The role of the dietitian in the management of PCOS Samantha

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					   The role of the dietitian in the management of PCOS
          Samantha Bailey, Specialist Dietitian
I currently work part time at Bedford Hospital NHS Trust where we run specific multidisciplinary PCOS clinics. Any
referrals from primary care to gynaecology that mention a diagnosis of PCOS get filtered in to the dedicated clinic and
others who are diagnosed at a general gynaecology or infertility appointment get transferred.
Mrs. Rosemary Wallace, consultant gynaecologist and obstetrician, and myself do one clinic a month together and the
ladies can be assessed by both of us, any bloods can be arranged, prescriptions can be given if needed and I try to
spend what time I can doing the education and dietary/lifestyle assessment. I often do not have enough time to cover
everything but I can introduce myself, make a start, give written information and then arrange for them to come back
to my dietetic clinic. I do 2-3 dietetic/PCOS clinics a month where I can review the ladies and see new patients
referred directly by their GP.
Weight loss is often the main agenda whether to access fertility treatment, improve symptoms, self-esteem or long-
term health. It can be frustrating for consultants when ladies do not seem to make any progress between appointments
and it often leaves the ladies tearful when they feel they have not achieved anything. I take over the
management of many ladies and try to tackle weight and lifestyle before they get re-referred back to the consultant
when there is often more treatment options. This helps with waiting times and prioritises the consultant’s time
to those with other symptoms to tackle. Doing the MDT clinics also helps improve referrals, transfer of information,
helps us understand each other's role and also reduces my DNA rates (can be a patient group which DNA often as
apprehensive about being judged, however, having met me the MDT clinic they feel more comfortable coming back).

I have a special interest in PCOS which stems from my own diagnosis and need for fertility treatment in 2001. At this
time I conducted a comprehensive literature review which surprisingly provided little practical guidance on specific
dietary management. I combined my knowledge of the syndrome with my skills and knowledge in dietetics to
formulate guidelines and resources. I was also very fortunate to fall pregnant with my daughter during my second
cycle of clomiphene citrate and went on to have a son 2 years later without fertility treatment.

I am delighted to be representing dietetics at PCOSUK as I believe we can be a very useful resource in the
management of PCOS. Lifestyle intervention is integral and is an area where women can take back some control with
the right support and guidance.

The bulk of my NHS post and private/freelance clinics is now working in this area and it has become a specialist role.
There are currently limited PCOS specialist dietitians but I believe that with levels of obesity rising and more
diagnosis of PCOS being made, referrals to dietetics will continue to rise and as a profession we need to be
developing. I am very committed to driving this forward by developing a network of dietitians with an interest in
PCOS and sharing information and resources. This interest group now has around 100 members.

I have written 2 patient information booklets which are included in the PCOSUK resource pack. Packs of 25 or 50 are
also available directly from me.

If you have any queries or if you are a dietitian who would be interested in joining the informal interest group, please
email me at

PCOSUK conference presentation slides

Aims of dietary management
         Achieve/ maintain healthy BMI
         Reduce insulin resistance
         Nutritionally adequate diet
         Nutrition education
         Detect dysfunctional eating

Weight reduction and PCOS
         Symptomatic improvement with 5% wt loss in overweight women with PCOS
         No quick-fixing diet
         Healthy diet will address other health concerns
         Insulin resistance makes it more difficult to lose weight
Dietary Assessment
       Patient agenda
       Current diet and activity
       Consider other factors such as family life, work, social life
       Dieting history

Dietary Advice
       Healthy eating, Balance of good health model, variety of foods from each food group, at least 5 portions of
       fruit and vegetables a day
       Regular meal pattern
       Low fat, low sugar
       Adequate fluid intake (>8 cups)
       Limit alcohol

Importance of exercise
       Women who do even a little more will be more successful with weight management
       Improves insulin sensitivity
       Lots of other benefits
       Lots of barriers
       Must be realistic and practical
       Aim 5 x 30 minutes moderate intensity

