Podcast Episode 23 Transcript – Nutrition for PCOS


00:00:05 – 00:01:43

Welcome to the ideal nutrition podcast. I’m one of your host, Leah Higl, and I am here with my co host, Aidan. Today we’re going to talk about nutrition for PCOS or polycystic ovarian syndrome. 

We know PCOS effects about 12-18% of women of reproductive age, but up to 70% of women go undiagnosed. So, this is a really big area where a lot of people have the condition but don’t actually have a diagnosis. “Polycystic” means many cysts. Usually in PCOs, people will have cysts on their ovaries, but it’s not always part of the condition. There are three things that go into PCOS, and you do need to have at least two of these symptoms to be diagnosed. The first is irregular menstrual cycles. Whether that’s being too often or too infrequent, or no cycle at all. The second is excessive testosterone that can be detected in the blood test. The third is obviously the cysts.


00:01:43 – 00:02:22

Other symptoms of PCOS include things like excessive hair growth, particularly like body and facial hair. But it could also be hair loss. In a lot of cases, people experience skin changes, so like darkening of the skin or experiencing things like acne. Something that does get talked a lot about in regards to PCOS is weight gain. There’s also things that go into it like anxiety, depression, sleep apnea and a difficulty conceiving. So, the issues with fertility are also a big one under this topic.


00:02:23 – 00:03:14

Another common thing to go alongside PCOS is that most women with PCOS also experienced insulin resistance. Not every single person with PCOS has insulin resistance, but it is about 85% that will. I was even reading a paper earlier today that was titled sometime along the lines of “Every woman with PCOS should be treated as if they have insulin resistance”. Then there was a legislative editor in response to that, saying “Not everybody with PCOS has this”. On average women with PCOS, are 35-40% less sensitive to insulin than the average woman. This is skewed a little bit because, as we said, weight gain or being of a higher BMI is commonly linked with PCOS.


00:03:15 – 00:04:14

But not everybody with PCOS have a higher body weight. There is lean PCOS as well. Those with lower body fat have less insulin resistance than those with higher body fat. But on that topic, they still have more insulin resistance than their lean counterparts without PCOS. So, it is still on average, something that is worth being aware of. This is why some other conditions (like diabetes) risk is increased due to PCOS. A lot of the steps taken in the management of PCOS can include addressing the insulin resistance, and they also seem to have common outcomes in improving other symptoms of PCOS.


00:04:14 – 00:04:53

In terms of managing PCOS, the first thing that I always tend to do is just generally look at is does the person have a healthy diet? Do they kind of meet their core food groups, eg. getting enough fruits and veg, whole grains, all that stuff because, like many conditions, it does come down to just having a quality diet. I kind of consider that as being like the base of the pyramid when we’re thinking about treating PCOS. Um, so that base of that pyramid is generally having a well-rounded diet. And then you can kind of move up that pyramid to more like specific strategies. Person to person. 


00:04:53 – 00:08:05

A lot of it does come back to that, and that’s also interesting because a lot of people take slightly more extreme approaches in the management of PCOS. So, the fact that we come back to them being like a healthy diet is the foundation can help filter through some approaches as well. Leading on from that weight management is often one of the most looked at areas. As I said, in a lot of cases people can benefit from getting leaner because we know decreased body fat can improve insulin sensitivity. 

In saying that, it is harder to lose weight with PCOS. I’ve tried to bring a little bit more awareness to this one study that basically showed that in their sample size, people with PCOS typically had a basal metabolic rate that was 14-40% lower than what would be expected without PCOS.

For context, someone’s basal metabolic rate could be somewhere between 50-70% of the total energy expenditure, or 40-70% depends on how much exercise depends on all these other variables. But, like let’s say you’re at the extreme end of that spectrum is lowered by 40%. That could be like a 20% reduction in total daily energy expenditure. Most people diet on 20% lower than the total daily energy expenditure. So you could argue that it’s kind of like perpetually dieting just to maintain your body weight. 

