Supervised short-term nutrition and exercise promotes weight loss in overweight and obese patients with polycystic ovary syndrome

Thirty-two mid-reproductive-aged overweight and obese patients with polycystic ovary syndrome, most of whom had never exercised regularly, lost 3% to 4% of baseline weight, body mass index, and circumference of waist and hip while participating for 8.8 ± 2.7 weeks in a medically supervised fitness program. Thirty-two mid-reproductive-aged overweight and obese patients with polycystic ovary syndrome, most of whom had never exercised regularly, lost 3% to 4% of baseline weight, body mass index, and circumference of waist and hip while participating for 8.8 ± 2.7 weeks in a medically supervised fitness program. Few studies have examined the impact of both supervised exercise and nutrition in patients with polycystic ovary syndrome (PCOS) (1Chad K. Effects of exercise and nutritional counseling in women with polycystic ovary syndrome.Appl Physiol Nutr Metab. 2006; 31: 384-391Crossref PubMed Google Scholar, 2Vigorito C. Giallauria F. Palomba S. Cascella T. Manguso F. Lucci R. et al.Beneficial effects of a three-month structured exercise training program on cardiopulmonary functional capacity in young women with polycystic ovary syndrome.J Clin Endocrinol Metab. 2007; 92: 1379-1384Crossref PubMed Scopus (150) Google Scholar, 3Hoeger K.M. Kochman L. Wixom N. Craig K. Miller R.K. Guzick D.S. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study.Fertil Steril. 2004; 82: 421-429Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar). Our objective was to determine whether our community-based fitness program for patients with PCOS would promote a clinically relevant 2%–5% (4Huber-Buchholz M. Carey D.G.P. Norman R.J. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone.J Clin Endocrinol Metab. 1999; 84: 1470-1474Crossref PubMed Scopus (425) Google Scholar) weight loss from baseline.This was an institutional review board–approved, retrospective chart review from the University of Cincinnati/St. Luke West Hospital Center for Reproductive Health that evaluated nonpregnant women with PCOS according to the Rotterdam criteria (5The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop GroupRevised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS).Hum Reprod. 2004; 19: 41-47Crossref PubMed Scopus (4480) Google Scholar), aged ≥18 years, with a body mass index (BMI) ≥25 kg/m2 who participated in a medically supervised fitness program from February 2006 to October 2006. Duration of participation was open-ended and allowed for up to 14 weeks. Participants received individualized exercise and nutrition assessments (1 hour each) before the program and a 30-minute nutrition post-program assessment. Group exercise consisted of a combination of both resistance and moderate-intensity aerobic training for at least 60 minutes per session, with a goal of 200–300 minutes total per week. Group nutrition classes (90 min/wk for 4 weeks) and monthly support groups covered basic healthy eating principles, meal planning, grocery shopping, stress-related eating, behavior modification, social dining, and prenatal nutrition. Recommendations were made for a 500-kcal/d reduction in current diet with 45%–50% carbohydrate, 20%–25% protein, and 30% unsaturated fat, with a decrease of simple sugars and increase in nutrient-dense foods.Primary outcomes were pre-program and post-program changes in weight, BMI, waist circumference, and hip circumference. Secondary outcomes included number of exercise sessions per week, changes in body fat (bioelectrical impedance; Omron Healthcare, Bannockburn, IL), and clinical pregnancy rates (fetal heart motion on ultrasound). Statistical analyses were performed by SPSS (version 15.0, 2007; SPSS, Chicago, IL). Data were analyzed with paired t-tests, with significance assessed at a two-tailed P value of <.05. Subgroup analysis was used to relate changes in body composition to exercise frequency, pregnancy, and eating behavior, with significance assessed at a two-tailed P value of <.01.Of 37 women who enrolled, 4 did not participate and were lost to follow-up, and 1 only participated in the nutrition component. The remaining 32 subjects were aged 30.7 ± 5.2 years (mean ± SD), obese (Table 1), not using fertility treatment within 3 months of participation, and mostly nulliparous. Thirty women met criteria for PCOS by both hyperandrogenism and anovulation. Twenty-seven took metformin, 1 took insulin, and 4 