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Síndrome do ovário policístico

Propaganda
Reviews
JOURNAL OF WOMEN’S HEALTH
Volume 00, Number 00, 2017
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2016.5792
Lifestyle and Behavioral Management
of Polycystic Ovary Syndrome
Leah Brennan, PhD,1 Helena Teede, PhD,2,3 Helen Skouteris, PhD,4
Jake Linardon, B Psych Sci (Hons),1 Briony Hill, PhD,4 and Lisa Moran, PhD2,5
Abstract
Polycystic ovary syndrome (PCOS) is a common condition with serious physiological and psychological health
consequences. It affects women across their reproductive lifespan and is associated with pregnancy complications, including gestational diabetes, preeclampsia, and large gestational-age babies. PCOS is associated with
excess weight gain, which, in turn, exacerbates the health burden of PCOS. Therefore, weight management,
including a modest weight loss, maintenance of weight loss, prevention of weight gain, and prevention of excess
gestational weight gain, is a first-line treatment for women with PCOS during and independent of pregnancy.
Despite evidence-based guidelines, international position statements, and Cochrane reviews promoting lifestyle
interventions for PCOS, the optimal complexity, intensity, and behavioral components of lifestyle interventions
for women with PCOS are not well understood. The focus of this narrative review is the evidence supporting the
use of behavioral strategies in weight management interventions for reproductive-aged women to apply to
PCOS. Behavioral theories, behavior change strategies, and psychological correlates of weight management
have been thoroughly explored in weight loss interventions in the general population, reproductive-aged women, and peri-natal women. This article uses this parallel body of research to inform suggestions regarding
lifestyle interventions in women with PCOS. Outcomes of weight management programs in women with PCOS
are likely to be improved with the inclusion of behavioral and psychological strategies, including goal setting,
self-monitoring, cognitive restructuring, problem solving, and relapse prevention. Strategies targeting improved
motivation, social support, and psychological well-being are also important. These can be applied to the clinical
management of women with PCOS at different reproductive life stages.
Keywords: polycystic ovary syndrome, diet, exercise, physical activity, lifestyle, weight management
using the internationally accepted Rotterdam criteria of two
of the three features of androgen excess, ovulatory dysfunction, and polycystic ovarian morphology.8–10 This has expanded the definition of PCOS from the older National Institute
of Health (NIH) expert opinion criteria of androgen excess and
ovulatory dysfunction11 to include two additional categories of
women with a milder reproductive presentation. PCOS is associated with excess weight gain, which, in turn, exacerbates the
health burden. Prevention of excess weight gain and achieving and maintaining modest weight loss are key aspects of its
management and improved reproductive, metabolic, and psychological health. Women with PCOS are, therefore, in need of
Introduction
P
olycystic ovary syndrome (PCOS) is a common condition affecting between 12% and 18% of reproductiveaged women, and one in three overweight women.1,2 It has
serious reproductive (infertility and pregnancy complications),
metabolic (insulin resistance and risk factors for type 2 diabetes
and cardiovascular disease), and psychological (depression,
anxiety, and reduced quality of life) implications,2–5 and it has
health implications from adolescence through to menopause.6,7
PCOS is highly heritable, and its health burden extends to the
next generation.8 Its diagnosis is based on reproductive features
1
School of Psychology, Australian Catholic University, Melbourne, Australia.
Monash Centre for Health Research Implementation, School of Public Health and Preventative Medicine, Monash University,
Melbourne, Australia.
3
Diabetes and Endocrine Unit, Monash Health, Clayton, Australia.
4
School of Psychology, Deakin University, Burwood, Australia.
5
Discipline of Obstetrics and Gynecology, The Robinson Research Institute, University of Adelaide, North Adelaide, Australia.
2
1
2
targeted lifestyle prevention and management. The behavioral
components of weight loss interventions are critical to increasing participation and compliance and minimizing attrition.
