Defending a Carbohydrate-Restricted Option for PCOS Management
Although the author of the course gave a good overview of the disease and recommended avoiding refined carbohydrates, I found that several of the dietary suggestions were not particularly helpful for many women who struggle with PCOS, such as:
- Eat plenty of whole grains, starchy vegetables, and beans
- 130 grams of carbohydrate per day is the bare minimum that should be consumed, and meals should preferably contain 45-60 grams of carbohydrate each
- Snacks should include approximately 15 grams of carbohydrate combined with a protein food (i.e., peanut butter on crackers)
PCOS is one of the most common endocrine disorders among reproductive-aged women, as well as the leading cause of infertility. Instead of an egg being released from one of the follicles in the ovaries on a monthly basis as occurs in normal ovulation, a hormonal imbalance (too much luteinizing hormone and not enough follicle stimulating hormone) results in the egg failing to mature; instead, the follicle forms a small cyst. This process is repeated, and eventually the ovaries contain dozens of these cysts. Although the clinical presentation varies from person to person and some women have few symptoms, its hallmarks are insulin resistance and hyperinsulinemia. Other common features include:
- obesity
- acanthosis nigricans (skin tags and darkened pigment in skin folds, such as the armpits, groin, thighs, and neck), a sign of insulin resistance and hyperinsulinemia
- menstrual irregularities such as ammenorrhea (skipped periods) and menorrhagia (heavy periods) as a result of not ovulating
- masculinization, including hirsutism (excessive facial and body hair), acne, male-pattern baldness, and deep voice related to increased ovarian production of testosterone and other androgens
- depression
Women with PCOS are more than twice as likely to meet the criteria for metabolic syndrome as those without the disorder; in fact, in one study, women between the ages of 20-39 were found to have a 4-fold to 8-fold increased prevalence of metabolic syndrome compared to women of the same ages in the general population (1). Those with both PCOS and metabolic syndrome are therefore at much higher risk for developing type 2 diabetes and cardiovascular disease. Since research has demonstrated that carbohydrate restriction improves markers of insulin resistance (IR) and other features of metabolic syndrome (2), it would seem logical to consider it an appropriate — if not the most appropriate — diet for PCOS. Even nonobese women with PCOS experience IR, though, and are at increased risk for progression to diabetes in the future.
A small 2005 study evaluating the effects of a ketogenic diet on women with PCOS found significant improvements in fasting insulin, body weight, and hormone levels among subjects who completed the study — including two pregnancies in women who had previously been unable to conceive (2).
This is why I find it disappointing to read recommendations like those given in the PCOS course, which sound very similar to the one dietitians often make for people with diabetes. While this type of diet may work for insulin-sensitive people, it simply doesn’t result in beneficial outcomes for most women with insulin resistance and hyperinsulinemia. For people with defective hormonal regulation, it can be difficult to control insulin levels and appetite when eating more than minimal amounts of carbohydrate.
The authors of a recent review looking at six different diets and their effects on physiological and psychological outcomes in women with PCOS came to the following conclusion: “Weight loss should be targeted in all overweight women with PCOS through reducing caloric intake in the setting of adequate nutritional intake and healthy food choices irrespective of diet composition (4).”
While the researchers noted moderate to severe bias among all the studies, I found some other issues:
- In one study, the “low carbohydrate” diet contained 2000 calories with 43% as carbohydrates, which equates to 215 grams — not low in carbs, by most standards. However, it still resulted in greater weight loss and improvements in postprandial insulin response than a high-monounsaturated-fat diet containing 55% of calories (275 grams) as carbohydrate (5).
- Stamets, et al., reported that for diets containing 1000 calories, carbohydrate intake of 40% (100 grams) vs. 55% (138 grams) didn’t seem to matter much; at such hypocaloric intakes, insulin levels would be expected to improve significantly, and they did (6). But who can maintain such a low-calorie diet for any length of time without getting hungry and experiencing a lowering of metabolic rate and other adverse effects? This was only a one-month study, fortunately, but to the participants it probably felt longer.
