Category: PCOS

We are moving through some questions to determine if we should try a Very Low Carbohydrate Ketogenic Diet (VLCKD) to help with PCOS.  If you have not read them, then you should read the previous posts before this one.

In previous posts, we examined the Dietitian’s Association of Australia’s (DAA) press release recommending that ladies with PCOS increase their carbohydrate intake with ‘grainy bread’.  We concluded that the evidence cited by the DAA did not support that recommendation.

The next question we will look at is:

Is there Other Evidence that Supports Lowering Carbohydrate Intake?

Here, with appropriate cautions, we can leverage the work of an expert.  I point you to this post by Franziska Spritzler a dietitian who favours a low-carb approach for PCOS.

To be clear, we should be as sceptical of Franziska as we are of the DAA and need to be of all experts when ‘the experts are dead’.

In summary, she says:

1. Her opinion is that standard carbohydrate amount, and timing advice for people with diabetes and PCOS is unhelpful.
2. Women with PCOS are likely to have metabolic problems, type 2 diabetes and cardiovascular disease.
3. She mentions the VLCKD pilot study that interested us.
4. She focuses on hyperinsulinemia and insulin resistance (IR) as core problems for PCOS. The previous study and DAA the press release that we examined also noted that.
5. She puts forward that the usually recommended carbohydrate diets are not helpful for those conditions whereas a low carbohydrate approach is.
6. A study looking at the best dietary approach (examining six) was inconclusive; however, none of those was a VLCKD.
7. She is in favour of a very low carb diet to address PCOS.

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.

What is the Common Ground?

But now I recall that the DAA referred paper put forward that saturated fat caused insulin resistance.

So it seems that most dietitians would agree that a diet that addresses hyperinsulinemia and insulin resistance is best for PCOS; however, they differ over whether those conditions cause (or remediate by the removal of) saturated fat or carbohydrates. Also diets for weight loss are recommended.  Now we are getting somewhere! 

The DAA referred paper cites this study to support that saturated fat (expressed here as fat quality) is the villain.  That study concludes:

Most studies (twelve of fifteen) found no effect relating to fat quality on insulin sensitivity. However, multiple study design flaws limit the validity of this conclusion. In contrast, one of the better designed studies found that consumption of a high-saturated-fat diet decreased insulin sensitivity in comparison to a high-monounsaturated-fat diet. We conclude that the role of dietary fat quality on insulin sensitivity in human subjects should be further studied …

It is inconclusive to me from this study that saturated fat causes insulin resistance.  Further, we find this study which found that in laboratory testing, saturated fat did not cause insulin resistance.  It said about that conclusion:

We acknowledge that this does not agree many epidemiological reports supporting the notion that diets high in saturated fats are associated with insulin resistance and an increased prevalence of type 2 diabetes [1].

It appears that saturated fat causing insulin resistance is far from proven.

More Evidence to Lower Carbohydrates for PCOS?

So back to carbohydrate restriction for PCOS and there is this study.

An 8-week low-starch/low-dairy diet resulted in weight loss, improved insulin sensitivity and reduced testosterone in women with PCOS.

I note that this was a low carb diet, but not necessarily low enough to be ketogenic.  It was also not a randomised control trial as there was no control group. Most participants would have been on less than 130 grams of carbohydrates per day. At 79g of fat (19.5g saturated), this is a high fat, high saturated fat diet.

Nonetheless, the results showed improvements in weight, testosterone and insulin sensitivity (insulin resistance) and an improvement in vitamin D levels, blood lipids (triglycerides, VLDL) with no adverse effects to ‘cholesterol’ overall.

Finally, a third study is this study, which might be missed by many because the 15 PCOS participants were in the cohort of sixty people.

Patients with polycystic ovary syndrome lost 14.3%+/-20.3% of TBW (P=.008) … at 24 and 52 weeks, respectively, without adverse effects on serum lipids.

The diet in this study was a ketogenic diet. The results were similar to the last study. They lost weight, reduced fasting insulin and had no adverse effects on their ‘cholesterol’.

I think it is significant enough to comment that anecdotally, women have a hard time losing weight with PCOS yet the experts are unanimous that overweight women with PCOS should lose weight.  These studies all demonstrated weight loss by carbohydrate reduction for women with PCOS was significant and effective.

Decision Time

But at about this time I come back to the point.  Do I cut my carbs or not or do I I wait for the boffins to settle their argument?

Well this is where I invoke another macrofour principle: 

The experts do not care about N=1 but you do!

In case you are not familiar “N=1” is the retort from an expert to refute an anecdote that someone was cured by doing something. You see they need a lot more evidence than one person before they will agree with or recommend it.  You don’t because you care about your N=1. So at this point, it is simple. You are not getting advice because scientists haven’t solved their arguments in time to advise you now.  You can make this decision for yourself- or it may be years for them to settle their argument. 

