Are
Polycystic Ovary Syndrome and Eating Disorders Related?
By Angela Grassi, MS, RD, LDN
Today’s Dietitian
Vol. 8 No. 10 P. 32
Life the age-old chicken and egg debate,
what comes first: the eating disorder or PCOS? Resarchers theorize
that disordered eating could lead to PCOS and vice versa.
The first time I heard of polycystic ovary syndrome
(PCOS) was in 1999 while working for an eating disorder treatment
facility. A patient named Sarah, age 27, tearfully explained
the symptoms she was experiencing: severe acne and hair growth
on her face, absent periods, thinning hair, and her weight had
been increasing nearly 2 pounds per month for the past year.
She hated her body and believed it was out of control. She had
been diagnosed with PCOS three weeks prior and her doctor recommended
that she try the Atkins diet to manage her insulin and lose
weight. Through the tears, Sarah admitted that she had tried
to follow the diet but just kept bingeing on carbohydrates and
felt so guilty afterward that she purged to get rid of them.
Sarah also had a long history of bulimia nervosa (BN).
What Is PCOS?
PCOS is perhaps the most complex endocrine disorder, affecting
5% to 10% of reproductive-age women, and is the No. 1 cause
of infertility.1 It is characterized by high levels of androgens
(male hormones such as testosterone) from the ovaries as well
as elevated follicle-stimulating hormone (FSH) and low levels
of luteinizing hormone (LH). Tiny cysts, hence, “polycysts,”
usually, but not always, surround the ovaries, appearing on
ultrasound as a strand of pearls. The cysts are a result of
hormonal imbalances, not the cause of them.
An estimated 50% to 70% of women with PCOS are
also insulin resistant and experience weight gain in the abdominal
area, difficulty losing weight, hypoglycemic episodes, and intense
cravings for carbohydrates.2,3 In addition, many women with
PCOS are overweight or obese and are at risk for developing
diabetes and heart disease. Other signs and symptoms of PCOS
may vary among individuals both in intensity and type and include
excessive hair growth on the face and body (hirsutism), alopecia,
acne, skin problems, and irregular or absent periods. Because
most of these signs and symptoms have a direct effect on body
image, not to mention struggles with weight and intense carbohydrate
cravings, many researchers have questioned the theory that a
relationship exists between PCOS and eating disorders.
Menstrual Disturbances
It is widely accepted that women with eating disorders, including
anorexia nervosa, BN, or a combination of several symptoms of
eating disorders commonly referred to as eating disorder not
otherwise specified (EDNOS), have menstrual disturbances.4-6
And much like with PCOS, these menstrual disturbances include
anovulation and oligomenorrhea (menstrual cycles longer than
40 days).7
In a recent study, researchers examined the
hormonal dysfunctions associated with improper eating habits
among 14 subjects with BN and 22 subjects with EDNOS.7 They
found decreased levels of FSH and LH among both groups, and
the EDNOS group had the lowest levels of the two hormones as
well as higher amounts of testosterone than subjects in the
control group. The researchers suggest that a reason why many
women with BN and EDNOS may have menstrual disturbances is related
to low levels of LH, which is a sensitive variant affected by
dramatic changes in eating habits.7 Thus, crash dieting or restricting—common
behaviors for individuals with BN and compulsive eating habits—may
cause low levels of LH, resulting in an insufficient luteal
phase and producing oligomenorrhea or anovulation.
The Emotional Toll
Like my patient Sarah, the symptoms many women with PCOS endure
can have a direct effect on their body image and self-esteem
and may lead to the development of distorted eating habits or
eating disorders.8 Although there does seem to be a genetic
component to PCOS development, with studies indicating that
some girls are even born with cysts on their ovaries, most symptoms
do not appear until the onset of puberty—another factor
in common with eating disorders.9
For example, at a time when a young woman’s
self-esteem is vulnerable, she may start to experience acne,
excessive hair growth on her face and other parts of her body,
and weight gain in her midsection—setting her apart from
her peers. Not knowing she has PCOS or why her body is reacting
the way it is, she may begin to blame herself and hate her body.