- Another study investigated the responses of women with PCOS who followed a carb-counting vs. fat-counting diet for six months after completing an 8-week diet containing meal replacements for two meals a day. Interestingly, the caloric intakes were nearly the same — 1396 for the carb-counters and 1475 for the fat-counters — and the amount of carbohydrates consumed was also very close, at 140 grams and 158 grams, respectively. (Protein intake was 21% in each group, and fat was 35% in the carb-counting group and 31% in the fat-counting group.) The researchers’ findings? “No significant difference between any outcomes.” Not surprising when the composition of the two diets was so similar.
The other three studies didn’t look at “low-carb” diets per se but found less depression and lower triglycerides in subjects consuming higher amounts of protein and improvements in insulin sensitivity among women following a low GI diet.
My point is that aside from one small study, researchers haven’t attempted to investigate whether a very-low-carbohydrate diet containing adequate calories is effective in improving IR and hyperinsulinemia, promoting weight loss, and improving hormonal balance in order to reduce masculinization and facilitate ovulation. However, I’ve read anecdotal reports where carb restriction did improve symptoms, and at least one woman I’ve worked with definitely experienced benefits. There’s also the spontaneous decrease in caloric intake that occurs for many, although not all, people who consume a carbohydrate-restricted diet (8).
Now, I’m not claiming that low-carb diets work for everyone or that they’re the only thing needed to achieve results. Certainly insulin-sensitizing medications such as metformin, stress management, exercise, support groups, and supplements play a large role in managing PCOS as well. But for the overweight woman suffering from this disorder, I don’t feel that it’s enough to simply encourage weight loss without providing guidance on how to do so in a sustainable way that has been shown to improve IR and insulinemia — i.e., limiting carbs to 50 net grams per day or less.
I understand that some women with PCOS may not want to follow a carb-restricted diet, and I certainly respect and support everyone’s right to make dietary choices. But I believe dietitians and other healthcare professionals who work with women who struggle with PCOS should present a low-carb diet as an option rather than insist that everyone consume “a minimum of 130 grams of carbohydrate per day.” Unless you have lived with PCOS, diabetes, or metabolic syndrome and tried carbohydrate restriction, it’s impossible to understand what an impact making this type of change could have on your health and quality of life.
* Please speak with your doctor or health care provider prior to making any changes to your diet.
References:
1. Apridonidze T, et al. Prevalence and Characteristics of the Metabolic Syndrome in Women with Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2005 Apr;90(4):1929-35
2. Volek JS, Feinman RD.Carbohydrate restriction improves features of the Metabolic Syndrome. Metabolic Syndrome may be defined by the response to carbohydrate restriction. Nutr Metab(Lond) 2005 ;2:31
3. Mavropoulos JC, et al. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: A pilot study. Nutrition & Metabolism. 2005;2:35
4. Moran IJ, et al. Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines. J Acad Nutr Diet. 2013 Apr;113(4):520-45
5. Douglas CC, et al. Role of diet in the treatment of polycystic ovary syndrome. Fertil Steril.2006; 85(3):679-688
6. Stamets K, et al. A randomized trial of the effects of two types of short-term hypocaloric diets on weight loss in women with polycystic ovary syndrome. Fertil Steril. 2004;81(3):630-637
7. Moran LJ, et al. Short-term meal replacements followed by dietary macronutrient restriction enhance weight loss in polycystic ovary syndrome. Am J Clin Nutr. 2006;84(1):77-87
8. Westman EC, et al. Low carbohydrate nutrition and metabolism. Am J Clin Nutr.August 2007; 86(2):276-284
Franziska, what about a moderate carbohydrate diet like what is usually recommended of pairing a carb and protein (like the IR Diet) for PCOS?
Hi Vicki,
Thanks for your question. I think some people may have success with this approach, but for many that is just too many carbs. It’s really beneficial to experiment and see what works best for you in terms of insulin levels, weight, excessive androgen levels, and how you feel overall. Of course, “moderate carb” can mean different things depending on who you talk to. Some people might consider 50 grams moderate, while another would say it’s closer to 100 grams. I have heard from several women (many just since I wrote this post a couple of days ago) who have experienced great results by consuming 30-50 grams of net carb daily, and I’d recommend that as a starting point and adjusting as needed from there. Best of luck to you!
