Macros & Calories Don't Count? Better Food Choices Make Diet More Than 10x More Effective for PCOS Sufferers

Normal-weight women can have PCOS, too. Recently, Macruz et al. did DXA scans on young women with PCOS and a normal BMI and found increased truncal and leg fat compared to healthy controls in a similar age (12–39 years) and BMI range (at least 18.5 but below 25 | Macruz. 2017). More evidence that weight alone doesn't explain PCOS.

PCOS is by no means an issue only obese women suffer from. Yes, obesity is and will always be the #1 risk factor for developing the polycystic ovarian syndrome (PCOS = a condition in which a woman's levels of the sex hormones estrogen and progesterone are out of balance; this leads to the growth of ovarian cysts (benign masses on the ovaries); PCOS can cause problems with a women's menstrual cycle, fertility, cardiac function, and appearance), but eventually it seems as if both occurred in response to the same hitherto not fully elucidated triggers.

In that, it is unquestionable that a woman's diet plays a minor part in the development of PCOS. Accordingly, scientists all over the world are currently trying to determine the optimal diet for people like the 60 overweight or obese patients with PCOS who participated in a recent study from the Kashan University of Medical Science in Iran (Foroozanfard 2017).

Learn more about the (often ;-) small but significant difference at the SuppVersity

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The study was designed to evaluate the effects of the Dietary Approaches to Stop Hypertension (DASH diet) on weight loss, anti-Müllerian hormone (AMH) and metabolic profiles in women with polycystic ovary syndrome (PCOS). To this ends, the scientists conducted a randomized controlled clinical trial among 60 overweight or obese patients with PCOS. Patients were randomly assigned to receive either a low-calorie DASH (N=30) or control diet (N=30; designed to mirror the traditional Iranian diet) for 12 weeks. What is particularly interesting is that both diets had identical macronutrient compositions: 52-55% carbohydrates, 16-18% proteins, and 30% total fats.

Table 1: Constituents of the DASH and control diets in the study; data are presented for a calorie intake of 1800 kcal/day - (b) at least 3 servings of whole grains in the DASH diet; (c) low-fat (lower than 2%) in the DASH diet; (d) 4 servings of lean meat in the DASH diet and 2 servings in the control diet (Foroozanfard 2017).

However, the DASH diet was designed to be rich in fruits, vegetables, whole grains, low-fat dairy products, and low in saturated fat, cholesterol and refined grains (cf. Table 1). Both diets were equicaloric. Physical activity was monitored and identical in both groups. To further promote the comparability between the study arms, all subjects were...

The way we eat is not just obesogenic it is also acidogenic... or is the former just a consequence of the latter? Learn more!

[...] provided with 7-day menu cycles that were individually planned using a ‘calorie count’ system. To facilitate the compliance to the diets, participants were given and instructed an exchange list. 

[...] Compliance with the consumption of diets was controlled once a week through phone interviews. The compliance was also double-monitored by the use of 3- day dietary records completed throughout the study. 

[...] To control for dietary intakes of subjects throughout the study, the dietitian was calling the participants to resolve their probable problems" (Foroozanfard 2017).

The significant difference in the study outcomes you can see in Figure 1 are thus a function of the foods and not the macronutrient composition or the total energy intake of the women.

Figure 1: Anti-Müllerian hormone and metabolic profiles at baseline and after the 12-week intervention in women with polycystic ovary syndrome; p-values indicate stat. significance of the inter-group difference (Foroozanfard 2017).

More specifically, there was almost no change in glucose management in the control, but significant benefits in the DASH group; a further increase in the hallmark features of PCOS, i.e. anti-Müllerian hormone (AMH) and the free androgen index (FAI), but a significant decrease of these indices in the DASH group; and no change and a small improvement in heart-healthy NO and inflammation, respectively, in the control, but a huge increase in NO and decrease in inflammation (MDA) in the DASH diet group.

