The Hemp Connection [Search results for BMI] 

For some reason, I have been placed on the mailing list for a fertility researcher in the UK who is doing some interesting work looking at how fertility doctors conduct their treatments around the world. I actually tried to answer his survey, but since none of the choices available to me had anything to do with changing diet and lifestyle, I was not allowed to complete it.

That is something I find very interesting, that it would not even occur to a fertility specialist to consider the nutritional status of the client and the nutritional interventions provided clients as important variables to consider. Dr. Balen, if you ever wish to consider those factors, now you know where I am.: )

Anyway, I thought the readers of this blog would find some of the results of this study to be interesting. I'll put my commentaries in italics.

This is a summary of 179,300 IVF treatments conducted in 262 fertility centers on every continent where there is a fertility center…meaning Antarctica was not on the list.

1. 73.3% of these cases were assessed for impaired glucose tolerance. That means that 26.67%, or 47,694 women, were not.
--I would be interested to see the geographic distribution of these answers. Several years ago, I moderated a listserve in Spanish for women with PCOS and it was rare in that group to hear of women being treated for insulin resistance. I actually had to go on strike and refuse to give out any more information until the women in the group who had not been evaluated, got the evaluation. About three months later, we had about 6 pregnant women amongst us.: )
--Not sure why, since PCOS has such a strong connection to insulin resistance and it is the number one cause of infertility, this assessment simply is not a universal precaution?

2. 61.3% of the physicians who chose to assess for impaired glucose intolerance were only doing so in obese patients.
--Here we go again, the invisible lean cyster. If up to 70% of women with PCOS are NOT obese, consider the number of infertility cases that are made more complicated than they need to be, simply because of a misperception of what PCOS has to"look like" in order to be taken seriously.

3. 69% of the physicians surveyed, in their PCOS patients, considered clomiphene citrate to be the first line of treatment.
--I would love to know how they would have answered this if they had been given the option of nutrition/lifestyle/sleep hygiene consultation had been an option to answer.

4. Cutoffs for treatment based on BMI:
30% would not treat if BMI was greater than 30
33% would not treat if BMI was greater than 35
20% would not treat if BMI was greater than 40
6% would not treat if BMI was greater than 45
--Which has me wondering, again, why nutrition/lifestyle/sleep hygiene consultations are not considered the absolute essential first line of treatment.

So lean women, apparently, even though their BMI's would be considered appropriate by these practitioners, would not be given the assessment that would help them get the proper treatment.

And obese women, apparently, are not given any direction regarding what to do to bring their BMI into a workable range.

If you're still wondering why your patients with PCOS can be so angry, skeptical, and emotional, maybe you would have better success with an accounting career.

Imagine how much more successful my colleagues in these 262 treatment centers would be if they partnered with professionals who know how to do something about those quandaries.

We'd love to help you improve on those statistics.

The invitation is open.

Source: PCOS – Definition, Diagnosis and Treatment, a survey compiled by Prof. Adam Balen, Leeds Centre for Reproductive Medicine, Seacroft Hospital, Leeds, U.K

Multiple gestation pregnancies are increasing dramatically in the United States. This often leads to increasing frequency of low birth weight infants, preterm labor and other conditions associated with high risk pregnancies. Nutrition is a key element to reducing the risk of birth defects, suboptimal fetal growth and development and chronic health problems for both mother and child. Nutritional intervention has been proven consistently to improve outcomes in multiples.

Weight gain recommendations are based on pre -pregnancy Body Mass Index ( BMI ) whether for singleton pregnancies or multiple gestations. Twins and higher multiples do require both more calories and increased weight gain (over a singleton pregnancy). The following are guidelines that I have gathered from the literature:
Singleton: Twins: Triplets: Quadruplets:
Underweight (< 18.5 BMI) 28-40 lbs. No guidelines established
Normal weight (18.5-24.9 BMI) 25-35 lbs. 37-54 lbs. 50-60 lbs. 65-80 lbs.
Overweight (25-29.9 BMI) 15-25 lbs. 31-50 lbs.
Obese (> 30 BMI ) 11-20 lbs. 25-42 lbs.

Some additional things to consider:
Multiple gestation in a woman's first pregnancy: Gain an additional 5-7 lbs as quickly as possible
Multiples as a result of infertility treatments: Gain an additional 4-6 lbs. during the first half of the pregnancy
(This has been shown to decrease the liklihood of miscarriage-reason unknown)
Smokers or those who have recently quit smoking should gain an additional 5-7 lbs. to help replace nutrients lost through smoking and to replenish lost nutrients.

