militaryfamilieslearningnetwork.org/event/22060 International Lifestyle Recommendations for Polycystic Ovary Syndrome (PCOS) Thanks for joining us! We will get started soon. While you’re waiting you can get handouts, etc. by following the link below. This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
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militaryfamilieslearningnetwork.org/event/22060
International Lifestyle Recommendationsfor Polycystic Ovary Syndrome (PCOS)
Thanks for joining us! We will get started soon.While you’re waiting you can get handouts, etc. by following the link below.
This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
Connecting military family service providers and Cooperative Extension professionals to research
and to each other through engaging online learning opportunities
militaryfamilieslearningnetwork.org
2This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
Reproductive• Infertility• Pregnancy-related risks• Endometrial cancer
References: Fauser et al. 2012.
Background
Obesity & PCOS
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Hyperinsulinemia
Obesity
Central adiposity
Ovarian dysfunction• Follicle excess• Follicle arrest and anovulation• Overproduction of androgens
Insulin resistance
Hyperandrogenism
References: Jarrett & Lujan 2017; Note: Solid lines denote direct relationships and dotted lines denote indirect relationships.
Background
Role of Lifestyle Intervention• Heralded as first-line therapy in patients with obesity
– Improves weight and metabolic abnormalities– Has unknown impact on reproductive outcomes
9References: Moran et al. 2009; Moran et al. 2011; Jarrett & Lujan 2017. Note: Dotted lines denote proposed mechanisms.
Obesity Insulin resistance Hyperinsulinemia
Hyperandrogenism Ovarian dysfunction (?)
Dietary interventionwith caloric restriction
Recap• PCOS is a complex endocrine disorder.
– Has significant effects on women’s health across the lifespan.
• Obesity is linked to the pathogenesis of PCOS.– Can worsen reproductive and metabolic features.
• Lifestyle intervention may reduce disease severity.– Likely targets obesity and insulin resistance.– Has unknown effects on menstrual cyclicity, ovulation, or fertility.
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• Includes 166 evidence-based (EBR) and clinical consensus recommendations (CCR), plus clinical practice points (CPP)– Conducted systematic reviews on prioritized questions– “…To promote consistent, evidence-based care and improve
the experience and health outcomes of women with PCOS.”
• Lifestyle-related items comprise:– 1 of the 5 guideline chapters – 24 of 166 recommendations
11References: Teede et al. 2018.
Teede H, Misso M, Costello M, et al. Hum Reprod 2018; 33(9): 1602 – 1617.
“Healthy eating and regular physical activity should be recommended to achieve [or] maintain healthy weight and to optimize hormonal outcomes, general health, and quality of life across the life course.”
2018 International Evidence-Based Guideline for PCOS
Effectiveness of Lifestyle Interventions
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CCR
General population recommendations for healthy eating should be followed across the life course.
For women with PCOS and body mass index < 25 kg/m2
CCR
References: Teede et al. 2018; Jarrett, Lin, & Lujan 2019.
Multi-component lifestyle intervention should be recommended for reductions in weight and insulin resistance.
2018 International Evidence-Based Guideline for PCOS
Effectiveness of Lifestyle Interventions
13References: Teede et al. 2018; Jarrett, Lin, & Lujan 2019.
EBR
“A variety of balanced dietary approaches could be recommended to reduce dietary energy intake.”
For women with PCOS and body mass index ≥ 25 kg/m2
CCR
Achievable weight loss (i.e., 5% to 10% within 6 months) yields significant clinical improvements.
CPP
Summary of Recent Systematic or Narrative Reviews
Energy-Restricted Diets in PCOS• Interventions have primarily focused on hypocaloric
diets ± physical activity in obese patients.– Moran et al. (2009)
• Androgen Excess and PCOS Society Position Statement
– Moran et al. (2011)• Cochrane Systematic Review
• Most trials have noted improvements in endocrine and metabolic status with 5% – 10% weight loss:– Adiposity– Hyperandrogenism– Insulin sensitivity
14References: Moran et al. 2009; Moran et al. 2011.
Summary of Recent Systematic or Narrative Reviews
Caloric Restriction & Ovulation• Little evidence to support an impact of caloric
restriction on ovulatory cyclicity in PCOS.– Jarrett and Lujan (2017)
• Included N = 22 studies with ovulation as primary outcome.
• Findings may relate to:– Use of infrequent or surrogate measures of ovulation.– Degree of change in salient endocrine/metabolic features.
