What is the best diet for Polycystic Ovary Syndrome (PCOS)? Written by: Felice Ramallo, MSCN, RDN, LD – Lead Dietitian at Allara Polycystic ovarian syndrome (PCOS) is known as a multifactorial condition, which means it’s caused by more than one contributing factor. Prominent symptoms associated with PCOS include hirsutism (excessive hair growth), hyperandrogenism, insulin resistance, and acne. However, one of the most noted and widely discussed PCOS symptoms is difficulty losing weight, along with the increased incidence of weight gain, overweight, or obesity in comparison to non-PCOS counterparts. As a result, international medical consensus finds that the first-line interventions to treat PCOS should be lifestyle changes, including a PCOS diet, exercise, and stress management. These are fundamental to decreasing the risk for chronic disease, reducing inflammation, preventing unfavorable weight changes, and other side-effects seen with the condition. Lucky for you, here at Allara, we are well-versed in the latest evidence, and can offer some support in understanding how you can manage PCOS. Here’s what we’ll be covering throughout this article: What influences a “PCOS diet”The role of insulin resistanceWhat are the components of a PCOS friendly diet?CarbohydratesFatsProteinsGlycemic index, glycemic load, and non-nutritive sweetenersAre there foods I should exclude from my PCOS diet?What will work best for me?Managing PCOS through diet What influences a “PCOS diet” Two things influence diet recommendations: most common symptoms and underlying causes of PCOS. Symptoms of PCOS include higher risk for chronic diseases like cardiovascular disease, type 2 diabetes, and hypertension/high blood pressure due to the increased genetic predisposition associated with the condition. Knowledge is power, and in this case, awareness and screening for these common issues means that you can play a part in preventing them. The preventative diets for these conditions overlap with the foundations of a healthy PCOS diet. Additionally, the condition is not caused by one sole thing. It is characterized by a complex hormonal imbalance throughout the body, particularly androgens (male hormones), which 70-80% of people with this condition experience. The imbalance of androgens is often exacerbated by another hormonal issue in the body: insulin resistance (IR). Insulin is a growth hormone that every body produces steadily throughout the day, and more at mealtimes to help nutrients circulating through the blood into body cells. Most widely mentioned, it lowers blood glucose or sugar (BG) by getting it into those cells. Here, normal function is impaired and the body becomes insulin resistant, or desensitized to insulin, when BG spikes or swings often. The role of insulin resistance A highly dramatized example of how IR can happen is as follows: You are really hungry, and you feel your blood sugar is low (dizzy, tired, poor focus). You look for a quick sugar boost, and choose a slice of cake. Upon the first taste and smells of sweetness, you release insulin. As you continue to eat, you release more and more insulin. There is very little fat, protein, or fiber to slow the absorption of sugar from the GI tract to the bloodstream, so it occurs in one large dump. As quickly as you begin eating, you are done. Your body is still producing insulin to get the sugar in your veins to your body cells. The move of sugar into the cells is quick, and there is extra insulin now circulating. The cells begin learning to ignore the circulating insulin because it is released frequently in high amounts and also might be over-released in response to eating – that “ignoring” is what is called insulin resistance. Now, in reality, IR does not happen after one meal, but over time it develops if instances like that happen often. Diet matters because it can make the response to insulin slower, steadier, and prevent or reverse the development of insulin resistance. A balanced PCOS diet can also mean better PCOS symptom management, more regular ovulation, and improved fertility; along with optimizing health now, to prevent chronic diseases later. What are the components of a “PCOS Friendly Diet”? A PCOS-friendly diet isn’t far off from what would be generally healthy for the average individual, and it includes all food groups and aims for representation of all macronutrients (carbohydrate, fat, and protein) with fiber at all meals and snacks. Carbohydrates Carbohydrates include sugars (simple carbohydrates), starches (complex carbohydrates), and fiber (indigestible carbohydrates). Sugar is the most ready-to-use source of energy one can eat. It can be quickly absorbed from food and immediately used, However, if you do not use it right away (for example, through exercise or movement), it can spike blood sugar levels and contribute to insulin resistance. Though a little bit of sugar as part of a well-balanced meal can help with satisfaction, thus preventing cravings later on, refined sugars should be limited if possible. A note on sugar Often, sugar is demonized as a major nutrient to exclude from your PCOS diets. But we’d like to point out that sugars and desserts are not inherently “bad,” though it is recommended to include them with or directly after a meal so that absorption of the sugar is slowed, preventing BG spikes. Complex carbohydrates include starches, which take a little bit more time to break down, and are preferable to sugars for regular sources of carbohydrates at meals because they do not spike blood sugar so much. Getting enough complex carbohydrate prevents blood sugar from dipping too low, and helps prevent intense cravings that can be hard to ignore or control. (Check out our article on the science behind sugar, insulin resistance, and how to satisfy your sweet tooth as part of a balanced PCOS diet here). Incorporating fiber Lastly, fibers are indigestible sources of carbohydrates, meaning the human body cannot break them down into usable units of energy. However, gut bacteria can! Soluble