Top Clin Nutr

Vol. 34, No. 1, pp. 14–30

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ORIGINAL RESEARCH
Polycystic Ovary Syndrome,
Fertility, Diet, and Lifestyle
Modifications
A Review of the Current Evidence
Melinda Boyd, DCN, MPH, MHR, RD;
Jane Ziegler, DCN, RD, LDN

Polycystic ovary syndrome (PCOS) is a complex metabolic disorder impacting women of repro-
ductive age. Globally, PCOS is estimated to impact 5% to 18% of the female population. Diagnosis is
based on various characteristics, including hyperandrogenism, ovulatory dysfunction, and polycys-
tic ovaries. Given the involvement of female reproductive organs, PCOS impacts fertility. Currently,
there are no evidence-based guidelines for dietary management. The purpose of this article is to
describe PCOS, the role it plays in fertility, and the management of the disease through diet and
lifestyle modification. Key words: fertility, nutrition, ovulatory dysfunction, PCOS, polycystic
ovary syndrome

impact 5% to 18% of the female population.6,7

P OLYCYSTIC OVARY SYNDROME (PCOS)
is the most common metabolic and en-
docrine disorder impacting women of repro-
ductive age.1-6 Globally, PCOS is estimated to
Author Affiliation: Department of Nutritional
Sciences, School of Health Professions, Rutgers
University, Newark, New Jersey.
The authors thank Dr Mindy Christianson, Division of
Reproductive Endocrinology and Infertility, Johns Hop-
kins University School of Medicine, for her mentorship
and support with the case study and focus on polycys-
tic ovary syndrome (PCOS) during the authors’ clinical
nutrition residency rotation. The authors also thank
Dr Adrian Dobs, Division of Endocrinology, Diabetes,
and Metabolism, Johns Hopkins University School of
Medicine, for her guidance and support in arranging
rotations and learning experiences related to PCOS.
The authors have disclosed that they have no signif-
icant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Melinda Boyd, DCN, MPH, MHR, RD,
Department of Nutritional Sciences, School of Health
Professions, Rutgers University, 65 Bergen St, Stanley
S. Bergen Bldg, Rm 149, Newark, NJ 07107 (melinda
.jill.boyd@gmail.com; melinda_seff@yahoo.com).
DOI: 10.1097/TIN.0000000000000161
14
PCOS is a complex disease with multiple
metabolic implications. Despite an increase in
research and recognition of the condition, the
pathophysiology remains somewhat unclear.8
One relatively well-accepted component that
plays a role in the development of PCOS is
insulin resistance (IR).2,8 It is believed the eti-
ology of IR is post–insulin receptor defects.8
A lack of phosphorylation at insulin recep-
tor β results in IR and when occurring at
P450c17 the result is hyperandrogenemia.8
Another possible cause is that IR results in
hyperinsulinemia.5 In turn, it is the hyperin-
sulinemia that produces ovarian dysfunction.5
Through stimulation of the production of
androgens in the ovaries by elevated levels
of insulin in the blood, ovulatory func-
tion is suppressed.9 An excess of luteiniz-
ing hormone, reduced secretion of follicle-
stimulating hormone, and the secretion of
gonadotropin hormone contribute to ovula-
tory dysfunction.9 An additional theory on
the etiology of reproductive dysfunction in
PCOS is “that an internal defect on ovarian

