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Carolynn Francavilla Brown, MD, FOMA
Family Medicine and Obesity Medicine
Green Mountain Partners for Health and Colorado Weight Care
Thinking Like an Obesity Physician: Nutrition and Weight Loss Strategies for PCOS
Nutrition and Weight Loss Strategies for PCOS
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Goals
Feel comfortable offering brief but focused nutrition counseling to women with PCOS
Understand appropriate weight loss goals for PCOS
Be aware of pros and cons of popular diet strategies
Nutrition and Weight Loss Strategies in PCOS
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Pillars of Obesity Management
What does an obesity physician do?
Identify Underlying Causes of Obesity Utilize Medications Advise Exercise Nutrition Counseling Behavior Modification
Obesity Treatment
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Relationship of PCOS and Obesity
PCOS is a heterogenous disease state with different phenotypes
PCOS has different criteria by different expert groups
Underlying Causes
ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome. (2018). Obstetrics & Gynecology, 131(6),158.
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Relationship of PCOS and Obesity Overweight or obesity affects approximately
60–80% of PCOS patients Approximately 70% of women with PCOS have
insulin resistance Women with PCOS who have obesity or are
lean both show increased incidence of insulin resistance
Identifying insulin resistance: A1C, fasting glucose, glucose tolerance test (75g 2 hourglucose tolerance test), HOMA-IR (fasting glucose to insulin ratio), acanthosis nigricans on exam
Underlying Causes
R. Azziz, L. A. Sanchez, E. S. Knochenhauer et al., “Androgen excess in women: experience with over 1000 consecutivepatients,” Journal of Clinical Endocrinology and Metabolism, vol. 89, no. 2, pp. 453–462, 2004.Deugarte, C., Bartolucci, A., & Azziz, R. (2005). Prevalence of insulin resistance in the polycystic ovary syndrome using the homeostasis model assessment. Fertility and Sterility, 83(5), 1454–1460. doi: 10.1016/j.fertnstert.2004.11.070
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Goals of Weight Loss in PCOS
Many women with PCOS have improvement in cycles, fertility and insulin resistance from modest weight loss, but not all.
What should be the weight loss goal?5-10% weight loss
If symptoms have not been reduced with a 10% weight loss, additional weight loss is unlikely to improve symptoms and other treatment modalities should be maximized.
Prevent weight gain for women at normal weight with PCOS
Underlying Causes
Guzick, D. S., Wing, R., Smith, D., Berga, S. L., & Winters, S. J. (1994). Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertility and Sterility, 61(4), 598–604. doi: 10.1016/s0015-0282(16)56632-1Huber-Buchholz, M.-M. (1999). Restoration of Reproductive Potential by Lifestyle Modification in Obese Polycystic Ovary Syndrome: Role of Insulin Sensitivity and Luteinizing Hormone. Journal of Clinical Endocrinology & Metabolism, 84(4), 1470–1474. doi: 10.1210/jc.84.4.1470
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Underlying Causes
Why is weight loss (and maintenance) so hard?Adaptive thermogenesis
Ø Decreased energy expenditure with weight lossØ Most studies show it does not fully restore to normal with weight regainØ Maintenance of a 10% or greater reduction in body weight in lean or obese
individuals is accompanied by an approximate 20%-25% decline in 24-hour energy expenditure
This decrease in weight maintenance calories is 10–15% below what is predicted solely on the basis of alterations in fat and lean mass
Biggest Loser Study. Mean RMR after 6 years was ~500 kcal/d lower than expected based on the measured body composition changes and the increased age of the subjects
Increase appetite Increased Ghrelin, PYY, CCK, Amylin (hunger signals) with weight loss=hunger which
resolves with weight loss Leptin (fullness signal) decreases It’s not WILL POWER!
Int J Obes (Lond). 2010 October ; 34(0 1): S47–S55. doi:10.1038/ijo.2010.184Obesity (Silver Spring). 2016 August ; 24(8): 1612–1619. doi:10.1002/oby.21538.