In that study, one of the key things that they noted was that people who had more insulin resistance were the ones who had their BMR drop by the most. People with the least insulin resistance were closer towards that 14% than they were towards the 40%. That is something that isn’t across the board with insulin resistance. That seems to be unique to PCOS from what I can see. As a side note there are also other studies on this topic that kind of make it a little bit more complex. There are two other studies that I’m aware of, where they did you smaller sample sizes. But they also looked at the same kind of thing, and they couldn’t find any differences in total daily energy expansion between PCOS and people without PCOS. 

So, the best-case scenario is that there’s no difference. The worst-case scenario is that it is a little bit harder to lose weight. For me personally, I kind of look towards the worst-case scenario. If anything, it gives me a little bit more empathy to a certain degree. 


00:08:06 – 00:08:18

You approach it with a bit more compassion. If they do have, like a 30% lower basal metabolic rate than what would be expected, it is going to be harder for them to lose weight. So, I don’t like to brush it off.


00:08:18 – 00:08:51

Another aspect of that I personally think about is it doesn’t change the rules. It doesn’t mean we don’t have to. It doesn’t mean we have to do anything differently. We don’t have to start doing a drastically different approach. It’s just on a higher difficulty setting. Basically, that’s how I think it’s really still a challenge that can be overcome. 


00:08:51 – 00:09:33

The next thing we’re going to talk about is anti-inflammatory style diets. So when it comes to PCOS there’s so many different approaches that all different kind of practitioners take. But I find when we look at the research, it really comes down to having a well-balanced diet, like I said before and then on top of that following something that is generally anti-inflammatory in terms of maybe it’s like the Mediterranean diet or predominantly plant based. That contains a lot of fibre, omega-3 and antioxidants and things like that. 


00:09:33 – 00:09:45

I use features from it. The high healthy fats, the high vegetable intake, higher fibre intake, more plant based foods, those kind of things. I definitely utilise the most people. 


00:09:45 – 00:10:01

In my thoughts, like the Mediterranean diet, it really is just a style of a healthy diet. So, it just makes sense. So this is not like a low carb approach, but it does show to have, like, it has been shown to have a lot of positive outcomes in the research. 


00:10:01 – 00:10:33

That’s exactly what I’m referring to when I’m like it allows you to filter through some stuff like being aware that the research on the Mediterranean diet and PCOS is consistently linked with positive outcomes. The mechanism behind why some people will be pitching low carb diets is related to insulin resistance almost all the time. The concept basically is if you have carbs high, all the time and your insulin resistant there’s a lot of insulin going around at all time. Obviously, it makes sense to go lower card that can help address that, because insulin will suddenly be lower. Then all of these other things that are potentially related to insulin resistance and causing other symptoms related to PCOS can suddenly be a little bit diminished. But that’s why I come back to the Mediterranean showing such positive outcomes because it’s like hang on. If it was just about carbs, that wouldn’t be the case. It wouldn’t work because the Mediterranean diet is not a low carb diet. It’s not a high, high carb diet, but it is higher than some of the alternatives we’re looking at. 


00:11:08 – 00:12:36

One side thing to factor in is, if you decrease your carbohydrate intake, you often always decrease your calorie intake, so that’s going to help from the weight management side of things. There is small scale research utilising very low carbohydrate diets, which are showing positive outcomes, but that’s putting it out there being like, well, that’s another option that’s available to us. It’s more being like you don’t have to choose that option. You don’t have to choose the Mediterranean diet either. There are multiple options here that work well. Um, challenges associated with that are obviously adherence, quality of life and micronutrient intake. Like going through all of those individually, in terms of like adherence. I have seen quite a few studies where people have been striving for particularly ketogenic diets and at the end of a decent time frame where it’s three months, six months, twelve months or whatever, almost nobody is in ketosis. Because it’s hard to stay that low, low carb. It’s hard to stay strictly low carb if you like. If you want to eat out with friends, family, all those kinds of things, you can do it. It’s just hard, like a lot of people might not necessarily want to do that.

In terms of a slightly more balanced way of potentially thinking about it, there’s reducing the glycemic index of your foods. 