If only other health professionals shared your respect for individual choice & actually presented options. No end to the propaganda for whole grains & high carb meals.
Thank you for your continued efforts fighting the good fight!
Thank you so much for your very kind words of support, Gerri!
Franziska, another very balanced and thought out post for all to read. I am in total agreement with the earlier comment from Gerri “respect for individual choice & actually presented options”. People / patients deserve to be given all the options, all the choices ….. they can then make fully informed decisions.
All the best Jan
Sincere thanks for the nice feedback and your continued support, Jan! Appreciate your insight.
Kind regards, Franziska
This is an excellent post Franziska. You presented it in a balanced and thorough manner.
Thanks for your evaluation of the research comparing low-fat to low-carb in the treatment of PCOS. It helps to know that one of the diets studied wasn’t low-carb at all.
I agree that PCOS is a condition of insulin resistance and should be treated as such. I recommend low-carb eating to all my PCOS patients.
I am going to share your post with all my PCOS patients!
Thanks so much for your comments and for sharing my article with your PCOS patients, Sam! So glad you recommend carb restriction for all of them 🙂
Another VERY good column, Franziska. I’m posting it to my Facebook page.
Thank you, Dan! I appreciate that very much.
I am a woman with PCOS. I was thin until we monkeyed with my hormones for three years of infertility treatment. I finally conceived my first child after IVF and continued to gain a lot of weight from there.
At the age of 41 I read about new treatments for PCOS. Although I very much wanted more children, we had long given up hope. I went on a regimen of low carb diet and Metformin for health reasons–to lose weight and avoid diabetes. Within 30 days (and with very little weight loss at that point) I had my first EVER ovulatory period without fertility drugs, and to my utter surprise found myself pregnant six months later.
My second daughter is 14, very thin, and has PCOS too. Because she is slightly below normal body weight, PCOS would never have been recognized by her doctors had I not insisted on testing. And we found she is highly insulin resistant. The prescribed diet, of course, is low fat and lots of “healthywholegrains” (and she was told that losing weight would help, though I can’t imagine where she could lose an ounce!). When I pointed out that I control my own insulin resistance with a low carb diet and NO grains, I was admonished that she would be missing crucial nutrients without whole grains, particularly B vitamins. There is NO recognition that all of the vitamins and minerals in grains are present in other whole foods and more bioavailable when carbs, particularly grains are not ingested.
Never once has our healthcare provider (Kaiser) ever mentioned restricting carbohydrates as a way to treat PCOS–to me or my daughter. They are huge proponents of low fat, high carbohydrate, and mostly vegetarian diets–exactly the diet I was eating until age 41. It did me no good at all.
Thanks so much for sharing your story and your daughter’s as well, Janknitz. I’m thrilled to hear that you resumed ovulating after switching to low carb and starting metformin, and that you were able to have more children. Two women reported the same thing on my Facebook page shortly after I published this article.
I completely understand your frustration with the dietary advice your daughter was given and the response that your LC diet is unbalanced and lacks vital nutrients. Shaking my head that they suggested losing weight would help, when she is already so thin. Fortunately for her, she has a mother understands the benefits of carb restriction for her condition.
Thanks again so much for sharing. I wish you and your entire family the very best of health.
I’m so happy to hear from women who have improved or reversed PCOS with low carb. I’d request that anyone who’s had this type of success post her story here, anonymously or not. Thank you!
Great post! I have had PCOS since puberty, with all the associated conditions. When I was in my late twenties I joined a program that advised a low carb diet (not labled as such) and I lost almost 100 pounds. My doctors were amazed when I became pregnant and had a healthy baby.
I’m 64 now and recently found that peppermint or spearmint tea is thought to be anti-androgenic (?) and has dimished my hirsutism as long as I have a cup every day or two. That was the best news I’ve had in years, because it’s so embarrassing.
Thank you so much for your very nice feedback and for sharing your story, GG! Congratulations for losing nearly 100 pounds and keep it off for more than 30 years! I’m also very happy to hear that you were able to get pregnant and delivered a healthy baby.
Thank you for the information regarding the peppermint and spearmint tea. I will add them to the list of foods and supplements I recommend to my PCOS patients, particularly those that struggle with excess facial and body hair.