15References: Jarrett and Lujan (2017).
Summary of Recent Systematic or Narrative Reviews
Macronutrient Composition & PCOS• Impact of dietary composition appears marginal.
– Moran et al. (2013)• Included N = 6 studies that provided diets with a specific composition.
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Outcome Main Findings
Anthropometric • Little to no differences in weight loss among diets.
Reproductive • Subtle differences in changes in androgens.• Improved menstrual cyclicity on low glycemic index (GI) diet.
Metabolic • Improved insulin sensitivity / lipid profiles on a low GI diet.
Psychological • Improved quality of life on all diets.• Improved depression and self-esteem on high-protein diet.
There is limited evidence that any one dietary pattern is better than another for improving health outcomes in women with PCOS.
Slide Courtesy of: Marla Lujan, PhD.
Supplement Author (Total N) Main Findings
Vitamin D± Calcium
Azadi-Yazdi 2017(N = 183)
Fang 2017(N = 502)
• Improved androgen status• Improved menstrual cyclicity• No effect on glucoregulation or lipids
Omega-3s Hajishafiee 2016(N = 298)
Sadeghi 2017(N = 145)
• Improved androgen status• No effect on insulin sensitivity
Inositol Mendoza 2017(N = 1017)
Unfer 2016(N = 496)
• No effect on infertility treatment outcomes• Decreased insulin resistance
Chromium Fazelian 2017(N = 351)
• Decreased weight• Decreased insulin resistance
Summary of Recent Systematic or Narrative Reviews
Dietary Supplements for PCOS
17Slide Courtesy of: Marla Lujan, PhD
Summary of Recent Systematic or Narrative Reviews
Dietary Supplements for PCOS
18Slide Courtesy of: Marla Lujan, PhD.
• Evidence is heterogeneous and still emerging.– Greater focus on general health vs. PCOS-specific outcomes– Inclusion of essential vitamins/minerals and popular supplements
• Use caution in interpreting previous studies due to:– Age– Race and ethnicity– Dose, form, bioavailability– Purpose (physiologic vs. pharmacologic)
2018 International Evidence-Based Guideline for PCOS
Improvements appear to occur independent of type, intensity, frequency, or duration of physical activity.
Slide Courtesy of: Marla Lujan, PhD.
“Health professionals and [patients] should be aware that women with PCOS have a higher prevalence of weight gain and obesity…with a clear need for prevention.”
CCR
2018 International Evidence-Based Guideline for PCOS
Obesity & Weight Assessment
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CPP Assessment should be respectful of weight-related stigma, negative body image, and low self-esteem.
References: Teede et al. 2018; Jarrett, Lin, & Lujan 2019.
CCR “All those with PCOS should be offered regular monitoring for weight changes and excess weight.”
CPP Monitoring weight, preventing weight gain, and “encouraging evidence-based and socio-culturally appropriate healthy lifestyle [behaviors] is important in PCOS, particularly from adolescence.”
2018 International Evidence-Based Guideline for PCOS
Obesity & Weight Assessment
22References: Teede et al. 2018; Jarrett, Lin, & Lujan 2019.
Jessica is a 29-year-old female patient in your clinic. For the past couple of years, her periods have been irregular and
have only happened every six months. She is now complaining of acne and excessive hair growth on her lip and chin. She also has a body mass index of 35.4 kg/m2. She has recently tried Weight Watchers and the ketogenic
diet, but describes difficulties losing weight.
Jessica’s physician suspects that she has PCOS.
Which of her features are consistent with the established diagnostic criteria for PCOS?
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Case Study
Presenter
Presentation Notes
Irregular cycles + hirsutism Irregular cycles + acne Irregular cycles + obesity Difficulty losing weight All of the above http://www.easypolls.net/poll.html?p=5c880c7fe4b064bdfdc61a0f
Jessica is a 29-year-old female patient in your clinic. For the past couple of years, her periods have been irregular and
have only happened every six months. She is now complaining of acne and excessive hair growth on her lip and chin. She also has a body mass index of 35.4 kg/m2. She has recently tried Weight Watchers and the ketogenic
diet, but describes difficulties losing weight.
Which nutrition recommendation(s) would you provide to Jessica?
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Case Study
Presenter
Presentation Notes
Follow a hypocaloric diet based on government recommendations. Aim for 5-10% weight loss over 6 months. Follow a low glycemic index and high protein diet. Continue with the ketogenic diet. Both A & B. http://www.easypolls.net/poll.html?p=5c880cd9e4b064bdfdc61a1c
Recap• New international guidelines support lifestyle as an
important component of the management of PCOS.