fiber helps form gels in our gastrointestinal tract (GI tract), binding and slowing absorption of cholesterol, sugar, and other nutrients. Insoluble fiber acts as a broom, sweeping stool through the GI tract, and keeping bowel movements regular. Fibrous foods often contain a mixture of these two types. Both types of fiber can be prebiotic, meaning they feed and support healthy gut bacteria. Gut flora/bacteria are important because they act as part of our immune system, support healthy hormone production, synthesize vitamins, and more. Here are some carbohydrate-rich food groups: Vegetables: one of the best sources of insoluble fiber, vitamins A and CStarchy vegetables offer nutrient-dense complex carbohydrates to a meal; the most common include potatoes (sweet or white), squash, and root vegetablesLeafy greens are packed with antioxidants, insoluble fiber, vitamins (like vitamin K), and minerals (like iron)Fruits: great source of potassium, fiber, vitamin C, and antioxidantsBerries and other dark fruits like blood oranges or pomegranates are especially high in antioxidantsFruits are a great way to add nutrients, fiber, and flavor to a dessertGrains: high in B vitamins and minerals like selenium and magnesium (especially in fortified grains/cereals)Half of grain intake should be whole grains, including whole wheat, brown/black rice*, corn (including popcorn)*, oats*, quinoa*, spelt, bulgur, amaranth*, sorghum*, buckwheat*, and teff*“ * ” = gluten free → However, there is no evidence that those with PCOS need a gluten-free diet unless they otherwise have an allergy, celiac disease, or intoleranceWhole grains are the #1 source of fiber in our dietsSee ‘legumes’ under the discussion about protein foods Fats Fats have many amazing roles. More than half of the vitamins are fat soluble, meaning they are absorbed with the help of fats. Fat also blunts spikes in blood sugar, and thus are a great addition to meals with CHO foods. One of the best sources of fats is liquid oils, like those from plants and fish, which also help combat inflammation and heart disease. Some oils are better than others in terms of their antioxidant and anti-inflammatory properties. The top recommendations include olive oil, avocado oil, walnut oil, or flaxseed oil. Some fatty foods are also shown to be anti-inflammatory or health promoting, including fatty fish or fish oil (wild salmon, mackerel, cod, trout), nuts (especially walnuts), seeds (chia, flaxseed, sesame), or avocado. Protein Protein boosts satiety (feeling of fullness/satisfaction after meals) and keeps our muscles and cells strong. Like fats, protein also prevents blood sugar spikes. Although, it is easy to overestimate how much one needs. For most people, a large steak or piece of meat at every meal is unnecessary; but if you include nuts, seeds, dairy, beans/legumes, seafood, or eggs with your meal, that is often enough and provides nutrient-dense variety to the diet. Some protein-rich foods are: Animal proteins: offer protein and essential B-vitaminsIncludes poultry, beef, pork, eggs, etc.Seafood is especially high in anti-inflammatory minerals and fats (omega-3 fatty acids)Dairy: is an animal protein, but also contains fat and carbohydrates. It is high in essential bone-building nutrients like phosphorus, calcium, and vitamin DCan come from cows, sheep, goats, and any other mammalFull-fat, or whole, dairy is the recommended form for those with PCOS because whole dairy is shown to promote ovulationWhey protein is also shown to increase insulin secretion and reduce T2DM prophylaxis, meaning it can benefit those with PCOSSome individuals do notice an increase in acne with increased dairy consumption (especially from milk; not cheese or yogurt), so those with acne should look out for symptoms of intoleranceDairy products include fermented products/yogurt (which also contains probiotics), cheese, and whole milkLegumes: beans, peas, lentils are examples of legumes, and provide soluble fiber, starches, protein, folate, potassium, iron, and magnesiumNuts and Seeds: whole nuts/seeds and their “butters” contain a mix of fiber, healthy fats, protein, antioxidants, vitamin E, magnesium, selenium, and moreSome favorites at Allara are walnuts, pecans, almonds, sesame (tahini), pumpkin, sunflower, chia, and flax seeds Finding the right balance This is a graphic we often use with our patients to illustrate portions of the food groups for PCOS. The dotted lines signify variability between the neighboring food groups. The solid line is a more firm suggestion for proportions. Though, the key here is to listen to your body above all else, to determine which breakdown feels best to you. Glycemic Index, Glycemic Load, and Non-nutritive Sweeteners If you have questions about how these items pertain to a PCOS diet, please view our article: PCOS and Sugar: Every Single Thing You Want to Know. In short, we say sugar may be eaten in recommended quantities (read to learn how much), with the suggestion to avoid non-nutritive, zero calorie, or artificial sweeteners. Are there foods I should exclude from my PCOS diet? One key to our program is that there are no “bad” foods. Well, for the most part. There are two common foods that we’d like to expand on: zero/low calorie sweeteners are not recommendedlow- or nonfat dairy (anything not labeled “whole”) should be avoided – we propose a switch to whole dairy, if you eat dairy products Why do we not recommend zero calorie sweeteners and low fat (or completely nonfat) dairy? Well, though there is more research to be done in this area, the science indicates it is not helpful for women with PCOS to consume these foods, given their inflammatory nature. Given that PCOS is associated with a “proinflammatory state,” we want to decrease inflammation, not consume foods that potentially trigger, or exacerbate, it. Examining low-fat dairy and the PCOS diet For instance, a cross-sectional study, published in 2014, studied 400 women in Iran and found that for “individuals with PCOS … [they were] revealed to have a