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 Polycystic Ovary Syndrome, Fertility, Diet, and Lifestyle Modifications
theca cells is the primary underlying cause of
hyperandrogenism.”10(p39)
Obesity is a known risk factor for de-
veloping PCOS5 ; however, not all patients
with PCOS are obese2 as PCOS can be
seen in both obese and lean phenotypes.
There is a greater risk for the development
of metabolic abnormalities in women with
PCOS who are classified as obese.11 In the
absence of obesity, women diagnosed with
PCOS remain at greater risk for developing
metabolic syndrome compared to women
without PCOS.2,5,8 Similar to metabolic syn-
drome, PCOS results in a clustering of
metabolic risk factors, including increased
risk for developing type 2 diabetes mellitus
and cardiovascular disease.8,11
Echiburú et al3 found that in their sample
of women with PCOS compared to women
without PCOS (n = 289), those with PCOS
had a higher rate of metabolic syndrome
throughout their reproductive years.3 No dif-
ferences were noted in the prevalence of
metabolic syndrome once the women en-
tered perimenopause.3 In a study of obese and
nonobese patients with PCOS (n = 115), pa-
tients classified as obese were more likely to
have menstrual irregularity and infertility (P =
.004 and P = .063, respectively).2 There were
no differences between obese and nonobese
subjects in the common hyperandrogenism
indicators of acne, hirsutism, and alopecia.2
Results from this study indicated that women
with PCOS and a higher waist circumference
with a subsequently higher waist to hip ratio
were more likely to have metabolic syndrome
and develop fatty liver disease.2
Psychological concerns, including depres-
sion and anxiety, are also more prevalent in
women with PCOS than those without this
condition.12 These are attributed to poor body
image resulting in low self-esteem13 and con-
cerns about fertility when attempting to start
a family.10 Anxiety and depression are more
likely to occur in cases where the diagnosis
of PCOS took longer to be made.12 Other fac-
tors associated with depression identified by
Deeks et al12 included low self-evaluation of
their appearance using the Multidimensional
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15
Body-Self Relations Questionnaire, low self-
worth, and less importance placed on fitness.
Binge eating has also been noted as commonly
occurring in women with PCOS.10
The purpose of this article is to describe
PCOS, the role of PCOS in fertility, and
the management of PCOS through diet and
lifestyle modification. This article also aims to
bring awareness to the lack of research spe-
cific to diet, nutrition, and PCOS. A systematic
approach to literature review was not utilized.
Initially, findings from search queries yielded
limited results for articles specific to PCOS
and diet or PCOS and nutrition. The litera-
ture search was conducted, and once articles
specific to diet or nutrition and PCOS were lo-
cated, those reference pages were reviewed
to help identify additional relevant articles.
Studies including diet interventions targeting
PCOS management were included in the re-
view. Inclusion criteria also included studies
from any country; however, the search was
limited to only those published in English. The
search was then generalized to all articles on
PCOS, with a specific focus on the topics of
pathophysiology, diagnosis, and medical man-
agement. Additionally, a published book on
the topic of PCOS and diet was reviewed for
content and references related to medical nu-
trition therapy for PCOS.
DIAGNOSTIC CRITERIA
There are currently 3 sets of criteria used in
diagnosing PCOS. These include the National
Institutes of Health criteria (1990, which
require clinical and/or biochemical hyperan-
drogenism and ovulatory dysfunction), the
Rotterdam criteria (2003), and the Androgen
Excess and PCOS Society criteria (2006).
Although the Rotterdam criteria are generally
accepted, the American Association of Clini-
cal Endocrinologists and American College of
Endocrinology (AACE/ACE) state in their re-
port on best practices in evaluating PCOS that
the Androgen Excess Society guidelines may
better indicate the pathogenesis of PCOS.1
These guidelines include the use of clinical or
16 TOPIC IN CLINICAL NUTRITION/JANUARY–MARCH 2019
biochemical hyperandrogenism as a primary
indicator of the disease, with less focus on
polycystic ovary morphology (PCOM).1 Free
testosterone levels are the standard mea-
surement used to assess hyperandrogenism.1
Variations exist in reference values for testos-
terone, and there is no uniform technique
used in measuring free testosterone; there-
fore, it is recommended to use a specialty
laboratory for the analysis of testosterone.13
As a result of differences in assays for total
plasma testosterone, a wide range of 70 to
90 ng/dL has been accepted as the normal
cutoff point in females.13
For other diagnostic tools, the use of
transvaginal ultrasound is considered the
standard method for identifying PCOM.1
Additional biochemical tests used in the
diagnosis of PCOS include serum 17-hydroxy-
progesterone and anti-Müllerian hormone.1
Clinical signs noted on examination that are
indicative of PCOS include hirsutism, acne,
and alopecia.1 These are all clinically signif-
icant signs to indicate hyperandrogenism.1
Unresolved acne in adulthood is also an
indicator of PCOS.10 The prevalence of
hirsutism in women with PCOS has been
estimated around 72%.10 Hirsutism is assessed
using the Ferriman-Gallwey Scoring System.13
The measurement is based on assessing
hair growth in 9 body locations that are
associated with higher levels of androgens.13
Acanthosis nigricans observed during the
physical examination may be an indicator
of IR10 and warrants the need for further
biochemical testing to help in the diagnosis
process. Acanthosis nigricans alone is not
a diagnostic tool. Ovulatory dysfunction is
also typically noted in patients with PCOS.
Ovulatory dysfunction, as required for PCOS
diagnosis by the 3 sets of criteria, is generally
defined as an unpredictable menses occurring
at either less than 21-day intervals or greater
than 35-day intervals.9
Symptoms often occur early in the repro-
ductive years. Young women may use oral
contraceptive medications to help regulate
their irregular menstrual cycle. This can re-
sult in inadvertently treating the symptoms of
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PCOS10 and result in the delay of a correct
diagnosis of PCOS made at this developmen-