patients were not taking any glucose-lowering medication. Twenty-six had normal glucose tolerance, and no one had metabolic syndrome according to Adult Treatment Panel III criteria (6Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III).JAMA. 2001; 285: 2486-2497Crossref PubMed Scopus (24008) Google Scholar). At baseline, 30% reported exercising at least twice weekly, and 54% reported emotional or boredom eating triggers. Of 19 not desiring pregnancy, 10 used hormonal contraception.Table 1Initial and final anthropometric parameters.InitialFinalP valueaPaired t-test.Weight (kg)100.44 ± 17.1396.78 ± 16.35<.001BMI (kg/m2)36.41 ± 5.2635.23 ± 5.32<.001Waist (cm)112.86 ± 13.23108.03 ± 13.77<.001Hip (cm)126.42 ± 12.89121.56 ± 13.17<.001Note: Values are mean ± SD.a Paired t-test. Open table in a new tab Participants completed 8.8 ± 2.7 weeks of exercise, with personal obligations cited as the most common reason for not continuing for the allotted time. Sixty-six percent of the participants lost ≥3% of their baseline weight, with specific parameters listed in Table 1. Body fat decreased 1.4% ± 1.8% (P<.001), but no differences were observed in waist/hip ratio.Of the 6 who conceived during (3 patients) or within 3 months of completion, all desired pregnancy. Subgroup analysis showed no significant differences in body composition changes and pregnancy occurrence or eating behavior. Exercise frequency at least two times per week (60%) was associated with decreased waist circumference: 6.45 ± 4.86 cm vs. 0.7 ± 5.47 cm (P<.01) compared with less-frequent exercise. No differences were observed when compared with exercising three or more times per week (24%).This was a retrospective analysis of the first 6 months of a community-based, supervised group nutrition and exercise program for overweight and obese patients with PCOS. Participant adherence of 8.8 weeks was less than the allotted 14 weeks, mostly owing to personal time commitments. We observed similar 3% to 4% losses in weight, BMI, and waist circumference with twice-weekly exercise over 8.8 weeks as seen in programs with thrice-weekly workouts over 12 weeks (1Chad K. Effects of exercise and nutritional counseling in women with polycystic ovary syndrome.Appl Physiol Nutr Metab. 2006; 31: 384-391Crossref PubMed Google Scholar, 2Vigorito C. Giallauria F. Palomba S. Cascella T. Manguso F. Lucci R. et al.Beneficial effects of a three-month structured exercise training program on cardiopulmonary functional capacity in young women with polycystic ovary syndrome.J Clin Endocrinol Metab. 2007; 92: 1379-1384Crossref PubMed Scopus (150) Google Scholar) and 24 weeks (3Hoeger K.M. Kochman L. Wixom N. Craig K. Miller R.K. Guzick D.S. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study.Fertil Steril. 2004; 82: 421-429Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar).We did not specifically evaluate ovulation, but our program was notable for a 46% pregnancy rate in patients desiring conception. Likely this rate would be lower had we focused on infertile patients, but nonetheless it compares favorably to reports of anovulatory infertile women (with and without PCOS) who in 6 months of lifestyle modification achieved pregnancy rates of 11%–23% (4Huber-Buchholz M. Carey D.G.P. Norman R.J. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone.J Clin Endocrinol Metab. 1999; 84: 1470-1474Crossref PubMed Scopus (425) Google Scholar, 7Clark A.M. Ledger W. Galletly C. Tomlinson L. Blaney F. Wang X. et al.Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women.Hum Reprod. 1995; 10: 2705-2712Crossref PubMed Scopus (31) Google Scholar). The 3.6% weight loss in our program was also within the 2%–5% range that has been suggested to promote ovulation (4Huber-Buchholz M. Carey D.G.P. Norman R.J. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone.J Clin Endocrinol Metab. 1999; 84: 1470-1474Crossref PubMed Scopus (425) Google Scholar).Some of the body composition changes in this study may have resulted from metformin, an insulin sensitizer taken by the majority of our program participants, although the literature does not indicate consistent effects of metformin on weight loss (3Hoeger K.M. Kochman L. Wixom N. Craig K. Miller R.K. Guzick D.S. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study.Fertil Steril. 2004; 82: 421-429Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar, 8Ehrmann D.A. Cavaghan M.K. Imperial J. Sturis J. Rosenfield R.L. Polonsky K.S. Effects of metformin on insulin secretion, insulin action, and ovarian steroidogenesis in women with polycystic ovary syndrome.J Clin Endocrinol Metab. 