3/12/ Click on McKittrick webinar description page COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS

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1 COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS March 21, 2018 Nutrition Management of Polycystic Ovary Syndrome (PCOS) Moderator: Lisa Diewald MS, RD, LDN Program Manager MacDonald Center for Obesity Prevention and Education Nursing Education Continuing Education Programming Research FINDING SLIDES FOR TODAY S WEBINAR Click on McKittrick webinar description page DID YOU USE YOUR PHONE TO ACCESS THE WEBINAR? If you are calling in today rather than using your computer to log on, and need CE credit, please cope@villanova.edu and provide your name so we can send your certificate. 1

2 OBJECTIVES 1. Identify the steps taken in the diagnosis and treatment of PCOS 2. Discuss the role of insulin resistance in PCOS 3. Incorporate strategies for nutrition and lifestyle education as part of an overall PCOS treatment plan CE DETAILS Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration The American College of Sports Medicine s Professional Education Committee certifies that Villanova University College of Nursing Continuing Education, Center for Obesity Prevention and Education (COPE) meets the criteria for official ACSM Approved Provider status (2015-December, 2018). Providership # CE CREDITS This webinar awards 1 contact hour for nurses and 1 CPEU for dietitians Suggested CDR Learning Need Codes:4180, 5000, 5370, 9020 Level 2 2

NUTRITIONAL MANAGEMENT OF POLYCYSTIC OVARY SYNDROME (PCOS) Martha McKittrick, RD, CDE, CHWC Owner, Martha McKittrick Nutrition DISCLOSURE Neither the planners or presenter have any conflicts of

3 NUTRITIONAL MANAGEMENT OF POLYCYSTIC OVARY SYNDROME (PCOS) Martha McKittrick, RD, CDE, CHWC Owner, Martha McKittrick Nutrition DISCLOSURE Neither the planners or presenter have any conflicts of interest to disclose. Accredited status does not imply endorsement by Villanova University, COPE or the American Nurses Credentialing Center of any commercial products or medical/nutrition advice displayed in conjunction with an activity. UPCOMING 2018 COPE WEBINARS April 28 May 30 It takes more than food: Promoting health and self-sufficiency in food pantry settings Katie Martin, PhD Vice-President and Chief Strategy Officer FoodShare Provider Competencies for the Prevention and Management of Obesity Jeanne Blankenship, MS, RDN Vice-President, Policy Initiatives and Advocacy Academy for Nutrition and Dietetics 3

presented by Martha McKittrick RD, CDE, CHWC Website:

com Contact: martha@marthamckittricknutrition.

Provide background information on PCOS Discuss the role of insulin

4 presented by Martha McKittrick RD, CDE, CHWC Website: MarthaMcKittrickNutrition.com Blog: CityGirlBites.com Contact: Facebook: PCOSNutritionistMarthaMcKittrick Provide background information on PCOS Discuss the role of insulin resistance in PCOS Diagnosing & treating PCOS Provide guidance for nutrition & lifestyle education for the patient with PCOS Part One: Background Information on PCOS 4

PCOS was first identified by Stein & Leventhal in 1935 They

enlarged ovaries and multiple cysts Few of these original

is possibly the most common hormone abnormality that exists!

5 PCOS was first identified by Stein & Leventhal in 1935 They described a group of women who were obese and infertile, with enlarged ovaries and multiple cysts Few of these original features are now considered consistent findings in PCOS PCOS is possibly the most common hormone abnormality that exists! Up to 15 % of all females have PCOS Leading cause of infertility in women 5

6 PCOS is a complex hormonal, metabolic and reproductive disorder that affects the whole body It has numerous implications for general health and well being It can affect all females from adolescence to post menopause Insulin resistance (up to 80% of women with PCOS) Metabolic syndrome (~ 1 in 3 women with PCOS) Increased risk of diabetes/prediabetes (> 50% by age 40) Obesity (~ 50% of women with PCOS) HTN Some studies have shown: 3x higher risk for endometrial cancer 2x higher risk for ovarian cancer 2-4x higher risk for breast cancer 6

7 Heart disease (4-7x increased risk of heart attack) Inflammation Mood disorders Eating disorders Inflammation Pregnancy complications Obesity, Cigarette Smoking, Dyslipidemia, HTN, IGT, Subclinical Vascular Dz = At risk Metabolic syndrome and/or type2 DM = High risk The absence of the important cardiometabolic risk factors represented by obesity often misguides clinicians when lean PCOS patients are evaluated However, IR even in lean women represents an important risk factor for glycometabolic and cardiovascular sequelae 7

