by Walter Futterweit, MD, FACP and Martha McKittrick, RD, CDE
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.
• Try to select whole-grain starches over refined or processed starches and whole fruit over fruit juice. The higher fiber foods will cause a slower rise in blood glucose. For example, select bran cereal (10 grams of fiber per half cup) over cornflakes (1 gram fiber per half cup) or an apple (four grams of fiber for a medium apple) over apple juice (zero grams fiber for six ounces).
• If possible, combine some fat and protein with the carbohydrate (starch or fruit). This will slow the rise of blood sugar from the carbohydrate. For example, eat toast with two teaspoons of peanut butter rather than toast with jam.
• Legumes and most vegetables are loaded with nutrients and fiber and will cause a slow rise of blood sugar.
• Do not take your carbohydrate levels so low that you induce ketosis. Ketosis is an unhealthy condition whereby your body uses fat for energy. You can test for this by purchasing ketone test strips at a pharmacy. Eating fewer than 40 grams of carbohydrate a day may induce ketosis.
• Space the carbohydrates out during the day. This will cause less of a rise in blood sugar and insulin peak as compared to eating all carbohydrates at one meal. (Note: The Carbohydrate Addicts Diet recommends eating all the carbs at one meal. If this diet helps control food cravings and is promoting weight loss.keep it up!)
• Avoid those carbohydrates that trigger more hunger or cravings (e.g., pasta triggers craving for some people).
• Suggested vitamin/mineral supplements:
• calcium 1,000 to 1,500 milligrams (take two to three 500-milligram pills a day and be sure to space them out, as you can only absorb 500 milligrams at a time)
• multivitamin with minerals (make sure it contains folic acid (400 micrograms) if you're trying to get pregnant)
• Drink at least eight cups of noncaffeinated fluid as a low-carbohydrate intake can cause dehydration.
• For heart health, limit foods high in saturated and trans fats (e.g., fatty red meat, whole-milk dairy products, butter and stick margarine, chicken skin, fried foods, rich desserts, etc.) Select mainly monounsaturated fats (e.g., olive oil, canola oil, nuts) and omega-3 fats (fatty fish such as salmon and bluefish, flaxseed, nuts), as these fats are heart healthy.
• Exercise on a regular basis. The benefits of aerobic exercise include:
• burning calories and aiding in weight control
• lowering blood pressure
• raising HDL cholesterol
• may improve insulin resistance (this is proven in type 2 diabetics)
• Benefits of resistance training include:
• builds lean mass, which will speed metabolism
• helps prevent osteoporosis
• may improve insulin resistance (this is proven in type 2 diabetics)
• If you are on a very low carbohydrate diet, check with your MD regarding a potassium supplement.
• If constipation is a problem, try a natural fiber supplement such as sugar free Fiber-All or Metamucil. Be sure to drink plenty of fluids as well.
Counting carbohydrate grams
For women who are interested in counting grams of carbohydrate, you can figure out your suggested carbohydrate intake by doing the following:
• Calculate your caloric needs, whether it be to maintain or lose weight. Multiply your caloric needs by .4 (this will be a diet that is 40 percent carbohydrate) and then divide by 4 (carbohydrate has 4 calories per gram.
• If you are obese and insulin-resistant, then you may need less than 40 percent from carbohydrate. Check with your MD or nutritionist. For example: If the number of calories you need to lose one and one-half pounds a week is 1,425, then multiply that number by .4 and then divide by 4 (1,424 x .4 = 569, divided by 4 = 142 grams of carbohydrate per day).
• Count total grams of carbohydrate.not just grams of sugar. All carbohydrates eventually turn into sugar in the blood.
• To count "effective" grams of carbohydrate, subtract the grams of fiber in a food from the total carbohydrate content. For example, six whole-wheat crackers might have 15 grams of total carbohydrates and three grams of fiber. The effective grams of carbohydrate would be 12 grams. This is what you count when you are adding up your grams of carbohydrate.
Sample meal plan
The following is a sample meal plan for 1,400 calories, 35 percent carbohydrates.118 grams effective carbohydrates (e.c.)
• One ounce oatmeal (14 gm e.c.)
• ½ cup cottage cheese (3 gm e.c.)
• ½ cup blueberries (8 gm e.c.)
Total: 220 calories/25 gm e.c.
• Grilled chicken, 4 ounces
• 2 cups greens
• 1 cup assorted vegetables (approximately 5 gm e.c.)
• ½ cup kidney beans (14 gm e.c.)
• 1 apple (18 gm e.c.)
• 2 tsp olive oil
• unlimited wine vinegar
Total: 490 calories/37 gm e.c.
• 1 ounce low-fat mozzarella stick (1 gm e.c.)
• 6 Finn Crisp crackers (22 gm e.c.)
Total: 180 calories/23 gm e.c.
• Poached salmon, 5 ounces
• ½ cup spinach (4 gm e.c.)
• salad (approximately 3 gm e.c.)
- 1 cup greens
- ½ cup assorted vegetables
• 1 tsp olive oil, vinegar
• ½ cup brown rice (20 gm e.c.)
Total:485 calories/27 gm e.c.
• 1 ounce dry roasted soy nuts ( 9 gm e.c.)
Total: 134 calories/9 gm e.c.
Conclusion We know that weight loss is key in decreasing insulin resistance in obese women. It appears that a lower glycemic diet may play an important role in helping to control insulin levels as well as promoting weight loss. However this is an area that needs to be further researched.
Dr. Walter Futterweit is Clinical Professor of Medicine of the Division of Endocrinology of the Mount Sinai School of Medicine, New York, NY. He is also Chief of the Endocrine Clinic at the Mount Sinai Medical Center, and Attending in Medicine. He is board certified in Internal Medicine and Endocrinology and Metabolism. His main interest has been the study of polycystic ovary syndrome (PCOS) for the last 25 years, and has written extensively in this area and wrote the first textbook on the subject, "Polycystic Ovarian Disease", in 1984. His extensive practice which comprises mostly of patients with PCOS has allowed him the means to study insulin dynamics as well as recent genetic studies of the syndrome. As an international expert in the field of PCOS, he is invited to speak at many meetings, and still maintain his busy practice and teaching committments at the Mount Sinai Medical Center.
Dr. Futterweit also was past Chairman of the Membership Committee of the Endocrine Society, and also is a member of the ad hoc Task Force on Women's Health of the American Association of Clinical Endocrinologists (AACE). For the past several years he has been active in the Polycystic Ovary Association (PCOSA).
Martha McKittrick, RD, CDE is a registered dietitian and certified diabetes educator. She specializes in weight control, hyperlipidemia, polycystic ovarian syndrome, diabetes, and preventative nutrition. A staff dietitian at The New York Presbyterian Hospital for the past 17 years, she also counsels clients privately and is a consultant to physicians, corporations, and health clubs. She was the nutritionist for the NYC Marathon. She is also an exercise instructor and has been teaching exercise classes in NYC health clubs for the past 10 years.
Ms. McKittrick has appeared on numerous television, radio, and webcast programs. She lectures on a regular basis and has been interviewed and written for publications including Shape, Family Circle, Women's World, New York Newsday, and the Journal of The American Dietetic Association. For the past several years, Ms. McKittrick has been specializing in polycystic ovarian syndrome. She is on the medical advisory board for PCOSA and is on the editorial advisory board for PCOS Pavilion of OBGYN.NET. She lectured on diet and PCOS at PCOSA conferences.
Copyright © Martha McKittrick and Walter Futterweit. Permission to republish granted to Pregnancy.org, LLC.