The multidisciplinary treatment of PCOS – a dietitian’s role

9 min read /
Diabetology General Nutrition

The following article is a summary of a paper entitled ‘The role of dietitian in the multidisciplinary treatment of PCOS’. The paper is authored by Olga Nemchikova, Department of Systems Medicine, University of Rome Tor Vergata and Simona Frontonie, Department of Systems Medicine, University of Rome Tor Vergata and Unit of Endocrinology. The paper was published in ScienceDirect.com in January 2022. View the scientific paper here.

Background
 
Polycystic ovary syndrome (PCOS) is a common hormonal disorder affecting both lean and overweight women in 15-20% of women in their childbearing years. Up to 40% of female infertility cases in South Africa are PCOS related. It causes hormonal imbalances, irregular menstrual cycles, excess androgen levels, and small cysts on the ovaries. PCOS can lead to infertility, insulin resistance, obesity, and hirsutism. Its heterogeneity may pose challenges for healthcare professionals in diagnosing the condition. Despite research, PCOS remains an enigmatic condition resulting from interactions between genetics, epigenetics, ovarian dysfunction, endocrine neuroendocrine, and metabolic alterations. Patients with PCOS face higher long-term health risks, including cardiovascular disease, endometrial cancer, psychological disorders and infertility.

Problems faced by dietitians in PCOS management
 
Several studies highlighted a few significant obstacles that are faced by dietitians in real-world clinical practice. They are a lack of health system coverage; and lack of physical referrals.

Dietitians face significant obstacles in real-world clinical practice, including a lack of health system coverage and limited physician referrals for patients with PCOS. In the ESAR (Eastern and Southern Africa) region, rural areas make access to facilities difficult, and a lack of confidence in lifestyle intervention methods further contribute to limited physician referrals. Moreover, there is a lack of knowledgeable dietitians in this particular area. As a result, only 15% of PCOS patients have ever seen a dietitian, and a mere  3% have had 2 appointments with a dietitian.

The role of dietitians in PCOS management

1. The importance of an accurate nutritional assessment
The nutritional assessment aims to collect and evaluate the data and information to identify the problems related to nutrition that affect the clinical/physical condition and eating behaviours of the patient. Since the manifestation of the syndrome is extremely heterogeneous, the dietitian must be ready to face the variety of clinical cases in order to formulate a patient-centred diet and lifestyle interventions irrespective of the patient’s BMI. They must take a number of aspects, which couldn’t be neglected, into consideration. These aspects include cardiometabolic risks, nutritional deficiencies, ED and a DE aspect. 

  • Cardiometabolic risks: All women with PCOS should undergo anthropometric evaluation and body composition measurement; and an accurate assessment of their cardiometabolic profile through laboratory testing of lipid and glucose values and reading of blood pressure levels. The International Guideline uses BMI as a starting point for the evaluation of the lipid profile. Even though a normal BMI does not guarantee the absence of an altered metabolic profile, there is a phenomenon known as “normal weight obese”, that could be even more critical for women with PCOS.
     
  • Nutritional Deficiencies: More research is needed, but some concern is emerging on the deficiency of vitamin B12 with long-term metformin use and vitamin D in patients with PCOS. A well-informed dietitian should keep this in mind and consider dietary supplementation, especially if the patient follows a particular dietary regime like a vegan or vegetarian diet.
     
  • Eating disorders and disordered eating: A frequently overlooked aspect when treating patients with PCOS is a higher risk and prevalence of ED and DE compared to the general population.

    PCOS patients have a higher risk and prevalence of eating disorders (ED) and depressive symptoms compared to the general population. A recent meta-analysis found a significant association between PCOS and the clinical diagnosis of bulimia nervosa (BN), binge-eating disorder (BED), and any ED, with BED being the most prevalent disorder. Women with PCOS have risk factors such as body dissatisfaction, eating and weight concerns, depressive symptoms, chronic dietary restraint, and higher BMI. An international guideline recommends increased awareness and effective assessment to improve psychological functioning and overall quality of life in women with PCOS. Dietitians can contribute to ED/DE treatment by being trained to recognise unbalanced eating patterns and being confident in using various screening tools.
     

2. Nutritional and supplementary support in patients with PCOS

As PCOS is extremely heterogeneous it must be addressed with the attention and ability of healthcare professionals to see the whole picture, ideally applying a multi-disciplinary approach. Greater emphasis must be placed on educating healthcare professionals, including dieticians, about the importance of nutritional counselling. The involvement of educated dietitians is more than likely the best way to ensure that PCOS patients have access to correct lifestyle interventions. These interventions include a combination of dietary changes, increased physical activity, stress management and smoking cessation. Since there are no official guidelines for nutritional professionals to address women with PCOS, it is the dietitian’s responsibility to consider and choose the most appropriate and safe intervention that can be done only after a detailed nutritional assessment. 

