PCOs Diets

 Kyle J. Norton (Draft article)

Approximately half of women with polycystic ovary syndrome (PCOs) are obese and overweight. Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 5% to 10% of women worldwide.
1. High Protein Diet with Low-Glycemic-Load Hypocaloric Diet
Diet with 30% of protein is now considered reasonable, high protein diet is the term reserved for consumption of 50%.
Suggestions of linking High Protein Diet with Low-Glycemic-Load Hypocaloric Diet and PCOs to control and combat in polycystic ovary syndrome (PCOS) have drawn attention in scientific community over last decade. It may be due to its effect in reduced appetites and calorie intake. But epidemiological studies focusing the benefit of diets in treating obese and overweight patients have produced an inclusive results. The National Nutrition and Food Technology Research Institute showed that both composition of hypocaloric and hypocaloric diet lead to significantly led to reduced body weight and androgen levels.  Compared with a conventional diet, the combination of high-protein and low-glycemic-load foods and Hypocaloric diett also found to be effective in enhanced insulin sensitivity and decreased hsCRP level when (1). But the alternation of metabolic rate of hypocaloric diet  in glucose utilization and decreased antioxidant defenses, in some case may result in life-threatening(8a).

2. Hypocaloric diet
 Comparison with Metformin in the same subjects, hypocaloric(low calories) diet showed an reduction of 5-10% of weight on markers of insulin resistance with  equal efficacy with Metformin in decreasing serum hs-CRP levels(2) and improving inflammatory biomarkers and adipokines independently of dietary composition(3). In a 20 weeks of a high-protein energy-restricted diet to evaluate the Markers of endothelial dysfunction, including elevated markers of endothelial dysfunction, presented in overweight and obese women with polycystic ovary syndrome, showed an significant weight loss, improved testosterone, sex hormone-binding globulin and the free androgen index (FAI) and insulin resistance(4). Sibutramine(the hydrochloride monohydrate salt) removed from the market because of the concerns of risk of heart attack and stroke, in a comparison test with hypocaloric diet, showed a significant weight loss in overweight and obese women with PCOS and improvement in hyperandrogenemia and insulin sensitivity after 6 months of treatment(5). Clomiphene citrate (CC) used comjuction with hypocaloric diet with structured exercise training (SET) after 6 weeks in overweight and obese CC-resistant PCOS patients, enhancing the probability of ovulation under CC treatment, through a a significant improvement in clinical and biochemical androgen and insulin sensitivity indexes(6).
Comparison of  a hypocaloric low-fat diet with those of a very low carbohydrate diet, showed the positive effects in both diets in significant improvements in BMI, WC, and menstrual function and induced weight loss through targeting both the menstrual dysfunction and risk factors for long-term morbidity associated with PCOS in adolescents(7). Short-term hypocaloric diet including high protein (HP: 30% protein, 40% carbohydrate, and 30% fat) or high carbohydrate (HC: 15% protein, 55% carbohydrate, and 30% fat) showed a significant weight loss reduction and  improvement in their reproductive and metabolic abnormalities with no increased benefit to a high-protein diet(8).
Some researchers suggested that Hypocaloric (low-calorie) diets can alter your metabolic rate in glucose utilization and decreased antioxidant defenses, in some case may result in life-threatening(8a).

3. Low-carbohydrate diet
  A high-fat, adequate-protein, low-carbohydrate diet  used in medicine primarily to treat difficult-to-control (refractory) epilepsy in children with purpose to induce the body to burn fat other than carbohydrate. In a women 24 weeks study with  limit carbohydrate intake to 20 grams or less per day for women diagnosed with PCOs, showed non-significant decreases in insulin, glucose, testosterone, HgbA1c, triglyceride, and perceived body hair but improvement in weight, percent free testosterone, LH/FSH ratio, and fasting insulin in women with obesity(9). According to the University of Padova study, "Epidemiological studies over last decade or so has provided evidence of the therapeutic potential of ketogenic diets in many pathological conditions, such as diabetes, polycystic ovary syndrome, acne, neurological diseases, cancer and the amelioration of respiratory and cardiovascular disease risk factors"(10). Some researcher insisted that the presence of high levels of insulin in the blood causes unnecessary water retention in the body(10a), the diet may produce a short term effect through eliminating excess body fat but may cause to cause dehydration as an early-onset complication(10b)

4. Low glycemic index diet
Glycemic index diet originally is developed to help improve blood sugar control in diabetes by choosing foods Low-GI foods (55 and under) for steadier rise in blood sugar.In a Twenty-six participants recruited at baseline, 22 commenced and 21 participants completed the low-GI dietary intervention phase, low glycemic diet improved insulin sensitivity, changes of lipids(11). Comparison of low glycemic index with a conventional healthy diet in overweight and obese premenopausal women, low glycemic index attendants showed to improve more in glucose tolerance through oral-glucose-tolerance test (ISI(OGTT)), menstrual cyclicity, with serum fibrinogen concentrations significant differences between diets(12). Researchers also suggested that longer term compliance needs more evaluation in subsequent studies to reduced long term health risks to women with PCOS on a low GI diet(13). In comparison of low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus, some researchers suggested that The diet containing fewer carbohydrates, the low-carbohydrate, ketogenic diet, was more effective for improving glycemic control than the low glycemic diet(12a).