tal stage. As some of the symptoms noted in
PCOS also coincide with normal symptoms
of puberty, diagnosing PCOS in adolescence
can be more challenging.9,10 It is important
to make the diagnosis early since this stage
of development is where PCOS patients typ-
ically begin to have weight gain.1 Early diag-
nosis and management also reduce the risk of
metabolic comorbidities in adulthood.1
IMPACTS ON FERTILITY
PCOS is reported to be “the most common
cause of anovulatory infertility.”9(p54) The clas-
sical appearance of a polycystic ovary is re-
lated to an accelerated early follicular growth
with the failure of a dominant follicle to
develop.10 This results due to an imbalance of
follicle-stimulating hormone, luteinizing hor-
mone, and androgens, which are all involved
in regulating ovulation.10 Fertility specialists,
specifically those with expertise in reproduc-
tive endocrinology, can help in the manage-
ment of infertility in patients with PCOS.
Obesity, a common clinical feature in
PCOS, has been implicated in the develop-
ment of infertility due to the role of obe-
sity in ovulatory dysfunction.10,11 A minimum
weight loss of 5% can result in improved re-
productive function.5,11 It is recommended
that women with PCOS work toward a healthy
weight and adopt healthy lifestyle changes be-
fore becoming pregnant.6,8,10 Although it is
common for PCOS to be a cause of infertility,
assessment of infertility should include inves-
tigation of all possible causes in both males
and females.8
It is important to note that while obesity
is a major contributing factor to infertility,
other nutrition factors can play a role in fertil-
ity and should be considered in the manage-
ment of a patient with PCOS. Chavarro et al14
studied the dietary intake of a large cohort
of women diagnosed with infertility to deter-
mine whether dietary patterns played a role in
fertility. Data collection involved self-report of
 Polycystic Ovary Syndrome, Fertility, Diet, and Lifestyle Modifications
intakes using a validated food frequency ques-
tionnaire. Scores for a “fertility diet” were de-
veloped using dietary factors previously stud-
ied that impact fertility.14 Higher “fertility
diet” scores were those reported to be low
in trans fat and animal protein consumption
while high in fiber, vegetable-based protein
sources, nonheme iron sources, and high-fat
dairy products.14 Women with dietary pat-
terns more closely related to the “fertility diet”
were found to have a lower risk of ovulatory
disorder fertility.14 Higher body mass indexes
(BMIs) were also associated with infertility.14
The authors concluded that there are di-
etary modifications that can improve fertility,
including consumption of low glycemic in-
dex, high-fiber carbohydrates, and vegetable
protein sources in place of animal protein
sources.14
TREATMENT
Obesity is not a defining factor in PCOS;
however, a majority of women diagnosed
with PCOS are classified as obese. At least 50%
of PCOS cases occur in women who are clas-
sified as obese.11 The AACE/ACE guidelines
present weight loss as the primary treatment
option in women with PCOS to help regulate
menses.1 Weight loss has also been shown to
improve insulin sensitivity.5,10 These are both
significant benefits to ensuring obese patients
with PCOS are provided with the tools and
support needed to achieve weight loss. Many
women with PCOS struggle with attempts
at weight loss and may require medications
to assist in the process6 even when utilizing
dietary and lifestyle modifications. Metformin
acts 2-fold in the process by helping control
blood glucose and aiding in weight loss.9
Moreover, the risks associated with met-
formin remain less compared with other
insulin-sensitizing medications.8 A reduction
in testosterone levels is an additional benefit
from metformin use.10 Lastly, hirsutism can
worsen with weight gain1 ; therefore, weight
loss may help with improving this symptom of
PCOS.15
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17
Additional treatment options for managing
symptoms of PCOS include oral contraceptive
medications and spironolactone. Oral contra-
ceptives should be used in women with PCOS
who are not looking to become pregnant.9 In
patients experiencing irregular menses who
feel they may not need this medication as a
method of birth control, oral contraceptives
should still be considered for other treatment
reasons.9 Beyond the typical use for contra-
ception, these medications provide multiple
benefits to women with PCOS, including regu-
lation of menstruation, improvements in acne,
and decreased risk of developing endometrial
hyperplasia.9 Oral contraceptive medication
choice should be carefully evaluated due to as-
sociated risks. Some oral contraceptive medi-
cations may exacerbate glucose intolerance.16
These medications also have the potential to
worsen dyslipidemia, a common comorbidity
in PCOS.16 Furthermore, there is an increased
risk of myocardial infarction in women who
smoke and use oral contraceptives.16 Spirono-
lactone is used to treat hirsutism as it is an
androgen-receptor agonist.9 Spironolactone is
a known teratogen; therefore, it should only
be used in women actively using methods
of birth control to prevent pregnancy.10 Met-
formin is another potential medication for use
in PCOS. It has been shown to decrease serum
testosterone levels and helps in the treatment
of IR.9 Lastly, in women actively trying to con-
ceive, clomiphene can be used to assist in
ovulation induction.9
DIETARY AND LIFESTYLE MANAGEMENT
Dietary and lifestyle modifications are typ-
ical treatment recommendations for women
with PCOS.11 However, a lack of research to
support specific evidence-based intervention
guidelines has resulted in more general guid-
ance used in managing this condition. Diet
and lifestyle modifications help with weight
loss in an effort to improve metabolic symp-
toms of PCOS and fertility, but as an added
benefit, diet modifications in overweight and
obese women with PCOS have been shown
18 TOPIC IN CLINICAL NUTRITION/JANUARY–MARCH 2019
to improve depression.17 A Cochrane review
of the effects of lifestyle modification in
women with PCOS found that modifications
for a healthy lifestyle resulted in reductions in
body weight, abdominal fat, and testosterone
levels.4 The reduction in testosterone levels
resulted in hirsutism improvement and de-
creased IR.4
Various diet modifications have been
studied as treatment modalities for PCOS
(Table).4,15,18-21 Despite results from studies
