weight loss

strategy is obtained through reduced calorie intake (500 to 1000 kcal per day) along with regular

physical activity as well as stress reducing behavioral and psychological therapy, and social

support (8).

The macronutrient composition of weight-loss diets

Two studies assessing the effect of low-carbohydrate diet (40% vs. 55%) in women with PCOS

found no significant differences in weight loss, metabolic /endocrine profiles (20, 21). In a short-

term study, the effects of a low carbohydrate diet (43% energy) and rich in unsaturated fatty

acids (17% energy) was compared to a standard diet (low-fat and high carbohydrate) and

revealed a reduced insulin levels after a low carbohydrate diet; however, no significant changes

in insulin sensitivity or sex hormones was reported(22).

Those diets rich in unsaturated fatty acids and polyunsaturated fat (PUFA) resulted in a

significant increase of Pregnanediol 3-glucuronide in women with PCOS, though only 2 out of

17 women showed signs of ovulation. Moreover, the levels of LH, FSH, SHBG, DHEAS and

testosterone did not change (23). Limiting energy intake, independent of weight loss, led to

improved reproductive parameters (21).

Recently, a great interest has been observed regarding the use of high protein diets among the

ones who wish to lose weights and control diabetes, as well as among women with PCOS.

However, there is little evidence confirming the beneficial effects of such diets on insulin
resistance and in some studies, it has also been reported that such foods will aggravate insulin

resistance and impairment of glucose metabolism (24, 25).

Two studies in women with PCOS showed that, while low-calorie diet resulted in significant

weight loss and improvement in metabolic and reproductive disorders, high-protein diets were

found to be more effective compared to high-carbohydrate diets (20, 21). Concerns remain on the

safety of high-protein and low-carbohydrate diets due to their negative effects on kidney

function, bone mineral density, and a reduction in the proportion of protective foods like fruits,

vegetables, and whole grains. Additionally, some studies have shown a positive relationship

between iron intakes through the consumption of red meat (the best source of easily-absorbed

iron) and risk of type 2 diabetes (28-26).

The findings of a study conducted by Attica et al. showed that red meat consumption is

positively associated with hyperglycemia, hyperinsulinemia, and higher levels of homeostatic

model assessment after adjusting for potential confounders, such as body mass index (29). The

important thing to consider is that the increased intake of fruits, vegetables and whole grains has

protective effects against cardiovascular disease, diabetes, and cancer while a high intake of

protein from animal sources increases the risk of malignancy (30).

Hence, the dietary advice to considered in women with PCOS include high-carbohydrate (55%

calories) and low fat (30% of calories) with average protein (15%) along with regular physical

activity (8)

Glycemic index and polycystic ovary syndrome

There is much evidence supporting the benefits of diets with a low glycemic index. This diet can

improve insulin resistance (31, 32) while foods with a high glycemic index exert opposite effects

(33). Epidemiological studies have also shown that a low glycemic index diet is associated with

reduced risk of cardiovascular disease, type 2 diabetes, insulin resistance, and metabolic
syndrome, as well as a reduced risk of endometrial, breast, and ovarian cancers (39-34)

Therefore, it seems that the type of carbohydrate intake has a more important role in maintaining

metabolic health rather than the total amount received.

Fatty acids and polycystic ovary syndrome

Diets high in fat, especially saturated fat and trans-fatty acids mainly reduce insulin sensitivity

and increase the risk of type 2 diabetes, metabolic syndrome, and cardiovascular disease (40, 41,

while receiving foods containing unsaturated fats reduces the risk of chronic diseases. This is

true especially for the diets containing fatty acids and omega-3 unsaturated fatty acids with a

double bond that may decrease many risk factors for metabolic disorders seen in women to

PCOS, such as high levels of serum lipids, insulin resistance and impaired endothelial function

(42).