Lifestyle and Behavioral Management of PCOS:
Overview and Rationale
PCOS is underpinned by intrinsic insulin resistance, present in 75% of lean and 95% of overweight and obese women,
that is further exacerbated by obesity.12 The prevalence and
severity of PCOS are exacerbated by obesity,13 with one unit
increase in body mass index increasing the risk of PCOS by
9%.2 Women with PCOS are also at a higher 10-year weight
gain compared with controls in longitudinal communitybased studies.2 Importantly, a modest weight loss of 5%–10%
significantly mitigates its reproductive, metabolic, and psychological features, including central adiposity, hyperandrogenism, insulin resistance, quality of life, depression,
glucose tolerance, and cardiovascular risk factors, including
dyslipidemia and inflammation, as demonstrated in primary
research and a Cochrane review.14–17 Although this Cochrane
review contained no data on clinical fertility outcomes, additional studies in PCOS reported that modest weight loss
(>5% initial body weight) is associated with an increase in
spontaneous pregnancies and live births.18,19
Weight management, defined as prevention of excess
weight gain, modest weight loss, or maintenance of a reduced
weight, through lifestyle (diet, physical activity) behavioral
interventions is a primary first-line treatment strategy in
PCOS recommended by evidence-based guidelines.16,20 Although it has been proposed that the new milder categories of
PCOS introduced by the Rotterdam criteria may not experience the same burden of obesity and cardiometabolic risk as
the severe categories defined by the NIH criteria, the Rotterdam criteria are now internationally accepted and insulin
resistance is present across all the diagnostic criteria independent of, but worsened by, adiposity and central adiposity.21 Weight management strategies should, therefore, apply
to all women with PCOS regardless of reproductive diagnostic phenotype.
Women with PCOS have high (up to 50%) attrition in
weight loss studies16 compared with 31% in the general
population (n = 80 studies, aggregated n = 26,45522). An
identical 4-month diet intervention had 45% drop-out rates
for PCOS, compared with 9% for the general population.23
Long-term weight management may be more difficult in
PCOS due to the higher risk of obesity24 and longitudinal
weight gain,2 psychological dysfunction,25 hormonal abnormalities such as hyperinsulinemia, and hyperandrogenism
affecting abdominal fat deposition26 or altered appetite regulation.27 Worsened weight management in PCOS may also
relate to other underlying psychological mechanisms affecting trial adherence, such as depression, anxiety, body image
disturbance, and disordered eating, given the higher prevalence of psychological concerns such as anxiety and depression and body image issues in PCOS.3,28
Although lifestyle intervention can achieve weight loss in
the short term in controlled clinical settings, there are limited
data assessing the success and sustainability of these strategies
in the long term in PCOS. This is relevant given that <10% of
the general population maintain a clinically meaningful weight
loss in the long term.29 In PCOS specifically, a Cochrane re-
BRENNAN ET AL.
view reported a maximum of 6.8 – 3.8 kg weight loss over 3–12
months16 but included only one long-term (>12 month) study
(n = 13, 46% attrition).30 This was also the only study to use
lifestyle interventions containing behavioral components (although the complexity and intensity of strategies were not
described).30 There is, therefore, a need for the development
and implementation of weight management interventions incorporating appropriate behavioral strategies in PCOS.
Behavioral theories, strategies for behavior change, and
psychological correlates of weight management have been explored more widely in lifestyle and behavioral weight loss interventions in the general population, in reproductive-aged
women, and in pregnancy. This parallel body of research can be
used to inform lifestyle interventions in PCOS, given that PCOS
is a common condition across the reproductive lifespan in women and is associated with worsened pregnancy complications.
Definition of Weight Management
Weight management incorporates prevention of excessive
weight gain, weight loss, and weight loss maintenance. Population weight gain is the result of a small positive energy balance over time.31 It has been proposed that a modest change
approach, including changes that do not reach optimal diet and
activity recommendations but may be more easily maintained,
may be enough to prevent excess energy balance and gradual
weight gain.32 With regards to weight loss, interventions aim at
achieving negative energy balance. This can be through promoting dietary changes (reducing energy intake via reduced
energy density, reduced food volume, and/or adjusted macronutrient balance). It can also include physical activity changes
(increasing energy expenditure via increased structured aerobic or resistance exercise, increased incidental activity, and/or
reduced sedentary time). However, few individuals maintain
this weight loss, which is largely attributed to biological factors
(e.g., fat storage capacity, reward pathways) that function to
maintain the individual’s highest body weight by reducing
energy expenditure and increasing hunger.33 These drivers are
particularly powerful in an environment that encourages
overeating and inactivity.34 In addition, behavioral (e.g., selfmonitoring) and cognitive (e.g., realistic weight loss goals and
perceived self-efficacy of weight loss maintenance) factors
may also be important for weight maintenance.35
Behavioral and Psychological Correlates
of Weight Management
Behavioral and psychological correlates
of weight management in general population
Weight gain prevention has received little research attention. Research suggests that making small behavioral changes,
including taking an extra 2000 steps/day,36 taking stairs instead of escalators,37 having cereal for breakfast,38 or replacing
sugar-sweetened with artificially sweetened drinks,39 can reduce gradual longitudinal weight gain. There is also support
for low-fat diets, eating more fruits and vegetables, eating less
take-away meals, and self-monitoring.40 Qualitative research
reports that the behavioral and psychological correlates of
healthy weight maintainers include monitoring weight/shape,
flexible eating, regular exercise habits, stress management, and
social support.41 This is consistent with research exploring
correlates of weight loss.