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Anti-Obesity Medications Phentermine (and other sympathomimetic
amines) Orlistat Naltrexone/Bupropion ER (Contrave) Phentermine/Topiramate ER (Belviq) Liraglutide (Saxenda)
Current recommendations to use medications LONG TERM as neededShould achieve a 5% weight loss by 12 weeks of medication
Medications
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Metformin
Not a first line for hirsutism, anovulation, or fertility
Utilized frequently for treatment of insulin resistance and obesity, so consider if either of these is present
Helps insulin resistance, weight ovulation, improvement of symptoms
Dose 1500-2000mg daily
Medications
Neil F. Goodman, Rhoda H. Cobin, Walter Futterweit, Jennifer S. Glueck, Richard S. Legro, and Enrico Carmina (2015) AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, AMERICAN COLLEGE OF ENDOCRINOLOGY, AND ANDROGEN EXCESS AND PCOS SOCIETY DISEASE STATE CLINICAL REVIEW: GUIDE TO THE BEST PRACTICES IN THE EVALUATION AND TREATMENT OF POLYCYSTIC OVARY SYNDROME - PART 2. Endocrine Practice: December 2015, Vol. 21, No. 12, pp. 1415-1426
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Exercise and PCOS
Guidelines for everyone 150-300 minutes a week of moderate intensity physical activity
Patients who lose weight and keep it off are exercising and average of 60 minutes a day, with the most common exercise being walking
Create an “Exercise Prescription” Any movement is good for health
Exercise
Physical Activity Guidelines for Americans, 2nd Editions. Accessed at: https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdfNational Weight Control Registry Retrieved from http://www.nwcr.ws/Research/default.htm
https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdfhttp://www.nwcr.ws/Research/default.htm
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General Approaches to Dietary AdviceAsk permission to discuss weight-Consider if patient has or had an eating disorder (ED)-Screening tools- EDDS, EAT, QEWP-R, BEDS7. -“Are there times when you feel like you eat out of control?”-If concern for ED If present refer to therapist, psychiatrist or obesity specialist that you know is comfortable with ED.
Nutrition
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General Approaches to Dietary Advice Find out what they are currently eating-24 hour recall-“Typical day”-Food journal
Why?-Low hanging fruit like sweet drinks, alcohol, snacks, sweets, fastfood, restaurant food-Preferences- eating pattern, homemade food, restaurant food, packaged food-Lack of patient confidence if you tell them to do what they are already doing-Already eating pretty healthy? Is there binge eating present? Do you need to consider a medication or step up care to someone else like and obesity physician or RD
Nutrition
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General Approaches to Dietary Advice
What is a calorie?
Nutrition
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There is no good evidence that one type of diet is superior to another for women with
PCOS
Nutrition
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Mediterranean Diet
Summary: pattern of eating high in fruits, vegetables, whole grains, beans, nuts, and seeds, olive oil, and moderate wine consumption. It generally includes low to moderate amounts of fish, poultry, and dairy products, with little red meat.
Pros:• Better studied than
most diets• Improved overall
mortality, CVD, cancer, Alzheimer’s, Parkinsons
Cons:• No specific
“Mediterranean Diet”, really a pattern of eating associated with health
• In of itself does not lead to weight loss, need calorie goal to with it
Adherence to Mediterranean diet and health status: meta-analysis.Sofi. BMJ (Clinical research ed.) Volume: 337 (2008) ISSN: 0959-8138 Online ISSN: 1756-1833
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Plant Based Diet
Summary: (Vegan, Lacto-Ovo Vegeterian, Lacto Vegeterian)Avoidance of Beef, lamb, poultry, seafoods. May avoid eggs or dairy.
Pros:• Appears to be
cardio-protective• May reduce risk of
cancers
Cons:• Long-term effects of diet
are difficult to separate from those associated with a vegetarian diet like regular exercise, avoidance of tobacco and alcohol products
• Without calorie or macronutrient goals may not lead to weight loss
• Many plant-based foods favored by average person are also high glycemic (potato, rice, pasta, chips, crackers, tortillas)
• Deficiencies in b12, vit D and omega 3s if not supplemented
Rao, V., & Al-Weshahy, A. (2008). Plant-based diets and control of lipids and coronary heart disease risk. Current Atherosclerosis Reports, 10(6), 478–485. doi: 10.1007/s11883-008-0075-2
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Ketogenic Diet
Summary: Diet very low in carbohydrates, leading body to burn fat as a fuel source producing ketones as a result
Pros:• Rules of diet are
clear- limit carbs to 20-40g daily (depending on protocol)
• Getting into ketosis suppresses appetite making it easier to stick to
• Improved insulin resistance quickly
Cons:• Often high in saturated
fat, red meat (though does not have to be)
• Long term adherence• Weigh regain when
diet is stopped
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Paleolithic Diet
Summary: based upon presumed dietary pattern in the PaleolithicPeriod excludes grains, legumes, dairy, and ultra-processed foods.
