PCOS and Insulin Resistance: Part 7 PCOS and Obesity
Weight, and Obesity more specifically, is a pre-existing and pre-disposing condition and risk factor for many, if not most, of the serious health ailments plaguing us today. BMI will not help determine the type of fat accumulation, and some fat, like fat around the organs, will have a more severe metabolic effect. Nevertheless, BMI is a way of categorizing individuals based on weight and height alone (http://healthland.time.com/2013/08/26/why-bmi-isnt-the-best-measure-for-weight-or-health/). Although there are ethnic variations, obese individuals are at an increased risk for Type 2 Diabetes, Cardiovascular Disease, and Cancer, among other equally detrimental diseases.
Figure 1: BMI Chart (http://www.lifestyleat.com/body-mass-index-bmi-body-mass-index-to-define-your-obesity-level/)
What has caused such a severe, and seemingly, disproportionate rise, based on efforts, in obesity rates? Genetics can’t be it as the gene pool doesn’t change that quickly, not in the course of a couple of generations anyway. Lifestyle? For sure. But what, is it, exactly? What has changed so dramatically since the 1970’s to today, less than 50 years later? Physical activity may play a part. It is true that people overall have become more sedentary. Less manual labour, more desk jobs. Less walking everywhere, more cars. But there are also more gyms everywhere and more people joining them. Performance athletes are not immune to metabolic syndrome.
Having a very active life in today’s world doesn’t seem to protect from obesity, either. Countries with less per capita cars and public transportation don’t seem to have less rates of obesity. Countries where people still live more humble lives and work the fields don’t either. What has changed, for sure, and much more so in the last 50 years, are the foods that we eat, changed in quality, quantity and frequency. People eat more processed food, in greater amounts, more times a day. The recommendation is to eat 6 to 7 small meals per day focusing on “whole-grains”, low-fat and lots of fruit and vegetables. Processed, processed and partially modified.
From a disease perspective, obesity as the pre-existing and predisposing condition that it is, has a major and negative impact on all ailments that we care about. Since obesity is a preventable condition, according to me and the WHO, most of these conditions may also be prevented, reversed or at least improved. Obesity is commonly linked to Type 2 Diabetes, Cardiovascular Disease, Chronic Inflammatory conditions, such as arthritis, and yes, even Cancer. There are many others, less talked about and equality important concerns, affecting an overwhelming number of people.
Figure 2: Medical Complications of Obesity
PCOS is one of these conditions. There are 1,137 articles linking Obesity and PCOS in one journal alone. The Journal of Clinical Endocrinology & Metabolism. I have stated that not all obese women have PCOS and not all PCOS women are obese. I am an example of this. Having said that though, 80% of women with PCOS, in the United States, are Obese. It is unknown whether obesity per se can cause PCOS, and obesity is not defined as a diagnostic criterion for PCOS. A woman does not have to be obese to develop PCOS, but one is more likely to develop PCOS if she is already obese. Obese women with PCOS are also more likely to express its most severe phenotype, the Frank of classic polycystic PCOS (chronic anovulation, hyperandrogenism with polycystic ovaries – 3/3 criteria). Both sides of the weight coin apply to PCOS. Obese PCOS women will show more serious signs and symptoms and weight loss will improve all signs and symptoms. There is a spectrum to this disease with lean women being at the earlier stages of the spectrum and obese women at the very top.
Figure 3: Effects of Obesity and Adiposity in PCOS
As weight increases, all the defining features of PCOS become more prominent. The heavier the woman the more “masculinizing her features”: acne, hirsutism, male-pattern baldness, deeper voice, and central adiposity. The heavier the woman the less likely she is to menstruate, ovulate and conceive. The heavier the woman the higher the number of follicles in her ovaries. All 3 diagnostic criteria of PCOS are directly and negatively impacted by obesity.
Obesity aggravates PCOS and influences its development clinically, biochemically, reproductively and metabolically. Women with PCOS, in turn, are much more likely to develop obesity, both generalized as well as central obesity. One of the most frustrating factors of this condition is that women know and are constantly told to lose weight to improve PCOS, but overtime they gain ever more weight, ever faster and ever easier. This is a vicious, almost sadistic, cycle. Not only are PCOS women more likely to have a higher BMI and total obesity, but premenopausal women afflicted with this syndrome very often present with central obesity, and higher concentrations of fat on their organs, known as visceral adiposity, as well as, or because of, hyperandrogenemia. This is referred to as “masculinized body fat distribution” (http://press.endocrine.org/doi/10.1210/jc.2012-3698).
Women without PCOS, tend to have a higher concentration of peripheral (limb) and subcutaneous (under the skin) fat on their bodies rather than on their organs. Visceral fat (on the organs) is considered much more concerning, whereas peripheral fat may actually be protective against cardiovascular disease and Metabolic Risks (http://circ.ahajournals.org/content/108/23/e164).