8 Research suggests that PCOS associated with long-term, low-grade inflammation polycystic ovaries to produce androgens Inflammation is associated with hardened arteries major risk factor for heart attack & stroke? inflammation results from obesity and metabolic dysfunction or whether it s an independent symptom of the disorder Increased incidence of mood disorders (i.e. depression, anxiety or to engage in bingeing). Possibly due to: Abnormal levels of androgens and other hormones are related to mood disorders Obesity is linked to mood disorders as well as to abnormal hormone levels. Mood disorders is even greater is presence of obesity spx Spontaneous Abortions - increased in high BMI/PCOS pts Impaired Glucose Tolerance Gestational Diabetes HTN Small for Gestational Age presentations/pcos-improving-feritliy-mark-perloe.pdf 8

9 80%+ show polycystic ovaries on ultrasound (but having PCO does not mean PCOS!) 40 80% will have a fertility problem 60-80% hirsuitism 40-70% scalp hair thinning (alopecia) Acanthosis nigricans Hirsutism Alopecia 75-90% irregular menstrual periods 40-60% acne 70% - hyperlipidemia (often low HDL, high triglycerides, high LDL)* 10% - acanthosis nigricans * Legro RS, et al, Am. J. Med. 111, (2001). 9

Likely a Genetic & Environmental component Genetic.

produce testosterone which causes many of the symptoms of PCOS

stimulating the ovary to produce excessive androgens.

10 Likely a Genetic & Environmental component Genetic. Research has found subtle changes in insulin receptor gene which may alter its function in the ovaries. It is known that insulin is capable of stimulating the ovaries to produce testosterone which causes many of the symptoms of PCOS Combination effect of pituitary lutenizing hormone (LH) & insulin on stimulating the ovary to produce excessive androgens. Obesity magnifies this. Intrinsic enzymatic abnormalities have been demonstrated in the ovaries as well as the adrenal glands Part Two: Role of Insulin Resistance in PCOS 10

11 IR is a condition where cells do not adequately respond to insulin IR appears to result from several defects in the relationships among insulin, its receptor, and the genome IR increases with age and is aggravated by obesity IR is exacerbated at puberty and in pregnancy Stimulation of ovarian and adrenal androgen production Stimulation of pituitary luteinizing hormone (LH) secretion Inhibition of hepatic sex hormone binding globulin (SHBG) production, leading to increased free testosterone Increased risk of miscarriage Increased BP Low HDL, high TG Increased apolipoprotein B levels Increased small dense LDL chol particles Increased fibrinogen levels Increased C reactive protein & other inflammatory markers Increased acanthosis nigricans Premature atherosclerosis 11

12 Can also lead to Increased food cravings Weight gain and/or difficulty losing weight Diagnosing Insulin Resistance is tricky! Insulin levels vary throughout the day Normal fasting insulin range is up to 18, however many experts feel any number over 8 is high. Not an accurate test HbA1c =/> 5.8 likely indicates IR 2 hr glucose tolerance test with insulin levels 2 hr insulin: < 30 mu/l: 98% chance NOT hyperinsulinemic >50 mu/l: 99% chance hyperinsulinemic mu/l: unclear (so diet & lifestyle important!) via Dr. Catherine Crofts Lean women with PCOS tend to secrete more insulin after the glucose challenge as compared to fasting levels 12

Elevated LH/FSH ratio Low SHBG Low HDL and/or TG Upper-body obesity Acanthosis

or glucose intolerance Age > 40 Study: 72% of overweight/obese pts with PCOS were IR

intrinsic form of IR whereas obese patients have a combined form of IR due the

13 Elevated LH/FSH ratio Low SHBG Low HDL and/or TG Upper-body obesity Acanthosis nigricans BMI > 25 (or waist circumference > 35 in women) Fam hx of type 2 diabetes or glucose intolerance Age > 40 Study: 72% of overweight/obese pts with PCOS were IR compared to 26% lean Hypothesized that lean PCOS pts could be affected by an intrinsic form of IR whereas obese patients have a combined form of IR due the syndrome itself & weight excess. S X 13

14 Even in lean PCOS, a higher waist-to-hip ratio is seen in those with PCOS compared to those without PCOS. This is supported by the higher proportion of visceral adiposity measured by ultrasound in lean PCOS patients compared to weight-matched control subjects Obese women with PCOS have greater insulin resistance than weight-matched control subjects or lean PCOS subjects Part Three : Diagnosing and Treating PCOS Symptoms and physical exam Hormonal testing Ultrasound 14

Controversy on what the proper diagnostic criteria are!

-elevated circulating levels of androgens (usually testosterone) Ovulatory dysfunction manifested as oligomenorrhea or infrequent

gov/publications/ourpublications/fact-sheet/polycystic-ovary-syndrome.