• Recommendations for the lifestyle management of PCOS reflect ones made in the general population.– Focus on healthy eating and physical activity behaviors.– Prioritize weight management across the lifespan.
• Assessments should be respectful of the unique physical and emotional consequences of PCOS.
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Baseline Knowledge, Behavior, and Beliefs
Usual Dietary Intake in PCOS• 8 of 17 studies identified differences in caloric intake:
• Recent focus on dietary patterns: – Those with PCOS more likely to consume Mediterranean-style diet.– Western and plant-based diet patterns associated with PCOS.
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Results (PCOS vs. Non-PCOS) Number of Studies
Total daily caloric intake N = 6
Total daily caloric intake N = 2
Total daily caloric intake N = 9
References: Lin & Lujan 2013; Cunha et al. 2018; Shahdadian et al. 2019; Zhang et al. 2018; Moran et al. 2015.
Presenter
Presentation Notes
Since we last published our narrative review, there are now 17 studies that examined the usual dietary intake of women with PCOS that spanned across different countries. 8 studies reported differences in daily total energy intake between women with and without PCOS, with the majority finding that women with PCOS consumed higher energy diets than women without PCOS. 9 studies found no differences in caloric intake between women with and without PCOS. Notably, two studies in the US, when using the NIH criteria, found there were no differences in daily energy intake, though these studies were limited by the enrollment of women around menopausal age and did not adjustment for potential confounders. Collectively, the mixed evidence may be attributed to variability measurements, small sample sizes, and different diagnostic criteria across studies. There has been more focus on dietary patterns in more recent studies, albeit in three that I have reviewed thus far. It appears that women with PCOS are more likely to consume healthier diet patterns. However, more studies are needed to confirm these findings. Interestingly, we have noticed a trend in the literature in which recent studies are reporting that women with PCOS did not consume more calories than those without PCOS, and are more likely to consume healthy diet. These results are promising as it suggests that the PCOS population may be interested in participating in healthy diet behaviors.
• 1 of 6 studies reported differences in PA.• Found more sedentary behavior in PCOS.
• Changes in PA in PCOS vs. Non-PCOS over time:– No differences in recent PA between groups.– In the past, women with PCOS spent less time:
• Housekeeping• Walking• Being physically active during commuting• Participating in activities of moderate intensity
– Women with PCOS spent more time sitting 5 years ago.
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Baseline Knowledge, Behavior, and Beliefs
Usual Physical Activity (PA) in PCOS
References: Lin & Lujan 2013; Zhang et al.2018.
Presenter
Presentation Notes
When examining physical activity, our review found that one study reported women with PCOS had longer sitting intervals, but no differences in time spent in moderate and vigorous intensity activities. I especially wanted to highlight one study that recently came out by Zhang et al. . This study was unique because the investigators examined past and recent self-reported physical activity between women with and without PCOS. Although there were no differences in recent activity between the groups - in the past, women with PCOS were less likely to participate in structured activities. Again, this is consistent with the trend that we have examined, in which recent studies support that women with PCOS are likely to adopt more healthy behaviors in present time.
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Odd
s R
atio
(95%
CI)
Exercise
Commercial Programs
Meal Replacement
Portion Size
Reduce Fat, Sugar
Low GI diet
* Significant(P < 0.05)
*
**
Baseline Knowledge, Behavior, and Beliefs
Weight Management Practices in PCOS
References: Moran et al. 2018. Logistic Regression: Adjusted for age, BMI, martial status, education, occupation, income, country of birth.
Presenter
Presentation Notes
The previous literature is consistent with a recent study by the Moran group in Australia. Using a longitudinal population-based study Australian women., they investigated the weight management practices of those with and without PCOS. In this figure, each weight management practice is presented on the x-axis, while the odds ratios are represented by the y-axis. Compared to those without PCOS (and accounting for age, BMI and other participant demographics), women with PCOS were more likely to consider portion sizes, reduce their fat and sugar intake, and consume a low glycemic index diet. NOTE: 7767 women who responded to the question on PCOS diagnosis in Survey 4 or 5 (‘In the last three years have you been diagnosed with or treated for polycystic ovary syndrome’) (n = 556 PCOS; n = 7211 non-PCOS)
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Diet Books
Pharma-ceuticals
Fasting Smoking Alternative PracticesHealthy
Practices
*
Baseline Knowledge, Behavior, and Beliefs
Weight Management Practices in PCOSO
dds
Rat
io (9
5% C
I)* Significant
(P < 0.05)
References: Moran et al. 2018. Logistic Regression: Adjusted for age, BMI, martial status, education, occupation, income, country of birth.
