*This article was published in an association magazine intended for health professionals; all names are fictions
While on the rise in women over the age of 20, PCOS seems to affect South Asian women disproportionately. Due to the metabolic nature of the condition and phenotypic propensity for metabolic disease, South Asian women are more at risk for the symptoms of this chronic endocrine disorder.
During the 75-minute intake, Kiran, a 22-year-old South Asian female sat across from my desk recounting her challenges with weight gain, facial hair, and irregular cycles. Accompanied by her mom, Kiran was soft spoken and calm as she told me that her weight had steadily increased, and her endocrinologist had put her on Metformin last year. She reported that despite weight training several times per week, her weight did not budge. Brought to near tears, Kiran’s mom asked why this would be happening to her daughter and what could be done to get her daughter back to her healthy self.
One of the most common causes of infertility[i], PCOS often leads to a number of life threatening and emotional stressors such as increases in cardiometabolic diseases, insulin resistance, obesity, hirsutism, as well as depression and anxiety. It is estimated that over 100 million women of reproductive age worldwide are affected by the syndrome with a rise in incidence in rapidly developing urban environments such as India[ii], China and Korea[iii]. According to the Rotterdam criteria, PCOS is diagnosed by the presence of two of the following three features: 1) oligo- or anovulation 2) clinical and/or biochemical signs of hyperandrogenism or 3) polycystic ovaries[iv]. These findings are usually accompanied by other comorbidities, such as increased risk of developing infertility, cardiovascular disease (CVD), metabolic syndrome, type-2 diabetes and endometrial cancer[v].
Many South Asian women face challenges in their quest for optimal health and emotional wellness. Just a few generations past, South Asian women would serve as the head of the household managing several children and perhaps even extended family members in traditional settings. Broad family support networks were in place to prevent feelings of isolation, excess burden and to enhance self-worth even in the face of tremendous responsibilities. In fact, prior generations of South Asian women enjoyed better health and less chronic disease than what we are seeing in the general population today. In our current day and age, many modern South Asian women have migrated away from their families sometimes alone to start a life in a country far from their native land. Consequently, families in the Western world are smaller and the supportive extended family is often lost as a result.
While juggling work-life balance and managing the stress of domestic responsibilities are not isolated to South Asian women, poor lifestyle choices such as low emphasis on exercise, a toxic food environment, limited sunlight exposures and digital stress are chronically affecting women all over the world.
Every South Asian woman should know the signs and symptoms of PCOS. Similarly, as a practitioner, screening for this condition can help to identify warning signs early. Although the global incidence of PCOS is 20-30 percent, a recent British study found that the highest reported incidence was in South Asians – just over half of South Asian (52 percent) had PCOS[vi]. Researchers found that the degree of insulin resistance uncovered in these non-diabetic women with PCOS was similar to that of type 2 diabetics. Compared to Caucasians, South Asians develop PCOS at an earlier age and have more severe symptoms, excess insulin levels and a higher incidence of infertility[vii] The extra insulin triggers the formation of cysts in the ovaries along with the production androgens and the accumulation of excess body fat. Besides physical challenges, PCOS can be detrimental to the emotional well being of teenagers and young women as obesity, acne and facial hair adversely affect a woman’s self-esteem.
What Causes PCOS?
The underlying thread in PCOS seems to be insulin resistance resulting in increased androgens which in turn suppress ovulation. As well, increased C-reactive protein in many women with PCOS points to low grade chronic inflammation which can be a marker for cardiovascular disease[viii].
A deeper look into the underlying genetic component in South Asian women could offer more insight as to the increased prevalence of the condition in this population. Evidence suggests that certain genetic polymorphisms, particularly in the vascular endothelial growth factor (VEGF) gene play an important role in the pathogenesis of PCOS[ix]. During the time of ovulation, increased vascularization of the ovaries is a normal part of thecal cell development. However due to dysregulation of VEGF, several anomalies of ovarian angiogenesis have been described in women with PCOS leading to the formation of cysts.[x] This coupled with hyperandrogenism due to insulin resistance may explain the complex nature of the condition.
Researchers also conclude that women with PCOS tend to be hyperandrogenic during pregnancy, and endocrine alterations during pregnancy may contribute to an increased risk for their female offspring to also develop PCOS.
