Journal of Human Nutrition and Dietetics
RESEARCH PAPER Poor quality diet is associated with overweight status and obesity in patients with polycystic ovary syndrome A. M. dos S. Rodrigues,1 L. B. Martins,1 A. M. T. Franklin,1 A. L. Candido,2 L. C. dos Santos1 & A. V. M. Ferreira1 1 2
Department of Nutrition, Nursing School, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil Department of Medical Clinic, Medicine School, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
Keywords diet quality, obesity, polycystic ovary syndrome. Correspondence A. V. M. Ferreira, Department of Nutrition, Nursing School, Universidade Federal de Minas Gerais, Av. Alfredo Balena, 190, 30130-100 Belo Horizonte, Minas Gerais, Brazil. Tel.: +55313409 9858 Fax: +55313409 9853 E-mail: [email protected] How to cite this article Rodrigues A.M. dos S., Martins L.B., Franklin A.M.T., Candido A.L., dos Santos L.C. & Ferreira A.V.M. (2014) Poor quality diet is associated with overweight status and obesity in patients with polycystic ovary syndrome. J Hum Nutr Diet. doi:10.1111/jhn.12205
Abstract Background: The high rates of overweight status observed in women with polycystic ovary syndrome (PCOS) may reflect dietary intake, and so it is important to investigate diet quality and its relationship with the rates of overweight status and obesity among these patients. Methods: A cross-sectional study was conducted in which 100 women with PCOS (Rotterdam criteria) were evaluated considering anthropometric and dietary data. The anthropometric evaluation included the measurement of weight, height, body mass index (BMI), waist circumference (WC), hip circumference and waist–hip ratio. Food intake data were collected from two 24-h dietary recalls to assess dietary patterns using the Brazilian Healthy Eating Index – Revised (BHEI-R). Results: The anthropometric analysis indicated a high prevalence of overweight status, obesity and increased visceral fat (30.0%, 60.0% and 90.0%, respectively). The mean BHEI-R score was 56.1 12.0 points (range 34.5–77.5 points). Diet quality was negatively correlated with obesity, which was evaluated by BMI (r = 0.248; P = 0.013) and WC (r = 0.278; P = 0.005). Conclusions: Dietary interventions focused on improvement of diet quality should be targeted to treat patients with PCOS because obesity in these women is associated with worsening endocrine, metabolic and reproductive functions.
Introduction Polycystic ovary syndrome (PCOS) has heterogeneous clinical features and is the most common endocrinopathy in women of fertile age, with a prevalence as high as 15% when the broader Rotterdam criteria are applied (Fauser et al., 2012). The clinical features are quite variable but commonly include at least two of the following criteria: oligo-ovulation or anovulation, hyperandrogenism and presence of polycystic ovaries (ESHRE/ASMR, 2004; Fauser et al., 2012). Polycystic ovary syndrome is associated with risk factors for developing type 2 diabetes mellitus (Wild et al., 2010; Wang et al., 2011), cardiovascular disease and the metabolic syndrome (Wild et al., 2010). In addition, it ª 2014 The British Dietetic Association Ltd.
has been reported that most patients have insulin resistance and intrinsic hyperinsulinaemia, irrespective of the presence of obesity (Barber et al., 2006; Wild et al., 2010; Stepto et al., 2013). Approximately 38.0–86.0% of patients are overweight and have central fat accumulation (Barber et al., 2006; Hoeger & Oberfield, 2012). Excess body weight worsens symptoms of PCOS, including hyperandrogenism, menstrual disturbances, infertility and metabolic profile (Barber et al., 2006; Fauser et al., 2012; Hoeger & Oberfield, 2012; Lim et al., 2013). Although there is evidence of the far-ranging negative effects of obesity in the pathogenesis of PCOS, it is unclear whether women with this syndrome have a predisposition to be overweight or whether obese women are predisposed to PCOS (Fauser et al., 2012; Hoeger & 1
