PCOS and Sugar: Every Single Thing You Want to Know Written By: Felice Ramallo, MSCN, RDN, LD Sugar might be the most publicly demonized nutrient at the moment, especially for people with polycystic ovarian syndrome (PCOS). To understand the relationship of sugar to the condition, some of its underlying mechanisms need to be explained. Three hallmark symptoms of PCOS that are used to diagnose the condition are elevated androgens (i.e. testosterone), oligo- or amenorrhoea (irregular or absent menstrual cycle), and fluid-filled follicles on the ovaries (shown by ultrasound). These symptoms can be triggered and perpetuated by increased inflammation throughout the body, such as stress, poor sleep hygiene, shoddy dietary patterns, or something intertwined with all of those: insulin resistance (IR). Insulin resistance is often referred to as the pathway to type two diabetes, and it is also a very probable contributor to your PCOS symptoms, along with why you may be experiencing what feels like insanely intense sugar cravings – a symptom 99% of people with PCOS report having. The science behind insulin explained Insulin is a hormone that nearly every body produces. As we reach mealtime, smell or taste food, and eventually ingest and absorb our food’s nutrients, the body responds with the increasing release of the hormone. Insulin works by telling cells that it’s time to take sugar from the blood and accept it into the cell to convert to energy. All foods eventually break down to sugar, no matter if they’re made of carbohydrate, fat, protein, or alcohol. How does insulin resistance happen? Insulin resistance builds up over time. The most common way that it develops is by eating easily-digestible carbohydrates on their own, in high quantities, and when they aren’t needed. For example, if one were to eat a large quantity of sweets without protein foods or a source of fats, it would quickly be absorbed into the bloodstream. When that happens, the body pumps out plenty of insulin to get the sugar into the cells and out of the bloodstream as quickly as possible. Because cells are so sensitive to the hormone, if they are regularly inundated by it, they start to ignore whatever the message is. However, if there is a lower intensity message that happens predictably throughout the day, the cells respond much more appropriately, and can take in sugar at a healthy pace that they won’t become desensitized to. That is where discussion about smaller, frequent meals, incorporating protein or fat, and glycemic index or load comes in; as these are all players in maintaining healthy blood sugars and responses to insulin. Notably, stress and lack of sleep or activity make insulin resistance worse and happen more quickly, which can initiate full-blown type 2 diabetes. Maintaining Healthy Blood Sugar Balanced Meals Preventing insulin resistance goes hand-in-hand with maintaining healthy blood sugars in the long run. There are a handful of effective strategies that can be used together in this pursuit. At minimum, one’s diet should include ample sources of protein, fat, and carbohydrate (the macronutrients) at all meals or snacks. As the body digests food, everything gets mixed around and partially broken down in the stomach before being passed along to the intestine for the absorption of nutrients. When foods that contain the macronutrients combine, they create a slurry that takes more time to absorb. When fiber is added to that mix, the food takes even longer to absorb, partly because our gut bacteria has to break down the fiber and other components more before our bodies can accept the nutrients. Instead of stand-alone refined carbohydrates (low in fiber) that can be immediately taken in by the first sections of the intestine, alternatively, the diverse food mass has more nutrients to unlock and deconstruct before being accepted into the bloodstream. That extra digestion time means that blood sugar spikes are lower, longer, and more sustained – something that very directly translates to energy levels throughout the day. Glycemic Index and Load Fiber is also involved in the glycemic index and load of food items. Glycemic Index (GI) is a scale of 0 to 100 measuring how much a food would increase one’s blood sugar, with pure glucose (sugar) being 100. Glycemic Load (GL) adds nuance to GI by considering serving size of the food, which matters in a few instances where a food’s glycemic index may be high, however, per the serving size, it doesn’t raise blood sugar to the same extent. For foods like fruits, GI may be high, but GL is low, indicating it would be a good choice to prevent blood sugar swings. Foods with a lower GI or GL are typically higher in fiber and lower in sugar or more