Due to the potential underlying genetic component of PCOS, it is important that as practitioners we don’t place all the blame on the patient’s poor food and nutrition choices for the state of their health. Rather we educate them about the importance of diet, lifestyle and nutrition as a basis of effective treatment combined with an understanding that PCOS has strong genetic and epigenetic roots.
The Risk for Insulin Resistance in South Asians
The abundance of food, specifically processed foods is undoubtedly having a detrimental effect on the health of most people today. The increased frequency of eating one may argue is likely one of the greatest challenges in attaining normal glucose levels in the body. Certain cultures such as South Asians are exquisitely sensitive to the rise and fall of blood sugar throughout the day. As a theory, insulin resistance was a useful tool at a time when food was scarce because it kept energy in the blood for a longer duration – particularly useful if a person didn’t know when they would be able to have their next meal. However, this genetic adaptation to starvation seems to be the reason for the greater risk for insulin resistance seen in South Asians. No chips, cookies, cakes, or any other food desired can be acquired within minutes of thinking about it. This combination of insulin resistance and excess calorie consumption is a recipe for chronic disease seen in the general South Asian population.
Which Diet is best for PCOS?
The scientific literature on diets for PCOS is sparse. However, researchers suggest that women with PCOS will do best by eating complex carbohydrates and avoiding sugar. This suggestion was confirmed in one study on the effects of low-glycemic index diet on women with PCOS[xi].
The ketogenic diet may offer positive outcomes in terms of improving fertility by producing weight loss in women who are obese[xii], the restriction of carbohydrates on this diet may induce stress and low adherence. A new modified approach is to restrict total carbohydrates to below 35-45g per day, eating high fibre vegetables with each meal along with adequate protein and eating enough calories[xiii].
As a generalization, the typical South Asian diet unfortunately can be higher in carbohydrates. As many are vegetarians, adequate protein intake to offset carbohydrate intake can be challenging. However, a focus on complex carbohydrates, fiber and healthy fats is the first step to gaining a nutritional hold on PCOS.
Resistance Training: In a 4-week study, performing resistance training one hour three times a week led to lower androgen and sex-hormone binding globulin levels, weight loss, and increased muscle mass in women with PCOS.[xiv]
Aerobic Exercise: Aerobic exercise has been shown to help lower inflammation, reduce insulin resistance, promote weight loss, and improve reproductive function in women with PCOS. In one study, 56% of women with amenorrhea who performed aerobic exercise for 12 weeks began menstruating again[xv].
Yoga: Proven to lower stress and cortisol levels, yoga may be a good option as it is also thought to have anti-depressant effects as well[xvi].
Evidence Based Supplementation
Most of the research on supplementation for PCOS focuses on the metabolic aspects of PCOS. While each patient’s needs are unique, below is a list of a few evidence based nutrients to consider in the management of PCOS.
Chromium: A study involving 64 women showed decreased serum insulin levels, HOMA IR levels and cholesterol levels. Dosage recommendation 200 mcg per day[xix].
Back to Kiran’s case. To support her nutritionally and to address her BMI, I used a novel nutritional program which uses 37 blood values to generate a meal plan specific to her nutritional and caloric needs. I also used a combination of supplements and seed cycling to help regulate her cycle. Homeopathic Calcera Carbonica 30C was also prescribed twice daily for 7 days then once weekly[xxiv] based on repertorization and this remedy’s affinity in addressing PCOS symptoms. With these interventions and mindfulness practice, Kiran was able to lose 15 pounds in 8 weeks as well regulate her cycles from every 60 days to every 30 to 34 days. She chose to lift weights with her brother regularly as she understood moving her body was an essential part of the equation.
In conclusion, what appears to be at the centre of PCOS is appropriate BMI, increased nutrition, increased movement and adequate nutrient supplementation. While the exact dietary intervention for PCOS has not been established, we can all agree that an emphasis on whole foods, fresh vegetables and adequate fruit, protein and fat are the keys to success in the management and treatment of PCOS.