POLYCYSTIC OVARY SYNDROME
Although behavioral and psychological correlates of
weight loss and maintenance have received more attention,
few consistent findings have emerged. Fewer previous weight
loss attempts, autonomy and self-motivation, self-esteem,
body image, outcome expectancy, weight-related quality of
life, exercise and eating self-efficacy, but not mood (e.g.,
depression) and eating behaviors/cognitions (e.g., restraint,
disinhibition, binge eating), are associated with weight loss.42
Consistent mediators of weight loss success include higher
self-regulation, processes of change, and decisional balance
self-efficacy in the short term and autonomous motivation in
the long term. Inconsistent mediators include higher body
image, cognitive restraint, and lower eating disinhibition and
perceived hunger in the short term and higher self-regulation,
body image, self-efficacy, flexible cognitive restraint, and
outcome expectancies in the long term.43 Similar variables
are also associated with attrition from weight loss intervention. Younger age, lower education, more previous weight
loss attempts, greater body dissatisfaction, lower physical
activity, poorer mental health, lower self-efficacy, lower social support, higher weight loss expectations, and lower initial weight loss are associated with an increased risk of
attrition.44,45 In The Diabetes Prevention Program, weight
loss was associated with older age, later overweight onset,
fewer weight loss attempts, exercise self-efficacy, dietary
restraint, low-fat diet behaviors, and more sedentary time.46
Dietary monitoring frequency, fat intake reduction, and
achievement of physical activity goals (i.e., at least 150
minutes/week) were associated with weight loss, and early
behavior changes and weight loss were strong predictors of
long-term weight loss. These findings support the use of intensive initial behavioral intervention.47,48
The National Weight Control Registry provides information
regarding psychosocial and behavioral correlates of weight
maintenance after significant weight loss. This includes 3000
registrants (80% women, 97% Caucasian) who have lost at
least 30 lb (13.6 kg), the majority using lifestyle/behavioral
methods, and maintained this for at least 12 months. Registrants typically weigh themselves regularly, eat less than
1500 kcal/day, eat five times/day, eat breakfast regularly, and
exercise regularly.49,50 Compared with weight re-gainers,
weight loss retainers were more likely to maintain physical
activity and monitor their diet.49,50 Weight maintenance is
associated with lower levels of depression, disinhibition, binge
eating, longer duration of weight maintenance (i.e., > compared with <2 years), and smaller initial weight loss (i.e., <30%
compared with >30% of highest weight); maintaining weight
loss for >2 years was the best predictor of ongoing weight
maintenance.49,50 A systematic review identified unrealistic
weight loss goals, poor coping or problem-solving abilities,
low weight-maintenance self-efficacy, lack of vigilance, binge
eating, dietary restraint, disinhibition, and hunger as potential
contributors to weight regain.51
Behavioral and psychological correlates of weight
management in reproductive-aged women
As PCOS is typically first identified and targeted for
treatment in reproductive-aged women, weight management
research in this group can inform PCOS interventions. Higher
attrition is reported in weight loss interventions for both
women and younger participants.52 Longitudinal population
3
studies also report increased weight gain in young women (18–
44 years).53,54 In Australia, young women (18–23 years)
gained more weight (6.32 kg) over longitudinal follow-up
(8–10 years) than mid-aged (3.43 kg) or older women
(weight loss of 1.69 kg).54 These results are supported by the
NHANES.53 Younger women may experience greater difficulties with weight management related to critical life transitions, including young adulthood, pregnancy, the post-partum
period, and perimenopause. This greater longitudinal weight
gain and poor program adherence and weight loss is proposed
to be related to increased family and time commitments; lack
of motivation, childcare, time and support; increased prevalence of physical inactivity; and pregnancy-associated weight
gain and retention.54–56
There is limited research specifically examining psychological or behavioral factors related to weight management,
attrition, or compliance in reproductive-aged women. In
qualitative research in women aged 18–50 years undergoing a
12-month weight gain prevention intervention, the initiation
and continuation of positive behavior change was likely to be
facilitated by factors such as internal motivation and selfefficacy.57 A reduced score on the appearance evaluation
subscale and body image satisfaction score was associated
with a prior weight loss of 10 lb (4.5 kg) or more in a subset of
n = 1143 black women aged 24–42 years from the Coronary
Artery Risk Development in Young Adults study.58 In
n = 203 women aged 17–37 years randomized to a general or
prescriptive weight loss intervention over 12 weeks, attrition
was related to a greater baseline internal weight locus of
control, psychological distress, and higher food cravings.59 In
a qualitative examination in women aged 25–45 years
undergoing an 18 week intervention, self-motivation and
internal factors, including self-regulation, were identified
as behavioral facilitators or barriers to weight loss and
maintenance.60 The limited literature, therefore, suggests that
behavioral or psychological factors may play a role in determining the success of a weight management intervention
in young women.