Struggling with these issues at such a vulnerable time can lead
many young women to deal with emotional distress through unhealthy
dieting practices such as taking laxatives and diet pills, fasting,
and engaging in excessive exercise and vomiting—all of
which could set the stage for a lifetime of eating issues and
body hatred.
Researchers have investigated the relationship
between monozygotic and dizygotic twins with PCOS and BN by
using the BITE (Bulimia Investigation Test, Edinburgh) questionnaire,
a self-rating scale used to diagnose BN that includes 30 questions
about dieting and binge behaviors such as, “Does your
pattern of eating severely disrupt your life?” “Do
you ever experience overpowering urges to eat and eat?”
and “Do you ever fast for a whole day?”10
They found that 76% of twins with PCOS had elevated
scores on the BITE, suggesting that a relationship does exist
between BN and PCOS. Other studies conducted using the BITE
questionnaire support a relationship between PCOS and binge
eating, with one third of women with PCOS in one study having
binge eating behavior.11
Jessica Setnick, MS, RD, LD, creator of Eating
Disorders Boot Camp and a specialist in eating disorder treatment,
has noted the connection between binge eating and PCOS. She
says, “Many women with PCOS are so frustrated with their
diagnosis. They feel immense pressure because they really want
to lose weight and improve their symptoms, so they’ll
restrict carbohydrates in order to lose weight.” But,
she adds, “sometimes they eat such little amounts of food
and, combined with their carbohydrate cravings, they end up
bingeing and feeling even more horrible about themselves.”
Thus, a vicious cycle ensues.
In addition, women with PCOS, because of their
hormonal imbalances, may be more prone to mood swings and depression
than women without PCOS. Elevated testosterone may make women
with PCOS more aggressive, angry, anxious, and depressed, but
many women with PCOS may also have mood disturbances from dealing
with the symptoms associated with their diagnosis.12 Codiagnosis
of other mental health problems is common among people with
eating disorders.
The Insulin Effect
It is understandable that women with PCOS may become more susceptible
to developing an eating disorder and suffer from body image
disturbances, but can women with eating disorders develop PCOS?
Researchers have proposed that insulin may have
an appetite-stimulating effect and can perpetuate binge behavior.4
For example, during an eating binge when large quantities of
food are consumed over a relatively short amount of time, there
is a surge of excess insulin—much more than experienced
during a normal meal. Constant bingeing could, therefore, result
in a chronic state of elevated insulin and when insulin levels
become elevated, androgen levels can become elevated as well.4
As a result, women with PCOS who engage in binge eating will
further increase insulin levels and cause a worsening of their
PCOS symptoms.
Researchers have investigated whether women
with BN are insulin resistant and examined the relationship
between insulin and androgen levels, ovarian morphology, and
severity of bulimic behavior.4 Although their study did not
find that women with BN had insulin resistance, they did find
that they were chronically hyperinsulinemic, with 10 of 12 normal
weight subjects having polycystic ovaries.4 This leads researchers
to speculate that hyperinsulinemia may be one reason why BN
and PCOS are connected, with the bulimic pattern of bingeing
followed by starvation and/or vomiting perpetuating the insulin
response and leading to the development of polycystic ovaries.4
It may also suggest why some women who are overweight or obese
develop PCOS through overfeeding.
There is some encouraging news: It appears that
when women with PCOS and BN can return to normalized eating
patterns with treatment involving cognitive behavioral therapy,
it can result in improved ovarian morphology.6 Thus, chronic
bingeing can worsen the appearance of polycystic ovaries, but
ovarian morphology does seem to resolve when bingeing ceases
and normal eating patterns are established.