Apart from being responsible for nutritional and lifestyle interventions, dietitians have a growing role in non-pharmacological treatment. The use of dietary and herbal supplements to improve metabolic and reproductive parameters in PCOS patients is a promising concept that instigates more research.

Two groups of PCOS patients still require more attention in both the research field and clinical practice, especially from the perspective of nutritional and lifestyle intervention. These groups are PCOS patients with ED and DE; and lean PCOS patients.

- PCOS patients with DE and ED

Women with PCOS and with ED and DE face conflicting recommendations for weight loss and seek treatment that doesn't focus on intense weight loss. Overemphasising weight loss can be harmful, especially in women with PCOS, where it's seen as a gender-role endorsement. Weight-neutral nutrition programming can reduce weight stigma, promote permanent dietary and physical activity changes, reduce DE patterns, improve self-esteem, and reduce depression. Women with PCOS and with ED and DE can benefit from sustainable behaviour change techniques, self-efficacy, and health-centred nutrition recommendations, along with psychological therapies.

- Lean PCOS patients

While the weight loss strategy remains the core of lifestyle modifications for overweight and obese patients with PCOS, the correct approach for lean women with PCOS is much less evident, but not of minor importance.

Lean PCOS patients, despite normal BMI, are still at risk of altered metabolic profile, long-term health complications and ED/DE behaviour. This, therefore, requires a nutritional support and lifestyle intervention through a multidisciplinary treatment. Thus, adjustment of dietary and lifestyle regimen, identification of dysfunctional thoughts and feelings around food, eating and body image; a focus on nutritional education and prevention of weight gain; and long-term health conditions associated with PCOS could be the core of dietary intervention.

3. Long-term follow-up

Sustainable lifestyle changes and PCOS-related cardiovascular risk factors require patients to maintain a strong relationship with a dietitian for monitoring metabolic health and nutritional behaviour. However, real-life clinical settings may face challenges such as a lack of awareness, high dropout rates, and communication barriers.

  • Lack of awareness about long-term health conditions: A recent international cross-sectional study that focused on women’s diagnosis experience identified that only a few women were satisfied with the information about PCOS given at diagnosis. The study included lifestyle management and long-term complications, with 45% and 53.5% of responders stating that this information was not even mentioned.
     
  • High drop-out rates among obese and overweight patients: Adherence to lifestyle recommendations among women with PCOS has been found to be particularly challenging, with drop-out rates as high as 50% in lifestyle intervention studies when compared to 31% in the general population. Some reasons for discontinuing the weight loss intervention included time constraints, medical problems, hunger and frustration, perceived ineffectiveness of the diet, adherence difficulties, and cost. Unfortunately, there are no known factors that will predict the change of individual patients dropping out.
     
  • Communication settings: Most studies on lifestyle interventions in the PCOS population include several visits with a dietitian every two to four weeks, and the presence of supervision at an exercise facility and/or multiple telephone calls to participants on weekdays and weekends. Unfortunately, this couldn’t be further from the truth in real-life clinical practice settings, with a lack of health system coverage; long waiting periods between appointments; and no access to clinical services for patients in rural areas. In addition, short consultation times and a small chance of being monitored on a long-term basis by the same dietitian make communication even more compromised.
     

Conclusion

It’s widely accepted that lifestyle intervention is a first-line treatment, independently of BMI, to address the complexity of PCOS. However, there are a number of barriers that prevent health professionals, especially dietitians, from its application in real-life clinical settings. This viewpoint was designed to put a greater emphasis on the need to:

  • Elaborate on evidence-based guidelines, specifically designed for nutritional specialists with respect to the complexity of the syndrome and its multiple complications. 
     
  • Raise awareness among dietitians and other healthcare professionals about the heterogeneity of the syndrome and the role of preventative healthcare. 
     
  • Shift the focus from weight loss being a primary lifestyle intervention and make it more inclusive for lean PCOS patients and patients with ED and DE patterns.
     
  • Pay more attention to the role of the dietitian being a person of reference in relation to lifestyle, nutritional and dietary supplementation intervention in the multidisciplinary management of PCOS. 
     

*With acknowledgments to the authors of the full technical paper, Olga Nemchikova, Department of Systems Medicine, University of Rome Tor Vergata, and Simona Frontonie, Department of Systems Medicine, University of Rome Tor Vergata and Unit of Endocrinology. Download the technical paper here.