Even the young and lean will benefit from disrupting the insulin-androgen cycle

Healthy lifestyle advice is critical to the management of polycystic ovary syndrome (PCOS), regardless of BMI, says Associate Professor Lisa Moran, a research dietitian and Accredited Practicing Dietitian.

Women with PCOS are more susceptible to weight gain and at a faster rate, and have greater difficulty losing weight than women without PCOS, she says.

The prevalence of PCOS increases by ~9% for every one unit increase in BMI, Associate Professor Moran says. But this isn’t due to excess weight causing PCOS— it’s because as the BMI increases, the likelihood of experiencing the clinical features of PCOS is more pronounced, leading to diagnosis, she explains.

Lifestyle advice and support is important for lean women too

It’s particularly important to discuss prioritising healthy lifestyle with women who are younger and lean “because that’s where you can stop the problem before it happens,” she says.

Most women with PCOS already have PCOS-associated insulin resistance, which becomes a ‘double whammy’ with weight-associated insulin resistance if they gain excess weight. This leads to hyperinsulinaemia and increased ovarian androgen production, resulting in clinical features such as irregular menstruation, fertility issues and hirsutism.

“We recommend talking about healthy lifestyle even if someone is at a lean body mass index at earlier life. Like many Australian woman, as life challenges hit them, they’re going to be gaining weight over time. And so we know that if women with PCOS gain weight, they’re going to have excess weight associated insulin resistance on top of their PCOS pathophysiology, and so that will possibly worsen their PCOS features.” – Associate Professor Lisa Moran

While many people tend to switch off at talk of healthy eating and exercise, Associate Professor Moran says community consultation with women with PCOS has shown that explaining the pathophysiology behind symptoms—and the positive impact that healthy lifestyle can have on those symptoms—makes a big difference.

“Explain the biology of why healthy lifestyle improves PCOS. So don’t just throw one-size-fits-all healthy guidelines advice at them, say ‘Well, if you follow healthy guidelines this is what it will do to your androgen levels. This is what it will do to your insulin levels. This is why a healthy diet and being more active is needed,’” Associate Professor Moran says.

Challenges of managing weight with PCOS

It’s also important to acknowledge that PCOS can present unique challenges for weight management.

“They may see their friends doing exactly what they’re doing and losing weight, and they’re losing half the weight, and it’s really frustrating.”

There are biological reasons for this, but researchers are still unpacking exactly what they are. However, the bottom line is that people need realistic goals, and they need adequate support.

In one study that compared women with and without PCOS who all had an unhealthy diet and unhealthy levels of physical activity and sitting time, those with PCOS gained more weight.

“They’re differentially affected by an unhealthy lifestyle compared to those without PCOS, so it’s even more important for them to follow a healthy lifestyle to stop that weight gain,” Associate Professor Moran says.

The best diet and exercise plan is the one that’s sustainable

There is no evidence to support one particular diet or exercise regimen as being more effective in people with PCOS. Associate Professor Moran recommends any healthy diet that is sustainable and nutrient sufficient – which tends to rule out long-term use of diets which exclude major food groups with important nutrients.

Weight stigma is a serious issue for women with PCOS, and as this condition is associated with a greater risk of psychological comorbidities, including disordered eating, it’s essential to set realistic goals that account for the physiological challenges around weight management.

She says it’s important to encourage patients:

• Not to blame themselves
• To give themselves extra time to reach their goals
• Either slow down, or take weight out of the equation and focus on healthy lifestyle instead

But despite the challenges, research shows that having appropriate support can offset this.

“We’ve done reviews where we compare women with or without PCOS, given structured, supportive weight loss diets, and women with and without PCOS can lose the same amount of weight when they have the right structure and support,” she says.

“With the right support and structure, women with PCOS can achieve their lifestyle goals,” Associate Professor Moran says.

That includes both ongoing support from medical or allied health professionals who can help them work through challenges, as well as support from family and social networks to make healthy changes.

She recommends considering a Chronic Disease Management Plan to help women with PCOS get subsidised access to support from allied health professionals. There are also free health programs available to women with PCOS in various states, such as the Life! program by Diabetes Victoria and Get Healthy in NSW.

Key points:

• Healthy lifestyle is important in all women with PCOS, regardless of BMI, because the features of PCOS will likely worsen with weight gain
• Healthy lifestyle changes without a specific focus on weight changes can also improve features of PCOS
• Frame the healthy eating advice with the WHY this improves their features of PCOS (insulin resistance, increased androgen production etc)
• Women with PCOS have a biological predisposition to weight gain and have greater challenges losing weight and therefore need structured support and realistic expectations
• Associate Professor Moran recommends a diet that is healthy, sustainable and nutrient sufficient for women with PCOS—but cautions against anything too restrictive, given the higher prevalence of eating disorders in this population

For more information on managing PCOS, see the 2023 updated PCOS guideline here.