utilizing dietary modifications to show im-
provements in the metabolic components of
PCOS and a decrease in weight, small sam-
ple sizes and a lack of comparison with a
control group make it difficult for a consen-
sus to be reached for best practices. Stud-
ies have looked at varying combinations of
macronutrients,18-20 as well as the restriction
of calories,15,20,23 in the pursuit of weight loss
and improvements in laboratory values related
to metabolic abnormalities seen in PCOS.
Phy et al18 conducted an 8-week interven-
tion (n = 24) of women with PCOS using a
low-starch/low-fat dairy diet to assess changes
in PCOS-related laboratory parameters. A di-
etitian provided the initial dietary education.
Participants were instructed on dietary proto-
cols, including use of lean meats, nonstarchy
vegetables, and fruits determined by the re-
searchers to be low in sugar. Additionally,
participants were instructed to consume fat
sources rich in monounsaturated fats and to
include coconut oil if desired, with no limit set
on calorie intake. Exclusions included dairy
(except 1 oz of full-fat cheese daily), all grains,
legumes, high-fructose corn syrup, and natu-
ral sweeteners. The rationale for dietary exclu-
sions was to eliminate foods known to have
insulinemic properties. Participants were told
to eat until they were satisfied and were not
instructed to count calories or amount of car-
bohydrate consumed. Results at the conclu-
sion of the 8-week period showed a statis-
tically significant decrease in weight, BMI,
waist circumference, and waist-to-height ra-
tio (P < .0001). Fasting glucose values were
also significantly decreased (P = .01). Addi-
tional decreases were noted in fasting and
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2-hour insulin levels. No changes were noted
in blood glucose values 2 hours postprandial
and there was a 0.3% ± 0.3% decrease noted
in hemoglobin A1c (HbA1c , P = .001). Triglyc-
erides were also decreased significantly
(P < .0001).
Gargari et al19 conducted a case-control
study in Iran comparing dietary macronutri-
ent intakes of women with PCOS (n = 30) and
women with PCOS that were matched for age
and BMI (n = 30). A combination of 3-day food
diaries, food frequency questionnaires, and a
24-hour recall was used in collecting dietary
data. Although dietary data were collected us-
ing self-report methods, interviewers did re-
view all dietary information with subjects to
confirm information and obtain more detail
on recipes for foods consumed and serving
sizes. Additionally, interviewers used prob-
ing questions to help identify possible miss-
ing items from the self-reported data to im-
prove accuracy. Results showed women with
PCOS were eating fewer calories than women
without PCOS (P < .05). Ghrelin, which is
known to increase appetite, was assessed in
both groups, with no statistically significant
relationships found between ghrelin and di-
etary macronutrient intake for either group.
Leptin appears to play a role in the regula-
tion of reproduction-related hormones, such
as follicle-stimulating hormone and luteiniz-
ing hormone.19 Results from this study found
higher saturated fat intake inversely corre-
lated with leptin levels in women with PCOS.
No statistically significant relationships were
noted in the control group.
Salama et al20 studied overweight and
obese women (n = 75) diagnosed with PCOS
and the role of an anti-inflammatory diet for
management of metabolic outcomes. This
12-week trial utilized a low glycemic in-
dex Mediterranean-style diet and excluded
foods determined as inflammatory by the re-
searcher. The anti-inflammatory diet was de-
scribed as including 2 g of protein along with
3 g of carbohydrate for every gram of fat con-
sumed. To follow this principle, diets were
prescribed as 50% of calories from carbohy-
drate, 25% of calories from fat, and 25% of
 Table. Summary of Polycystic Ovary Syndrome and Diet Interventions
Author, Year, Country,
Study Design Intervention/Study Parameters
Papakonstantinou et al22 - Weight maintenance diet: 40% carbohydrate, 25% protein,
(2016), Greece, 35% fat.
randomized crossover - Intake set as a 3 meals or 6-meal pattern.
(n = 40) - Participants followed one of the meal patterns for 12 wk and
then changed to the other pattern (3 or 6 meals/d).
- Meals were those food intakes consisting of at least 150 kcal
and at a time of day typically associated with a meal.
- Snacks were food intakes less than 150 cal.
- Carbohydrate intake was split as 20% at breakfast, 50% at
lunch, and 30% at dinner for the 3-meal pattern and 20% at
breakfast, 10% at morning snack, 30% at lunch, 10% at
afternoon snack, 20% at dinner, and 10% at the bedtime
snack for the 6-meal pattern.
- Participants were told to maintain their current activity level.
- Diet intake was recorded and analyzed for adherence to
Mediterranean diet patterns.
- No calorie level appears to have been prescribed; however,
there was a sample meal plan provided for 1900 cal.
Phy et al17 (2015), USA, - Subjects followed a low-starch/low-fat dairy diet.
prospective dietary - Instruction on study diet guidelines provided by RD during a
intervention (8 wk) 2-h individual intensive education session.
(n = 24) - Diet instruction included lean sources of animal protein,
eggs, fish, shellfish, nonstarchy vegetables, fruits classified by
the researcher as “low-sugar fruits” (berries, apples, oranges,
plums, etc), olive and coconut oil, avocado, olives, nuts,
seeds.
- 6 oz of red wine daily allowed for subjects over 21 y.
- Only 1 oz of full-fat cheese per day.
- The diet excluded grains, beans, all other dairy, sugar (all
added forms, including honey), and fruit juice from
concentrate.
- Nondairy fortified milk alternatives could be used as a source
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
of calcium.
Results
- Total calorie intake was similar between the
2 groups.
- Macronutrient intakes in grams total for the day
were similar between the 2 groups.
- No statistically significant differences between the
groups on measurements of hunger, satiety, and
desire to eat; however, there were slight
decreases in huger and desire to eat in the 6-meal
pattern group.
- There were no statistically significant changes in
weight or BMI in either group.
- The 6-meal pattern appeared to have a beneficial
impact on insulin sensitivity measured during an
OGTT.
- No statistically significant differences were found
from either meal pattern on changes in HDL, DLD,
triglycerides, HbA1c , and fasting glucose.