[ii] Ganie, M. A., Vasudevan, V., Wani, I. A., Baba, M. S., Arif, T., & Rashid, A. (2019). Epidemiology, pathogenesis, genetics & management of polycystic ovary syndrome in India. The Indian journal of medical research, 150(4), 333–344. https://doi.org/10.4103/ijmr.IJMR_1937_17
[iii] Kshetrimayum, Chaoba et al. “Polycystic ovarian syndrome: Environmental/occupational, lifestyle factors; an overview.” Journal of the Turkish German Gynecological Association vol. 20,4 (2019): 255-263. doi:10.4274/jtgga.galenos.2019.2018.0142
[iv] Ricardo Azziz, Diagnosis of Polycystic Ovarian Syndrome: The Rotterdam Criteria Are Premature, The Journal of Clinical Endocrinology & Metabolism, Volume 91, Issue 3, 1 March 2006, Pages 781–785, https://doi.org/10.1210/jc.2005-2153
[vi] Jones, G.L., Palep-Singh, M., Ledger, W.L. et al. Do South Asian women with PCOS have poorer health-related quality of life than Caucasian women with PCOS? A comparative cross-sectional study. Health Qual Life Outcomes 8, 149 (2010). https://doi.org/10.1186/1477-7525-8-149
[vii] Jones, G.L., Palep-Singh, M., Ledger, W.L. et al. Do South Asian women with PCOS have poorer health-related quality of life than Caucasian women with PCOS? A comparative cross-sectional study. Health Qual Life Outcomes 8, 149 (2010). https://doi.org/10.1186/1477-7525-8-149
[viii] N. Boulman, Y. Levy, R. Leiba, S. Shachar, R. Linn, O. Zinder, Z. Blumenfeld, Increased C-Reactive Protein Levels in the Polycystic Ovary Syndrome: A Marker of Cardiovascular Disease, The Journal of Clinical Endocrinology & Metabolism, Volume 89, Issue 5, 1 May 2004, Pages 2160–2165, https://doi.org/10.1210/jc.2003-031096
[ix] Zhao, J., Li, D., Tang, H., & Tang, L. (2020). Association of vascular endothelial growth factor polymorphisms with polycystic ovarian syndrome risk: a meta-analysis. Reproductive biology and endocrinology : RB&E, 18(1), 18. https://doi.org/10.1186/s12958-020-00577-0
[xi] Mavropoulos, J.C., Yancy, W.S., Hepburn, J. et al. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: A pilot study. Nutr Metab (Lond) 2, 35 (2005). https://doi.org/10.1186/1743-7075-2-35
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[xiii] Farshchi H, Rane A, Love A, Kennedy RL. Diet and nutrition in polycystic ovary syndrome (PCOS): pointers for nutritional management. J Obstet Gynaecol. 2007 Nov;27(8):762-73. doi: 10.1080/01443610701667338. PMID: 18097891.
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[xvi] Thirthalli, J et al. “Cortisol and antidepressant effects of yoga.” Indian journal of psychiatry vol. 55,Suppl 3 (2013): S405-8. doi:10.4103/0019-5545.116315
[xvii] Merviel, P., James, P., Bouée, S. et al. Impact of myo-inositol treatment in women with polycystic ovary syndrome in assisted reproductive technologies. Reprod Health 18, 13 (2021). https://doi.org/10.1186/s12978-021-01073-3
[xviii] Fruzzetti F, Perini D, Russo M, Bucci F, Gadducci A. Comparison of two insulin sensitizers, metformin and myo-inositol, in women with polycystic ovary syndrome (PCOS). Gynecol Endocrinol. 2017 Jan;33(1):39-42. doi: 10.1080/09513590.2016.1236078. Epub 2016 Nov 3. PMID: 27808588.
[xix] Jamilian M, Asemi Z. Chromium Supplementation and the Effects on Metabolic Status in Women with Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial. Ann Nutr Metab. 2015;67(1):42-8. doi: 10.1159/000438465. PMID: 26279073.
[xx] Yildizhan R, Kurdoglu M, Adali E, Kolusari A, Yildizhan B, Sahin HG, et al. Serum 25-hydroxyvitamin D concentrations in obese and non-obese women with polycystic ovary syndrome. Arch Gynecol Obstet. 2009;280:559–63.
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