higher consumption of low and free-fat milk.” The study goes on to explain that low-fat dairy products may increase the level of insulin-like growth factor I (often shortened to IGF-I), which may play a role in the formation of PCOS. Though researchers point out they don’t know if IGF-I may contribute to the manifestation of PCOS, eating low fat dairy products has been associated with an excess of androgen secretion, of which many women with PCOS already struggle with (physical symptoms of which can include hirsutism, acne, and hair loss). The result of what they found in this study, then? Dairy in and of itself was not significantly correlated to the manifestation of PCOS, but since whole dairy products have a higher estrogen concentration, this can decrease levels of IGF-I. Until more is known about the relationship between low-fat dairy products and PCOS, we recommend you opt for whole fat dairy products (if you consume dairy, that is). Afterall, healthy, whole fats are nothing to be scared of! They can help keep you full, and give you energy for the day ahead. Artificial sweeteners and the PCOS diet So what’s the deal with artificial sweeteners? Well, as you may already know, several different ones are cleared for use in both the US and Europe. But their long-term effects, as suggested by Harvard’s Medical School, are less well known. This is especially worrying given their potency. Dr.Ludwig, an obesity and weight-loss specialist whom Harvard consulted in this article, explains that since “non-nutritive sweeteners are far more potent than table sugar and high-fructose corn syrup … a miniscule amount produces a sweet taste comparable to that of sugar, without comparable calories.” The problem then arises from “overstimulation of sugar receptors from frequent use of these hyper-intense sweeteners” which then “may limit tolerance for more complex tastes.” Essentially, then, this means that over time naturally sweet foods, such as fruit, may not taste very sweet to us. This puts us off eating foods with high nutritional value, and to give us that kick, potentially puts us on adding increasing sugar to our drinks and meals. This may be a recipe for long-term negative health implications, such as type 2 diabetes. We don’t say this to scare you or fear-monger, but merely as a word of caution: to avoid downstream, unexpected health concerns, avoid super-potent sources of sweetness – such as artificial sweeteners – and instead opt for more natural sources, such as fruit, dates, honey, and even regular granulated sugar. (Other than the foods described above, the only ones you should staunchly avoid are foods that you don’t like or are sensitive, allergic, or intolerant to!). Okay, so let’s go back to what ARE some excellent foods that can help you form the best PCOS diet. To do this, let’s put emphasis on foods that one may need more of, like vegetables, legumes, or whole grains. At Allara, we don’t stick to the age-old tale of only shopping the perimeter of the grocery store for two reasons: 1) beans, grains, and other nutritious products live in the center of the store; and 2) convenience foods are sometimes a necessity for people short on time, skill, or ability to cook. When looking for shelf-stable, frozen, canned, or other convenience options, a helpful rule of thumb to start with is to look at the ingredient label and prioritize foods that list ingredients you would cook with at home. It may sound like an oxymoron, but less-processed is better, but not all processed is “bad.” A lot of the suggestions beyond that are best determined one-on-one with a registered dietitian nutritionist (RD/RDN), like we have at Allara. What diet will work best for me? We do not recommend any specific PCOS diet, counting calories, tracking macros, or eliminating foods or food groups as a long-term and sustainable solution for managing PCOS. Nutrition and eating are both highly personal and variable depending on the individual. No same diet regimen works for everyone. With that being said, we follow some of the same evidence given by the Dietary Guidelines for Americans (DGA) and draw from the Mediterranean and DASH diets it mentions, per the body of evidence we collect for PCOS treatment. Additionally, we follow Allara-adapted versions of the Intuitive Eating and Health at Every Size philosophies to fit the unique needs of those with PCOS. Basically, we treat each person’s body as the ultimate source of wisdom when it comes to nourishing their bodies. We help our patients build or strengthen their relationship with their body and food. We teach patients how to tune in and listen to what their bodies are telling them. We highlight the worth of stress-management and develop personalized plans based on self-care and self-love needs. Last but not least, we always make behavior-first counseling goals. That means focusing on changes one can directly make (like eating more fruit, or regularly moving more), not a long-term desired outcome like weight loss or improved fertility. It takes the pressure off of what you cannot control, and builds self-efficacy by turning monstrous goals into tiny, achievable changes. For many, those long-term outcomes are simply side-effects of implementing healthy behaviors. Even without drastic weight loss, one can improve their symptoms and expression of PCOS. Also, studies show that the more you diet, the more weight you gain and damage done to your body in the end. We said it and we can prove it: you do not have to lose weight to effectively treat your PCOS. Managing PCOS through diet Following a healthy diet looks different for everyone. For most, that means including all food groups. To prevent cravings and manage insulin resistance, it is best to include all macronutrients and fiber at all meals and snacks. A PCOS-friendly diet supports symptom reduction and prevents the development of chronic diseases down the road. Beyond that, using mindfulness and a weight neutral approach is the foundation of our highly effective treatment at Allara.