Behavioral and psychological correlates of weight
management in pregnancy
The beginning of pregnancy is a critical time for the health
of the mother and her child. The key peri-conception health
challenge currently in many countries is the rise in obesity.
Half of women entering pregnancy are either overweight or
obese.61–63 Critically, around 60% of women have excessive
gestational weight gain (GWG), and *65% have post-partum
weight retention 1 year after giving birth, by which time 20%
who entered pregnancy at normal weight are overweight or
obese, and 40% starting as overweight are now obese.62,64
Excessive GWG places the mother and baby at an increased
risk of pregnancy and birth-related complications, including
pre-eclampsia, gestational diabetes, and instrumental and
operative delivery.64,65 Infants born to mothers with excessive GWG are also at an increased risk for higher weight
across the lifespan: large for gestational age or macrosomia
at birth,66 and overweight and obesity during childhood,
adolescence, and adulthood,67–69 which are independently
exacerbated by excess GWG.61 Given the association of
PCOS with an increased prevalence of pregnancy complications, including preeclampsia, gestational diabetes, and large-
4
for-gestational-age babies,9,10 this highlights the importance
of optimizing GWG for pregnant women with PCOS.
There is an urgent need to develop effective strategies to
assist optimal weight gain during pregnancy. Pregnancy is a
time where women are believed to be motivated to be healthy
for the benefit of their unborn baby.70 However, more than 30
interventions have been conducted since 200071 and it is reported that traditional behavior and lifestyle change approaches, such as education and advice alone, lack efficacy.72
The majority of previous behavior change interventions
aimed at preventing excessive GWG focused primarily on
diet and physical activity, neglecting other important psychological, social, and health behavior change factors73,74
such as weight gain expectations, eating attitudes, depression, stress, body image, coping skills, and social support.74
Women’s weight gain expectations more strongly predict
GWG than their weight gain desires.75 This may be because
women who experience excessive GWG are more likely to
overestimate the minimum amount of weight gain needed to
have a healthy baby and knowledge of GWG is strongly associated with actual gain.75 Furthermore, women who exceed
GWG recommendations report ‘‘eating for two’’ whereas
women achieving appropriate GWG are more likely to report
modest or no increases in energy calories.76 These findings
suggest that women set themselves up to gain excessively by
taking an attitude that fosters enabling of behaviors associated with higher GWG.
The limited research exploring the relationships between
other psychological factors and GWG reports depressive
symptoms, and disorders are associated with both excessive77
and lower GWG.78 Stress, but not anxiety, is also associated
with inadequate GWG.79,80 Low levels of social support may
place women at an increased risk of higher GWG,81 and the use
of positive coping strategies, such as acceptance of issues or
problems, is associated with lower GWG.82 It is argued that
coping ability mitigates the effects of pregnancy-induced
stress, leading to improved health and energy-balance-related
behaviors and, ultimately, healthy GWG.83 There is more research examining the association between body image and
GWG with overall body dissatisfaction84,85 and feeling less
attractive earlier in pregnancy and feeling less fat in late
pregnancy associated with higher or excessive GWG.86 Further
research is needed to better understand the influence of psychosocial factors of weight management during pregnancy.
Readers may refer to Table 1 for a synthesis of psychological
correlates in the general population, reproductive aged women,
and in pregnancy.