15 Controversy on what the proper diagnostic criteria are! Using the Rotterdam criteria, need 2 of the 3 following features: Hyperandrogenism based on: -sx: acne, excessive hirsutism or alopecia -elevated circulating levels of androgens (usually testosterone) Ovulatory dysfunction manifested as oligomenorrhea or infrequent menstruation Small cysts on the ovaries as seen on ultrasound. Legro BMC Medicine (2015) 13:64 Traditional: the individual symptoms were treated BCP, anti-androgens, fertility treatments More recent: targets insulin resistance as well as the individual symptoms Traditional treatments as above as well as weight loss, nutrition, exercise, supplements, stress management, sleep, acupuncture and insulin sensitizing agents 15

16 Individualization is essential Regulation of cycle Promote weight loss if overweight Improve insulin sensitivity Correction of metabolic abnormalities - lipids, glucose, insulin resistance, blood pressure Decrease androgens - skin, hair Improve fertility & healthy pregnancy Improve overall well-being Lowers blood glucose Slows release of glucose from liver Decreases insulin resistance in muscle Lowers androgen and insulin levels May lower LDL May aid in weight loss slightly Off label usage in PCOS Helps overweight and normal weight women achieve ovulation Gastrointestinal intolerance in 30% (take with meal) Contraindications: - Creatinine 1.4 mg/dl (for women) - Liver disease (or risk thereof: alcohol abuse/binge drinking) - Other risks for lactic acidosis: pulmonary disease, congestive heart failure Dosages range from mg bid. Start slow!! Likely needs B12 supplement 16

17 Part Four: Nutrition & Lifestyle Counseling Tips -Nutrition -Exercise - Lifestyle -Practical tips Genes Gut microbiome Metabolism Activity level Food preferences Concurrent medical issues Lifestyles Food preferences 17

18 Insulin resistance Inflammation Gut health Weight management Increased risk of diabetes Increased risk of heart disease Carb cravings Increased mood disorders & depression Higher prevalence eating disorders 1. Select low glycemic carbs and limit added sugars to decrease insulin & inflammation 2. Calorie control if trying to lose weight. 5-7% wt loss lowers can cause 66% women to resume ovulation Dr. Walter Futterweit 3. Consume carbs in moderation to decrease insulin. Amount varies on the individual (range: moderate carb keto) 4. Add protein to meals to stay full longer & aid in wt loss 5. Add fats to meals to stay full longer & slow rise of blood sugar. 6. Fill up on fiber to aid in satiety, slow rise of blood sugar, lower cholesterol & aid in gut health 18

19 7. Increase anti-inflammatory foods/decrease inflammatory foods 8. Avoid highly processed foods (higher glycemic index, more sodium/sugar/additives). Avoid refined oils. 9. Eat for gut health (pre/probiotics) 10. Eat fewer calories/carbs later in the day - helps with weight loss, lowered blood sugar & insulin levels 11. Increase intake of magnesium rich foods to aid in insulin sensitivity/decrease risk of DM 12. Meal timing/frequency varies on individual 13. Try intermittent fasting and time restricted eating 14. Assess food sensitivities as they may increase inflammation 15. Limit dairy especially if acne (but don t need to avoid it totally if you enjoy it!) Fermented is likely better 16. Choose hormone free, organic meats, poultry, dairy when possible 17. Adequate sleep 18. Stress management/emotional support 19

plastic bottles, such as: BPA Hormones Antibiotics I don

Be Fruitful Victoria Maizes MD Integrative Healthcare

blood pressure Raises HDL, decreases TG Burns calories &

20 19. Exercise (see upcoming slides) 20. Avoid endocrine disruptors found in some canned goods & plastic bottles, such as: BPA Hormones Antibiotics I don t always address these just food for thought! Be Fruitful Victoria Maizes MD Integrative Healthcare Symposium, NYC Increases insulin sensitivity Decreases blood pressure Raises HDL, decreases TG Burns calories & speeds metabolism Increases lean mass Aids in stress management & improves mood Lowers glucose 20

21 Aerobic exercise increases insulin sensitivity (especially in skeletal muscle) from ~ 25-50% in all ages, gender, body weights HIIT demonstrates improved insulin sensitivity 21

RISC Study: activity has beneficial effects on insulin sensitivity Total

a beneficial effect on insulin sensitivity http://www.ncbi.nlm.nih.

of sports activities per week had improvement in acne and menstrual

weight loss (< 5% weight loss) improved insulin sensitivity and free

Julie L. Sharpless, MD http://clinical.diabetesjournals.