5. High-protein diet
High-protein diet is a diet mostly recommended for people who want to build muscle and lose fat. A comparison of a high protein (HP) and a normal protein (NP) diet on patients with polycystic ovary syndrome (PCOS) in 8-week randomized trial, showed a significantly reduced body weight, body mass index (BMI), waist circumference, percent of body fat,  decreased total testosterone also decreased in PCOS and sum of trunk skinfolds decreased in both diets(14).  In fact, increased dietary protein-to-carbohydrate ratios showed no differences in testosterone, sex hormone-binding globulin, and blood lipids between the groups after 6 months, but adjustment for weight changes led to significantly lower testosterone concentrations in the standard-protein (SP) diet group, according to the University of Copenhagen(15). Unfortunately, some studies showed that consumption of HP diets may cause alterations in renal health status and some metabolic parameters(15a) and reduce the level of osteocalcin(15b)

7. High monounsaturated fat diet
High monounsaturated fat diet is a diet high in monounsaturated fatty acids (HMUFA) by replacing them for daily intake of bad fat. In a comparison of Carbohydrate-restricted diets high in either monounsaturated fat or protein, showed that magnitude of weight loss was smaller in the LF-HP group than in the HF-SP(16). The Mediterranean diet, a High monounsaturated fat diet is characterized by a high intake of olive oil, plant products, fish and seafood; a low intake of dairies, meat and meat products; and a moderate ethanol intake, but unfortunately, exploring the relationship between the Mediterranean diet and overweight/obesity is complex with inclusive results, some studies showed a significantly related to less overweight/obesity or more weight loss but many found no evidence of this association(16a).

8. Low fat diet 
Low fat diet restricts consumption of fat, stressing foods high in carbohydrates, mostly recommended to patients with some gallbladder conditions. Comparison of hormonal and metabolic markers after a high-fat, Western meal versus a low-fat, high-fiber meal in women with polycystic ovary syndrome, showed a reduction of free testosterone within 2 hours after both meals, however, the levels of testosterone remained below premeal values for 4 hours after the isocaloric low-fat, high-fiber meal (HIFIB) meal and 6 hours after the a high-fat, Western meal (HIFAT) meal. Levels of glucose was higher for 1 hour after the HIFIB meal compared with the HIFAT meal. DHEAS decreased 8%-10% within 2-3 hours after both meals, then increased during the remainder of the study period. Cortisol decreased during the 6-hour period after both meals(17). There is a suggestion of individuals on a low-fat vegan in ensured adequate intakes of  of vitamin D, vitamin K, folic acid, calcium, magnesium, zinc, vitamin B12, phosphorous, and selenium(17a).

