WIDLIMS ep #13: Anti-diet lifestyle approaches to PCOS with Dr Nitu Bajekal

In this week's episode, I was honoured to talk to an inspiration of mine, Dr Nitu Bajekal (she/her) about...

• what PCOS (polycystic ovarian syndrome) is and how it manifests
• lifestyle approaches to managing PCOS symptoms
  • AGEs, anti-inflammatory foods, benefits of a whole food plant-based dietary pattern
  • the importance of sustainable, non-restrictive diets
• the role of soya in PCOS and women’s health in general
• why lifestyle medicine is so important to have in our toolkits

Dr Nitu Bajekal’s website is absolutely brimming with resources for people with a uterus/who menstruate/are post-menopausal, and you can find it here. You can also follow her on Instagram and Twitter, where she regularly updates followers on research news, plant-based cooking and her adorable rescue dogs.

Dr Bajekal is a consultant gynaecologist working in London, with over 35 years’ experience in the field, and founder of the voluntary service Women for Women’s Health. She is also board certified in Lifestyle Medicine. You can read her full story here.

As I have alluded to above, what is typically considered women’s health’ does apply to people who are not women as well. For example, trans men, intersex and non-binary people with a uterus and ovaries, what is thought of as female reproductive organs. Other than saying ‘women’, it would be more accurate and inclusive to use the terms ‘people who menstruate’ or persons assigned female at birth (AFAB). And this is yet another thing that is simply not mentioned in medical education, and therefore certainly not drilled into us. Read Kenny Ethan Jones’ article, where he discusses periods and health care for non-cisgender people here for more on the topic.

Mentioned in episode

• Dr Nitu Bajekal’s fact sheets on PCOS and PCOS nutrition
• Associations between PCOS and other disorders such as depression and eating disorders – read more here and in the article below!
• Characteristics of an optimal diet in PCOS – read research paper here
• AGEs in PCOS – read more here
• The BROAD study – read more here
• Soy in PCOS – read more here and Dr Nitu Bajekal’s fact sheet here
• Moving away from diets in PCOS – I recommend checking out Julie Duffy-Dillon, RD on her website or guest appearances on podcasts such as FoodPsych or Don’t Salt My Game

Summary article and background

What is Polycystic Ovary Syndrome (PCOS)?

PCOS is a chronic endocrine condition (which means it affects hormones) which about 10% (potentially up to 20%) of women/AFAB persons live with (1) . The exact cause for it is still not clear, although the mechanisms by which it manifests involve:

• insulin resistance: the body responds poorly to insulin, similarly to how it acts in the lead-up to type 2 diabetes mellitus
• sex hormone imbalance: excess testosterone
• genetics and probably lifestyle elements, too

PCOS received its name due to causing several (poly) small follicles (cysts) on the ovaries, which may be seen on ultrasound imaging. These are essentially due to maturing ovarian follicles, which are growing and ought to be released during each menstrual cycle; in PCOS, however, the follicles arrest due to the abnormal hormone balances. PCOS is not a perfect name for the condition, though, as not all people with PCOS have said cysts. For a diagnosis of PCOS, two out of the three following must be present:

• oligomenorrhoea: irregular periods, or anovulation
• hyperandrogenism: elevated ‘male’ hormone levels (testosterone), either as seen on blood tests, or manifested clinically despite normal-range blood levels (increased body hair, acne, male-pattern hair loss etc.)
• ovarian follicles visible on a pelvic ultrasound scan

PCOS thus may manifest quite differently in different people. Although the majority are overweight at diagnosis, persons with a ‘normal’ BMI may still be diagnosed with PCOS.

More on what causes PCOS and about PCOS by the charity Verity can be found here, and from a dietician with a special interest in PCOS and food peace here. There also is an interesting page on ‘PCOS myths’ here.

Other than irregular periods, and signs of higher testosterone levels, PCOS can cause an entire host of symptoms.

Food cravings, eating disorders and weight stigma

Due to insulin resistance, people with PCOS typically are of a higher body weight, with central adiposity and find it difficult to shed any weight. However, one of the first management strategies is typically to advise women to lose weight. Shedding 5-10% of body weight supposedly helps with controlling symptoms. But for someone weighing 80kg, that is an entire 4-8 kgs to lose! And, most importantly, if weight loss is achieved through dieting or in any way changing your habits in an unsustainable way in the long term, there is literally no point to do so in the first place. Better to look at some healthier approaches to managing symptoms, not focused on weight-loss, but wellbeing and health instead.