Personally, I am uninterested in scientist’s careers, egos and the various other distractions that could come into it like pharmaceutical profits or that someone wants to sell me a box of cereal.  I just want to get well.

If you have followed a low-fat (and particularly a low saturated fat diet) and your PCOS has not improved enough, then you have already tried the low saturated fat advice.  Did it work for you? If not then your N=1 says to favour the low-carb diet.  Alternatively, if you have been on a low-carb diet for a while and have PCOS, then try cutting saturated fat. 

Finally, if you have followed a high carbohydrate and high saturated fat diet you are either going to have to choose or cut both.  Before we move on to the safety of carb reduction, let us see whether we should lean one way or the other.

Low Carb or Cut Saturated Fat?

I think that the reader can conclude that the weight of evidence presented leans towards reducing carbohydrates, not saturated fat as having a positive effect on PCOS. We couldn’t find anything to suggest that increasing carbohydrates would help.

So despite dietitians being discordant, the weight of evidence leans towards carbohydrate restriction for PCOS.

Further, by looking behind the press release, we found that in particular, some women were reducing sugar.  So, to finish off, here is a recent post from Dr Jason Fung about sugar and insulin resistance.  Dr Fung is a Canadian kidney disease specialist. He advocates low-carb and fasting to help fix insulin resistance and to stop you losing your kidneys to diabetes.

While you read, please consider whether the wisdom of the crowds was present when the PCOS ladies in the DAA referred study chose to cut their sugar. I will prime you with the fact that sugar is the same as sucrose and each sucrose molecule breaks down into a molecule each of glucose and fructose.

Next, we will look at the safety of a VLCKD.

A Cure for PCOS?

In our previous post, it seemed there might be a dietary treatment for ‘our’ chronic condition of PCOS. The treatment was a Very Low Carbohydrate Ketogenic Diet (VLCKD). That advice lowers carbohydrate intake against the opinion of the ‘expert’ dietitians (DAA). Before we do that, it is prudent to ask a few questions to see if we could use that to aid our condition,  These are:

1. What is the evidence for raising carbohydrate intake?
2. Is there other evidence that supports lowering carbohydrate intake?
3. Is a VLCKD going to be safe?
4. On balance, is this worth trying (or should I eat more wholegrain bread)?

Let’s tackle these questions over this and the next few posts.

What is the evidence for raising carbohydrate intake?

The Dietitian’s Association of Australia (DAA) cites one study to justify that women should increase (wholegrain) carbohydrate intake.  We can read an abstract of that study at the link below. This DAA published the study in it’s journal ‘Nutrition & Dietetics’ which the DAA says is: “Australia’s leading peer-reviewed journal in its field …”.

Suboptimal dietary intake is associated with cardiometabolic risk factors in women with polycystic ovary syndrome

Let’s take a closer look, but before we start, I will uncouple comments about saturated fat. The focus here is on carbohydrate recommendations.  The reason for that is not to avoid the issue.  Saturated fat is a topic on its own, and you can have a VLCKD that is high in protein or fat. Also, any fat in a VLCKD need not be mostly saturated.

The paper concludes that:

The present study has identified suboptimal dietary patterns in women with PCOS, and highlighted dietary factors associated with cardiometabolic risk factors that warrant monitoring in both lean and obese women with PCOS.

In plain English, the authors found: Ladies with PCOS are not eating to the dietary guidelines. Dietitians should look closely at the diets of women with PCOS regardless of their weight.

How was the Study Conducted?

The study came to that conclusion by comparing the diets of 38 women who had PCOS to 30 women who did not have PCOS (control).  This type of study is a matched case-control study.  The women were matched to be roughly similar in body mass index (how overweight or obese they were). The participants recorded what they ate in a seven-day food diary, and then that was analysed and compared between the two groups.

This is not a randomised control trial (RCT) nor is it a crossover study. It is not designed to test a hypothesis about a low carb diet. It does look at the different diet and health of an average ‘healthy’ group with a sick group.

The DAA appears to have taken this study and indicated an association between the level of carbohydrate in the sick group compared to the control group. The reader might conclude that the healthy group is more healthy because they eat more carbohydrates. The reader might also conclude that the sick group became sick because they eat fewer carbohydrates.  Those would both be wrong conclusions. A problem with using this study in that way is that while there may be an association, the reason for that connection may not be apparent or even investigated. In fact, there may be no reason for the connection at all.

Food diaries are regarded as being better than food questionnaires, but still may not be accurate- especially if the seven day period does not reflect long-term eating patterns.  Some of the problems with associational studies and food diaries are discussed in more detail here.