The pattern of weight gain is also important when having multiples. This is because often multiples do not go to term, so early weight gain is important. Weight gain in the first 24 weeks has the most influence on
weight gain after 24 weeks.
The recommendation is as follows: Before 24 weeks After 24 weeks
Goal weight gain/week Goal weight gain/week
Singleton 1/2 lb. 1 lb.
Twins 1 lb. 2 lbs.
Triplets 1 1/2 lbs. 2 1/2 lbs.
Quadruplets 2 lbs. 3 lbs.

How many calories are needed for appropriate weight gain?
The following guidelines (based on pre -pregnancy weight) can be used to estimate individual needs:
Singleton:
Normal pre -pregnancy weight: 30 calories/kilogram(kg.) (1 kg = 2.2 lbs.) Your weight/2.2=weight in kg.
Overweight: 24 calories/kg.
Underweight: 36-40 calories/kg.

Twins: Add 500 calories per day to the above recommendations as soon as the multiple pregnancy
is diagnosed.

If you need assistance with determining or reaching goals, seek out a nutrition professional/Registered Dietitian who works with high risk pregnancies.

I just found this abstract in Pub Med. The full article is referenced at the bottom. I would love to hear any and all comments from readers about this issue!

Resource allocation towards fertility treatment has been extensively debated in countries where fertility treatment is publicly-funded. Medical, social and ethical aspects have been evaluated prior to allocation of resources. Analysis of cost-effectiveness, risks and benefits and poor success rates have led to calls of restricting fertility treatment to obese women. In this debate article, we critically appraise the evidence underlying this issue and highlight the problems with such a policy. Poor success rate of treatment is unsubstantiated as there is insufficient evidence to link high body mass index (BMI) to reduction in live birth. Obstetric complications have a linear relationship with BMI but are significantly influenced by maternal age. The same is true for miscarriage rates which are influenced by the confounding factors of polycystic ovary syndrome and age. Studies have shown that the direct costs per live birth are no greater for overweight and obese women. With changing demographics over half the reproductive-age population is overweight or obese. Restricting fertility treatment on the grounds of BMI would cause stigmatization and lead to inequity, feelings of injustice and social tension as affluent women manage to bypass these draconian restrictions. Time lost and poor success of conventional weight loss strategies would jeopardize the chances of conception for many women.
Pandey S, Maheshwari A, Bhattacharya S. Should access to fertility treatment be determined by female body mass index? Hum Reprod. 2010 Feb 3. [Epub ahead of print]

The findings in this study are probably not news to you if you have PCOS, but it's nice to see your emotional PCOS finally validated with a scientific study.

480 women with PCOS participated in the psychological evaluation portion of this study.

Women who were not menstruating were more likely to have lower self-esteem, and to have a greater fear of being negatively viewed with regard to their appearance. These women also appeared to have an earlier onset of maturity.

High androgen levels and acne were associated with poorer body satisfaction. The greater the degree of hirsutism and BMI (body size), the lower the scores on psychological tests.

The obvious social explanations for these findings have been covered elsewhere. I believe that hormones have a huge part to play in these tendencies…I've worked in eating disorders and I've seen literally thousands of women lose the weight and remove the hair…and STILL be unhappy. Women with PCOS need help in understanding how hormones affect mood (and that hormones ARE mood) and to have access to qualified professionals who can help with that aspect of PCOS.

It's why I'm so happy Gretchen Kubacky and Anna Ahlborn are in the inCYST Network. They are here to help us better understand these conditions and what can be done to minimize any potentially negative influence they may have on your quality of life.: )

de Niet JE, de Koning CM, Pastoor H, Duivenvoorden HJ, Valkenburg O, Ramakers MJ, Passchier J, de Klerk C, Laven JS. Psychological well-being and sexarche in women with polycystic ovary syndrome. Hum Reprod. 2010 Mar 31. [Epub ahead of print]

Bisphenol-A (BPA) is everywhere. In addition to cans and plastic packaging, it is found in thermal paper and carbonless copy paper, which are commonly used for receipts, airline tickets, event tickets, and labels. It is so ubiquitous that it was found in the urine of 95% of all people the CDC tested between 1988-1994.

One study found a strong correlation between body mass index (BMI) and BPA levels. That, to a dietitian, seems like a vicious cycle, since a lot of the foods I personally believe are associated with obesity (sodas, chips) are packaged in BPA-containing materials. So not only do you expose yourself to the chemical when exposing those foods and beverages…you are highly likely encouraging your body to hang on to those chemicals if you're eating them in a way that is out of balance with your daily caloric needs.

