Practically every time I hear a health professional explain, on the Internet or in person, why a woman with PCOS has carbohydrate cravings, they blame it on insulin resistance. The rationale is, that because glucose is not getting into cells, the cells are hungry and asking for sugar.
Did you know, as rational as this explanation sounds, research does not support it?
A study published in 2004 (and one of the few I've ever even seen that acknowledged that women with PCOS crave sugar) compared several appetite hormones to appetite measures in 16 pairs of women with PCOS matched with controls. They could find no statistically significant correlation between reported appetite and insulin levels. Rather, it was testosterone levels that seemed to be the problem.
Because insulin resistance has some effect on how much free testosterone is available to affect appetite, it could be argued that the effect is still there, but more indirect. However, another study reported that it is the eating of too much sugar and the resulting change in liver function that ultimately determines free testosterone levels, not insulin. (In this particular study the diet was up to 70% sugar, to be sure the desired metabolic effect was achieved and could be studied.) The resulting fat production by the liver was correlated with reduced levels of sex hormone binding globulin, the blood protein that binds to testosterone and inactivates it.
So while the cravings are there, be sure not to blame their cause on a solution that may not help. Our philosophy at inCYST is that balancing fatty acids helps calm down the nervous system and reduce its need for sugar. It also helps the liver better process fats, thus preventing the testosterone issue described above.
I know, I know, you're getting tired of hearing about fish oil.
I won't belabor the point, today I'll just challenge you to think outside the same old test tube.: )
Hirschberg AL, Naessén S, Stridsberg M, Byström B, Holtet J. Impaired cholecystokinin secretion and disturbed appetite regulation in women with polycystic ovary syndrome. Gynecol Endocrinol. 2004 Aug;19(2):79-87.
Selva DM, Hogeveen KN, Innis SM, and Hammond GL. Monosaccharide-induced lipogenesis regulates the human hepatic sex hormone–binding globulin gene. J Clin Invest. 2007 December 3; 117(12): 3979–3987.
I've invited the members of our Facebook fan page to ask questions, and here is the first one we got. Here is a little primer on triglycerides.
When you get your cholesterol reading, something that is measured is a type of fat called a triglyceride. What this is, is a type of fat the body uses to carry extra calories in the blood. If you're eating calories in greater quantities than the liver can process them, they hang around in your blood waiting in line to be taken care of. Sometimes that gets measured in a blood test, because high triglycerides are associated with increased risk of heart disease.
Triglycerides' favorite place to be stored, is in the belly, which is why people with high triglycerides often have an apple-shaped body type.
And what is really interesting about high triglycerides, is that they are a place your body can store DHA, that chemical you see me write a lot about here, because it is essential for healthy memory, problem solving, and overall brain function.
Modern medicine tends to think of high triglycerides as a problem that needs to be fixed. I tend to think of high triglycerides as a strong indicator that your life and eating habits are out of balance. They respond extremely well to pulling yourself back into moderation; therefore, I strongly encourage you to take a look at the list of changes you can make, summarized here, and give them your best college try before resorting to medication.
1. Excess calories, in general, all day long. If you are a compulsive overeater, your intake may simply exceed your body's ability to keep up. You don't need to starve yourself, however. Rather, start to explore the reasons why food is so prevalent in your life, begin to tackle the reasons why, replace triglycerides with other activities and coping behaviors that are not so hard on your liver.
2. Stacking too many calories at one time of day. Are you on Weight Watchers…with a tendency to deny yourself food earlier in the day so you can indulge later on? Your liver is not much different from the engine in your car. You can't simply dump fuel into the system and expect it to run efficiently. Your car has a carburetor to regulate the rate at which the engine gets gasoline. When it starts to run too rich, your engine doesn't run well. The only carburetor humans have is a behavioral one…remember, it isn't just about how many calories you eat in the course of a day. It's how you spread them out to up your liver's efficiency.
3. Eating too much sugar. Sugar is so quickly and easily absorbed, that eating too much of it can leave too many calories in the system at once. You still need carbohydrates to fuel your brain and muscle, but the other type of carburetor you have is something called a complex carbohydrate. It takes longer to absorb and digest, therefore slowing down the entrance of those carbs into your system. In general, low glycemic foods also help triglycerides. You know what those are from paying attention to insulin resistance. Eat more of them!