00:12:43 – 00:14:34

I don’t talk about glycemic index much. Most people know what glycemic indexes like high is typically considered bad. Our blood glucose levels is what people are talking about. I prefer to think of in terms of glycemic load, which is basically the amount of carbohydrate multiplied by the glycemic index. So, if somebody is high carb and high GI, it’s going to raise your blood glucose levels more. Insulin is going to be required, but like it makes it more interesting because it’s like watermelon, for example, is high G. 

But if you had a small to moderate serve of watermelon and set seven grams of carbs like, it’s not much carbs and this idea, it doesn’t matter. It’s not really spiking blood glucose because there’s so little carbohydrates the glycemic load is factoring in the total amount of carbs and the glycemic index. But like theoretically, if you were going to eat the same amount of carbs and you reduce your glycemic index slightly, it can help with management of PCOS that’s been shown in the research that even links up with the Mediterranean diet and stuff like that because typically that is low added sugar and stuff like that to.

But as a side note, where a lot of people are talking about low carb diets are often when they’re pointing to the research, whether knowingly or unknowingly, they’re pointing to these studies that are showing people dropped from like 55% of their diet in terms of calories coming from carbohydrates to like 40%. Then being like lower carbohydrate diets is just kind of extrapolating that dropping from 40 down to 20% would be a further improvement or dropping from 20 down to 10% would be a further improvement where it’s like we know that like 55% stuff is quite high. Dropping from 40% is showing massive improvements and stuff like that. It’s like you could taper down. And that’s what I often do in practice. Like if I was to, for example, right out macros for somebody with PCOS, I would take a little bit off. 


00:14:38 – 00:14:53

As I said, with all of this, like, there’s many ways to do it. Low carb could work. Mediterranean Diet could work. Lowering the glycemic index of your diet could work. There’s heaps of options, it’s choosing whatever you think would personally work best for yourself. 


00:14:53 – 00:15:17

I think when it also comes to low carb, we also must take into account that not everyone with PCOS is insulin resistant. If there is insulin resistance, what symptoms is that attributed to? What’s linked together like that could be symptoms of PCOS that have nothing to do with insulin resistance 


00:15:17 – 00:16:14

Actually, talking through that as well, like there was a study I was reading earlier on metformin. We know metformin improves insulin sensitivity and improves ability of the pancreas to put out insulin as well. One of these studies on Metformin improve pretty much all symptoms of PCOS, like quite literally. Like the changes in hair growth that was massively fixed. Um, the menstrual cycle improve population improved. They started losing weight. Um, cholesterol improved. All these things improved just promoting Metformin. But then there were two other studies where metformin didn’t really do anything, it was just as simple as insulin resistance. Then metformin should be consistent across the board. I’m just extrapolating from that being like, if it was just instant resistance, that’s all we need to care about. It should be more consistent. 


00:16:14 – 00:17:19

There’s no easy answer to PCOS, unfortunately, at the moment. So, it’s like we’re just going to talk through the different things that are on the table just to give you an idea of what’s out there. The next thing that I’m going to talk about is the dairy and gluten free to all of like PCOS management. Um, and I find this to be very comment online. 

That’s something you will hear about all the time, even just googling nutrition for PCOS. Um, but there’s really no strong research or evidence saying that going dairy or gluten free is going to be tied to better management of PCOS. All the symptoms of PCOS, like we just don’t have that data. It’s basically it’s based on the assumption that dairy and gluten cause inflammation in the body. PCOS is an inflammatory condition, so it must make it worse. And then it’s just people kind of going on that down that rabbit hole and going okay, we’re going to go dairy and gluten free without any actual evidence behind it. 


00:17:20 – 00:18:33

And, like anecdotally, I could say, like somebody doing that, eating less calories, losing weight, Maybe that helps like I can see. And it’s like heaps of people who would actually find that that has helped and if it has helped you for even reasons unrelated, that that’s awesome. But based on the research we have like, it doesn’t seem like it’s necessarily helping in any way. I was trying to look at from the other angle, being like, How could this help? And one of the things that did pop into my mind was there’s a small link between dairy and acne and PCOS has a link with acne, obviously. And maybe there could be some improvements there because I’m always like every time I try, every time I’m going to dismiss something I’m like, What? 