Staying lean, however, is not a guarantee you'll be protected. It is looking like BPA can elevate liver enzymes, a common problem with PCOS. And that problem persists even in normal weight individuals.

Scientists do believe BPA passes through the body very quickly. However, some of the problems associated with BPA seem to be nonreversible. And unborn babies and newborns, who are going through rapid development, seem to be highly susceptible to this effect. That means that you can reduce your exposure to BPA and lower your current levels, but you may not be able to undo all of the changes that BPA had the opportunity to make. You can eliminate future problems…but you may not be able to undo all that's been done.

I really want this blog to be positive and not scary. However, this is a very serious issue. Since many of you are eating to conceive and eventually eating for more than yourself, it's important to understand that how you choose to eat can impact more than just you. And it's not just about eating to conceive…it's about eating for a healthier next generation.

The less packaging your food comes in, over time, the less likely it is you'll be consuming BPA.

Gehring, Martin; Tennhardt, L., Vogel, D., Weltin, D., Bilitewski, B. (2004) (PDF). Bisphenol A Contamination of Wastepaper, Cellulose and Recycled Paper Products. Waste Management and the Environment II. WIT Transactions on Ecology and the Environment, vol. 78. WIT Press. http://rcswww.urz.tu-dresden.de/~gehring/deutsch/dt/vortr/040929ge.pdf. Retrieved 2009-10-15.

http://arstechnica.com/old/content/2008/09/plastic-additive-bpa-connected-to-diabetes-heart-disease.ars

It's not uncommon to read blog posts, tweets, and chat room conversations in which women with PCOS describe their depression, and attribute it to the weight gain and appearance that their PCOS has promoted. It can be easy to blame the discomfort, fatigue, restless, and anxiety that depression provokes, on tangible and unwanted physical changes

A recent study helps to verify what I've believed all along…that depression, like hirsutism, weight gain, and infertility, is another condition that PCOS has potential to create. It is not the result of other symptoms associated with PCOS.

Here's the study.

Thirty women with PCOS and thirty women without PCOS participated in this study. All subjects had similar BMI's/weights. Only women who were not on any psychotropic medication were included. Women with PCOS scored higher on an anxiety scale than women without PCOS. They also slept less, worried more, and experienced more phobias than women without PCOS. Weight was not associated with any of the symptoms, except for sleep.

In other words, regardless of your weight, you can be depressed if you have PCOS.

If you attach or blame your depression on your weight, your appearance, or your infertility:

--you can set yourself up for an eating disorder…if you actually lose weight and discover it didn't change how you feel.
--you can feel even worse if you spend time and money on cosmetic surgery, only to realize you don't feel as good as you hoped you would.
--you can put yourself through the tremendous stress of infertility treatment, and get the baby, only to discover that you still feel depressed, and now you've got a baby who isn't sleeping through the night who is dependent on you.

That's the bad news. The good news is that the inCYST program is very helpful at reducing anxiety and depression. So in addition to helping you normalize your weight, reducing the progression of testosterone-related programs, and increasing your fertility, it helps you to feel better. It literally rebuilds your nervous system so it can reduce the influence depression can have. And in rebuilding the nervous system, it helps to balance hormones so that symptoms can lessen.

We like to focus on feeling better, since we know that in women who do, the other problems tend to fall into place. That's not to say that being anxious about your PCOS doesn't worsen when you focus on your symptoms, and that when you learn better coping skills you won't feel even better. Gretchen Kubacky has done a great job of discussing that here, on her blog, and on PCOS Challenge.

It's just that you want to be sure you're tackling the core cause of the problem, and not simply putting band-aids on the symptoms. Nothing can be more frustrating than investing all your time, resources, and money into diets and medical procedures, only to feel the same or even worse once you've done so.

Anxiety and depression symptoms in women with polycystic ovary syndrome compared with controls matched for body mass index

REFERENCE
E. Jedel1, M. Waern2, D. Gustafson2,3, M. Landén4, E. Eriksson5, G. Holm6, L. Nilsson7, A.-K. Lind7, P.O. Janson7 and E. Stener-Victorin8,9 Anxiety and depression symptoms in women with polycystic ovary syndrome compared with controls matched for body mass index

1 Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden 2 Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 3 Rush University Medical Center, Chicago, IL, USA 4 Department of Clinical Neuroscience, Section of Psychiatry, Karolinska Institutet, Stockholm, Sweden 5 Department of Pharmacology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 6 Department of Metabolism and Cardiovascular Disease, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 7 Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 8 Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 434, 40530 Gothenburg, Sweden

Monika, I want to add to your post about a"Bill of Rights" for pcos cysters, only I have termed it"Fifteen Tips for PCOS Physicians". Everyone, please feel free to add to it.