4. Drinking too much alcohol. Alcohol has 7 calories per gram, and it adds up quickly! We don't talk much about alcohol here, but if you are using it to cope, and you have a love of sweetened drinks, you're getting a double whammy. Alchohol is best used in moderation and best used as an accompaniment to a healthy meal. Happy hour drinking, which encourages less control over high fat, high calorie foods, is likely to render you vulnerable to higher triglyceride readings.
5. Not getting enough"effective" omega-3 in your diet. I use the word effective to remind you that if all you do is add omega-3 to your diet without reducing omega-6, the latter will keep the former from having any effect. You have to do both. Physicians will often tell you that the dose of omega-3 you need is too high to be safe, and that you need medication in order to achieve this. I beg to differ, as I have seen, many times, that when you add the fish and fish oil, and reduce the"s" and"c" oils, triglycerides do drop. I have come to believe that since DHA is so important for brain function, when our omega-6 to omega-3 ratio is so high that the brain starts to be at risk for having what it needs to do its job, the body starts creating triglycerides as a desperate attempt to hang on to what omega-3 it has. When you don't need triglycerides as a last-ditch effort, your body won't have to make them.
6. Not enough exercise. One of the benefits of physical activity is that because it requires you to use calories as fuel, it trains your body to use calories. So when you eat them, your body is more likely to use them efficiently. Get out and move, even a little bit at first, but get in the habit!
7. Of course, there are people with genetically high triglycerides who DO need to be on medication. But if you have not tried the suggestions listed above in an attempt to reduce your triglycerides, please try them first before adding another medication to your lineup. And if you do decide to use medication, don't use that as an excuse to eat whatever you want. Eating as best as you can, can help to reduce the amount of medication you DO need to manage your problem.
I have heard the following recommendations made by the American Heart Association repeatedly for years now. And I hear them parroted everywhere by well-intended medical experts who, it seems, did not stop to check the math on which the recommendations are based:
Population Recommendation Patients without documented coronary heart disease (CHD) Eat a variety of (preferably fatty) fish at least twice a week. Include oils and foods rich in alpha-linolenic acid (flaxseed, canola and soybean oils; flaxseed and walnuts).
Patients with documented CHD Consume about 1 g of EPA+DHA per day, preferably from fatty fish. EPA+DHA in capsule form could be considered in consultation with the physician.
Patients who need to lower triglycerides 2 to 4 grams of EPA+DHA per day provided as capsules under a physician's care.
Patients taking more than 3 grams of omega-3 fatty acids from capsules should do so only under a physician's care. High intakes could cause excessive bleeding in some people.
Evidence from prospective secondary prevention studies suggests that taking EPA+DHA ranging from 0.5 to 1.8 grams per day (either as fatty fish or supplements) significantly reduces deaths from heart disease and all causes. For alpha-linolenic acid, a total intake of 1.5–3 grams per day seems beneficial.
I couldn't sit back anymore. Ellen Reiss Goldfarb, RD, a member of this blog's inCYST Network for Women With PCOS collaborated with me on hopefully setting the record straight. We hope it helps, especially to get a mathematically-correct set of recommendations out to the public so they can go grocery shopping with a better sense of empowerment.
Regarding the omega-3 recommendations recently discussed, you all may want to consider that there are several contradictions within that make it very difficult (maybe even impossible) for the average American to follow them. As dietitians, it is important that we understand this math so that we help, not confuse or hurt, people who look to us for advice.
First of all, we are telling people that they are not to eat more than 3 grams of omega-3's per day unless they are under a physician's care. However, if you try to get 1.8 mg of combined EPA + DHA combined, in the form of food first, 3 ounces of Alaskan salmon, which contains 384 mg of EPA plus DHA, would have to be eaten in a DAILY QUANTITY OF 14 ounces in order to get there. Are you really saying that if you're eating enough fish to get the amount of omega-3's we recommend, that the MD has to manage it??? You are unnecessarily putting yourself out of business if you are!!!
Secondly, given those numbers for salmon, the densest seafood source of omega-3's, there is no way eating fish just a few times a week is going to get you to the level of omega-3 intake these recommendations are making. It is so frustrating watching colleagues parrot these recommendations and wondering if we're the only ones who've actually sat down and done this math.
We also went to three popular fish oil brands and calculated out how many pills you would need to get the upper level of DHA + EPA recommended. Two of those, Nordic Naturals and Carlson's, if taken at the level needed to get there, would also place your client at levels you say a physician needs to manage.