Presenter
Presentation Notes
Collectively, the authors found that women with PCOS were more likely to participate in alternative practices (such as use of laxatives, diuretics or diet pills, fasting or smoking) to manage their weight, which can have implications in medical nutrition therapy.
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Compared to most people your age and weight in the U.S., what would you say are your chances of getting ____?
1 = Much lower than average; 3 = Same; 5 = Much higher than average
β = 0.83 (0.11)P < 0.01
β = 1.25 (0.11)P < 0.01
β = 0.89 (0.11)P < 0.01
β = 1.05 (0.09)P < 0.01
Baseline Knowledge, Behavior, and Beliefs
Beliefs in PCOS: Perceived Susceptibility
References: Lin et al. 2018. Raw Data: Mean ± SD. Multiple Linear Regression: Adjusted for age, BMI, education.
Presenter
Presentation Notes
But what beliefs are driving these behaviors? Our research group examined the health-related beliefs of women with PCOS and compared their responses against a comparison group without PCOS. In this figure, PCOS-related health outcomes are presented on the x-axis, while the 5-point response scale is presented on the y-axis. We found that women with PCOS reported they were at higher risk of CVD, diabetes, endometrial cancer, and weight gain than the average US resident of similar age and weight. When compared to women without PCOS, the PCOS group reported feeling more susceptible for heart disease, diabetes, endometrial cancer, and weight gain.
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There’s a lot I can do to prevent getting __________.
1 = Disagree; 3 = Neutral; 5 = Agree
Baseline Knowledge, Behavior, and Beliefs
Beliefs in PCOS: Disease Prevention
References: Lin et al. 2018. Raw Data: Mean ± SD. Multiple Linear Regression: Adjusted for age, BMI, education.
β = -0.19 (0.09)P = 0.04
β = -0.44 (0.10)P < 0.01
Presenter
Presentation Notes
Women with PCOS also were likely to somewhat agree that heart disease, diabetes and weight gain were preventable, but these findings were not reflected with endometrial cancer and infertility. Although the PCOS group reported poorer perceived control over cardiovascular disease and weight gain than the comparison group, this pattern was not observed for endometrial cancer and infertility as evidenced by the regression models (after adjusting for age, BMI and education. The result with diabetes was trending.
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A healthy diet will reduce my risk of __________.
1 = Disagree; 3 = Neutral; 5 = Agree
Baseline Knowledge, Behavior, and Beliefs
Beliefs in PCOS: Disease Prevention
References: Lin et al. 2018. Raw Data: Mean ± SD. Multiple Linear Regression: Adjusted for age, BMI, education.
β = -0.19 (0.09)P = 0.03
Presenter
Presentation Notes
A similar trend was observed with healthy diet where women were more likely to believe a healthy diet and PA were able to reduce CVD, diabetes and weight gain.
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It is important for me to meet government __________ recommendations.
Baseline Knowledge, Behavior, and Beliefs
Beliefs in PCOS: Disease Prevention
References: Lin et al. 2018. Raw Data: Mean ± SD. Multiple Linear Regression: Adjusted for age, BMI, education.
1 = Disagree; 5 = Agree
β = 0.38 (0.13)P < 0.01
Presenter
Presentation Notes
Although women with PCOS are more likely to participate in healthy behaviors, it does not appear that they place great importance in meeting government recommendations for dietary and physical activity. However, women with PCOS did place greater importance on meeting physical activity recommendations than women without PCOS.
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Please select how confident you are in your ability to do the following for the next month.
Baseline Knowledge, Behavior, and Beliefs
Self-Efficacy of Diet Behaviors
References: Lin et al. 2018. Raw Data: Mean ± SD. Multiple Linear Regression: Adjusted for age, BMI, education.
1 = Cannot do; 5 = Certainly can do
Presenter
Presentation Notes
When examining the self-efficacy of women with PCOS, they were confident in their ability to incorporate government recommendations, especially aimed at weight loss. Although women with PCOS did not score as confidently on items related to resisting cues, mean scores fell between “possibly can do” and “mostly can do.” No significant differences were observed in self-efficacy scores between women with and without PCOS in either the unadjusted or adjusted models.