Fifteen Tips for PCOS Physicians
Stacy Korfist, LMFT

1. Please do not minimize, downplay, disregard or discourage our researching on the internet. PCOS is a chronic condition, one that requires our understanding of what is happening to our bodies. That cannot occur in a 20 minute doctor’s appointment and to take better care of ourselves we need to have a full understanding of a very complicated endocrine system.
2. If you do have concerns however, please ask which websites we are obtaining our information from, be familiar with them and either offer better alternatives or affirm the resources we have.
3. When assessing degree of hirsutism please be sure to ask about our maintenance practices. Sometimes it can look fairly mild but it is misleading because we spend an extraordinary amount of time plucking.
4. Be conscientious, but thorough when addressing weight. For those that are not obese, but hovering around the high end of the normal BMI range or over, it’s probably not ok with us. Please do not say that we are ok and not to worry. We are worried. Worried that we will stay that way, worried that we will continue to gain, worried about plenty.
5. If you do not know the answer to something, please just say so. We know doctors aren’t taught everything in medical school. It will earn our respect. In fact, if we teach you something don’t be shy to tell us so.
6. Please do not tell us to exercise more and eat less without also referring us to a dietitian. Have the name of several good dietitians that treat pcos and develop a professional relationship with them as well.
7. In fact, work with a multidisciplinary approach. Ask if we are interested in seeing a psychotherapist if needed. Know of various referral sources such as hair removal clinics, acupuncture centers, infertility support programs.
8. Be aware of each and every medication, herb and supplement we are taking.
9. When we make our appointment, ask us to be prepared with questions and concerns upon our arrival so that we may make good use of your time.
10. Allow us to take part in the decisions being made about our health. Inform us of respected alternative therapies, even if it’s something you may not provide or even agree with.
11. Be certain we are aware of all health risks related to pcos, now and over the lifespan. There are many and this will take time. Be sure we understand strategies for prevention. If we are minors be sure our parents know how to best support our needs.
12. Stay current with treatment approaches and healthcare industry trends. Be an advocate and get involved. Step out and teach others.
13. Make a follow up appointment with us.
14. Explain the lab work. Don’t just say everything is in normal range, especially if it’s something that shows deterioration. Allow us to ask questions.
15. Most importantly, treat us as an individual and not just be a cookie-cutter practitioner. This can only be accomplished with good listening skills.

If you are a physician and have taken the time to read this then you are one of the good ones.

Stacy Korfist, LMFT Redondo Beach, CA
310 720-6443

Here's a study about lean women with PCOS--the women who I like to call"the forgotten cysters". I have lost track over the years of the number of women who have written me to share that they went to their physician asking for help with a list of PCOS symptoms they had…only to be told they couldn't possibly have PCOS because they were not overweight. Up to 70% of women who have this disorder are not overweight!!!

My belief is that many women who have adopted extreme eating and exercise behaviors to manage their weight, quite possibly many women who have been diagnosed with and who are being treated for eating disorders, actually have undiagnosed PCOS.

We need to get over this belief that thin equals healthy, and that a person cannot have PCOS if her BMI and weight are within normal limits. If you have to adopt extreme measures to stay within your recommended weight range, that is a serious problem and your physician needs to listen to you.

Now for this study to illustrate. Eight lean women who actually had been diagnosed with PCOS ("cysters") were compared to 7 lean women without PCOS. The cysters had higher testosterone, and prolactin levels. They also had lower sex hormone binding globulin levels (this protein binds and inactivates testosterone).

There you have it. You can be thin AND out of balance. Sisters…and cysters…it is your right to be heard and to not be told that nothing is wrong with you when you know there is. That is where my program name, inCYST, came from. You have the right to inCYST on the appropriate treatment for the appropriate problem and not to be told you do not need treatment just because you may not fit the common profile for PCOS, or for any disorder.

Grimmichová T, Vrbíková J, Matucha P, Vondra K, Veldhuis PP, Johnson ML. Fasting insulin pulsatile secretion in lean women with polycystic ovary syndrome. Physiol Res. 2008 Feb 13 [Epub ahead of print]