Taking all together, there were subtle differences but correlation between diets, a monounsaturated fat-enriched diet greater weight loss, a low-glycemic index diet enhanced menstrual regularity, a high-carbohydrate diet increased free androgen index, a low-carbohydrate or low-glycemic index dietgreater reductions in insulin resistance, fibrinogen, total testosterone, and high-density lipoprotein cholesterol, a low-glycemic index diet improved quality of life, a high-protein diet.improved depression and self-esteem for a high-protein diet. Maximize weight loss control is important for women with PCOS regardless of dietary composition in the majority of studies and should be targeted in all overweight women with PCOS through reducing caloric intake with adequate nutritional intake and healthy food choices irrespective of diet composition(18).
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References
(1) Beneficial effects of a high-protein, low-glycemic-load hypocaloric diet in overweight and obese women with polycystic ovary syndrome: a randomized controlled intervention study by Mehrabani HH, Salehpour S, Amiri Z, Farahani SJ, Meyer BJ, Tahbaz F.(PubMed)
(2) Effect of metformin compared with hypocaloric diet on serum C-reactive protein level and insulin resistance in obese and overweight women with polycystic ovary syndrome by Esfahanian F, Zamani MM, Heshmat R, Moini nia F.(PubMed)
(3) Effect of a low-fat versus a low-gycemic-load diet on inflammatory biomarker and adipokine concentrations by Heggen E, Klemsdal TO, Haugen F, Holme I, Tonstad S.(PubMed)
(4) The effect of diet and exercise on markers of endothelial function in overweight and obese women with polycystic ovary eby Thomson RL, Brinkworth GD, Noakes M, Clifton PM, Norman RJ, Buckley JD.(PubMed)
(5) Effect of hypocaloric diet plus sibutramine treatment on hormonal and metabolic features in overweight and obese women with polycystic ovary syndrome: a randomized, 24-week study by Florakis D, Diamanti-Kandarakis E, Katsikis I, Nassis GP, Karkanaki A, Georgopoulos N, Panidis D.(PubMed)
(6) Six weeks of structured exercise training and hypocaloric diet increases the probability of ovulation after clomiphene citrate in overweight and obese patients with polycystic ovary syndrome: a randomized controlled trial by Palomba S, Falbo A, Giallauria F, Russo T, Rocca M, Tolino A, Zullo F, Orio F.(PubMed)
(7) Effect of weight loss on menstrual function in adolescents with polycystic ovary syndrome by Ornstein RM, Copperman NM, Jacobson MS.(PubMed)
(8) A randomized trial of the effects of two types of short-term hypocaloric diets on weight loss in women with polycystic ovary syndrome by Stamets K, Taylor DS, Kunselman A, Demers LM, Pelkman CL, Legro RS.(PubMed)
(8a) Toxicity of hypercaloric diet and monosodium glutamate: oxidative stress and metabolic shifting in hepatic tissue by Diniz YS, Fernandes AA, Campos KE, Mani F, Ribas BO, Novelli EL.(PubMed)
(9) The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study by Mavropoulos JC, Yancy WS, Hepburn J, Westman EC.(PubMed)
(10) Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets by Paoli A, Rubini A, Volek JS, Grimaldi KA.(PubMed)
(1a) Eades, M. (1995) The Protein Power Lifeplan, Warner Books.
(1b) Early- and Late-onset Complications of the Ketogenic Diet for Intractable Epilepsy by Hoon Chul Kang¹, Da Eun Chung¹, Dong Wook Kim², Heung Dong Kim (Wily online library)(11) An isocaloric low glycemic index diet improves insulin sensitivity in women with polycystic ovary syndrome by Barr S, Reeves S, Sharp K, Jeanes YM.(PubMed)
(12) Effect of a low glycemic index compared with a conventional healthy diet on polycystic ovary syndrome by Marsh KA, Steinbeck KS, Atkinson FS, Petocz P, Brand-Miller JC.(PubMed)
(12a) The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus by Eric C Westman^1*, William S Yancy¹², John C Mavropoulos¹, Megan Marquart¹ and Jennifer R McDuffie(Nutrition&Metabolism)
(13) Evaluating compliance to a low glycaemic index (GI) diet in women with polycystic ovary syndrome (PCOS) by Egan N, Read A, Riley P, Atiomo W.(PubMed)
(14) Effect of high-protein or normal-protein diet on weight loss, body composition, hormone, and metabolic profile in southern Brazilian women with polycystic ovary syndrome: a randomized study by Toscani MK, Mario FM, Radavelli-Bagatini S, Wiltgen D, Matos MC, Spritzer PM.(PubMed)
(15) Carbohydrate-restricted diets high in either monounsaturated fat or protein are equally effective at promoting fat loss and improving blood lipids by Luscombe-Marsh ND, Noakes M, Wittert GA, Keogh JB, Foster P, Clifton PM.(PubMed)
(15a) Effects of high-whey-protein intake and resistance training on renal, bone and metabolic parameters in rats by Aparicio VA, Nebot E, Porres JM, Ortega FB, Heredia JM, López-Jurado M, Ramírez PA.(PubMed)
(15b) Effects of dietary protein and glycaemic index on biomarkers of bone turnover in children by Dalskov SM¹, Müller M², Ritz C¹, Damsgaard CT¹, Papadaki A³, Saris WH⁴, Astrup A¹, Michaelsen KF¹, Mølgaard C¹; on behalf of DiOGenes(PubMed)
(16) Carbohydrate-restricted diets high in either monounsaturated fat or protein are equally effective at promoting fat loss and improving blood lipids by Luscombe-Marsh ND, Noakes M, Wittert GA, Keogh JB, Foster P, Clifton PM.(PubMed)
(16a) Obesity and the Mediterranean diet: a systematic review of observational and intervention studies by Buckland G, Bach A, Serra-Majem L.(PubMed)

(17) Comparison of hormonal and metabolic markers after a high-fat, Western meal versus a low-fat, high-fiber meal in women with polycystic ovary syndrome by Katcher HI, Kunselman AR, Dmitrovic R, Demers LM, Gnatuk CL, Kris-Etherton PM, Legro RS.(PubMed)
(17a) Effects of a low-fat vegan diet and a Step II diet on macro- and micronutrient intakes in overweight postmenopausal women by Turner-McGrievy GM, Barnard ND, Scialli AR, Lanou AJ.(PubMed)

(18) Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines by Moran LJ, Ko H, Misso M, Marsh K, Noakes M, Talbot M, Frearson M, Thondan M, Stepto N, Teede HJ.(PubMed)