The Cholecystokinin Connection
New research suggests that women with PCOS also have impaired
secretion of the hormone cholecystokinin (CCK), resulting in
a reduced feeling of satiety.3 CCK is released from the small
intestine in response to the presence of food and plays an important
role in regulating appetite. It was previously believed that
women with BN also have impaired CCK secretion, which could
also explain the tendencies of women with PCOS, BN, or EDNOS
to crave sweets, binge eat, or be overweight because of their
impaired ability to feel full.13 It is not known why women with
PCOS have impaired CCK secretion following meals, but researchers
have suggested that like individuals with BN and diabetes, women
with PCOS may have delayed gastric emptying.3
Nutrition and Lifestyle
Management
Although studies are lacking on the best dietary and lifestyle
treatments for PCOS, the most commonly agreed upon recommendations
to improve insulin levels and other symptoms in PCOS are to
consume a diet low to moderate in carbohydrates with an emphasis
on low-glycemic index foods and to engage in regular exercise.2
However, because women with PCOS may be more prone to binge
eating, it is imperative that dietitians screen patients with
PCOS for eating disorders first before recommending dieting
or changes in eating behavior. Effective questions to ask during
the initial assessment include the following:
• “How do you feel about your weight?”
• “Do you ever feel out of control
with food?”
• “Are you able to tell when you
are physically satisfied with food or full?”
• “How do you feel about eating
foods containing carbohydrates?”
• “Have you ever dieted, vomited,
or taken laxatives or diuretics to control your weight?”
If you suspect the client may have an eating
disorder, your first focus should be to help her normalize eating
patterns to control insulin levels and prevent bingeing and
weight gain. Even without weight loss, ovarian morphology and
insulin levels may improve by the restoration of normal eating
patterns.6 Clients need to be educated on the importance of
eating regular meals and snacks throughout the day to stabilize
blood sugar levels and prevent cravings and hypoglycemic episodes.
This may include eating every three to five hours with the addition
of at least one to two protein exchanges with meals and snacks.2
In addition, I have noticed that many clients with PCOS who
take insulin-lowering medications such as Metformin or Avandia
report little or no hypoglycemic episodes, less carbohydrate
cravings, and reduced interest in food overall.
“Dieting is a losing battle with PCOS,”
says Setnick, “as patients have to cut back drastically
in comparison to their peers in order to achieve any weight
loss.” And because of their struggles in maintaining weight
through dieting, many women with PCOS may have lost their internal
ability to regulate food. For example, they may not be able
to effectively distinguish when they are hungry, which could
result in unnecessary eating or waiting long periods to eat.
Or, if they do use food to cope with emotions, perhaps they
are unable to distinguish when they are physically satisfied
with food, leading them to eat more than they need.
Part of establishing lifelong normalized eating
patterns should involve education on self-care and mindful eating.
The use of food logs to rate hunger and satisfaction levels
before and after meals can be an effective technique for promoting
self-awareness in addition to conscious eating exercises used
with clients in nutrition sessions and at home.
Most of all, women struggling with PCOS and
eating disorders need to learn effective ways to deal with their
emotions without abusing food. Dietitians can help clients identify
possible alternative coping skills other than food and should
support clients to apply these new skills in their life.
For example, I encourage my clients to make
a list of things they can do when they have urges to binge,
such as walking, reading, writing in a journal, calling a friend,
surfing the Internet, or taking a bath. Clients are encouraged
to apply some of the activities on the list to overcome urges
and find the ones that work best for them. In addition, working
with a psychotherapist may help individuals identify their emotional
triggers and encourage mindfulness and behavior change.
Once normalized eating patterns have been established
and clients are able to respond to internal cues of hunger and
satiety without using eating disorder symptoms, further recommendations
on diet and exercise may be advised with caution and should
focus more on continuing to improve metabolic fitness rather
than weight loss.14,15
— Angela Grassi, MS, RD, LDN, is a
speaker, an author, and a consultant in Haverford, Pa. She specializes
in polycystic ovary syndrome and eating disorders and is currently
working on her first book, The Dietitian’s Guide to PCOS.
Visit her Web site at www.pcosnutrition.com.
References
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