- Statistically significant changes found in (mean
changes from baseline to 8 wk shown as follows):
• Weight (−8.6 kg ± 2.3)
• BMI (−3.2 kg/m2 ± 0.9)
• WC (−8.4 cm ± 3.1)
• WHR (−0.05 ± 0.02)
• Fasting glucose (−8.9 mg/dL ± 17.1)
• Fasting insulin (−17.0 μg/mL ± 13.6)
• HOMA-IR (−1.9 ± 1.2)
• HgbA1c (−0.3% ± 0.3)
• HDL cholesterol (−5.7 mg/dL ± 9.1)
• Triglycerides (−57.0 mg/dL ± 9.1)
Polycystic Ovary Syndrome, Fertility, Diet, and Lifestyle Modifications
• Total testosterone (−10.0 ng/dL ± 17.0)
• Ferriman-Gallwey score (−2.1 ± 2.7)
19
(continues)
 Table. Summary of Polycystic Ovary Syndrome and Diet Interventions (Continued)
Author, Year, Country,
Study Design
Gargari et al19 (2015), Iran, - Food frequency questionnaires and 24-h recalls were
case-control study
(n = 30 cases, n = 30
controls)
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Intervention/Study Parameters
- Instruction included that participants weren’t to count
their calories and instead just eat until they were
satisfied, without overeating.
- Instruction included not changing exercise routine.
- All study parameters measured at baseline and again at
8 wk. They did not interact with the dietitian after the
initial education session.
- Diet compliance monitored with the submission of 3-d
food records collected on Thursday-Saturday of weeks
1, 4, and 7.
- Only an intervention group, no control group used to
compare differences.
used to collect dietary information from all subjects.
- Analysis of diets included protein, total fat, saturated
fat, monounsaturated fat, polyunsaturated fat,
carbohydrates, and fiber.
- Anthropometric and biochemical data collected on all
subjects.
Results 20
- Study did not assess improvements in fertility, although
the majority of subjects were hoping to become pregnant
following the study.
- Although they were not instructed to restrict calories and
instead focus on eating until they were satisfied, the food
record analysis showed a mean energy intake of
1422 kcal/d ± 199.
- Mean carbohydrate intake was 94.3 g/d ± 22.8.
- No statistically significant differences were noted
between the cases and controls in weight or BMI.
- Women with PCOS were more likely (statistically
significant) to have elevated leptin, insulin, total
testosterone, sex hormone binding globulin, and
luteinizing hormone compared to the controls.
- Diet analysis showed:
TOPIC IN CLINICAL NUTRITION/JANUARY–MARCH 2019
• Women with PCOS were consuming fewer calories
(1334.9 kcal/d ± 143.4 compared to 1716.1 kcal/d ±
142.07; P < .05).
• Carbohydrate intake was lower, but this was not
statistically significant (171.6 g/d ± 9.3 compared to
222.57 g/d ± 20.4).
• Although women with PCOS were consuming less of all
3 macronutrients, the percentage of these as calories in
the diet was not statistically significant and the values
were similar (carbohydrate ∼51% in both groups,
protein ∼15% in both groups, fat ∼33%-34% in both
groups).
- In women with PCOS, there was a statistically significant
inverse relationship between dietary intakes of fat,
specifically saturated fatty acids, and leptin concentra-
tions. Ghrelin was not impacted by dietary intakes.
(continues)
 Table. Summary of Polycystic Ovary Syndrome and Diet Interventions (Continued)
Author, Year, Country,
Study Design Intervention/Study Parameters
Salama et al20 (2015), - Nonpregnant, overweight women aged 20-40 y diagnosed
Egypt, quasi- with PCOS using the Rotterdam criteria were included.
experimental trial - Lifestyle intervention described as hypocaloric diet coupled
(n = 75) with a physical activity intervention. Study lasted 12 wk and
measurements were taken every 2 wk in the clinic.
- The diet intervention included a Mediterranean-inspired diet
with low glycemic load foods, along with foods the
researchers determined had anti-inflammatory properties.
- Diet included legumes, fish, and low-fat dairy to be similar to
a Mediterranean diet.
- Diet composition of macronutrients as a percentage of total
calories was prescribed as 25% protein, 25% fat, and 50%
carbohydrate.
- Energy needs were calculated using the Institute of Medicine
predictive energy equation and then subtracting 500 cal for
energy restriction (hypocaloric diet intervention).
- Meal plans were designed using Diabetic Exchange list
patterns and options available included plans ranging from
800 to 2000 cal in 200-cal increments.
- Carbohydrates were evenly spaced throughout the course of
the day.
- Red meat restricted to intake once every other week.
- Chicken was to be included weekly and fish was to be
consumed at least twice per week.
- Five meals, with 1 consumed every 3 h, was also part of the
instruction.
- Participants were given a list of herbs and spices culturally
recognized as having anti-inflammatory properties.
- Participants were instructed to drink 5 cups of green tea each
day.
- Exercise intervention included instructing participants to use
stairs for 30 min/d and another 30 min/d doing crunches or
sit-ups (done as 3 sessions of 10 min).
- No control group, so unable to compare the intervention
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outcomes and changes outside of those receiving the
treatment.
Results
- Statistically significant decreases after the 12-wk
intervention included:
• BMI (−7.1%)
• WC (−6.6%)
• Body fat percentage (−9.2%)
• Visceral fat area (−21.7%)
• Fasting blood glucose (−5.15%)
• Fasting insulin (−27.86%)
• HOMA (−27.5%)
• Free androgen index (−31%)
• Sex hormone binding globulin (−65.6%)
• Total cholesterol (−8.9%)
• LDL cholesterol (−10.6%)
• CRP (−35%; used as their inflammatory marker)
• Serum amyloid A (−38%, also used as one of
their inflammatory markers)
- Measurements in parameters of metabolic
syndrome were also compared from baseline to
12 wk. Significant improvements were seen with
less participants classified as having metabolic
syndrome after the study. The greatest
improvements were seen in WC (>88 cm, n = 60
at baseline and n = 43 after intervention) and
blood pressure (>130/85, n = 17 at baseline and
n = 2 after intervention).
- 63% of subjects regained their menstrual cycle;
12% became pregnant (spontaneously) at the end
of the intervention (based on the 58 participants
eligible to become pregnant based on multiple
factors).
Polycystic Ovary Syndrome, Fertility, Diet, and Lifestyle Modifications
21
(continues)
 Table. Summary of Polycystic Ovary Syndrome and Diet Interventions (Continued)
22
Author, Year, Country,
Study Design Intervention/Study Parameters Results