Embarking on a diet or weight-loss journey may be particularly damaging for someone with PCOS, as they have a predilection for developing eating disorders, which are damaging in their own right – both physically and psychologically.

The insulin resistance and resulting hyperinsulinaemia (high insulin blood levels) are thought to be associated with very intense food cravings. People with PCOS have been shown to have higher prevalence of eating disorders such as binge-eating disorder and bulimia nervosa (2) . Krug et al. write ‘Taking a more flexible approach to weight management in women with both PCOS and ED would be optimal in order to prevent accomplishing a “healthy” weight at the cost of quality of psychological well-being.’ (3) A more flexible approach would involve focusing on having a healthy diet, gentle exercise and addressing mental health issues, which are also associated with PCOS. To name a few: anxiety, depression, obsessive-compulsive disorder, sleep disorders and sexual problems (4,5).

At this point I would like to draw your attention to registered dietician Julie Duffy Dillon, who has done a lot of work on managing PCOS while adopting an intuitive eating, anti-diet approach. You can find some more information on her webiste, or listen to some podcasts she has been on such as this episode here.

How should PCOS be managed?

Dietary strategies for PCOS management

There is a no clear evidence-base in favour of one particular diet specifically for those with PCOS. Research which has been conducted is limited, due to the intrinsic heterogeneity of the samples studied, and has also largely focused around outcomes in white European women, thus not necessarily being representative for everyone (6).

It does appear that a low-GI (glycaemic index) diet produces more favourable outcomes (6-8). Although weight loss is recommended, I would again urge doctors to keep in mind that any weight loss achieved through dieting and restriction is unlikely to be sustainable and long-lasting.

Other dietary aspects which are likely beneficial, include to avoid where possible refined carbohydrates, saturated fat and trans fats, and to emphasize foods high in fibre (fruits, vegetables, legumes & whole grains). (8). There may also be benefits from supplementation with vitamin D, chromium, inositol and magnesium, although this should be discussed with a healthcare practitioner.

AGEs (advanced glycation end-products) are pro-inflammatory components that are best to avoid for all humans, and particularly in PCOS, which is associated with a chronic low-grade inflammation and increased oxidative stress markers irrespective of body weight (9,10). Foods high in AGEs include most processed and ultra-processed foods (typically those with a label with a long list of ingredients) as well as animal products (11).

A whole-food plant-based diet therefore presents itself as an optimal diet for people with PCOS to adopt. Faghfoori et al concluded the following:

A favorable dietary plan in women with PCOS should contain low amounts of saturated fatty acids with average amounts of saturated fatty acids with one double bond and omega-3. Additionally, sufficient intake of fiber-rich diet from whole grains, legumes, vegetables and fruits with an emphasis on carbohydrate sources with low glycemic index is highly recommended.

Faghfoori et al. Nutritional management in women with polycystic ovary syndrome: A review study. Diabetes Metab Syndr. 2017. doi:10.1016/j.dsx.2017.03.030 https://www.sciencedirect.com/science/article/pii/S1871402117300115?via%3Dihub

It would appear that a focus on including minimally processed soy products is also beneficial (12); include 2 portions a day (13).

Read more about beneficial foods and lifestyle interventions for PCOS in Dr Nitu Bajekal’s fact sheet here. The best summary on considerations for a healthy plant-based diet can be found in the free Plant-Based Health Professionals UK fact sheet ‘Eatwell guide’.

Other lifestyle considerations

This episode mainly focused on lifestyle interventions for managing PCOS, as well as the underlying mechanisms. However, it is important to address other lifestyle factors for improving PCOS (14,15). Some of these include:

• Exercise
• Mindfulness and managing stress
• Good quality sleep
• Maintaining fulfilling social connection

As PCOS mainly affects women, it is my personal opinion that is the cause for our poor understanding of what causes it and need for further research. In the meanwhile, we know that an adapted whole food plant-based dietary pattern is of huge benefits to people with PCOS – not unsustainable unhealthy restriction or fad ketogenic diets! (16) – and as Dr Bajekal says ‘informed consent and informed choices are only possible when you have all the information to hand and I think that’s where we’re doing a big disservice to the people we are trying to make better’.