The detailed micronutrient breakdown shows that one of the reasons of the health benefits could be an increased intake of potassium, magnesium & co - eventually, that's yet not enough to explain the benefits of making better food choices - 'cause food ≠ macros.

Improving your health by eating healthy ≠ weight loss! Despite the impressive inter-group differences in all relevant health markers that were assessed in the study, the weight loss in both groups was identical, with the subjects' BMI dropping by -1.2±0.7 and -1.6±0.5 kg/m², respectively. That goes against the mantra that the best diet was always the one that produced the greatest weight-loss. Especially in people who are battling inflammation and insulin resistance, major health improvements can be achieved without concomitant weight loss... OK, usually you would expect anthropometric changes like a reduction in waist circumference as well as body and esp. visceral fat (Ehsani 2016; Orio 2016), but, unfortunately, these parameters were not assessed in the study at hand | Comment!

References:

• Ehsani, Behnaz, et al. "A visceral adiposity index-related dietary pattern and the cardiometabolic profiles in women with polycystic ovary syndrome." Clinical Nutrition 35.5 (2016): 1181-1187.
• Foroozanfard, Fatemeh, et al. "The effects of DASH diet on weight loss, anti‐Müllerian hormone and metabolic profiles in women with polycystic ovary syndrome: a randomized clinical trial." Clinical Endocrinology (2017).
• Macruz, Carolina F., et al. "Assessment of the body composition of patients with polycystic ovary syndrome using dual‐energy X‐ray absorptiometry." International Journal of Gynecology & Obstetrics (2017).
• Orio, Francesco, et al. "Obesity, type 2 diabetes mellitus and cardiovascular disease risk: an uptodate in the management of polycystic ovary syndrome." European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016): 214-219.

On Short Notice: Teas & Prostate, Metformin & Amenorrhea, Stevia & High, Omega-3 & Low Cortisol, Aminos & Weight Control, Nordic Hamstring Exercise & 20% More Power!

Image 1: This would be a case where metformin probably won't help you to get your menses back - unless this is just one of your "yous" and you are taking high doses of anti-psychotics, of course.

In view of the fact that I have piled up way more "On Short Notice" items than I can possibly squeeze into one installment, today's news on the right tea (green or black) for prostate cancer, the purported anti-obesity effects of leucine and alanine, which turn out to be inferior to those of whole protein, the anti-amenorrhea and weight loss effects of metformin in women on anti-schizophrenic drug and how this relates to PCOS, the surprising N=1 cortisol-raising, high blood pressure and water retaining effects of stevia, the stress and weight loss reducing effects of omega-3s and high DHA levels in the brain, and an effective yet rarely used hamstring exercise, the "Nordic hamstring exercise", will be complemented by another installment of "On Short Notice" either tomorrow (in case I don't find the time to write the next installment of the Circadian Rhythm Series) or earlier next week... but enough of these organizational matters, let's see what we have in stock, here:

• Differential effects of green and black tea on prostate cancer risk While we are, yet again, only dealing with epidemiological shenanigan in a population living in a, if not the juggernaut of the far east, the >50% increase in hazard risk in the 27,293 men from the Singapore Chinese Health Study Julia A. Montague and her colleagues report for men who drink 1 cup of black tea per day is somewhat alarming (Montague. 2012). The fact that the hazard risk decreases to +17% with more than 2 cups of black tea does yet suggest that this is nothing but a statistic outlier. That said, black tea is (at least based on the results of this study) overall probably as benign as green tea, which is totally devoid of statistical beneficial or detrimental effects on prostate cancer risk in this cohort of normal-weight men in their middle to late 50s.
  This result does by the way not conflict with previous research, which did - if anything - only suggest a "borderline significant" beneficial effect of green tea and absolutely no effect of black tea on prostate cancer risk (Zheng. 2012). Apropos prostate cancer, just in case you missed it I highly suggest you take a look at my brief write-up on the recently published "red meat will give you prostate cancer study" before you decide on whether or not you got to stop eating meat for the sake of your prostate.