Moran et al21 (2015), - Dietary pattern analysis conducted on using FFQ data - Women with PCOS had a higher mean BMI than
cross-sectional study collected in 2009. those without PCOS (P < .001).
(secondary analysis of - FFQ included 100 different foods and these were placed into - Women with PCOS had a higher mean WC than
data from large-scale 33 different food groups based on a prior study in Australia of those without PCOS (P < .001).
longitudinal study), food pattern analysis. - No statistically significant differences in income or
Australia (n = 8200) - Subjects divided into women with PCOS (n = 414) and education level.
women without PCOS (n = 7155). - Dietary pattern analysis resulted in the
development of 3 distinct meal patterns: noncore
(cakes, cookies, sweets, refined grains, takeaway
foods, and chips); high meat and takeaway (fried,
processed, canned fish, processed meats, red
meat, high in takeaway foods); and Mediterranean
style (variety of produce, nuts, and a small
correlation with fish intake).
- Women with PCOS were more likely to have a
typical intake pattern matching a Mediterranean
TOPIC IN CLINICAL NUTRITION/JANUARY–MARCH 2019

style. The researchers concluded this could result

from those women seeking nutrition counseling
after diagnosis and knowing that a
Mediterranean-style diet has some benefits for
women with PCOS.
- Although they were more likely than women
without PCOS to consume a Mediterranean-style
diet, there were no differences between
consumption in the other patterns. Both groups
were also just as likely to consume noncore or
takeaway foods.
- Authors concluded that women with PCOS may
be more likely to make positive changes to their
diet to help impact their disease.
(continues)