Check out the references linked in this post – as always, I am happy to chat further about what you thought of the episode, or any interesting research you have come across!

REFERENCES

1) Sirmans, Susan M, and Kristen A Pate. “Epidemiology, diagnosis, and management of polycystic ovary syndrome.” Clinical epidemiology vol. 6 1-13. 18 Dec. 2013, doi:10.2147/CLEP.S37559 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872139/

2) Jeanes YM, Reeves S, Gibson EL, Piggott C, May VA, Hart KH. Binge eating behaviours and food cravings in women with Polycystic Ovary Syndrome. Appetite. 2017;109:24-32. doi:10.1016/j.appet.2016.11.010

3) Krug I, Giles S, Paganini C. Binge eating in patients with polycystic ovary syndrome: prevalence, causes, and management strategies. Neuropsychiatr Dis Treat. 2019;15:1273-1285. Published 2019 May 16. doi:10.2147/NDT.S168944 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529622/

4) Thannickal A, Brutocao C, Alsawas M, et al. Eating, sleeping and sexual function disorders in women with polycystic ovary syndrome (PCOS): A systematic review and meta-analysis. Clin Endocrinol (Oxf). 2020;92(4):338-349. doi:10.1111/cen.14153 https://onlinelibrary.wiley.com/doi/abs/10.1111/cen.14153

5) Brutocao C, Zaiem F, Alsawas M, Morrow AS, Murad MH, Javed A. Psychiatric disorders in women with polycystic ovary syndrome: a systematic review and meta-analysis. Endocrine. 2018;62(2):318-325. doi:10.1007/s12020-018-1692-3 https://link.springer.com/article/10.1007%2Fs12020-018-1692-3

6) Moran, Lisa J., et al. “Dietary Composition in the Treatment of Polycystic Ovary Syndrome: A Systematic Review to Inform Evidence-Based Guidelines.” Journal Of The Academy Of Nutrition And Dietetics, vol. 113, no. 4, 2013, pp. 520–545. 

7) BUPA health PCOS. https://www.bupa.co.uk/health-information/womens-health/pcos

8) Faghfoori Z, Fazelian S, Shadnoush M, Goodarzi R. Nutritional management in women with polycystic ovary syndrome: A review study. Diabetes Metab Syndr. 2017;11 Suppl 1:S429-S432. doi:10.1016/j.dsx.2017.03.030 https://www.sciencedirect.com/science/article/pii/S1871402117300115?via%3Dihub

9) PCOS and inflammation https://juliedillonrd.com/pcosinflammation/

10) Murri M, Luque-Ramírez M, Insenser M, Ojeda-Ojeda M, Escobar-Morreale HF. Circulating markers of oxidative stress and polycystic ovary syndrome (PCOS): a systematic review and meta-analysis. Hum Reprod Update. 2013;19(3):268-288. doi:10.1093/humupd/dms059 https://academic.oup.com/humupd/article/19/3/268/726447

11) Tantalaki E, Piperi C, Livadas S, et al. Impact of dietary modification of advanced glycation end products (AGEs) on the hormonal and metabolic profile of women with polycystic ovary syndrome (PCOS). Hormones (Athens). 2014;13(1):65-73. doi:10.1007/BF03401321 http://www.hormones.gr/8461/article/article.html

12) Karamali, M., Kashanian, M., Alaeinasab, S., Asemi, Z. (2018). The effect of dietary soy intake on weight loss, glycaemic control, lipid profiles and biomarkers of inflammation and oxidative stress in women with polycystic ovary syndrome: a randomised clinical trial. J Hum Nutr Diet. 31, 533– 543 https://doi.org/10.1111/jhn.12545

13) Nitu Bajekal https://nitubajekal.com/pcos-nutrition/

14) Sedighi S, Amir Ali Akbari S, Afrakhteh M, Esteki T, Alavi Majd H, Mahmoodi Z. Comparison of lifestyle in women with polycystic ovary syndrome and healthy women. Glob J Health Sci. 2014;7(1):228-234. Published 2014 Aug 31. doi:10.5539/gjhs.v7n1p228 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4796416/

15) Cochrane Review on PCOS and lifestyle. https://www.cochrane.org/CD007506/MENSTR_effect-healthy-lifestyle-women-polycystic-ovary-syndrome

16) Julie Duffy Dillon, RD. PCOS and Keto. https://juliedillonrd.com/pcosketo/