Thanks again for commenting. Keep up the great work!
I actually did not keep it off, Franziska. When I married a man with a three-meals-a-day regimen and a sweet tooth, I gained it all back and more. Losing it again was much more difficult and menopause made it worse. I’m still 50 pounds from where I’d like to be despite low carb, minimally processed food and regular exercise. Being hypothyroid and T2 diabetic doesn’t help either. Still working on it, though! Hubby and I eat two different menus, with only meat and vegetables in common. 😉
Sorry to hear you experienced weight regain, but it sounds like you were able to get back on track with LC 🙂 It can be hard when your spouse eats differently than you do. I’m rooting for you to keep losing until you reach your goal!
I just found your website today. I love to see support for low carbing in the nutrition field. I have PCOS and have changed my lifestyle to low carb because it gives me the best results. Fortunately my doctors support low carbing too. Very informative site. Thank you!
Thanks so much for your comments and nice feedback, Andrea! I’m so glad you’ve found that carb restriction helps manage your PCOS. Also great to have a doctor who understands the benefits of LC. I wish you all the best!
Very good column. I actually came here searching whether there was any information available about the effect of a ketogenic diet on PCOS.
I started a low carb diet purely for much needed weight loss – my BMI was 31. To my utter surprise I didn’t just lose 34 pounds, I also suddenly got regular periods. Which is a very first for me. Ever. And it’s not just about the weight loss; I’m still about 20 pounds over the weight I had in my early twenties, yet I was already irregular back then.
I’ve now changed from a low carb weight loss diet to a sustainable low carb lifestyle, and am very happy to say that in spite of the rapid weight loss (you’d expect to gain some back) my weight has stayed stable for the past 6 weeks. And I had yet another 29 day cycle. I wish I’d known about this when we were struggling to conceive our first child.
I understand that what little scientific research exists isn’t conclusive about the effects of very low carb diets on PCOS, but it does make sense that a diet that results in a very stable blood sugar level would have a positive effect on people who have insulin resistance. I definitely agree with you that there are enough indications of benefits to present this kind of diet as an option to women who suffer from PCOS.
Thank you so much for the nice feedback and for sharing your own story, Suzy! I’m so happy to hear that you experienced benefits beyond weight loss with low carb, including hormonal regulation, as evidenced by monthly periods. Keep up the great work!
Oh, I definitely will. I actually had a stress induced cheat night the day before yesterday, and today am paying the price with obvious low blood sugar levels – I keep getting woozy, which is very inconvenient when caring for two toddlers.
That’s enough for me to drive home the point: the fleeting comfort of a portion of fries just isn’t worth the repercussions. Even though our family is complete, so I don’t need the hormonal regulation to conceive more kids, I just don’t want to go back to the way things used to be.
The only thing I am left to wonder is whether and how this way of life might benefit – or harm – our kids. For the time being I don’t deny them carbs – mostly in the form of grains – although I do tend to stay away from too much sugar (candy, but also things like apple juice) in favour of a larger portion of their calories from fat. It’s rather uncharted territory, I guess, to keep the balance between feeding them too much sugar, and going overboard feeding them a diet that benefits me but might not be the best for them. For now I’m trying to keep the middle road there.
Sounds like a good strategy! Best of luck with everything!
There is another interesting piece of information about the link between diet and PCOS. According to research, eating a big breakfast and a small dinner can cause a drop in testosterone levels and insulin resistance by at least 50%. Of course you need to do it consistently. Just try to eat the majority of your calories early in the day.
Thanks for your comments, Kate! Changing the distribution of calories during the day can indeed be helpful as well. On the other hand, carbohydrate restriction can help keep hunger levels under control by maintaining stable blood glucose levels, making it a very sustainable way of eating for many. I’ve certainly experienced this over the past 5.5 years of following a low-carb diet where I eat roughly the same amount of calories and carbs at each meal.
Meanwhile in Last century Australia… The DAA still have their head in the sand…
http://daa.asn.au/wp-content/uploads/2016/07/New-research-Diet-habits-of-women-with-PCOS-FINAL.pdf
I was diagnosed with PCOS when i was 19 (i’m 36 now) and have always had irregular periods except while on the pill. For at least the last 10-12 years i have had 1-2 periods a year max, many years i didn’t have any. During this time i have also suffered hirsutism. Within the last year i have started to develop male pattern baldness, with a receding hairline.