Key Results

However imperfect food diaries and associational studies may be, though, the paper (not the abstract) is detailed about what the researchers did and what the outcomes were.  The PCOS group had 42% of calories from carbohydrates vs. 47% for the ‘healthy’ subjects. The PCOS women ate significantly less sugar (88 grams per day) than the ‘healthy’ women (114 grams per day). That is about six teaspoons per day. As sugar is a carbohydrate, that difference accounts for almost all (about 95%) of the reduction in carbohydrates!

Analysis of Sugar is Omitted

We can conclude from the study that the PCOS women were eating fewer carbs (according to their diaries), and it appeared that the reduction was mostly by reducing sugar.  Anything outside the seven days of a diary is extrapolation.  It tells us nothing about whether, if the two groups and control increased or decreased carbohydrates (sugar consumption), they got better or worse. It says nothing about the diet that women were on when they developed the condition.

The World Health Organisation recommends that a maximum of 10% of daily energy come from free sugars with a target of 5% being desirable. I note that the ‘healthy’ group were getting about 23% of their energy from total sugars compared with about 18% for the PCOS group. The study did not break down the free sugars. However free sugars are a significant proportion of most people’s total sugars. For some reason, the study made no comment whatsoever about the lower total sugar and neither did the DAA.

In the Paper, not in the DAA Press Release

There are some other things that we cannot learn from the DAA press release or abstract that are significant.  We need to read the paper to find out that:

1. Neither of the two groups was compliant with dietary and physical activity recommendations for health!
2. Two-thirds of the PCOS sufferers were of healthy weight.
3. When we compare the ‘sick’ (PCOS) group with the ‘healthy’ group, the PCOS group do exhibit health markers indicating PCOS (as expected). In other health markers (such as cholesterol) they are not significantly different to the ‘healthy’ group. Given the sad progression of PCOS to affect cardiovascular risk, this is an interesting finding.
4. The PCOS participants came from a PCOS self-help charity, and it was possible that many had lowered their carb (sugar) intake after diagnosis (joining). While the charity does not advocate a low carbohydrate diet, there were articles on their website that discussed low carb diets. This provides the most likely reason for the lower sugar intake in the diet of the PCOS sufferers.

This last point may also actually indicate that some patients have discovered that a low carbohydrate approach works. However, if more moderate carb approach after diagnosis had effectively improved or worsened their condition, then this study was simply not set up to evaluate that.

In the DAA Press Release, not in the Paper

Finally, I note that the DAA mentions the following foods that are suggested as good to eat:  (whole)grain, apples, (grainy) bread, legumes and oats and tells you to avoid: butter, coconut (oil), (fatty) meat, biscuits, cakes and pastries.  None of these was specifically mentioned in the paper, and as far as can be told from reading the paper, it is just as likely that both groups ate or avoided them all.

I think the researchers did perhaps owe us a mention of the sugar differences in their results. However, the extraordinary thing is that the DAA seems to have taken this research and used it to suggest women with PCOS should be eating more carbohydrate by promoting the eating of grains, legumes and bread in particular.

It is my understanding that there is no specific diet guideline for PCOS although dietary plans for weight loss are recommended. I would have thought that the DAA would have highlighted the reduction of sugar that the women practised before advocating people eat more carbohydrate. If the aim was weight loss, then a message about sugar reduction should also help. The WHO targets are probably being exceeded, and dietary guidelines are to limit free sugar. At best, sugar is empty calories.

No Evidence to Increase Carbohydrates

There is no clear evidence that I can find from this study that women with PCOS should be increasing their carbs. There is nothing in this study that showed increasing carbohydrates would improve PCOS symptoms.

Alternatively, this study does indicates there is likely to be a trend or practice for some women with PCOS to lower their carbs.  That seems mostly due to them lowering their sugar intake.

Although it was a little frustrating to have to go beyond the press release, I am glad that we looked into the detail and did not discount lowering our carbohydrate just yet. If anything, it is of curious interest that some women with PCOS are reducing their carbs and sugar intake while the DAA does not appear to think this is a good strategy.  Is this the wisdom of crowds?

In my next blog, we will examine the next question on our list.

Is there other evidence that supports lowering carbohydrate intake for PCOS?

Horrible Histories

So, if you have read the previous posts in order, you may be ready to take control of your health. Maybe not. You may not be convinced that the experts are dead or you may still be sceptical of me and my posts.  In any case, you are probably wondering what the best course of action is?  How do you decide what to do to take action for your problem? Let’s look at an example so we can understand it in more detail.