A. M. dos S. Rodrigues et al.
Poor quality diet and obesity in PCOS
Oberfield, 2012). However, the importance of increased adiposity in PCOS is evident because modest to moderate weight loss improves symptoms of the syndrome (Barber et al., 2006; Moran et al., 2009; Wild et al., 2010). The higher obesity rates observed in women with PCOS may reflect poor dietary habits, although available data concerning diet intake in such a population are still sparse and contradictory. Most studies found that daily energy and macronutrients intake did not differ between women with and without the syndrome (Douglas et al., 2006; Toscani et al., 2011; Altieri et al., 2013), whereas others showed a higher energy intake and glycaemic index in women with PCOS (Jeanes et al., 2009; Moran et al., 2013). Based on these findings, an evaluation of overall diet quality (i.e. quality over quantity) may provide additional information with respect to the dietary intake patterns of PCOS patients and its correlation with obesity. Previous studies have analysed dietary patterns using diet quality index scores. These approaches evaluate nutrient intake and food quality and allow for a better understanding of the relationship between dietary factors and the development of diseases (Waijers et al., 2007; Previdelli et al., 2011). The diet quality index analyses the combination factors that broadly reflect an individual eating pattern, whereas the evaluation of isolated nutrients and foods represents a simplistic view of food intake (Waijers et al., 2007; Ervin, 2008). Cross-sectional studies report an inverse association between diet quality and blood pressure, total cholesterol, insulin resistance, glycaemia and obesity (Guo et al., 2004; McNaughton et al., 2009; Tande et al., 2010). Because dietary patterns can be an important environmental factor involved in the development of obesity, we investigated the role of diet quality and its relationship with overweight status and obesity rates among patients with PCOS. High rates of obesity in patients with PCOS should be associated with poor diet quality akin to that observed in the overall population. Materials and methods Study design and participants This was a cross-sectional study conducted from October 2010 to March 2012 in which all women (n = 100) treated in an endocrinology centre specialising in hyperandrogenism at the university hospital of UFMG (Belo Horizonte, MG, Brazil) were assessed using clinical, anthropometric and dietary factors. All patients had been previously diagnosed with PCOS according to the Rotterdam criteria (ESHRE/ASMR, 2004) and were of reproductive age (18–45 years). The length of time since diagnosis was 3.5 1.8 months. Pregnant women were excluded from the study, as well as women who had 2
previously received dietary counselling. The study was approved by the Ethics Committee of UFMG (registration number 0244.0.0203.000-10). Study protocol An anthropometric evaluation was performed, including the measurement in triplicate of weight, height, waist circumference (WC) and hip circumference (HC), according to the criteria set by the World Health Organization (WHO, 1995, 2011). After obtaining these measurements, body mass index [BMI = weight (kg)/height² (m)] was assessed and classified as normal (BMI 18.5–24.9 kg m–2), overweight (BMI 25.0–29.9 kg m–2), obesity class I (BMI 30.0–35.0 kg m–2), obesity class II (BMI 35.1–39.9 kg m–2) and obesity class III (BMI > 40.0 kg m–²; WHO, 1995). WC was classified according to the increased risk (>80 cm) and the substantially increased risk (>88 cm) of metabolic complications associated with obesity (WHO, 2011). Waist-hip ratio [WHR = WC (cm)/HC (cm)] was classified as the substantially increased risk (≥0.85) of metabolic complications (WHO, 2011). The physical activity level was assessed using criteria established by the Institute of Medicine (IOM, 2005). The energy content, macronutrients and quality of the diet were assessed using two 24-h dietary recalls, as described previously (Bir o et al., 2002). The food intake reported was converted to grams and millilitres and subsequently analysed using Nutrition Dietwin software (http://www.dietwin.com.br/). Quantitative analysis of energy intake, carbohydrates, proteins and lipids was performed in accordance with the recommendations of the Institute of Medicine (Institute of Medicine, 2005) and analysis of fibre was performed in accordance with the recommendations of the American Diabetes Association (2009). The 24-h dietary recall method was used to assess the dietary patterns of participants through of the Brazilian Healthy Eating Index – Revised (BHEI-R; Previdelli et al., 2011). The BHEI-R has twelve components: nine food groups from the 2006 Brazilian Dietary Guidelines in which daily portions are expressed in terms of energy density, two nutrients (sodium and saturated fats), and one of energy from solid fat, alcohol and added sugar (Previdelli et al., 2011). The elaboration of the BHEI-R and the definition of cut-off points for the maximum, intermediate and minimum scores for each component were based on recommendations from the 2006 Brazilian Dietary Guidelines (BRASIL, 2008), WHO (2004), IOM (2004), Healthy Eating Index 2005 (Guenther et al., 2008) and the Brazilian Cardiology Society (Sposito et al., 2007). The scores vary from the minimum (zero) to maximum (5, 10 or ª 2014 The British Dietetic Association Ltd.