• 

  Figure 1: If  ~50g of leucine and alanine /kg chow are good, then 500g of whey are magic; makes you wonder, why you would want to add just one amino acid, instead of more protein, no?

  "Dietary L-leucine and L-alanine supplementation have similar acute effects in the prevention of high-fat diet-induced obesity",  that's the somewhat ill-chose title of a recently published paper by Anne Freudenberg, Klaus J. Petzke, Susanne Klaus from the German Institute of Human Nutrition in Potsdam-Rehbruecke which does not show that the ingestion of l-leucine or alanine, but rather an isocaloric high protein diet version of the high-fat diets the researchers fed their 10-week-old male C57BL/6 mice, prevented them from getting obese (Freudenberg. 2012).
  While the high fat + complete protein mice hardly gained any body fat, the high fat + leucine and high fat + alanine (both diets were "adequate" in protein and contained 100g whey + 60g leucine and 100g whey + 45g alanine, respectively)  got only significantly less fat compared to their peirs on the 100g whey only diet control HFD diet. Now, the high protein mice (500g of whey per kg chow; =5x over baseline) simply consumed less energy, but so did the mice on the leucine and alanine enhanced diets, so that the title of the study is not just misleading, it also disguises the most important result of the study, which is high protein diets keep mice lean.
• "Cure-it-all-drug" metformin helps with anti-psychotic induced amenorrhea and weight gain, as well. If metformin was not (a) no longer protected by patent rights and (b) would not basically work via similar mechanisms as exercise I would really begin to smell fraud over the ever-extending list of pathologies this 1920s medication is good for (this is when it was originally discovered, it took however until 1958 before researchers realized the potentials and a pharma company introduced it to the UK market). New to the list are the negative side-effects women experience in response to anti-psychotic treatments. In a recently documented experiment, 48 women (ages 18-40 years) with amenorrhea and weight gain in response to clozapine, olanzapine, risperidone, or sulpiride (all anti-psychotic drugs administered to treat schizophrenia) received a dose of 1,000mg of the wonder-molecule per day (Wu. 2012). After 2 months 25% of the women had resumed menstruation, after another 2 weeks it were 80% and after 3 months all women were eumenorrheic, again (of the placebo group only 2 resumed menstruating). Instead of gaining another 2kg of body weight, they had lost 2kg and the previously thwarted prolactin, LH, and testosterone levels, as well as the LH/FSH ratio had normalized.
  Probably, some of you may now ask themselves: Will this work for me as well - though I am not taking anti-psychotics? I would love I could answer this question, but aside from polycystic ovarian syndrome (PCOS), where we have a couple of trials in which metformin was used with success (cf. Velazquez. 1998; Bela. 2009; Palomba. 2009), the scientific evidence is scarce and in view of the fact that we know even less about the underlying mechanisms by which risperidone & co cause amenorrhea and weight gain than about the almost magical omnipotence of metformin I honestly can't tell. One thing that comes mind, where metformin is yet very unlikely to of any use is diet or exercise induced amenorrhea (overtraining and undereating), because this form of amenorrhea presents with a totally different hormonal profile, with low levels of basically all reproductive hormones.
• Stevia as cortisol promoter? Case study: Bloating, high blood pressure and malaise in a young previously healthy woman. Before I go on, let me briefly remind you that the events that are described in a recent case report from the University of Iowa Hospitals and Clinics may should be regarded with the degree of caution that is indicated whenever we are talking about case reports, specifically because stevia does actually have a pretty decent safety profile (aside from the occasional allergic reactions you will see with almost every foreign molecule you put into your body, obviously).