Pros:• Limits processed
food• Encourages
vegetables and fruit
Cons:• Lots of paleo “junk
food” and processed food available now
• Not calorie restricted-so doesn’t always lead to weight loss
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Meal Replacement Programs
Summary: (Optavia, Nutrisystem, Optifast, etc) Pre-made meals, protein bars and shakes make up majority of calories
Pros:• Strong structure• Easy• High protein,
calorie controlled• Weight loss very
likely to occur if program is followed
Cons:• Transition to more “real
food” can be a challenge, can lead to yo-yo dieting
• Highly processed food
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Intermittent Fasting
Summary: Caloric intake is limited to part of the day. Recommend fasts start at 14-16 hours and sometime extend to 72 or more hours.
Pros:• Eating less often
exposes patient to less insulin
• Appears to reduce diabetes, heart disease, cancer an neurodegenerative disease
• May limit total calories eaten per day
Cons:• Can worsen poor
eating patterns, over eating in eating window
• Still need guidelines of what can be eaten
Cabo, R. D., & Mattson, M. P. (2019). Effects of Intermittent Fasting on Health, Aging, and Disease. New England Journal of Medicine, 381(26), 2541–2551. doi: 10.1056/nejmra1905136
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Nutrition SummaryWhat do these plans have in common?o Increasing vegetables and produceo Structure- reduce calories or
carbohydrateso Decreasing processed foods
Nutrition
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If you have 5 minutes or less to discuss nutritionThe best diet for weight loss is the one a patient will stick to!
What fits with the patient’s lifestyle, culture, interests and experience
The physical and psychological tendencies Plants are good for you! But too much fruit does not help with weight
loss, eat more veggies- 1 serving of fruit a day For most plans give a calorie goal- 1200 is a
reasonable target for most women, can use an online calculator to help patients set a goal
Nutrition
Source:Bays HE, McCarthy W, Christensen S, Wells S, Long J, Shah NN, Primack C. Obesity Algorithm eBook, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2019. https://obesitymedicine.org/obesity-algorithm/ (Accessed January 28, 2020)
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If you have 5 minutes or less to discuss nutrition
Nutrition
Calorie Goal:
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If you have 5 minutes or less to discuss nutrition
Nutrition
Protein Fat Carbs
MeatBreadGrains-Wheat-Rice-Corn-Oats
ButterEgg White Egg yolkSoySome dairy (greek yogurt, cottage cheese)Protein shakes and bars
OilsNutsAvocado
Fat on meat
CrackersChipsPotatoSweetsDessertsFruit
Cheese
Veggies
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General Approaches to Behavior Change Stimulus Control: portion control, limiting
snacking/grazing, removing trigger foods Cognitive Restructuring: realistic weight goals
and body image, change relationship with foods, let go of all or nothing mentality
Self- Monitoring: logging (apps like myfitnesspal or loseit, pen and paper)
Support/Accountability: therapist, obesity physician, personal trainer, support group, structured program (weight watchers, etc)
Behavior Change
Source:Bays HE, McCarthy W, Christensen S, Wells S, Long J, Shah NN, Primack C. Obesity Algorithm eBook, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2019. https://obesitymedicine.org/obesity-algorithm/ (Accessed January 28, 2020)
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Bariatric Surgery Requirements BMI ≥ 40, or more than 100 pounds overweight BMI ≥ 35 and at least one or more obesity-
related co-morbidities such as type II diabetes, hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.
Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts. (usually 3-6 months for insurance purposes)
Bariatric Surgery
Who is a Candidate for Bariatric Surgery?: Patients: ASMBS. (n.d.). Retrieved February 22, 2020, from https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery
Escobar-Morreale, H. F., Botella-Carretero, J. I., Álvarez-Blasco, F., Sancho, J., & Millán, J. L. S. (2005). The Polycystic Ovary Syndrome Associated with Morbid Obesity May Resolve after Weight Loss Induced by Bariatric Surgery. The Journal of Clinical Endocrinology & Metabolism, 90(12), 6364–6369. doi: 10.1210/jc.2005-1490
https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery
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Billing for Obesity Counseling Can add code 99401 for 15 minutes of
nutrition counseling for obesity in addition to your E&M code for management at visit
Modifier 25 on E&M Code (i.e. 99214) Document what you spent the 15 minutes
counseling on Some suggest a “separate note” to
document this
Billing
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Summary✭60-80% of women with PCOS have
overweight or obesity✭Obesity is a risk factor for diabetes, heart
disease, cancer and other disease states✭Treatment of weight in women with PCOS
can improve PCOS symptoms✭A 5-10% weight loss often improves PCOS
symptoms in addition to reducing disease risks from obesity
✭The best diet is the diet a patient can stick with!
Summary