A. M. dos S. Rodrigues et al.
20), depending on the component evaluated. The maximum values indicate an optimal food intake. The sum maximum score of the 12 components is 100, with a higher score indicating increased compliance with the dietary guidelines (Previdelli et al., 2011). A score over 80 on the BHEI-R was classified as a ‘good’ diet, a score between 51 and 80 was classified as a diet that ‘needs improvement’, and a score
RESEARCH PAPER Poor quality diet is associated with overweight status and obesity in patients with polycystic ovary syndrome A. M. dos S. Rodrigues,1 L. B. Martins,1 A. M. T. Franklin,1 A. L. Candido,2 L. C. dos Santos1 & A. V. M. Ferreira1 1 2
Department of Nutrition, Nursing School, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil Department of Medical Clinic, Medicine School, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
Keywords diet quality, obesity, polycystic ovary syndrome. Correspondence A. V. M. Ferreira, Department of Nutrition, Nursing School, Universidade Federal de Minas Gerais, Av. Alfredo Balena, 190, 30130-100 Belo Horizonte, Minas Gerais, Brazil. Tel.: +55313409 9858 Fax: +55313409 9853 E-mail: [email protected] How to cite this article Rodrigues A.M. dos S., Martins L.B., Franklin A.M.T., Candido A.L., dos Santos L.C. & Ferreira A.V.M. (2014) Poor quality diet is associated with overweight status and obesity in patients with polycystic ovary syndrome. J Hum Nutr Diet. doi:10.1111/jhn.12205
Abstract Background: The high rates of overweight status observed in women with polycystic ovary syndrome (PCOS) may reflect dietary intake, and so it is important to investigate diet quality and its relationship with the rates of overweight status and obesity among these patients. Methods: A cross-sectional study was conducted in which 100 women with PCOS (Rotterdam criteria) were evaluated considering anthropometric and dietary data. The anthropometric evaluation included the measurement of weight, height, body mass index (BMI), waist circumference (WC), hip circumference and waist–hip ratio. Food intake data were collected from two 24-h dietary recalls to assess dietary patterns using the Brazilian Healthy Eating Index – Revised (BHEI-R). Results: The anthropometric analysis indicated a high prevalence of overweight status, obesity and increased visceral fat (30.0%, 60.0% and 90.0%, respectively). The mean BHEI-R score was 56.1 12.0 points (range 34.5–77.5 points). Diet quality was negatively correlated with obesity, which was evaluated by BMI (r = 0.248; P = 0.013) and WC (r = 0.278; P = 0.005). Conclusions: Dietary interventions focused on improvement of diet quality should be targeted to treat patients with PCOS because obesity in these women is associated with worsening endocrine, metabolic and reproductive functions.
Introduction Polycystic ovary syndrome (PCOS) has heterogeneous clinical features and is the most common endocrinopathy in women of fertile age, with a prevalence as high as 15% when the broader Rotterdam criteria are applied (Fauser et al., 2012). The clinical features are quite variable but commonly include at least two of the following criteria: oligo-ovulation or anovulation, hyperandrogenism and presence of polycystic ovaries (ESHRE/ASMR, 2004; Fauser et al., 2012). Polycystic ovary syndrome is associated with risk factors for developing type 2 diabetes mellitus (Wild et al., 2010; Wang et al., 2011), cardiovascular disease and the metabolic syndrome (Wild et al., 2010). In addition, it ª 2014 The British Dietetic Association Ltd.
has been reported that most patients have insulin resistance and intrinsic hyperinsulinaemia, irrespective of the presence of obesity (Barber et al., 2006; Wild et al., 2010; Stepto et al., 2013). Approximately 38.0–86.0% of patients are overweight and have central fat accumulation (Barber et al., 2006; Hoeger & Oberfield, 2012). Excess body weight worsens symptoms of PCOS, including hyperandrogenism, menstrual disturbances, infertility and metabolic profile (Barber et al., 2006; Fauser et al., 2012; Hoeger & Oberfield, 2012; Lim et al., 2013). Although there is evidence of the far-ranging negative effects of obesity in the pathogenesis of PCOS, it is unclear whether women with this syndrome have a predisposition to be overweight or whether obese women are predisposed to PCOS (Fauser et al., 2012; Hoeger & 1