       Avoid low carbohydrate diets
       Carbohydrate cravings common in PCOS
       Glycaemic index (GI) or glycaemic load (GL)?
       High GI = quick digestion = rapid rise in blood sugar and insulin
       GL combines GI with standard portion size

GI or GL?
        Pros                                    Cons
GI      May be a useful ranking system          Affected by other factors, limited number of foods tested, can limit
                                                healthy foods, inter-person variation, variation in measurements, high
                                                fat foods can be low GI, difficult to predict effect in mixed meal. No
                                                relation to serving size
GL      Does not limit fruits and vegetables    Can encourage overall low carbohydrate diet
        Considers average portion size          Portion size perception
                                                GL analysed from GI data therefore same limitations

So what should we advise?
       Women with PCOS should try to swap some foods to lower GI foods
       A regular 3 meal pattern and limit any snacking (choose low GI, low calorie snacks)
       Don’t get too hung up on following GI strictly
       Don’t restrict normal portions of fruits and vegetables
       Try to use more pulses and legumes (beans and peas)

Reducing insulin resistance
       Weight management
       Regular meal pattern
       Limit snacking
       Choose lower GI foods where possible
       Regular exercise
        Eat more oily fish
        (omega 3) 1-2 portions or fish oil capsules
        Eat plenty of fruit and vegetables
        Watch the amount and type of fat you eat
        Limit saturated fats
        Choose monounsaturated fats
        Cholesterol lowering products?
        Limit salt
        Limit alcohol
        Limit sugar and alcohol

Prevention of diabetes
        Lifestyle intervention can reduce incidence of diabetes mellitus by up to 58%
        Weight management
        Reducing fat esp. saturated fat. Choosing monounsaturated fats.
        Adequate fibre, wholegrains, fruit and veg
        30 minutes of moderate exercise per day

Nutritional supplements and obesity medications
        Not enough evidence to support roles of supplements (except omega 3)
        Some good results with Orlistat and Silbutramine with right diet/exercise changes and support

What helps a successful change?
Just knowing what to eat and what foods to limit is only part of what helps us choose and maintain a healthier
I believe there are 3 important areas which affect how successful an individual is: knowledge, environment and

        What am I aiming for in terms of lifestyle?
        What is PCOS?
        How will my lifestyle affect my symptoms?
        What has worked well before?
        What have I found difficult before?

        Relationships, home, family, work, finance
        Timing is crucial
        Priorities change
        The right support
        Do your best when you can

        Belief that change can lead to better things
        Confidence and determination
        Low self-esteem very common in PCOS
        Ban negative thoughts!!

Bringing it all together
        Can be really difficult and may not be in your control always

Cravings and uncontrolled eating
        Very common in PCOS
        Reasons not fully understood
        Binge eating is big problem
        Regular meals pattern and lower GI foods can help

Food and Feelings
There are close links between PCOS, symptoms and binge eating. Vicious cycle of uncontrolled eating, weight gain,
further insulin resistance and worsening symptoms leading back to low self esteem and continued uncontrolled
eating/comfort eating.

Pressures of fertility issues
        Can be very distressing
        Can put huge amount of pressure on themselves
        Frustration can add to sadness
        Turn negative thoughts into positive thoughts

Boosting self-esteem
        Start to feel good about yourself
        Be clear about what you want
        Nurture yourself
        Self help groups

Making plans and sticking to them
        Useful questions
        How can I make it easier to stay on track?
        Remind yourself of goals/benefits
        Make changes gradually

Tackling uncontrolled eating
        Be strong when shopping
        Are you hungry?
        Desire rating
        Stop eating when full

Patient centred approach
        Can be young, distressed, confused, frustrated
        Their agenda
        My agenda
        Working together

Summary of dietitian’s role
        Can have expert knowledge of syndrome and diet therapy
        Have clinical and counselling skills to be able to take on an extended role in the management of PCOS
        Listening post, a source of information, a guide to help reach goals
        Currently limited number of specialists but interest is growing

My activities
        Ongoing work with Verity and PCOSUK
        Coordinating dietitian’s interest group
        Resource development
        Promotion within profession
        Articles/dietitian’s toolkit
        Clinic protocol update
        Freelance work

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