  

  Figure 2: If you block the 11bHSD2 enzyme that will convert cortisol into inactive cortisone, you are in trouble and a bloated tummy is certainly your least problem, not because "cortisol is bad", as common sense would dictate, but because not being able to manage it is bad (img. Michael. 2008)

  When a 32 year old Caucasian woman presented with generalized edema (feet, hands and face) that had persisted for over six months at her Dr office and was found to to suffer from pre-hypertension (138/88 mmHg) and hypokalemia (3.4 mM/l) that was brought about by a decline in serum aldosterone and plasma renin activity and corroborated by a concomitant  increase in the plasma cortisol/cortisone ratio, most Dr.'s would probably have thought of licorice intoxication. As it turned out, it were neither the glycyrrizinic acid, not the glycyrrhetinic acid from licorice which brought about these problem, but rather the stevia the lady had been using for over 9 months, now. Obviously, the sweetener (from an undisclosed brand) had blocked the 11 beta-hydroxysteroid dehydrogenase Type 2 (11-beta-HSD 2, see figure 2) enzyme that's responsible for the conversion (="deactivation") of cortisol to cortisone - with all the negative side effects of the subsequent 12x elevation of the ratio of active to inactive corticosteroids (Esmail. 2012).
  Now, I am certainly not suggesting that this is going to happen to everyone, but it could well be that the frequent reports of headaches people are developing after a couple of days "on stevia", could also be related to the effects the sweetener has on people with a certain genetic disposition. So, if you get a headache or start holding water like crazy, when you use stevia / stevia sweetened products, first try using a different brand (there have been issues with toxins in some products), make sure you have a pure stevia sweetener and not one with other sweeteners added (thx. to Amit for the reminder about erythritol that's in many products), switch to another preparation, e.g. from pure stevisoids to a a more "natural" extract and if all that does not help, just turn your back on it - you can live without it, I guarantee ;-)
• Omega-3's modulate adrenal activity What many people know from going overboard on fish oil has now been established in a recently published rodent study by Marie Hennebelle and her French (resident) colleagues (Hennebelle. 2012). The researchers fed a group of rodents a totally ALA free energetically restricted diet to produce male rats with brain phospholipid DHA levels that were 50% lower than those of the normal control. The 6 month-old rodents were then subjected to chronic restraint stress (6 h/d) for 21 days. As expected the rodents on the alpha linolic acid deficient diets had a much harder time coping with the torture they were exposed to and showed higher corticosterone levels, more pronounced behavioral abnomalies and slightly more pronounced weight loss in the 3-4 week of the 1-month experimental period. What's intriguing though is the the remarkable stress resistance (one could also say adrenal hypofunction ;-) in the rodents in a third experimental group, who had received an omega-3 enriched diet that boosted their brain DHA levels to 10% above normal: Compared to both the normal, as well as the omega-3 deprived rodents they had ~30% lower cortisol levels during week two and three of the experiment and lost only 50% of the weight their normal and ALA deprived peers did.
  That this is not necessarily a good thing for everyone is probably nothing I have to tell you. After all, the number of people who are hardly functioning due to over-supplementation with fish oil and (as this study would suggest) below normal stress responses is ever increasing. As with so many nutrients and supplements, it thus comes down to specificity and hitting the right ratios for you as an individual, again. And what's most important: Before you even start thinking about "fixing your adrenals" you should first take a look at the various stressors in your life. After all, the aforementioned fatigue is not simply a result of two much fish oil, but of its combination with a lifestyle which simply requires a robust and healthy cortisol response. You would not smoke weed to calm yourself down minutes before running away from a saber-toothed tiger, either, would you?

• 

  Video 1: These young ladies show you how it's done - well almost, you better go a little slower (click image to watch.