A. M. dos S. Rodrigues et al.
Poor quality diet and obesity in PCOS
Oberfield, 2012). However, the importance of increased adiposity in PCOS is evident because modest to moderate weight loss improves symptoms of the syndrome (Barber et al., 2006; Moran et al., 2009; Wild et al., 2010). The higher obesity rates observed in women with PCOS may reflect poor dietary habits, although available data concerning diet intake in such a population are still sparse and contradictory. Most studies found that daily energy and macronutrients intake did not differ between women with and without the syndrome (Douglas et al., 2006; Toscani et al., 2011; Altieri et al., 2013), whereas others showed a higher energy intake and glycaemic index in women with PCOS (Jeanes et al., 2009; Moran et al., 2013). Based on these findings, an evaluation of overall diet quality (i.e. quality over quantity) may provide additional information with respect to the dietary intake patterns of PCOS patients and its correlation with obesity. Previous studies have analysed dietary patterns using diet quality index scores. These approaches evaluate nutrient intake and food quality and allow for a better understanding of the relationship between dietary factors and the development of diseases (Waijers et al., 2007; Previdelli et al., 2011). The diet quality index analyses the combination factors that broadly reflect an individual eating pattern, whereas the evaluation of isolated nutrients and foods represents a simplistic view of food intake (Waijers et al., 2007; Ervin, 2008). Cross-sectional studies report an inverse association between diet quality and blood pressure, total cholesterol, insulin resistance, glycaemia and obesity (Guo et al., 2004; McNaughton et al., 2009; Tande et al., 2010). Because dietary patterns can be an important environmental factor involved in the development of obesity, we investigated the role of diet quality and its relationship with overweight status and obesity rates among patients with PCOS. High rates of obesity in patients with PCOS should be associated with poor diet quality akin to that observed in the overall population. Materials and methods Study design and participants This was a cross-sectional study conducted from October 2010 to March 2012 in which all women (n = 100) treated in an endocrinology centre specialising in hyperandrogenism at the university hospital of UFMG (Belo Horizonte, MG, Brazil) were assessed using clinical, anthropometric and dietary factors. All patients had been previously diagnosed with PCOS according to the Rotterdam criteria (ESHRE/ASMR, 2004) and were of reproductive age (18–45 years). The length of time since diagnosis was 3.5 1.8 months. Pregnant women were excluded from the study, as well as women who had 2
previously received dietary counselling. The study was approved by the Ethics Committee of UFMG (registration number 0244.0.0203.000-10). Study protocol An anthropometric evaluation was performed, including the measurement in triplicate of weight, height, waist circumference (WC) and hip circumference (HC), according to the criteria set by the World Health Organization (WHO, 1995, 2011). After obtaining these measurements, body mass index [BMI = weight (kg)/height² (m)] was assessed and classified as normal (BMI 18.5–24.9 kg m–2), overweight (BMI 25.0–29.9 kg m–2), obesity class I (BMI 30.0–35.0 kg m–2), obesity class II (BMI 35.1–39.9 kg m–2) and obesity class III (BMI > 40.0 kg m–²; WHO, 1995). WC was classified according to the increased risk (>80 cm) and the substantially increased risk (>88 cm) of metabolic complications associated with obesity (WHO, 2011). Waist-hip ratio [WHR = WC (cm)/HC (cm)] was classified as the substantially increased risk (≥0.85) of metabolic complications (WHO, 2011). The physical activity level was assessed using criteria established by the Institute of Medicine (IOM, 2005). The energy content, macronutrients and quality of the diet were assessed using two 24-h dietary recalls, as described previously (Bir o et al., 2002). The food intake reported was converted to grams and millilitres and subsequently analysed using Nutrition Dietwin software (http://www.dietwin.com.br/). Quantitative analysis of energy intake, carbohydrates, proteins and lipids was performed in accordance with the recommendations of the Institute of Medicine (Institute of Medicine, 2005) and analysis of fibre was performed in accordance with the recommendations of the American Diabetes Association (2009). The 24-h dietary recall method was used to assess the dietary patterns of participants through of the Brazilian Healthy Eating Index – Revised (BHEI-R; Previdelli et al., 2011). The BHEI-R has twelve components: nine food groups from the 2006 Brazilian Dietary Guidelines in which daily portions are expressed in terms of energy density, two nutrients (sodium and saturated fats), and one of energy from solid fat, alcohol and added sugar (Previdelli et al., 2011). The elaboration of the BHEI-R and the definition of cut-off points for the maximum, intermediate and minimum scores for each component were based on recommendations from the 2006 Brazilian Dietary Guidelines (BRASIL, 2008), WHO (2004), IOM (2004), Healthy Eating Index 2005 (Guenther et al., 2008) and the Brazilian Cardiology Society (Sposito et al., 2007). The scores vary from the minimum (zero) to maximum (5, 10 or ª 2014 The British Dietetic Association Ltd.
A. M. dos S. Rodrigues et al.
20), depending on the component evaluated. The maximum values indicate an optimal food intake. The sum maximum score of the 12 components is 100, with a higher score indicating increased compliance with the dietary guidelines (Previdelli et al., 2011). A score over 80 on the BHEI-R was classified as a ‘good’ diet, a score between 51 and 80 was classified as a diet that ‘needs improvement’, and a score