22 RISC Study: activity has beneficial effects on insulin sensitivity Total accumulated activity was the important factor rather than intensity of the activity. More movement during the day as well as from exercise, accumulated to exert a beneficial effect on insulin sensitivity In PCOS, women who self-reported 8 hours of sports activities per week had improvement in acne and menstrual irregularities Exercise as the primary intervention without attendant weight loss (< 5% weight loss) improved insulin sensitivity and free testosterone index and induced ovulation in 9 of 18 obese PCOS patients Julie L. Sharpless, MD Yoga decreases anti-inflammatory adipokine in patients with metabolic syndrome and high/normal BP Supriya R, et al. Scand J Med Sci Sports. 2017;doi: /sms

23 Anything is better than nothing Get a baseline and increase from there Ideally 3 aerobic & 2 weight training sessions a week Incorporate HIIT sessions if possible Increase everyday movement Consider activity tracker Beware of over-exercisers Yoga Vitamin D Vitamin B12 (especially if on metformin) Omega 3 (EPA/DHA) Inositol NAC Magnesium (most people are deficient) Berberine 23

24 Relatives of the B complex vitamins showing favorable results in improving nearly all aspects of PCOS including: Insulin sensitivity Reproduction (restores ovulation and improves oocyte quality) Hormonal imbalance, (improves androgens) Metabolic issues (inflammation, dyslipidemia, hypertension, and weight loss) Inositol is safe and relatively inexpensive Reasonable evidence of benefit in PCOS, but may be counterproductive in non PCOS patients Available from multiple sources online or in retail outlets Typical treatment regimen of 3 6 months Myo inositol vs. Metformin in one study, women taking 4 g myo inositol had higher pregnancy rates and percentage restored ovulation than women on 1500 mg Metformin (Raffone, 2010) Recommended dosage: 2 grams, bid. Safe in pregnancy. Brand I like: Ovasitol Reduces cholesterol & triglycerides Lowers blood pressure & risk of heart disease Lowers androgens May ease period pain Aids in weight loss Reduces insulin resistance Improves mood Recommended Dose:? 1-2 gm/day. Safe in pregancy 24

25 NAC is an antioxidant & amino acid Derivative of the amino acid L-cysteine, an essential precursor used by the body to produce glutathione Glutathione is an antioxidant produced by the body to help protect against free radical damage, and is a critical factor in supporting a healthy immune system. Recommended dosage: gm/day. Safe in pregnancy Improved menstrual regularity but not necessarily improved fertility Improved insulin sensitivity. Could be used with metformin or if metformin isn't an option Favorable effect of lowering cholesterol, TG and testosterone Improves integrity of the skin, reduces inflammation and may be helpful for acne Dr. Fiona McCulloch. ND Combination of CoQ10 and clomiphene citrate in the treatment of clomiphenecitrate-resistant PCOS patients improves ovulation and clinical pregnancy rates. It is an effective and safe option and can be considered before gonadotrophin therapy or laparosc 25

26 A herb which may: Reduce insulin Improve gut health Lower cholesterol Fight inflammation Reduce testosterone Boost fertility and pregnancy Aid in weight loss and body fat loss Recommended Dosage: 500mg/day tid Contraindicated in pregnancy Obtain medical history (including fam. hx), as well as labs, meds, supplements Ask about symptoms Obtain weight, diet history Ask about food/mood/energy level link Provide education on PCOS Develop referral network Discuss exercise Address sleep, mood, sitting time Develop individually tailored meal plans/goals Set realistic goals Maintain supportive demeanor 26

TO RECEIVE YOUR CE CERTIFICATE Look for an email containing a link to an evaluation. The email will be sent to the email address that you used to register for the webinar.

27 TO RECEIVE YOUR CE CERTIFICATE Look for an containing a link to an evaluation. The will be sent to the address that you used to register for the webinar. Complete the evaluation soon after receiving it. It will expire after 3 weeks. You will be ed a certificate within 2-3 business days. Remember: If you used your phone to call in, and want CE credit for attending, please send an with your name to cope@villanova.edu so you receive your certificate. UPCOMING 2018 COPE WEBINARS April 28 May 30 It takes more than food: Promoting Health and Self-Sufficiency in Food Pantry Settings Katie Martin, PhD Vice-President and Chief Strategy Officer FoodShare Provider Competencies for the Prevention and Management of Obesity Jeanne Blankenship, MS, RDN Vice-President, Policy Initiatives and Advocacy Academy for Nutrition and Dietetics 27

28 QUESTIONS & ANSWERS Moderator: Lisa K. Diewald MS, RD, LDN Website: 28

3/12/ Click on McKittrick webinar description page COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS

3/12/ Click on McKittrick webinar description page COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS FINDING SLIDES FOR TODAY S WEBINAR March 21, 2018 Nutrition Management of Polycystic Ovary Syndrome (PCOS) Moderator: Lisa Diewald MS, RD, LDN Program Manager