It is apparent that these differences are most evident after puberty. PCOS women most often present with an androgen-dominant picture as you already know. Why does this happen? Well, it appears that it is in the peripubertal, or around puberty, that obesity may determine the abnormal sex hormone concentrations (http://press.endocrine.org/doi/10.1210/jc.2006-2002). In other words, obesity around puberty, for girls, can lead to hyperandrogenism, or the production of higher than desired male hormone levels, as well as hyperinsulinemia.
During this very critical development period, obesity in fact influences or maybe even trigger the development PCOS. Childhood obesity influences the hormones that the gonads will produce. This in turn will determine where the fat concentration will be most prevalent when this child becomes an adult. If we are talking about an overweight or obese little girl just before puberty, it is very likely that her body will be triggered to produce an abnormal amount of androgens, instead of estrogens. This will cascade into many detrimental, and in fact devastating, health effects throughout her adolescent years, and her entire adult life. This little girl may very well have a delayed, irregular or not existent period, while her little friends will be whispering about getting their first period between the ages of 11 and 12 (http://www.obgyn.net/young-women/first-menstruation-average-age-and-physical-signs). Obese PCOS girl will likely start to develop acne, she will begin to show signs of facial hair, not like her little girlfriends, but like her boy schoolmates.
This little obese PCOS girl, may also start to lose some hair in the crown of her head at some point in her life. So now we have a little girl that is overweight, ever more obese, with more and more fat being deposited into her midsection, she has acne, and is starting to grow a moustache and beard. At a time when the emotional stability of these budding little people is so fragile. And at a time when other girls are so mean.
Later, this girl will grow into a young woman, likely having been told many times by her doctor that if she wants to get a more regular period, improve her acne, get rid of all that hair, she needs to lose some weight. And she will try, really hard, and she might lose some, but then it comes back so easily, with every little slip, or even when she is not slipping. And she is working out like crazy, likely by herself because she might not have many friends or many fun activities to be a part of. She does try. One day, this young lady, obese and with all the manifestations of PCOS, confirmed through lab tests, abnormal levels of testosterone, irregular or absent ovulation, and Polycystic Ovaries on ultrasound, might want to get pregnant. She will again be told that losing the weight will help! She will be told to eat less and move more, and she will try! She might be put on all kinds of meds to help improve her chances… She may even undergo IVF (In-vitro Fertilization). The more overweight she is, the less likely she is to conceive, either spontaneously or through interventions. This will have a distressing impact on an already stressed woman. This impact will be physical, emotional and even financial.
A little later in life, Obese PCOS woman will very likely develop Type 2 Diabetes, Fatty Liver, abnormal cholesterol levels, Hypertension and Heart Disease and this is when she finally becomes “The Bearded Woman with Diabetes”. The vicious cycle (obesity-androgens-insulin resistance-obesity) has continued throughout her life. The dooming reminders of cancer are always there every time she visits her doctor’s office or looks up ways to improve her condition, and she tries, yet again, to lose weight, because she knows that this might be the only thing that can help her (http://press.endocrine.org/doi/10.1210/jc.2005-1852).
Obesity then, especially in the pre-teens, is a major factor. Prevention and treatment of childhood obesity is an opportunity to prevent between 10-30% of women worldwide from developing PCOS. We have been watching obesity rise but the recommendations remain the same: “eat less, move more”. More whole grains and more snacking.
Figure 4: Prevalence of Obesity among Children and Adolescents
When I was diagnosed with PCOS I was by no means obese, but I did gain 20 lbs in a period of three months. Those 20 lbs made me stop ovulating. Those 20 lbs, at least to me, seemed to be totally concentrated on my belly and nowhere else in my body. I knew that losing that weight would help me conceive, so I went on a diet, a very low-carb diet, and in 1 month I lost 6 lbs. I did conceive the following month, although I hadn’t been able to spontaneously conceive after 1 year of trying and 6 months of ovulation-stimulation meds.
A baby, born to an obese PCOS mother who may even develop Gestational Diabetes during her pregnancy, will very likely develop childhood obesity, which may trigger her (if she is a girl) to develop PCOS as a preteen, but will for sure increase his/her chances of developing Type 2 Diabetes and Heart Disease as an adult, independently of whether he/she is a baby boy or a baby girl. Here, the story repeats itself, in a vicious cycle, from generation to generation, further increasing the obesity epidemic, further increasing the insulin resistance of each offspring born to the ever more insulin resistant mother.
Obesity is preventable and treatable. Finding the right method for that prevention and treatment is imperative. Simply telling a woman to lose weight, eat less and exercise more, does not help. Telling parents, in the most condescending of manners, to just feed their kids less, has definitely not been successful. It seems obvious that prevention is key at the prepubertal stage. Childhood is a sensitive time-period, when weight plays a crucial role in the development of Metabolic Syndrome. Treatment of obesity, however, is crucial at any stage of life.