1997; 82: 524-530Crossref PubMed Scopus (306) Google Scholar). We also acknowledge that short-term improvements in weight and adiposity may not necessarily translate into clinically relevant benefit. Our main goal was to give PCOS patients in the community, many of whom had never exercised regularly, an opportunity to initiate a medically supervised fitness program in a supportive environment that ideally they could continue on their own to promote long-term health (9Knowler W.C. Barrett-Connor E. Fowler S.E. Hamman R.F. Lachin J.M. Walker E.A. et al.Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.N Engl J Med. 2002; 346: 393-403Crossref PubMed Scopus (14324) Google Scholar, 10Orchard T.J. Temprosa M. Goldberg R. Haffner S. Ratner R. Marcovina S. et al.The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial.Ann Intern Med. 2005; 142: 611-619Crossref PubMed Scopus (776) Google Scholar). Another major limitation was the lack of an independent control group, which we will certainly address in future studies. Although all patients seen by the authors were counseled about the need for diet and exercise modifications regardless of program participation, nonparticipants were not followed as frequently as the participants; therefore, participants served as their own controls. In future studies we would also plan to evaluate serum markers of improved reproductive and metabolic function, similar to those reported previously (11Moran L.J. Noakes M. Clifton P.M. Tomlinson L. Galletly C. Norman R.J. Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome.J Clin Endocrinol Metab. 2003; 88: 812-819Crossref PubMed Scopus (395) Google Scholar, 12Tolino A. Gambardella V. Caccavale C. D'Ettore A. Giannotti F. D'Anto V. et al.Evaluation of ovarian functionality after a dietary treatment in obese women with polycystic ovary syndrome.Eur J Obstet Gynecol Reprod Biol. 2005; 119: 87-93Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 13Randeva H.S. Lewandowski K.C. Drzewoski J. Brooke-Wavell K. O'Callaghan C. Czupryniak L. et al.Exercise decreases plasma total homocysteine in overweight young women with polycystic ovary syndrome.J Clin Endocrinol Metab. 2002; 87: 4496-4501Crossref PubMed Scopus (152) Google Scholar), to further emphasize the benefits of fitness.In summary, we have established a community hospital-based lifestyle modification program specifically for patients with PCOS that shows promise for short-term users. On the basis of the results reported here, the program was modified to 8 weeks with supervised nutrition 1 hour per week and group exercise 2 hours per week, to set the stage for more controlled study. Few studies have examined the impact of both supervised exercise and nutrition in patients with polycystic ovary syndrome (PCOS) (1Chad K. Effects of exercise and nutritional counseling in women with polycystic ovary syndrome.Appl Physiol Nutr Metab. 2006; 31: 384-391Crossref PubMed Google Scholar, 2Vigorito C. Giallauria F. Palomba S. Cascella T. Manguso F. Lucci R. et al.Beneficial effects of a three-month structured exercise training program on cardiopulmonary functional capacity in young women with polycystic ovary syndrome.J Clin Endocrinol Metab. 2007; 92: 1379-1384Crossref PubMed Scopus (150) Google Scholar, 3Hoeger K.M. Kochman L. Wixom N. Craig K. Miller R.K. Guzick D.S. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study.Fertil Steril. 2004; 82: 421-429Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar). Our objective was to determine whether our community-based fitness program for patients with PCOS would promote a clinically relevant 2%–5% (4Huber-Buchholz M. Carey D.G.P. Norman R.J. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone.J Clin Endocrinol Metab. 1999; 84: 1470-1474Crossref PubMed Scopus (425) Google Scholar) weight loss from baseline. This was an institutional review board–approved, retrospective chart review from the University of Cincinnati/St. Luke West Hospital Center for Reproductive Health that evaluated nonpregnant women with PCOS according to the Rotterdam criteria (5The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop GroupRevised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS).Hum Reprod. 