What reason could there be benefits? This and that’s one of the things I was thinking. But I don’t even necessarily like talking about that, because me personally, if I did have acne, I probably still wouldn’t give up dairy completely. Maybe I’d reduce intake. Maybe, I don’t know, but like 

The first thing I’m going to try. So there is a link there, but it’s not like I hate putting this message out because I’d hate for somebody to listen to this and be like, Oh, I haven’t said, like there’s a link between dairy, and I think I’m never going to dairy again for that reason, when there’s a lot of other reasons and factors that should be in that decision.


00:18:33 – 00:18:55

I think when it comes to anecdotal evidence, particularly with the dairy and gluten free, it’s typically when I see people remove those things from their diet, they also just generally improve their diet quality anyway. So it’s really hard to say that it was that specific food that they got rid of that did the thing. Or maybe it’s the fact they’re exercising and eating fruit and veg and doing more of that now. 


00:18:56 – 00:19:18

So the next thing we’re going talk about is supplements. So the most common one that people would go to with PCOS right now is probably going be inositol, and the most common recommendation for this is 2-4 grams per day. But do you want to talk about that because you will know more on that topic. You’ve just written a blog post about this. 


00:19:18 – 00:20:21

This is kind of brand new information to me, but I’ve always recommended myo-inositol, that particular recommendation you just said because that’s what other dieticians around me had recommended. It was just something that everyone recommended. But looking further into the research, I found that what seems to be the most effective form of inositol is a 40:1 ratio of myo-inositol to D-Chiro inositol. 

So myo-inositol has demonstrated to be pretty good at improving egg quality and like those things around fertility, Whilst D-chiro has been shown more to help with insulin sensitivity and improving those factors, so that they’re both great across the board in terms of the research so far that we have like, it’s a bit mixed, but I’m like I’m pretty sold on this as a supplement. There’s not too many downsides to taking it. But the little bit of research we have that is that kind of 40:1 combo of the two tends to have the best outcomes across the board. 


00:20:29 – 00:20:45

I only read this the other day. But people with PCOS have a deficiency of myo-inositol at an ovarian level, and that’s part of what contributes to some of the symptoms of PCOS. 


00:20:45 – 00:20:50

And I’m assuming that would be like on average, they have a deficiency. 


00:20:50 – 00:21:01

Yeah, I guess, not across the board. But on average, there’s like that deficiency associated at the ovarian level. And that, of course, is a bit of a like an issue with hormone signaling in the ovaries. 


00:21:01 – 00:22:59

Cool, the next one that I’ll talk about this isn’t actually something like so me. Personally, I do recommend a hostile to pretty much everybody with PCOS with this next one. Magnesium is more of an of interest kind of thing, like if somebody super keen, I’ll go down this route, um, so magnesium always to actually have a really low intake of it, I should say. But magnesium typically can improve insulin sensitivity. 

The standard dosages 300 milligrams before bed, which theoretically can improve sleep. But like not always, it’s not like super strong, like I’m not going make that statement. The research is pretty hit and miss on that. Um, anecdotally, I see a lot of people. We’ve improved sleep quality from that. The research on people with insomnia it seems pretty clear it does help with them, most likely a rich person who just doesn’t get great sleep. Not as strong, but that’s part of why the time before bed, Um, and once again, as we talked about improving insulin sensitivity should help with all these other things. Personally, I think if somebody had a high intake of magnesium rich foods, they probably wouldn’t get additional benefit from supplementing. That’s part of where we go back to. A healthy diet Mediterranean style diet like these are dietary approaches that are high in magnesium. Start off with you’re probably reaping these benefits to start off with anyway. 

