Medical nutrition therapy options for polycystic ovary syndrome

Photo Cred: Nadine Primeau/Unsplash

By Kellie Blake, RDN, LD, IFNCP

Polycystic ovary syndrome (PCOS) is an endocrine disorder affecting up to 15 percent of women of reproductive age. While there is no one identified root cause of this disease, genetics, androgen exposure in utero, prenatal nutrition, environment, lifestyle, and weight are all important factors. 

Clients with PCOS often report menstrual irregularities, acne, ovarian cysts, difficulty conceiving, excessive hair growth or hair loss, sleep disturbances, stubborn weight gain, depression, and anxiety.  While the symptoms of PCOS certainly reduce quality of life, the risk of serious medical complications, such as insulin resistance, type 2 diabetes, cardiovascular disease, and cancer, make this an alarming diagnosis.

Traditional management of PCOS includes diet and exercise to promote weight loss, use of metformin to improve insulin resistance (IR), and oral contraceptives to help with menstrual irregularities. However, there are other targeted nutrition-related strategies that can be employed to improve metabolic parameters and reverse this disease, while simultaneously improving quality of life. 

Insulin, a hormone produced by the pancreas, functions to keep blood sugar in control by allowing the body to use or store glucose. IR, a condition where the cells of the body don’t respond well to insulin causing excess insulin production, is a hallmark of PCOS. The IR seen in PCOS seems to be independent of weight, so simply encouraging weight loss by restricting calories and increasing physical activity isn’t always an effective strategy. 

IR contributes to hyperandrogenism, elevated levels of androgens, which is responsible for many PCOS symptoms.  A meal plan that targets inflammation and reduces the amount of insulin secretion is required to achieve long-term weight loss, improve IR, and reduce androgens. 

Since one root cause of IR is inflammation, I like to start with an elimination food plan to strip away inflammatory foods, additives, allergens, and sensitivities. Removing alcohol, grain-fed beef, chocolate, coffee, soda, tea, corn, dairy, eggs, gluten, peanuts, pork, processed meats, shellfish, soy, and sugar for at least four weeks provides valuable information about food sensitivities, but also reduces the inflammatory response, improves gut health, and allows for the restoration of proper immune system function. Once the inflammatory process has been quieted, clients can be transitioned to a tailored low starch, low dairy meal plan.

A low starch, low dairy diet has been shown to be an effective strategy for PCOS. As reported in a 2015 study in the Journal of Obesity and Weight Loss Therapy, an eight-week low starch, low dairy diet with no change in exercise resulted in significant weight loss, increased insulin sensitivity, and a reduction in free and total testosterone.  The participants also experienced increased vitamin D levels and reductions in triglycerides and VLDL levels. The meal plan allowed for lean animal protein, eggs, non-starchy vegetables, low sugar fruits, avocados, olives, nuts, seeds, olive and coconut oils, one ounce of full-fat cheese per day, and up to six ounces of red wine per day. The meal plan excluded all grains, beans, sugar, and all other dairy products. In addition to the tailored meal plan, maintaining optimal levels of vitamin D and magnesium can be important considerations in PCOS. 

Vitamin D is a powerful hormone with immune-modulating, anti-inflammatory, and antioxidant functions, but it is also vital for glucose metabolism. Vitamin D deficiency is common in those with PCOS and bringing vitamin D levels into the optimal range can be an effective complementary strategy to improve IR. Test vitamin D levels and aim for the 50 to 80 ng/mL range via targeted vitamin D3 supplementation.

Magnesium is another important nutrient that functions as a co-factor in hundreds of reactions in the body and is required to convert glucose into energy. Low magnesium concentrations are associated with IR and women with PCOS often have lower magnesium concentrations and tend to under-consume magnesium-rich foods. As reported in a 2019 study in Current Developments in Nutrition, there is an association between adequate magnesium status and improved IR. While magnesium supplementation may be necessary, having clients focus on low carbohydrate food sources of magnesium like leafy green vegetables, nuts, and seeds is an effective strategy. Almonds, cashews, spinach, peanuts, avocados, and pumpkin seeds are particularly high in magnesium. Women with PCOS should aim for at least 320 milligrams of magnesium per day. If the diet is lacking in magnesium-rich foods, consider supplementing with magnesium glycinate, up to 400 milligrams per day.