  Scientists confirm efficacy of nordic hamstring exercise - up to +20% increase in peak torque! What? You don't know the nordic hamstring exercise - I bet you do, but probably not by this name. Check out video 1 to the right and you will know what the 18 male players from a club in the English professional soccer leagues (mean±SD; age, 22.9±3.6 years; stature, 1.81±0.08 m; body mass 78.0±9.7 kg) did for 1x 2x5, 2x 2x6, 3x 3x6 and 3x 3x8 (sessions per week x sets x reps) during week 1-4 of the study period to improve their peak torque by up to 21% in all assessment conditions (90-61°, 60-31° and 30-0° of knee extension; cf. Iga. 2012).
  What is yet important is that you stick to an adequate temp and don't mess around and hurt yourself. In the study at hand, the velocity of the movement was standardized to 30°/s. If we assume that you go over the full ROM it must therefore take you 3s until your nose hits the ground (if you are afraid to hurt your nose, you may be interested in the SuppVersity EMG Series and the Best Leg + Hamstring Exercises ;-)

I hope you enjoy this more digestible format, having 20 of these items in one installment is - at least in my view - somewhat beside the point. Not that this would not be possible, but if I go by the average attention span of my real-life students, multiply it by 2x to accommodate for your superior cognitive abilities and personal interest in the topic, it appears prudent to call it a day for today. And if can't stand the 24h for the next SuppVersity news to be released, I suggest you simply like the SuppVersity Facebook Wall, where you will find another seven allegedly shorter news-items... about the wheat-allergens in soap (+ scary pic of what can happen, when you use those), for example or the news photo-based cholesterol test (a photo of your hands is all it takes), which is probably going to give the sales of statins another boost.

References:

• Billa E, Kapolla N, Nicopoulou SC, Koukkou E, Venaki E, Milingos S, Antsaklis A, Adamopoulos DA. Metformin administration was associated with a modification of LH, prolactin, and insulin secretion dynamics in women with polycystic ovarian syndrome. Gynecol Endocrinol 2009; 25:427–434
• Esmail S, Kabadi UM. Edema, Enigma: 11 B-Hydroxysteroid dehydrogenase Type 2 Inhibition by Sweetener “Stevia”. Open Journal of Endocrine and Metabolic Diseases, 2012, 2, 49-52.
• Freudenberg A, Petzke KJ, Klaus S. Dietary L-leucine and L-alanine supplementation have similar acute effects in the prevention of high-fat diet-induced obesity. Amino Acids. 2012 Jul 31.
• Hennebelle M, Balasse L, Latour A, Champeil-Potokar G, Denis S, Lavialle M, Gisquet-Verrier P, Denis I, Vancassel S. Influence of omega-3 Fatty Acid status on the way rats adapt to chronic restraint stress. PLoS One. 2012;7(7):e42142.
• Montague JA, Butler LM, Wu AH, Genkinger JM, Koh WP, Wong AS, Wang R, Yuan JM, Yu MC. Green and black tea intake in relation to prostate cancer risk among Singapore Chinese. Cancer Causes Control. 2012 Aug 3.
• Palomba S, Falbo A, Zullo F, Orio F Jr. Evidence-based and potential benefits of metformin in the polycystic ovary syndrome: a comprehensive review. Endocr Rev 2009; 30:1–50
• Wu RR, Jin H, Gao K, Twamley EW, Ou JJ, Shao P, Wang J, Guo XF, Davis JM, Chan PK, Zhao JP. Metformin for treatment of antipsychotic-induced amenorrhea and weight gain in women with first-episode schizophrenia: a double-blind, randomized, placebo-controlled study. Am J Psychiatry. 2012 Aug 1;169(8):813-21. 
• Velazquez EM, Mendoza S, Hamer T, Sosa F, Glueck CJ. Metformin therapy in polycystic ovary syndrome reduces hyperinsulinemia, insulin resistance, hyperandrogenemia, and systolic blood pressure while facilitating normal menses and pregnancy. Metabolism 1994; 43:647–654
• Zheng J, Yang B, Huang T, Yu Y, Yang J, Li D. Green tea and black tea consumption and prostate cancer risk: an exploratory meta-analysis of observational studies. Nutr Cancer. 2011;63(5):663-72.