The next one is omega-3, so typically linked with reducing inflammation. Um, with PCOS, they could help, or they could help reduce testosterone and help with regularity of the menstrual cycle. Once again, this is dependent on what people are doing from a dietary approach. If somebody has a high omega-3 intake from food, say they’re having fatty fish or just fish 2-3 times a week, with at least one of those being fatty fish. They’re probably getting a decent amount anyway. But if they’re not doing something like that or doing a strategic dietary approach to get enough omega three in, then it could make sense to supplement was somewhere along the lines of 1000 to 3000 milligrams of fish oil per day or a plant based equivalent. What would you go with if you were doing that? 


00:22:59 – 00:23:07

Just your standard microalgae supplement. So, EPA and DHS version of an Omega three rather than you ELA.


00:23:07 – 00:23:46

Zinc. So, 50 milligram’s per day has been shown to help with hair growth or hair loss. Once again can also help with insulin resistance, the dosages and research that 50-milligram dosage is well above the recommended daily intake of eight milligrams per day for females. But that’s pretty much just due to absorption and stuff like that. So it’s quite a high dosage. But once again, if somebody had really high intake through food, like, say, they were getting well over eight milligrams per day, every day through food, once again, I don’t actually think that zinc supplementation would help, but it’s more once again and of interesting. 


00:23:46 – 00:24:19

This one actually like it worries me a little bit. In terms of like, I feel uneasy recommending something that’s above the upper limit. It’s quite high, so I don’t I see a lot of natural gas, recommends Inc to people with us, and they come through, um, the clinic and I don’t know. We do have researchers say that having a really high intake of zinc can lead to like copper deficiency and zinc toxicity. So I’m like, I’m not super sold on that one. I kind of like maybe the consequences of doing that, especially if you already have a decent amount in your diet. Probably worse than the benefit. 


00:24:19 – 00:25:00

I view it as a one of my lowest kind of recommendations that we do have evidence for being helpful. I use it as part of my what I call my kitchen sink approach first, like chucking the kitchen sink like if somebody’s like with PCOS and desperate for answers. It’s something that I’d consider the kitchen sink approach for a short phase will be like, Let’s do magnesium. Let’s do omega-3’s Let’s do zinc. Um, and then the next one going to talk about Chromium, vitamin D and inositol for this phase, and it’s like if you do it for a phase, I feel like the downside risks like that copper deficiency like that that’s quite small. But if you did it every day for the long term, that’s where I start to get a little bit more fearful of stuff like that. 


00:25:02 – 00:25:46

So next one, Chromium once again not what to actually recommend that often, but a systematic review from 2017 indicated that 200 micrograms of chromium picolinate per day could help reduce insulin resistance and testosterone and help with everything. The only reason why that’s not one of my front-line recommendations is because at this stage I’m already recommending a few things like I’m probably recommending inositol. I’m probably recommending omega-3’s like there’s only so many supplements I want to add to this as well like I don’t want to get out of hand, and another one is vitamin D, so a large percentage of people with PCOS are deficient in vitamin D. As I’ve spoken about before, I also believe that if you are on the low end of the healthy range, you could probably get additional benefits from it. 


00:25:47 – 00:25:58

It helps with insulin resistance and something we haven’t really touched on. But there’s a strong linkage between PCOS and mental health stuff as well, such as depression. So potentially vitamin D could help with mood and stuff like that, too. 


00:25:58 – 00:27:03

So a few key points to tie this all up, so we know that people with PCOS can benefit from reducing their weight if they are overweight. But again, it should be noted that this isn’t always an easy task. And there may be that added difficulty of potentially a lower resting metabolic rate for some people with PCOS, and that does need to be considered as part of this. Um, we know that a Mediterranean-style diet with a focus on a lot of plant foods and omega-3’s is a really great way to go about it. Um, and also a focus on low GI whole grains and carbohydrates, potentially with may be moderating your carbohydrate intake. They’re not necessarily going super low carb, but not going too overboard at the same time. Um And then there are all those supplements that you just talked through. So, inositol is definitely one I recommend quite across the board for people with PCOS as well as omega-3. Um, and then you have all the rest, which you can kind of pick and choose, depending on who you are and what you’re dealing with. So, this has been Episode 23 of the ideal nutrition podcast. Thank you for tuning in, and we’ll be back next week.