Case Study

Brittany is a 33-year-old nurse referred due to continued weight gain and PCOS symptoms. Her past medical history is positive for Epstein-Barr virus, hypertension, PCOS, urinary tract infections, and acne.  In addition to the PCOS symptoms, Brittany reported significant anxiety and increased symptoms of depression for which she had to be medicated. She had previously been a runner with a usual body weight of 145 pounds, but since 2012, Brittany had gained from 130 pounds to 224 pounds.

At the time of the initial assessment, she had reduced weight to 207 pounds by walking three and a half miles each day, following a very low carbohydrate diet of less than 30 grams of carbohydrate per day, and taking Belviq to suppress her appetite. Other medications included metformin, Effexor, and propranolol.  Initial lab work indicated inadequate vitamin D (32), normal homocysteine (8), elevated fasting insulin (14.8), and low DHEA-S (101). GGT and folate were within normal limits. 

Brittany indicated stress and sleep disruptions were problematic for her. She had cravings for sweets and crackers and her initial My Symptom Score (MySQ) was 73 indicating severe symptoms. Brittany wanted to lose weight, improve her blood pressure, and regulate her menstrual cycle. 

The initial plan for Brittany included:

1. Elimination food plan for four weeks with adequate magnesium-rich foods
2. Meditation for ten minutes once per day to address stress
3. Sleep hygiene techniques to address interrupted sleep pattern
4. Nutritional supplementation, including:
   • Methylocobalamin 1,000 milligrams per day to cover the metformin
   • Methylfolate 400 micrograms per day to cover the Effexor
   • CoQ10 100 milligrams per day to cover the propranolol
   • Probiotic (she declined to take) to target gut health
   • Omega-3 1,000 milligrams per day to target inflammation and brain health
   • Vitamin D3 (with K2) 5,000 international units per day
5. Continue current exercise routine

After four weeks, Brittany’s symptom score dropped from 73 to 14, indicating dramatic symptom improvement. She lost 11 pounds and decided to discontinue the Belviq. Brittany reported no anxiety, no more sugar cravings, a normal period, and her acne had significantly improved. She said she had more energy and was able to achieve eight hours of uninterrupted sleep each night. 

Brittany was transitioned to a low starch, low dairy PCOS meal plan and to further target the IR, she was prescribed two tablespoons of high quality extra-virgin olive oil, ¼ cup plain walnuts, and ½ teaspoon cinnamon per day. She was also instructed to add an overnight fast of 16 to 18 hours twice per week. All nutritional supplements were continued, and it was recommended that her vitamin D level be rechecked in three months with a goal range of 50 to 80ng/mL.  Brittany is very positive about her progress and plans to continue with the recommended plan with follow up in early 2020. In addition to her initial goals, she is now hopeful to discontinue all her prescription medications in the future. 

PCOS can be a frustrating diagnosis, but nutrition and lifestyle-related changes are the foundation for reversing symptoms and improving long-term outcomes. A personalized approach is required, but opting for a short elimination period, followed by a low starch, low dairy food plan with targeted nutritional supplementation can be an effective baseline strategy. 

References

Gaby, A (2008) Nutritional Factors in Polycystic Ovary Syndrome.  Integrative Medicine.

Hamilton, K., Zelig, R., Parker, A., and Haggag, A. (2019) Insulin Resistance and Serum Magnesium Concentrations among Women with Polycystic Ovary Syndrome. Current Developments in Nutrition. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/31696157

Phy, J., Pohlmeier, A., Cooper, J., Watkins, P., Spallholz, J., Harris, K., Berenson, A., & Boylan, M. (2015) Low Starch/Low Dairy Diet Results in Successful Treatment of Obesity and Co-Morbidities Linked to Polycystic Ovary Syndrome (PCOS).  Journal of Obesity and Weight Loss Therapy. Retrieved from: https://www.omicsonline.org/open-access/low-starchlow-dairy-diet-results-in-successful-treatment-of-obesity-and-comorbidities-linked-to-polycystic-ovary-syndrome-pcos-2165-7904-1000259.php?aid=50237

U.S. Department of Health & Human Services National Institutes of Health. (2019) Magnesium. Retrieved from: https://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/