• Recent studies have shown no differences in dietary intake or physical activity between women with and without PCOS.– Women with PCOS may be consuming higher quality diets. – They are confident they can perform healthy diet behaviors.
• Women with PCOS are less certain that healthy diet and physical activity can prevent weight gain.
• Women with PCOS place greater importance on physical activity recommendations than controls.– Potential area of encouragement.
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Recap
Presenter
Presentation Notes
Overall, recent studies have shown no differences in diet and physical activity between women with and without PCOS. However, the data are from cross-sectional studies. The Zhang et al article leads us to wonder, is there a critical period of time where a healthy diet and increased physical activity will have a greater impact on reproductive function? Duration might also have an impact? Further, although women with PCOS does believe a healthy diet and increased physical activity will ameliorate their risk for PCOS-related health outcomes, they are less certain that it can prevent weight gain. Something to highlight is that their definition of a healthy diet may not reflect those from the dietary guidelines for Americans, which is reflected by their higher likelihood to practice alternative approaches to manage their weight. Interestingly, women with PCOS place greater importance on the 2008 physical activity guidelines, which could serve as a potential area to target when providing weight loss strategies.
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Barriers to PCOS-Related Care
Visits with Healthcare Providers
References: Jarrett, Lin, & Lujan 2019. Note: Categories in figure are not mutually exclusive.
Presenter
Presentation Notes
But we started to wonder, who had more opportunity to provide weight loss counseling? When we went back to our data, out of 134 women with PCOS, only 8 women visited a dietitian for PCOS-related care.
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Barriers to PCOS-Related Care
Visits with Healthcare Providers
References: Jarrett, Lin, & Lujan 2019. Note: Categories in figure are not mutually exclusive.
Presenter
Presentation Notes
By far, most of the women with PCOS visited a primary care physician, a specialist, and/or a nurse practitioner or physician assistant.
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β = 0.30 (0.13), P = 0.02
1 = Never; 3 = Sometimes; 5 = Always
Barriers to PCOS-Related Care
Provider Support for PCOS
References: Lin et al. 2018. Raw Data: Mean ± SD. Multiple Linear Regression: Adjusted for age, BMI, education.
Presenter
Presentation Notes
Social support items were asked about healthcare providers (which included all types of physicians, nurse practitioners, and physician assistants). Response options on items related to social support ranged from ‘never’ to ‘always’ with higher scores indicating greater frequency. The PCOS group reported that they usually received general health advice (informational support) from healthcare providers, but did not usually receive specific information on nutrition and PCOS. Interestingly, though women with PCOS reported that they rarely had negative encounters with their healthcare providers, yet were only sometimes satisfied with the emotional support provided during their medical care. The limited satisfaction may be attributed to the patients’ inability to usually relax and discuss their health concerns with their healthcare providers, as well as the patients’ perception that they only sometimes were provided encouragement about their health. When examining differences in perceptions of social support by mixed models, the PCOS group reported that their healthcare providers argued with them more frequently about health-related issues than the comparison group.
• Limited access to nutrition services– Limited physician referrals to RDs– Limited insurance coverage
• Inadequacy of nutrition care for PCOS– Only 11% of patients with PCOS have reported being satisfied
with the support that they received for making lifestyle changes.– Most rely on information from unregulated sources.
• Failure to tailor care to the unique concerns of PCOS
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Barriers to Implementing the New International Guidelines for PCOS
References: Jarrett, Lin, & Lujan 2019; Lin et al. 2018; Gibson-Helm et al. 2017; Tomlinson et al. 2017.
Presenter
Presentation Notes
Based on the data, we identified three barriers to implementing these new international guidelines for PCOS. The first barrier includes limited access to nutrition services, particularly due to the medical infrastructure. Studies have shown that physicians often function as sole providers of weight loss counseling in primary care settings yet report having limited confidence in sharing weight management information with patients. This issue is exacerbated by the limited insurance coverage for medical nutrition therapy. The second barrier is inadequate nutrition care for PCOS. Less than 1/4th of PCOS patients are satisfied with the support they received while making lifestyle changes, and often rely on sources that are unregulated. The third barrier, and one that we have seen through the presentation, is that care is not tailored to the unique considerations associated with PCOS. Women with PCOS feel this condition increases their risk for health complications, and thus, it makes sense that they feel government recommendations suited for the general American may not be helpful for them.