My children are fans of the TV show ‘Horrible Histories‘. If you know it you will appreciate that they are fond of their alliterative titles like ‘Terrible Tudors’ or ‘Rotten Royals’.  I think that when we look back on the period from 1970 until 2020, they would say: ‘Discordant Dietitians’. Why do I say that?  Let us take a deep dive into one example where dietitians appear to be not preaching best practice.

Polycystic Ovarian Syndrome (PCOS)

PCOS is a chronic disease.  You can read a few articles about it here.  For a woman it is heartbreaking.  Excessive weight gain, hormonal problems, difficulty conceiving and increased risk of diabetes.   I am male and therefore not a sufferer, but I note that it is related to type 2 diabetes.  You see, like type 2 diabetes, PCOS shares an underlying ‘symptom’ of Insulin Resistance which I believe is likely to be their common heritage.  I have effectively cured my type 2 diabetes by using a low carbohydrate diet.  That is why I was surprised to come across the following press release which appeared to advocate eating more carbohydrates and to avoid the low carbohydrate approach for PCOS that had worked so well for me with type 2 diabetes.

Taking on PCOS!

Now you may or may not have PCOS.  I suggest that you pretend you do so we can use this as a beginning tutorial on why and how you might take control of your health.

I also recommend that you suspend any belief that this wouldn’t apply in your country.  There are international linkages between most of the dietetics associations, and I think it would be a mistake to assume that this is a purely Australian example.

Let us say you have PCOS and take the advice of the DAA.  You go and see an APD (Registered Dietitian) and, as the press release indicates they put you on a diet inclusive of wholegrains- under the Australian Dietary Guidelines, it would be between 45% and 65% of your recommended daily energy from (wholegrain) complex carbohydrates.

I cannot preclude that it would not make you better. I note that, as a consumer, you could always ask for a money-back guarantee if you adhere to their recommended diet and your PCOS does not resolve. Good luck!

Noting that PCOS is a ‘chronic condition’ we take the ‘Macrofour approach’.  The experts are dead, and all they promise you is a future of chronic disease. So if you have faith in an APD, still see one and do what they say. Equally, if your doctor has put you on medication you would be wise to get the benefit of that and not to vary it without discussion.

Become a PCOS Expert

But the Macrofour way is to become your own expert and do your own independent research. Maybe you ‘google’ and find this academic paper:

Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets

Finally, although we only have preliminary evidence of the positive effects of VLCKD in PCOS,⁷⁷ there are clear mechanisms that are consistent with the physiological plausibility of such dietary therapy.

Let’s unpack that statement. VLCKD is a Very Low Carbohydrate, Ketogenic Diet.  Fancy talk for a diet that restricts carbohydrates to something less than 20 grams per day.  That compares with the approx. 300 grams per day that the DAA would have you on if you followed the US or Australian Dietary Guidelines.  From the press release, the DAA advises:

Ms Hays also advised women to ignore current health trends, such as shunning carbohydrate-rich grains …

A quick calculation shows that if the VLKCD was the solution, and you were very strict on your other carbs, that would be only one slice of bread for the day (allowing for some sundry other carbohydrates in your diet).  Enough for half a sandwich! I would suggest that you would indeed need to shun grains to try this therapeutic diet. Again I quote from the press release.

Margaret Hays said in food terms, this means women with PCOS are … missing out on a thick slice of grainy bread …

So the DAA says that with PCOS we should eat an extra slice of bread every day because a study showed that women who suffer PCOS weren’t eating enough carbohydrates.  That would not allow me to have a VLCKD.

Is a VLCKD a Solution?

Would this VLCKD work? Maybe we should look for more evidence? We notice that the paper linked to a reference number 77.  Two clicks away we can read that in that (small) study:

There were non-significant decreases in insulin, glucose, testosterone, HgbA1c (sic), triglyceride, and perceived body hair. Two women became pregnant despite previous infertility problems.

Wow!  On the surface, it appears to sound promising. There were only five women at the end of the trial, but two of those became pregnant!  That alone would make me start to wonder. You may not know the significance of the other reductions mentioned, but I think you can appreciate that a reduction in body hair is desirable for any woman- let alone one with PCOS.  Testosterone, glucose, insulin, HbA1c and triglycerides reductions- trust me- that is all good too- especially if you have PCOS! A VLCKD sounds like a ‘cure’, but it is a very small study.

Too Soon to Rejoice

So do we run off and change our diet against all the recommendations of the DAA?  Well, it looks promising, but I would suggest that there are some other things that we should check first.  Foremost among them is whether this VLCKD might be dangerous. Maybe there are some other things we could do to check before we change our whole diet and lifestyle?  After all, the DAA is a not for profit body that says it is interested in the health of Australians at least.  They should have something useful to say for your health.  Shouldn’t we be wary of going against their very clear public advice?

If the ‘experts are dead’ for PCOS can you guess what our next move might be?