easily digestible carbohydrates. For the most part, GI or GL can be used interchangeably for guiding food choices. A goal for many people with PCOS should be to choose lower GI or GL foods whenever possible which would be items with GI or GL labelled at 45 or less, to reduce long-term disease risk. When it comes to grains, that means picking more ancient grains, whole grains, or sourdoughs. A more exhaustive list of food comparisons can be found in our education material “Glycemic Index Swaps.” Those swaps would support a more stable blood sugar throughout the day, prevent the development of insulin resistance, and improve other symptoms. Overall, people with PCOS get less than the recommended amount of carbohydrates (CHOs) each day, yet they choose higher glycemic index options. Although, chances are, if they were eating more CHOs and more frequently throughout the day, cravings wouldn’t higher GI options wouldn’t seem so attractive. This brings us to the next point: meal patterns. Meal Patterns Another strategy that may prevent or improve insulin resistance is eating more frequently throughout the day. Research shows that eating more frequently than the ‘3 meals per day’ standard improves markers of insulin resistance and tests of insulin sensitivity. Significant improvements were seen in individuals who consumed 6 small meals per day. Small, frequent meals keep blood sugar (BG) levels stable, therefore it won’t drop to a level that may trigger a sugar craving, one of the body’s mechanisms for regulating our BGs when it falls too low. Sugar Cravings Sugar cravings can be caused by emotional, environmental, or even physical triggers. A common biological one for those with PCOS and the associated insulin resistance is sugar cravings brought on by the low blood sugar that is caused by high levels of circulating insulin. This becomes a vicious cycle, where if one does not start eating more regularly throughout the day to prevent blood sugar dips, they will continue to experience intense cravings, then indulging, and creating worse insulin resistance, worsening the intensity of cravings. Bottom line: eat meals that contain a variety of food groups and lower GI/GL carbohydrates, regularly throughout the day as a first-line prevention for cravings. What to do when a craving hits PCOS is a chronic condition that exceeds typical health-related concerns because of the common effects it has on one’s appearance. Paired with the characteristic insulin resistance followed by intense carbohydrate cravings that people with PCOS experience, these factors are strongly associated with the development of depression, anxiety, and eating disorders (especially those characterized by binge eating symptomatology). Any of the associated negative emotions can also make cravings worse, eventually evolving into bingeing when there aren’t other coping mechanisms in place to handle these moments with self-care and compassion. Luckily, many studies have shown that both cognitive behavioral therapy (CBT) and mindfulness practices, such as those you’ll learn through our nutrition programming, are both effective ways to prevent and treat binge eating behaviors. We suggest the following progression: craving hits → indulge the craving and try your best to enjoy and eat mindfully → process whatever triggers prompted the incident → make a plan to either prevent the triggers or work on other ways to cope with negative emotions. From a nutrition perspective, the craving could simply be an indicator that your current dietary pattern isn’t suiting your needs. Sugar and Sweeteners Now for some myth busting and clarification! Excess sugar intake is in fact a contributor to insulin resistance and overall inflammation throughout the body. That doesn’t mean that it is bad, immoral, or “hiding” in foods. As mentioned in the section about GI/GL, more important than avoiding sugar at all costs is choosing lower glycemic foods (for a goal of <45), which may be impacted by sugar content. Because most foods don’t have their glycemic information printed on the label, another strategy to reduce excess sugar consumption is to generally keep tabs on the amount of added sugars consumed per day. Natural and Added Sugars Naturally occurring sugar is the sugar content before other sweeteners are added. Added sugars can be any nutritive sweetener (meaning providing energy/macronutrients) or sweetening agent that is incorporated into a product or recipe. Added sugars could include agave syrup, maple syrup, honey, fruit preserves, or any other ‘sweet’ ingredient. When considering options to buy, or guiding portion sizes, one should aim to stay below 50g of added sugar per day (per USDA guidelines). This is a separate line