Vitamin D deficiency and polycystic ovary syndrome

Studies have revealed that vitamin D plays roles in various metabolic pathways, including insulin

metabolism, and the vitamin D deficiency affects the pathogenesis of insulin resistance and

PCOS (45-43). A recent review article by Thomson et al. proposed an association between

vitamin D status and hormonal and metabolic disorders among PCOS cases (46). The mechanism

behind this effect is still unknown, but a possible role for ovarian dysfunction in the mechanisms

that regulate apoptosis has been reported (47). Moreover, due to its immunomodulatory role, lack

of vitamin D may cause inflammatory responses leading to insulin resistance (48). Several

studies have reported low levels of vitamin D in PCOS (49, 50) Therefore, supplementation with

vitamin D may be effective in modifying hormones and metabolism in these patients (51).
Minerals and polycystic ovary syndrome

Reduced levels of magnesium have been reported in women with high levels of testosterone or

insulin resistance, such as type 2 diabetes and metabolic syndrome. Therefore, magnesium

replacement seems to be effective in the adjustment and improvement of insulin resistance (52).

Two recent studies also showed high levels of copper in patients with PCOS, but there is a need

for clinical trials to investigate the use of chelating copper in these patients (53). Moreover,

decreased plasma levels of chromium have been reported in people with type 2 diabetes,

suggesting that chromium deficiency may reduce insulin sensitivity (54). Receiving 1000 mcg of

chromium picolinate in women with PCOS for 2 months resulted in improved glucose levels

and insulin sensitivity (55).

On the other hand, chromium picolinate is involved in reducing hirsutism and alleviating the

symptoms of PCOS (56). Among the few studies available on PCOS patients, Chromium

supplementation has been reported to lead to significant reduction of body mass (57).

Low selenium levels in PCOS compared with healthy controls have been reported and

manifested a negative correlation between serum testosterone level and selenium (58). So, it

seems that supplementation with chromium can decrease insulin resistance and weight loss

which is a therapeutic strategy in PCOS. However, further studies in this field are required due to

the contradictory results in some studies. In addition, low selenium levels in PCOS compared to

healthy control group have been observed and a negative correlation between testosterone level

and selenium serum was reported s well (58)

Caffeine and polycystic ovary syndrome

Caffeine is a dietary concern relevant to polycystic ovaries in women, which affects ovulation

and corpus luteum function through changing hormone levels (59). Most studies have confirmed
that caffeine intake is a risk factor for decreased fertility. Results of a study showed that taking

more than 500 mg of caffeine per day increases the risk of infertility (60). Wilcox et al. in their

study on 104 women attempting pregnancy reported that conception in a menstrual cycle reduced

significantly in women who consumed more than one cup of coffee per day. Women who drank

more than one cup of coffee daily were half as likely to conceive per cycle so that the possibility

of pregnancy decreased significantly by increasing the caffeine consumption (61).

Some evidence also suggests that there is an association between caffeine intake and the elevated

risk of spontaneous abortion (64-62). A meta-analysis study revealed a significant relationship

between moderate to high doses of caffeine intake with abortion and low birth weight (65).

Although not all studies have confirmed these findings (66), women with PCOS are

recommended to take special precautions to avoid receiving very high doses of caffeine.

Conclusion

The relationship between PCOS and insulin resistance provides an opportunity to intervene in

the dietary habits of the patients to prevent or delay the onset of type 2 diabetes and

cardiovascular disease. It seems that nutritional management should focus on weight loss plans

and special attention should be paid to the impact of the various components of the diet on

improving insulin sensitivity. A favorable dietary plan in women with PCOS should contain low

amounts of saturated fatty acids with average amounts of saturated fatty acids with one double

bond and omega-3. Additionally, sufficient intake of fiber-rich diet from whole grains, legumes,

vegetables and fruits with an emphasis on carbohydrate sources with low glycemic index is

highly recommended. Moreover, improving the symptoms of PCOS, such a diet may also reduce

the risk of developing chronic diseases associated with insulin resistance.

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