2004; 19: 41-47Crossref PubMed Scopus (4480) Google Scholar), aged ≥18 years, with a body mass index (BMI) ≥25 kg/m2 who participated in a medically supervised fitness program from February 2006 to October 2006. Duration of participation was open-ended and allowed for up to 14 weeks. Participants received individualized exercise and nutrition assessments (1 hour each) before the program and a 30-minute nutrition post-program assessment. Group exercise consisted of a combination of both resistance and moderate-intensity aerobic training for at least 60 minutes per session, with a goal of 200–300 minutes total per week. Group nutrition classes (90 min/wk for 4 weeks) and monthly support groups covered basic healthy eating principles, meal planning, grocery shopping, stress-related eating, behavior modification, social dining, and prenatal nutrition. Recommendations were made for a 500-kcal/d reduction in current diet with 45%–50% carbohydrate, 20%–25% protein, and 30% unsaturated fat, with a decrease of simple sugars and increase in nutrient-dense foods. Primary outcomes were pre-program and post-program changes in weight, BMI, waist circumference, and hip circumference. Secondary outcomes included number of exercise sessions per week, changes in body fat (bioelectrical impedance; Omron Healthcare, Bannockburn, IL), and clinical pregnancy rates (fetal heart motion on ultrasound). Statistical analyses were performed by SPSS (version 15.0, 2007; SPSS, Chicago, IL). Data were analyzed with paired t-tests, with significance assessed at a two-tailed P value of <.05. Subgroup analysis was used to relate changes in body composition to exercise frequency, pregnancy, and eating behavior, with significance assessed at a two-tailed P value of <.01. Of 37 women who enrolled, 4 did not participate and were lost to follow-up, and 1 only participated in the nutrition component. The remaining 32 subjects were aged 30.7 ± 5.2 years (mean ± SD), obese (Table 1), not using fertility treatment within 3 months of participation, and mostly nulliparous. Thirty women met criteria for PCOS by both hyperandrogenism and anovulation. Twenty-seven took metformin, 1 took insulin, and 4 patients were not taking any glucose-lowering medication. Twenty-six had normal glucose tolerance, and no one had metabolic syndrome according to Adult Treatment Panel III criteria (6Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III).JAMA. 2001; 285: 2486-2497Crossref PubMed Scopus (24008) Google Scholar). At baseline, 30% reported exercising at least twice weekly, and 54% reported emotional or boredom eating triggers. Of 19 not desiring pregnancy, 10 used hormonal contraception. Note: Values are mean ± SD. Participants completed 8.8 ± 2.7 weeks of exercise, with personal obligations cited as the most common reason for not continuing for the allotted time. Sixty-six percent of the participants lost ≥3% of their baseline weight, with specific parameters listed in Table 1. Body fat decreased 1.4% ± 1.8% (P<.001), but no differences were observed in waist/hip ratio. Of the 6 who conceived during (3 patients) or within 3 months of completion, all desired pregnancy. Subgroup analysis showed no significant differences in body composition changes and pregnancy occurrence or eating behavior. Exercise frequency at least two times per week (60%) was associated with decreased waist circumference: 6.45 ± 4.86 cm vs. 0.7 ± 5.47 cm (P<.01) compared with less-frequent exercise. No differences were observed when compared with exercising three or more times per week (24%). This was a retrospective analysis of the first 6 months of a community-based, supervised group nutrition and exercise program for overweight and obese patients with PCOS. Participant adherence of 8.8 weeks was less than the allotted 14 weeks, mostly owing to personal time commitments. We observed similar 3% to 4% losses in weight, BMI, and waist circumference with twice-weekly exercise over 8.8 weeks as seen in programs with thrice-weekly workouts over 12 weeks (1Chad K. Effects of exercise and nutritional counseling in women with polycystic ovary syndrome.Appl Physiol Nutr Metab. 2006; 31: 384-391Crossref PubMed Google Scholar, 2Vigorito C. Giallauria F. Palomba S. Cascella T. Manguso F. Lucci R. et al.Beneficial effects of a three-month structured exercise training program on cardiopulmonary functional capacity in young women with polycystic ovary syndrome.J Clin Endocrinol Metab. 2007; 92: 1379-1384Crossref PubMed Scopus (150) Google Scholar) and 24 weeks (3Hoeger K.M. Kochman L. Wixom N. Craig K. Miller R.K. Guzick D.S. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study.Fertil Steril. 