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 Table. Summary of Polycystic Ovary Syndrome and Diet Interventions (Continued)
Author, Year, Country,
Study Design Intervention/Study Parameters
Marzouk and Sayed Weight loss group:
Ahmed15 (2015), - Participants attended 2 sessions on day 1 of the study.
randomized controlled - Sessions were in small groups with 6 participants each.
trial, Egypt (n = 60) - The first session included education on PCOS definition,
symptoms, complications, and role of weight loss in
management.
- The second session included instruction on dietary plan to
follow for the study duration. The diet was to start on the
following day and would be continued for 6 mo.
- Diet plans were individualized and based on energy needs
calculated via the Harris-Benedict equation with a reduction
of 500 cal/d for weight loss.
- Protein prescribed at 15-20% of caloric intake, fat was 30% of
caloric intake, and carbohydrate was 50-55% of caloric
intake.
- Meal plans included 3 meals per day and no snacks.
- Instructed to choose carbohydrate foods with a low
glycemic index, high fiber intake with increased fruits and
vegetables, and to drink at least 2 L of fluid per day
(permitted fluids, but these were not defined).
- Instruction included foods to decrease meat, cheese, fried
food, and caffeine.
- They were told to take a multivitamin.
- Sample meal plans and an instruction manual were provided.
Control group:
- Instructed on the same healthy diet guidelines as the
intervention group, but not given a meal plan with calorie
restriction.
- Food records were kept by both groups to check for
compliance.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Results
- Statistically significant differences found between
intervention group and controls, while these
variables were comparable at baseline: body
weight (P = .041), BMI (P = .028), WC (P =
.029), hirsutism score (0.013), menstrual episodes
in prior 6 mo (0.010).
- Mean weight changes (kg) in both groups from
baseline to 6 mo: intervention group 90.8 ± 13.3
at baseline to 83.7 ± 10.3 at 6 mo; control group
90.5 ± 13.2 at baseline to 90.1 ± 12.4 at 6 mo.
- Hirsutism score changes in both groups from
baseline to 6 mo: intervention group 18.8 ± 5.9 at
baseline to 14.6 ± 4.4 at 6 mo; control group
17.5 ± 5.5 at baseline to 18.2 ± 6.2 at 6 mo.
- Menstrual episode over prior 6-mo period
changes in both groups from baseline to 6 mo:
intervention group 2.4 ± 1.6 at baseline to
3.1 ± 1.2 at 6 mo; control group 2.2 ± 1.3 at
baseline to 2.3 ± 1.3 at 6 mo.
Polycystic Ovary Syndrome, Fertility, Diet, and Lifestyle Modifications
(continues)
23

Table. Summary of Polycystic Ovary Syndrome and Diet Interventions (Continued)
Author, Year, Country,
Study Design Intervention/Study Parameters
Johnson et al23 (2015), - Participants prescribed with a low-calorie, low-fructose diet
randomized controlled that included consumption of a whole-grain CB or liquid meal
trial, Norway (n = 51) replacement that was high in fructose (∼9 g per shake). Diets
were followed for an 8-wk period.
- LCD described as less than 1100 kcal/d.
- Those consuming shakes were given 8 per day.
- LMR diet included unlimited vegetable intake of low-fiber
vegetables (described as salads, cucumber, tomatoes, and
onions), less than 150 g of root vegetables, and 1 fruit serving
per day (5-10 g of fructose). Total fructose estimated at
85 g/d.
- CB diet included consumption of the crispbread along with a
diet low in fat and high in protein. The dinner meal was to
include a serving of lean meat, poultry, or fish with
vegetables, rice, pasta, or potatoes. They were allowed
unlimited vegetable intake and 1 serving of fruit. Total
fructose estimated at 17 g/d.
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24
Results
- Estimated nutrition in diets: CB—1095 kcal,
33.8% protein, 24.1% fat, 45.3% carbohydrate;
LMR—1072 kcal, 37.7% protein, 17.8% fat,
43.8% carbohydrate.
- Statistically significant changes after the 8-wk
intervention included:
• Weight: CB −9.6 kg; LMR −10.4 kg (P < .001)
• BMI: CB −3.4 kg/m2 ; LMR −3.7 kg/m2 (P <
.001)
• WC: CB −8.7 cm; −8.2 cm (P < .001)
• HbA1c : CB −0.24% (P = .001); LMR −0.26%
(P = .002)
TOPIC IN CLINICAL NUTRITION/JANUARY–MARCH 2019
- No statistically significant changes in hirsutism
score for either group.
- There were no statistically significant differences
in changes between the 2 groups for
anthropometric measures or biochemical
measures related to glucose metabolism.
- There was a decrease in prevalence of metabolic
syndrome for both groups after 8 wk; however,
this was not statistically significant.
(continues)
 Table. Summary of Polycystic Ovary Syndrome and Diet Interventions (Continued)

Author, Year, Country,

Study Design Intervention/Study Parameters Results
4
Moran et al (2011), - Included RCTs with comparison of a lifestyle intervention - Lifestyle interventions resulted in:
systematic review with a minimal treatment. • Reduction in total testosterone and fasting
(Cochrane) - Lifestyle intervention defined as dietary, lifestyle, or behavior glucose
modification; included those designed for weight loss with • Decrease in weight (mean 3.47 kg) and body fat
calorie restriction and those without. percentage (7%)
- Minimal treatment defined as no treatment, standard • Decrease in surrogate markers of IR
unstructured and limited advice given on diet, behavior, and - No effects of lifestyle intervention noted for
lifestyle. changes in:
- Comprehensive search conducted and after review 6 RCTs • OGTT and fasting glucose
met inclusion criteria. • Lipid profiles
- Inclusion criteria included PCOS diagnosis by Rotterdam
criteria, overweight, and being postmenarchal at least 1 y and
the age of 12 y at a minimum.
- Exclusion criteria included pregnancy, glucose intolerance,
type II diabetes, fasting hyperglycemia, oral contraceptive
use, certain medication use prior to study, certain chronic
diseases, limited exercise, smoking, and alcohol use.

