by Walter Futterweit, MD, FACP and Martha McKittrick, RD, CDE

Introduction

PCOS (polycystic ovary syndrome) is a metabolic disorder that affects between 5 and 7.5 percent of all women. It is the number-one cause of infertility, and if left untreated, can increase risk of endometrial cancer. In addition, women with PCOS are at a greater risk for heart disease and diabetes. Until recently, diet was not thought of as an important adjunct in treatment. However, since the fairly recent discovery regarding the role insulin resistance plays in PCOS, many experts now believe that diet should be a part of the treatment plan. Although further research is needed, it is believed that diet can help reduce insulin resistance, which can not only help the symptoms of erratic periods, excessive body and facial hair, and acne, but may decrease the risk of heart disease and diabetes as well. This article will discuss the role of diet in PCOS and give practical suggestions for meal planning.

Role of Insulin in PCOS

Exactly why and how PCOS develops is not quite clear. Most experts, however, now agree that insulin plays a major role. Insulin is a powerful hormone that is released by the body's pancreas in response to eating food.especially carbohydrates. It transports sugar out of the blood and into muscle, fat, and liver cells, where it is converted to energy or stored as fat. Many women with PCOS have insulin resistance. This means that the process of getting the sugar out of the blood and into the cells is defective.the cells are "resistant" to insulin. The pancreas must secrete more and more insulin to get sugar out of the blood and into the cells. High levels of insulin or hyperinsulinemia, can wreak havoc in the body, causing any or all of the following conditions: polycystic ovaries, weight gain and/or difficulty losing weight, increased risk of heart disease by increasing LDL and triglycerides, decreasing HDL and increasing clotting factors.

The discovery of insulin's role in PCOS has brought hopes for better treatment. Treatment is no longer just aimed at treating the individual concerns (i.e. erratic menses, hirsutism, acne, etc.), but instead is now aimed at treating one of the underlying causes -- insulin resistance. If insulin resistance is present, it is best treated with diet, exercise and weight loss if needed. Insulin sensitizing medications may be used as well. Most physicians prefer to start with diet and exercise and turn to drugs if needed. Keep in mind that not all women with PCOS have hyperinsulinemia, but the majority do.

Why Don't the Typical Low-Fat Weight-Loss Diets Work?

Approximately 50 to 60 percent of women with PCOS are obese. It has been shown that losing even five percent of their body weight can lead to an improvement in skin, regularity of menstrual cycles, and decreased insulin levels. However many women with PCOS experience difficulty losing weight, possibly due to high insulin levels, which promotes fat storage. The standard low-fat, high-carbohydrate, weight-loss diet may not be the best approach for women with PCOS. High intakes of carbohydrates, especially refined carbohydrates (e.g., sweets, white bread, white rice, etc.) will quickly turn to sugar and cause elevated levels of insulin. Since high levels of insulin can cause a multitude of problems for women with PCOS, a better diet would be a low-glycemic index diet. This is a diet that includes foods or combinations of foods that do not cause a rapid rise in blood sugar. The low-glycemic diet will be discussed more in detail later in this article.

How Many Carbohydrates Should You Eat a Day?

At this point in time, I am not aware of any studies that provide data as to the recommended level of carbohydrates for a woman with PCOS. Some diets include The Food Pyramid-based diet (55 percent of calories from carbohydrates.but select mainly from whole grains), a diet which is 40 percent carbohydrates (The Zone), or a very strict diet that allows only 20 percent of calories from carbohydrates (Atkins or Protein Power). In my experience, there is no one level that will work for all women. Dr. Walter Futterweit, clinical professor of the Division of Endocrinology of the Mount Sinai School of Medicine, has been working with women with PCOS for 25 years. He suggests that nonobese women with PCOS who get regular periods eat a balanced diet, moderate.not excessive intakes of carbohydrates (approximately 50 percent of calories), and select complex unrefined carbohydrates over refined carbohydrates. An obese insulin-resistant woman should consume a diet that is 40 percent carbohydrates or less, depending upon the degree of insulin resistance. These are only guidelines.the diet should be tailored to fit the individual person. I would suggest starting with a diet that is 40 percent carbohydrates and work your way downward if need be. Some subjective indicators that the diet is "working" are: decreased cravings and increased energy levels. Some objective measures that the diet may be working are: weight loss, decreased insulin levels, regular periods. Clearly, this is an area that needs to be researched.

Hazards of Low Carbohydrate Diets That are High in Saturated Fat

Several of the popular low carbohydrate diets contain as much as 60 percent of calories from fat, much of it saturated. I do not recommend these diets as saturated fat has been linked to heart disease. These diets could be especially dangerous for women with PCOS, as they already have an increased risk of heart disease. In addition, these diets are low in fiber, vitamins, minerals, and disease fighting phytochemicals. Remember that this is not a temporary diet.it is one that you will need to follow long term! Therefore, you will need to make it as healthy as possible.

Calculating Your Caloric Needs

Since the majority of women with PCOS are overweight, calories are very important. For weight control, remember.all calories, whether from fat, protein or carbohydrate, in excess of your body's needs, will turn to fat. In order to lose weight, you must stay within your calorie goal.

Suggested caloric intakes for weight maintenance:

• Multiply your current weight by an activity factor between 10 and 20. Use a higher number (15 to 20) if you are younger, moderately overweight or of ideal weight and moderate to very active. The less active and more overweight you are, the lower the number should be (between 10 and 14).

Suggested caloric intakes for weight loss:

• To lose one pound a week, subtract 500 from your maintenance caloric level.
• To lose two pounds a week, subtract 1000 calories from the maintenance level.

Example: A 30-year-old female whose height is 5' 5", weight is 145 pounds, and who exercises three times a week for 45 minutes would multiply her weight by 15. Therefore, her maintenance caloric needs are approximately 2,175 calories a day. To lose one pound a week (subtract 500 calories), she would consume 1,675 calories a day. To lose one and one-half pounds a week (subtract 750 calories), she would consume 1,425 calories. It is not recommended that anyone eat less than 1,200 calories on a regular basis as this may slow the metabolism as well as be nutritionally inadequate.

Dietary Recommendations for PCOS

The following recommendations can help you plan your diet. The bottom line is that you need to find a diet that works for you and is one that you can live with.