I started keto about 2 months ago for the purpose of losing weight. for most of the 2 years previous, i had been following a low fat diet, i had lost 40lb, but due to depression i failed and put it all back on over the course of about 2 months. This weight loss had no effect on my periods, hair loss or hirsutism.
My weight loss on keto so far has been fairly slow (about 8lb lost so far) but i just started my period yesterday, approximately a month after the last one! the last period didn’t surprise me as i just assumed it was one of the odd yearly ones. I was surprised to have another so soon though. Intrigued by this i wondered about other symptoms and had a close look in the mirror. I was shocked, but thrilled to discover small tufts of hair about an inch long at the edge of of my receding hairline!
I had been told many times that weight loss was the way to improve my symptoms, but this appears to show that actually the type of food i’m eating is far more important than lbs lost. It’s still early days obviously, and could just be a fluke, but i’m very hopeful.
Thanks so much for sharing your story, including the encouraging changes you’ve seen after following a ketogenic diet for two months! I’m so happy to hear this. I think an 8-lb loss so far is great, but clearly being in ketosis is having powerful effects on hormonal regulation. Congratulations on restarting your cycle and the early hair growth! Keep up the great work 🙂 – Franziska
It is good to read this well thought out and researched article. My daughter was diagnosed with PCOS in high school and she struggles with weight gain and the hormonal acne. Even before she diagnosed, we felt something was different based on other girls her age. I tried to keep her on a low carb diet, but that is so hard to maintain with a child. And as an adult she resents that I did and says it set her up for “food issue”. She is in grad school and very sedentary and puts on weight very quickly due to low activity, poor diet, binge eating, alcohol intake, etc. (all of this she shares with me). We have paid for personal trainers (at her request) and provided more funds for healthy food purchases as a student, all to no avail. I worry so much about her self esteem, happiness, and more importantly heart disease. She has an appointment soon with a dietitian soon and I pray that she has your same professional opinion of low carb diets and PCOS. What is your opinion of alcohol intake and PCOS? I have no problem with alcohol in general, but consider it empty calories and have heard it lowers metabolism. I try to stay away from it as I have hypothyroidism.
Thanks for your comments and for sharing your daughter’s story, Ingrid. I’m so sorry to hear that she continues struggling with weight gain and other PCOS-related symptoms. I don’t know of any particular contraindications for alcohol intake with PCOS, but I agree that it is essentially empty calories. In addition, it may increase storage of abdominal fat and can lead to overeating by clouding judgment and resolve. I wish your daughter the very best of luck in getting her eating under control in order to improve her health and overall quality of life. – Franziska
Fantastic article. Not that I ever was diagnosed w PCOS, but irregular, heavy periods, enormous weight gain at puberty, etc, makes it seem likely to have been the case. Fast forward to my childbearing years, overweight w those heavy irregular periods and my husband and I simply not having any luck conceiving.
Not knowing anything about insulin resistance or low carb way of eating, I decided to go on a diet which, unbeknownst to me WAS the perfect lchf diet. This was in the early 1990s, the dawn of the Internet.
Well, we got pregnant, after we had given up hope of ever having children! Our beautiful son is 22.
Happy ending? Well, yes and no. Not having the information about diet and fertility, we did not make the connection between that little diet attempt of mine and our getting pregnant. Stupid. Thus, we never went on to conceive any more children. And we had wanted a large family. My heart cries about that sometimes.
Especially now as my niece is struggling to get pregnant. I had to stick my nose in to her business and send her some info and tell her my story, but she doesn’t seem to be buying it. Mainstream health brainwashing is a powerful force.
Hi Jayne,
Thanks so much for sharing your story. I’m so happy to hear that following a low-carb diet helped regulate your hormonal balance and led to a healthy pregnancy! I’m sorry you weren’t able to have more children. Hopefully, your niece will come around.
Thank you for this incredible article. You are a blessing to the low carb community.
Thank you so much for your kind and supportive words, Ella!