Abbreviations: BMI, body mass index; CB, crispbread; cm, centimeter; CRP, C-reactive protein; DLD, dyslipidemia; FFQ, food frequency questionnaire; HbA1c , hemoglobin
A1c test; HDL, high-density lipoprotein cholesterol; HOMA, homeostatic model assessment; HOMA-IR, homeostatic model assessment of insulin resistance; IR, insulin
resistance; LCD, low-calorie diet; LDL, low-density lipoprotein; LMR, liquid meal replacement; OGTT, oral glucose tolerance test; PCOS, polycystic ovary syndrome; RCT,
randomized clinical trial; RD, registered dietitian; WC, waist circumference; WHR, weight-to-height ratio.
Polycystic Ovary Syndrome, Fertility, Diet, and Lifestyle Modifications

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
25
26 TOPIC IN CLINICAL NUTRITION/JANUARY–MARCH 2019
calories from protein. Increased monounsat-
urated fat intake within the 25% of calories
from fat was encouraged as part of a reduced
calorie diet. The researchers calculated en-
ergy needs using the Institute of Medicine
equation with a reduction of 500 kcal per
day for weight loss.20 Meal timing was set at
3-hour intervals with a total of 5 small meals
per day. Subjects were asked to drink 5 cups
of green tea and to include a variety of spices
and herbs reported in this culture to have
anti-inflammatory properties. At the conclu-
sion of 12 weeks, there were statistically
significant decreases in both BMI and waist
circumference (7.1% and 6.6%, respectively;
P < .001). Decreases in fasting blood glucose
and fasting insulin were also noted to have
statistically significant decreases (P < .001).
In addition to those metabolic improvements,
C-reactive protein, a marker of inflammation,
was also significantly reduced from baseline
at the completion of the study (P < .001).
Moran et al21 conducted a cross-sectional
study using data obtained from the Australian
Longitudinal Study on Women’s Health (n =
7569). The dietary intakes of women with
and without PCOS were analyzed, and di-
etary patterns were identified using a method
known as factor analysis. Three patterns
were identified using this technique. The re-
searchers named these as “noncore foods,”
“takeaway,” and “Mediterranean style.” The
identified dietary patterns from participants’
typical food intakes using a food frequency
questionnaire were used to determine charac-
teristics of eating habits in women with and
without PCOS. Women found to adhere to
the “Mediterranean-style” pattern were more
likely to have a diagnosis of PCOS. The au-
thors indicated this finding could suggest that
women with PCOS sought dietary guidance
after diagnosis and were already aware that
following a Mediterranean diet could help in
managing PCOS.
One potential contributor to the lack of
evidence-based nutrition guidelines for PCOS
is limited dietary intervention studies with
comparison of PCOS patients to a control
group. However, some studies have provided
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
positive guidance for meal planning to assist in
the management of PCOS. Papakonstantinou
et al22 conducted a randomized crossover trial
with 40 participants with PCOS comparing
2 different meal patterns and the impact on
blood glucose levels. The dietary intervention
was specific to glucose and insulin manage-
ment and not intended for weight loss. The
meal patterns included consuming 3 meals or
6 meals daily. When consuming 6 meals daily,
the subjects reported lower subjective hunger
than when consuming 3 meals daily. The
6-meal daily pattern also resulted in positive
results on participant’s post–oral glucose tol-
erance tests for insulin sensitivity when com-
pared to a 3-meal daily pattern.
Calorie restriction has been identified as
a successful means for weight loss. Weight
loss has been noted based on calorie restric-
tion alone and not necessarily related to diet
composition. Marzouk et al15 conducted a ran-
domized controlled trial in Egypt focused on
adolescent females diagnosed with PCOS (n =
60). A calorie-restricted diet intervention was
used to compare weight loss and PCOS symp-
tom improvement with a group focused on a
“healthy diet plan” without calorie restriction.
The intervention group was provided inten-
sive education over the course of 1 day. This
included intensive instruction on a calorie-
restricted diet determined with the use of
the Harris-Benedict equation (as determined
appropriate by the researchers) and then re-
duced by 500 cal per day.15 Macronutrient
goals were set at 50% to 55% carbohydrate,
15% to 20% protein, and 30% fat. Participants
were instructed to eat 3 meals daily. Choices
were to include low glycemic index foods, in-
cluding nuts, whole grains, and fruits, along
with vegetables to help ensure high fiber in-
take. Foods to decrease included those high
in saturated fat and fried foods. Sample meal
plans were provided to the calorie-restricted
group, which ranged from 1800 to 2300 cal.
The control group was instructed on the same
dietary modifications; however, they were not
instructed to follow a calorie-restricted plan.
After 6 months, statistically significant de-
creases were seen in weight, BMI, waist
 Polycystic Ovary Syndrome, Fertility, Diet, and Lifestyle Modifications
circumference, and hirsutism score, as well
as an increase in the number of menstrual
episodes between the calorie-restricted group
and the control group.14 Weight loss oc-
curred in 86.6% of females in the intervention
group and only 20% from the control group.
These results support the role of weight loss
for improvements in menstruation, which, in
turn, helps improve fertility. This also sup-
ports the role of a healthy diet in managing
PCOS, but weight loss, decreases in hirsutism,
and improvements in waist circumference are
greater when calorie restriction is used.
Johnson et al23 compared the intake of
a whole-grain crispbread as part of a low-
calorie, low-fructose diet with a traditional
low-calorie diet utilizing liquid meal replace-
ments high in fructose. Participants (n = 51)
were obese women diagnosed with PCOS.
Meal plans were followed for 8 weeks. Calo-
ries were restricted to less than 1100 kcal per
day. Those assigned to the meal replacement
group were instructed to include low-fiber
vegetables, less than 150 g of root vegetables,
and 1 piece of fruit daily. The diet plan was
developed to be low in fat and high in protein
for those participants in the crispbread group.
The dinner meal was controlled in terms of
portions and included a lean protein with veg-
etables and a starch, such as potato, pasta, or
rice. They were allowed 1 fruit serving per day
and unlimited vegetable intake. Both groups
lost weight and had decreases in waist circum-
ference at the end of the study.
There were no statistically significant dif-
ferences in weight loss or decreases in waist
circumference between the 2 groups at com-
pletion of the study. Decreases in total serum
cholesterol, low-density lipoprotein choles-
terol, serum glucose, prolactin, estradiol, and
free testosterone were noted, but there were
no statistically significant differences between
the 2 dietary interventions. The low-calorie
diet plans regardless of use of meal re-
placements or whole-grain crispbreads were
shown to improve weight and metabolic out-
comes in women with PCOS.23
Interventions will also vary for weight
loss depending on whether the individual
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
27
is seeking to improve fertility and become
pregnant.24 Hoeger11 suggests that women
seeking to improve fertility outcomes should
receive a nutrition consult to assist with meal
planning that provides a 500 cal deficit per
day with a weight loss goal set at 5% to 10%
over the course of 3 months.11 A reduction
of 500 cal per day from results of a predictive
energy equation has been demonstrated to be
adequate as a reduced calorie diet in women
with PCOS.15,20
At this time, there does not appear to be a
specific dietary modification that works best
for managing PCOS,11 including restricted car-
bohydrate diets, which may be used to min-
imize spikes in postprandial blood glucose.
Evidence is lacking to support extreme carbo-
hydrate reductions as there have been no in-
dications that symptoms improve more signif-
icantly than in a diet with moderate carbohy-
drate intake.11,24 Women with PCOS should
follow guidelines for a heart healthy diet and
focus on low glycemic index foods when
selecting carbohydrate choices.11 The Mifflin
St. Jeor equation may be the most appropriate
predictive energy equation to calculate esti-
mated energy needs as this has been found
to be the most accurate in predicting resting
energy needs in obese adult populations.25
Reduced calorie intake should also be utilized
to meet weight loss goals.15,18,23 To achieve
weight loss, a reduction of 500 to 750 cal
per day can promote a weight loss of 1 to
1.5 pounds per week.26,27 Minimum protein
needs should be based on the recommended
dietary allowance of 0.8 g/kg per day28 and
adjusted as needed on an individualized basis.
In addition to dietary modifications, exer-
cise is an important component of lifestyle
modification. Exercise plays a role in improv-
ing health and managing metabolic outcomes,
not just as a method for weight loss.6,11,24
Lack of physical activity combined with
excess calorie intake is a risk factor for
metabolic syndrome.24 Therefore, it is im-
portant that physical activity levels are in-
cluded in the management of PCOS to help
decrease risk factors for cardiometabolic co-
morbidities. The Physical Activity Guidelines
28 TOPIC IN CLINICAL NUTRITION/JANUARY–MARCH 2019
for Americans state that adults need at least
150 minutes of moderate-intensity activity per
week or 75 minutes of vigorous-intensity ac-
tivity per week for general health benefits.29
For additional health benefits, recommenda-
tions double to 300 minutes of moderate-
intensity activity per week or 150 minutes
of vigorous-intensity activity.25 Guidelines in-
dicate aerobic activities should occur for at
least 10 minutes per session.29 Activities to
strengthen muscle groups are also recom-
mended and should occur on at least 2 days
per week.29 Before recommending an in-
crease in physical activity, patients should be
cleared medically by their doctor for those
levels of physical activity.
IMPLICATIONS FOR PRACTICE
As part of the diagnostic process, practi-
tioners should take time to discuss the dis-
ease process, treatment options, and future
health concerns with their patients. This is
particularly important in adolescence before
excessive weight gain and body image dis-
orders could develop. This may also reduce
the incidence of depression and anxiety in
those diagnosed with PCOS. Registered dieti-
tian nutritionists (RDNs) can also play a role in
helping patients better understand the disease
and the nutritional management appropriate
for both weight reduction and IR. RDNs have
the ability to serve as an extra support system
in patients struggling to manage their weight
and decrease disease risks. In cases of desired
fertility, RDNs can assist in weight loss prior
to conception and continued management of
weight throughout the pregnancy process. Af-
ter delivery, RDNs can play a role in weight
loss postpartum to help the mother return to
a healthy weight.
FUTURE DIRECTION FOR RESEARCH
The importance of nutrition in managing
PCOS is established; however, there is little
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
research to provide an evidence-based ap-
proach for PCOS dietary interventions. Cur-
rently, research supports the management of
symptoms or components individually. Future
research should include the evaluation of suc-
cessful diet modifications, weight loss strate-
gies in PCOS, and the impact of weight loss
in improving metabolic and fertility-related
outcomes. Research should focus on PCOS
as a whole condition rather than separate
pieces of a complex puzzle. Additionally, fu-
ture research should assess the PCOS knowl-
edge of RDNs and look to determine the
prevalence of managing PCOS patients in
practice. It is important for RDNs to un-
derstand the unique challenges with PCOS
and the role of lifestyle changes. Having
more research to support the development of
evidence-based guidelines in PCOS will help
RDNs better care for their patients with this
condition.
CONCLUSION
PCOS is a complex disease with multiple
health implications, including metabolic, car-
diovascular, and reproductive. Early diagnosis
and subsequent treatment can improve dis-
ease outcomes and reduce the risk of develop-
ing diabetes and dyslipidemia. Symptoms may
be recognized individually and not assessed
as a single condition, delaying the diagnosis.
RDNs can play an integral role in recognizing
PCOS in patients, particularly those coming
for services related to weight loss. Physical
examination can help identify key clinical
signs and symptoms, including hirsutism,
acne, and potentially acanthosis nigricans. At
this time, no evidence-based guidelines exist
for use in medical nutrition therapy for PCOS
although weight management appears to be
beneficial. In suspected cases, RDNs should
refer back to the patient’s primary care physi-
cian or gynecologist for further evaluation and
management.
 Polycystic Ovary Syndrome, Fertility, Diet, and Lifestyle Modifications
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