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Discussion Question
What are some strategies to increase the provision of tailored, evidence-based nutrition information to
patients with PCOS?
What are some strategies to increase physician referrals to nutrition experts for PCOS?
Presenter
Presentation Notes
So this leads us to the discussion question, what strategies do or would you use to provide tailored, evidence-based nutrition information to patients with PCOS? Also, how do we get physician buy-in to encourage referrals to dietitians? What are some strategies you would use to increase physician referrals to nutrition experts for PCOS?
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Proposed Solutions to Barriers in PCOS-Related Nutrition Care
References: Jarrett, Lin, & Lujan 2019.
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Translation of the PCOS Guideline
References: Teede et al. 2018.
• Tools for Patients– Evidence-based app (AskPCOS)
• Tools for Providers– Question prompts– Health literacy enhancing tools– Accredited courses– Webinars with international expert panels– e-Health information resources
https://www.monash.edu/medicine/sphpm/mchri/pcos
Conclusions• PCOS is linked to lifelong metabolic complications.
– Weight management is key.
• International evidence-based guidelines support lifestyle management in all women with PCOS –regardless of weight.– Interventions should be multicomponent and individualized,
and reflect government recommendations for healthy eating and physical activity.
• Providers should work to address barriers to effective nutrition care for women with PCOS.– Tailor nutrition counseling to unique concerns of PCOS.– Increase physician referrals to registered dietitians for PCOS.
Cornell Faculty, Staff, and Students• Pat Cassano, PhD• Jamie Dollahite, PhD• Jeffery Sobal, PhD• Kevin Klatt, PhD
University of Rochester• Kathleen Hoeger, MD
Study Participants
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Funding• Cornell University
– Division of Nutritional Sciences– CALS Alumni Association– CHE Alumni Association
• National Institutes of Health– T32-DK007158 (B.Y.J.)– T32-CA193193 (A.W.L.)
ReferencesBozdag G., Mumusoglu S., Zengin D., et al. The prevalence and phenotypic features of polycystic ovary syndrome: a systematic reviewand meta-analysis. Hum Reprod. 2016; 31(12); 2841–2855.
Christ J., Willis A., Brooks E., et al. Follicle number, not assessments of the ovarian stroma, represents the best ultrasonographic markerof polycystic ovary syndrome. Fertil Steril. 2014; 101(1): 280–287.
Fauser B., Tarlatzis B., Rebar R., et al. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the AmsterdamESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012; 97(1): 28–38.
Gibson-Helm M., Teede H., Dunaif A., et al. Delayed diagnosis and a lack of information associated with dissatisfaction in women withpolycystic ovary syndrome. J Clin Endocrinol Metab. 2017; 102(2): 604–612.
Jarrett B., Lujan M. Impact of hypocaloric dietary intervention on ovulation in obese women with PCOS. Reproduction. 2016; 156(1): R15–R27.
Jarrett B., Lin A., Lujan M. A Commentary on the New Evidence-Based Lifestyle Recommendations for Patients with Polycystic OvarySyndrome and Potential Barriers to Their Implementation in the United States. J Acad Nutr Diet. 2019; 119(2): 205–210.
Lin AW, Dollahite JS, Sobal J, Lujan ME. Health-related knowledge, beliefs and self-efficacy in women with polycystic ovary syndrome.Hum Reprod. 2018; 33:91-100
Lin AW, Bergomi E, Dollahite JS, Sobal J, Hoeger KM, Lujan ME. Trust in physicians and medical experience beliefs differ between womenwith and without polycystic ovary syndrome. J Endocr Soc. 2018;2(9):1001-1009.
Moran LJ, Pasquali R, Teede HJ, et al. Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excessand Polycystic Ovary Syndrome Society. Fertil Steril. 2009; 92(6): 1966–1982.
Moran LJ, Hutchison SK, Norman RJ, et al. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev.2011; CD007506.
Moran LJ, Brown WJ, McNaughton SA, et al. Weight management practices associated with PCOS and their relationships with diet andphysical activity. Hum Reprod. 2017; 32(3):669-678.
Teede H., Misso M., Costello M., et al, Recommendations from the International Evidence-based Guideline for the Assessment andManagement of Polycystic Ovary Syndrome. Hum Reprod. 2018; 33: 1602–1618
Tomlinson J., Pinkney J., Adams L., et al, The diagnosis and lived experience of polycystic ovary syndrome: A qualitative study. J AdvNurs. 2017; 73: 2318–2326.
49This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.