item than total sugars. ‘Added sugars’ are broken out on their own, below total sugars, on the nutrition label. This amount is what is necessary to ensure you are eating nutrient-dense foods and preventing risk of chronic diseases (i.e. insulin resistance and type 2 diabetes). Also of note, our bodies do not discern between added or naturally occuring sugars in food. To keep sugar intake in check, the most effective method is consuming a variety of whole foods from each food group, and aiming to stay below 50g (based on 2000 kcal per day diet; 10% of daily calories) from added sugars. Types of Sweeteners A common suggestion for combating insulin resistance or reducing sugar intake is to use non-nutritive sweeteners (NNS), also known as artificial sweeteners in place of nutritive sweeteners like sugar. These include brands like stevia and splenda. The names nutritive and non-nutritive come from whether or not the sweetener contributes significant energy (calories) or sugar to the diet. However, there are few indicators that stevia or splenda help general health or insulin resistance at all. In fact, many studies are showing that they may be doing the opposite and damaging our health. Importantly, artificial sweeteners are absolutely safe in small and infrequent amounts, however there are a number of reasons to steer away from them. Here is a synopsis of information from a comprehensive literature review on the subject. Artificial sweeteners have shown to be/have…: Better for dental hygiene by creating a less acidic mouth environment than sugarHigher association with headachesHigher association with Alzheimer’s diseaseHigher association with preterm laborVery consistently shown damage to gut health – The damaged gut microbiome is associated with increased weight, IBS symptoms, and insulin resistance.Associated with type 2 diabetes – This is likely due to excess insulin production triggered by taste buds sensing ‘sweet,’ and therefore cells begin to desensitize themselves due to insulin not matching the amount of blood sugar available.Modest weight loss of less than 2 lbs on average with no changes to fat mass/body composition – This benefit does not outweigh the other costs associated with artificial sugar. Key take-aways on sugar: Sweets are “fun foods” and have a place in a nourishing and balanced diet, just like anything else. They are associated with birthdays, family outings, or parties with friends. They are the 5-10 extra pounds that stick around when you have a happy and fulfilling social and personal life, and definitely nothing to be concerned or critical of. When you’re 80 years old and reminiscing, you’ll thank me for this encouragement. Additionally, artificial sweeteners may be damaging to your health, and there is no good indication to use them. Instead, when grocery shopping, use nutrition labels to make choices that help you stay beneath the goal of 50g added sugars per day. Aim for a variety of food groups at all meals, and choose lower glycemic foods when possible (refer to “Glycemic Index Swaps” handout as needed). Honor your cravings, but find compassionate and healthy ways to prevent them. There is never a necessity for militant restriction. Our bodies tell us so much about our needs, so trust them, honor them, and love them. If you’re looking for additional help navigating your nutritional needs with PCOS, our Registered Dietitians at Allara can help you develop a personalized nutrition plan that meets your goals. Citations Jeanes YM, Reeves S, Gibson EL, Piggott C, May VA, Hart KH. Binge eating behaviours and food cravings in women with Polycystic Ovary Syndrome. Appetite. 2017;109:24-32. doi:10.1016/j.appet.2016.11.010. Barr S, Reeves S, Sharp K, Jeanes YM. An isocaloric low glycemic index diet improves insulin sensitivity in women with polycystic ovary syndrome. J Acad Nutr Diet. 2013;113(11):1523-1531. doi:10.1016/j.jand.2013.06.347. Papakonstantinou E, Kechribari I, Mitrou P, et al. Effect of meal frequency on glucose and insulin levels in women with polycystic ovary syndrome: a randomised trial [published correction appears in Eur J Clin Nutr. 2016 May;70(5):646]. Eur J Clin Nutr. 2016;70(5):588-594. doi:10.1038/ejcn.2015.225. Krug I, Giles S, Paganini C. Binge eating in patients with polycystic ovary syndrome: prevalence, causes, and management strategies. Neuropsychiatr Dis Treat. 2019;15:1273-1285. Published 2019 May 16. doi:10.2147/NDT.S168944. Dietary Guidelines for Americans 2020-2025: U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.Lohner S, Toews I, Meerpohl JJ. Health outcomes of non-nutritive sweeteners: analysis of the research landscape. Nutr J. 2017;16(1):55. Published 2017 Sep 8. doi:10.1186/s12937-017-0278-x.