Realistically and honestly, how many of you are really doing that?
With regards to bleeding, in all of our collective years actively recommending fish oil, only one client encountered a bleeding problem. The people at greatest risk for that are people who are on medications such as coumadin…and if you work closely with a physician who"gets it"--the dose of that medication can be dropped as EPA levels rise and help normalize blood clotting function. Always start low, titrate up, look closely for symptoms in people not on contraindicated medicatoins and let the MD check blood levels in people who are…and work very hard to minimize omega-6 intake. You'll get a lot more bang out of your omega-3 buck if you focus on the omega 6 to omega 3 ratio than if you only think about one.
If you don't know how to use omega-3's to promote health, you may actually CREATE health risks for your clients, which I don't think any of you want to do.
Here are the numbers from our calculations for your reference.
Amount needed to meet n-3's needed to meet upper DHA + EPA recommendation/total omega-3 content of that amount 3 ounces salmon 14 oz DAILY/15.2 total gms n-3 Nordic Naturals 3.27 capsules/3.6 gm total n-3 Carlson's 3.6 capsules/6.0 gm total n-3 Barlean's 3.0 capsules/2.3 gm total n-3
Monika M. Woolsey, MS, RD Ellen Reiss Goldfarb, RD
I've gotten a handful of questions about almonds recently so it seemed like it was time to give them their own personal blog post. It's a good day to talk about the benefits of a handful of almonds, since it's also National Wear Red Day and heart disease is an important risk factor for women with PCOS. They're repeatedly shown to have heart healthy benefits. Eight peer-reviewed studies reported at www.almondsarein.com consistently produced the same results: lower LDL and lower total cholesterol. Other findings included increased HDL, and lower triglycerides.
The disclaimer is that the almonds were used to replace other foods in the diet. In other words, if you know your diet needs some"cleaning up", it won't help to keep eating the problem foods and add the almonds. You need to simultaneously reduce intake of other foods and replace those calories with almonds.
Fortunately, almonds are a tasty snack and can be added to your morning oatmeal, your lunchtime salad, or your favorite muffin recipe. If you'd like to take it one step further and cook more with almonds, the almond people have a great web page with a search engine to give you some ideas.
My parents have a time share on the island of Kauai. In a recent conversation they mentioned that they are gearing up for their every-other-year trip, and what came to mind? Not the beaches, not the snorkeling, not the sunsets…but the coffee-crusted macadamia nuts they always bring back.
When I started in this profession waaaay back when, I was taught to teach that nuts were to be avoided. And that macadamia nuts were the worst of the worst.
Recently, a colleague and I did an analysis of all nuts. Using a nutrient database, we developed a ratio: pro-inflammatory fats (saturated and omega-6) to anti-inflammatory fats (monounsaturated and omega-3). What we discovered when we did this was that the highest anti-inflammatory rating belonged to macadamia nuts. The reason is that macadamias proportionately have a very high monounsaturated fat content. Monounsaturated fats are the healthy fats often associated with olive oil and avocados.
Was I ever stoked!
Sometimes I feel like I'm in a"Where's Waldo?" drawing…and consumers have to find me in the middle of the crowd, the lone nutritionist who's encouraging them to eat all nuts, not just walnuts. It's not that I don't like walnuts, I just think they get way too much attention considering the health values of other nuts.
Looks like other researchers are making the same discovery. Recently a laboratory at Pennsylvania State University reported that an ounce and a half of macadamia nuts daily helped to reduce total cholesterol, low density lipoprotein (LDL), and triglycerides.
Macadamia oil is also a popular ingredient in acne lotions. And it is being researched as a potential anti-aging agent for skin preparations.
Of course, eating any nut in excess is as potentially detrimental as eating any food in excess. But I know in my counseling that clients are always looking for good snack ideas. It's so fun to help them learn how that ounce of nuts, in the middle of the afternoon, can help stave off hunger until dinnertime.
Nuts are not to be feared…anymore.
Griel AE, Cao Y, Bagshaw DD, Cifelli AM, Holub B, Kris-Etherton PM. A macadamia nut-rich diet reduces total and LDL-cholesterol in mildly hypercholesterolemic men and women. J Nutr. 2008 Apr;138(4):761-7.
Akhtar N, Yazan Y. Formulation and in-vivo evaluation of a cosmetic multiple emulsion containing vitamin C and wheat protein. Pak J Pharm Sci. 2008 Jan;21(1):45-50.