2004; 82: 421-429Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar). We did not specifically evaluate ovulation, but our program was notable for a 46% pregnancy rate in patients desiring conception. Likely this rate would be lower had we focused on infertile patients, but nonetheless it compares favorably to reports of anovulatory infertile women (with and without PCOS) who in 6 months of lifestyle modification achieved pregnancy rates of 11%–23% (4Huber-Buchholz M. Carey D.G.P. Norman R.J. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone.J Clin Endocrinol Metab. 1999; 84: 1470-1474Crossref PubMed Scopus (425) Google Scholar, 7Clark A.M. Ledger W. Galletly C. Tomlinson L. Blaney F. Wang X. et al.Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women.Hum Reprod. 1995; 10: 2705-2712Crossref PubMed Scopus (31) Google Scholar). The 3.6% weight loss in our program was also within the 2%–5% range that has been suggested to promote ovulation (4Huber-Buchholz M. Carey D.G.P. Norman R.J. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone.J Clin Endocrinol Metab. 1999; 84: 1470-1474Crossref PubMed Scopus (425) Google Scholar). Some of the body composition changes in this study may have resulted from metformin, an insulin sensitizer taken by the majority of our program participants, although the literature does not indicate consistent effects of metformin on weight loss (3Hoeger K.M. Kochman L. Wixom N. Craig K. Miller R.K. Guzick D.S. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study.Fertil Steril. 2004; 82: 421-429Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar, 8Ehrmann D.A. Cavaghan M.K. Imperial J. Sturis J. Rosenfield R.L. Polonsky K.S. Effects of metformin on insulin secretion, insulin action, and ovarian steroidogenesis in women with polycystic ovary syndrome.J Clin Endocrinol Metab. 1997; 82: 524-530Crossref PubMed Scopus (306) Google Scholar). We also acknowledge that short-term improvements in weight and adiposity may not necessarily translate into clinically relevant benefit. Our main goal was to give PCOS patients in the community, many of whom had never exercised regularly, an opportunity to initiate a medically supervised fitness program in a supportive environment that ideally they could continue on their own to promote long-term health (9Knowler W.C. Barrett-Connor E. Fowler S.E. Hamman R.F. Lachin J.M. Walker E.A. et al.Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.N Engl J Med. 2002; 346: 393-403Crossref PubMed Scopus (14324) Google Scholar, 10Orchard T.J. Temprosa M. Goldberg R. Haffner S. Ratner R. Marcovina S. et al.The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial.Ann Intern Med. 2005; 142: 611-619Crossref PubMed Scopus (776) Google Scholar). Another major limitation was the lack of an independent control group, which we will certainly address in future studies. Although all patients seen by the authors were counseled about the need for diet and exercise modifications regardless of program participation, nonparticipants were not followed as frequently as the participants; therefore, participants served as their own controls. In future studies we would also plan to evaluate serum markers of improved reproductive and metabolic function, similar to those reported previously (11Moran L.J. Noakes M. Clifton P.M. Tomlinson L. Galletly C. Norman R.J. Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome.J Clin Endocrinol Metab. 2003; 88: 812-819Crossref PubMed Scopus (395) Google Scholar, 12Tolino A. Gambardella V. Caccavale C. D'Ettore A. Giannotti F. D'Anto V. et al.Evaluation of ovarian functionality after a dietary treatment in obese women with polycystic ovary syndrome.Eur J Obstet Gynecol Reprod Biol. 2005; 119: 87-93Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 13Randeva H.S. Lewandowski K.C. Drzewoski J. Brooke-Wavell K. O'Callaghan C. Czupryniak L. et al.Exercise decreases plasma total homocysteine in overweight young women with polycystic ovary syndrome.J Clin Endocrinol Metab. 2002; 87: 4496-4501Crossref PubMed Scopus (152) Google Scholar), to further emphasize the benefits of fitness. In summary, we have established a community hospital-based lifestyle modification program specifically for patients with PCOS that shows promise for short-term users. On the basis of the results reported here, the program was modified to 8 weeks with supervised nutrition 1 hour per week and group exercise 2 hours per week, to set the stage for more controlled study.