Lifestyle and Behavioral Management of Obesity
Diet and physical activity are key components of lifestyle interventions for weight management and can achieve
short-term behavior change and weight loss. However, improvements are rarely maintained. Behavioral weight loss
interventions are informed by classical conditioning, operant
conditioning, and social learning theories.87 They typically
include self-monitoring, goal setting, stimulus control, cognitive restructuring, problem solving, strategies targeting
motivation, social support, coping skills, and psychological
well-being and relapse prevention strategies aimed at improving unhelpful eating and activity behaviors.87,88 The
implementation and intensity of behavior change strategies
BRENNAN ET AL.
varies across studies, and they are difficult to determine due
to poor intervention description.88 Although behavioral
weight loss interventions would be expected to be informed
by behavioral theory and use more intensive behavioral interventions than lifestyle interventions, the two terms are
often used interchangeably in the literature.89
Lifestyle and behavioral management of obesity
in the general population
Although lifestyle and behavioral interventions achieve
clinically significant short-term weight loss (5%–10% of
initial weight), long-term weight regain generally occurs.29
The addition of behavioral strategies, and the use of more
intensive behavioral and cognitive behavioral interventions,
are associated with improved initial weight loss and delayed
weight regain. However, they do not prevent eventual weight
regain. Behavioral interventions focus on modifying health
behaviors via making changes to the antecedents and consequences of behaviors to reduce energy intake or increase energy expenditure. Strategies include goal setting and stimulus
control. Cognitive behavioral focus is on modifying behaviors
and cognitions that are believed to be maintaining unhealthy
behaviors. Strategies include cognitive restructuring and motivational interviewing.90
A Cochrane review of psychological interventions for
weight loss included predominantly behavioral (83%) and
cognitive behavioral (11%) interventions. Behavioral interventions were more effective than no treatment (Mean difference [MD] -2.5 kg), and the combination of behavioral
and/or cognitive behavioral (MD -4.9 kg) interventions with
diet and physical activity was more effective than diet or
physical activity alone. Higher-intensity behavioral interventions resulted in greater weight loss (MD -2.3 kg).88 These and
other similar findings demonstrate the benefits of adding
behavioral therapy to diet and exercise interventions.22,91
A Systematic reviews have examined the impact of behavioral intervention components (e.g., goal setting, selfmonitoring) on weight loss. Diet and physical activity goal
setting and self-monitoring are associated with greater weight
loss, weight maintenance and prevention, reduced energy
intake, increased energy expenditure,92,93 and improved psychological outcomes (e.g., dietary restraint, body satisfaction,
and depressive symptoms).94 Frequent self-monitoring is associated with weight loss; however, the optimal duration and
frequency is unknown.93,94 Stimulus control (i.e., making
environmental changes to promote positive behavior change)
is also a core component of behavioral weight loss interventions. Monetary contingency contracting is associated with
greater retention and weight loss during treatment, but not
with retention or weight loss post-treatment.95 Single studies
have demonstrated weight loss benefits for various other
stimulus control strategies, including eating frequency96 and
food provision.97 However, there is limited research examining the impact of individual behavioral strategies.
These results suggest that the addition of behavioral interventions to diet and physical activity further improves weight
loss and delays weight regain. These findings are the basis of
international obesity management guidelines highlighting the
importance of diet (e.g., eating behavior, diet quality, energy
intake), physical activity (e.g., physical activity, sedentary
time), and behavioral (e.g., self-monitoring, goal setting,
5
General
Social support
Stress management
Regular exercise habits
Flexible eating
Self-monitoring food, weight, shape
Replacing sugar-sweetened with
artificially sweetened drinks
Low-fat diets
Eating more fruits and vegetables
Eating less take-away meals
Cereal for breakfast
Stairs instead of escalators
Extra 2000 steps/day
Prevention of excess weight gain
Weight loss maintenance
Higher dietary restraint
Low-fat diet behaviors
Less sedentary time
More frequent dietary
monitoring
Reduced fat intake
Higher physical activity goals
Earlier behavior changes and
weight loss
Later overweight onset
More use of processes
of change
More positive decisional
balance
Higher self-efficacy
Older age
Exercising regularly
Maintaining physical activity
Lower depression
Positive body image
Realistic outcome expectancy
Higher weight-related quality
of life
Higher exercise and eating
self-efficacy
Higher self-regulation
More realistic weight loss goals
Better coping or problemsolving abilities
Higher weight-maintenance
self-efficacy
Higher dietary restraint
Less hunger
Longer duration of weight
maintenance
Smaller initial weight loss
Lower binge eating
Lower disinhibition
Eating breakfast regularly
Higher self-esteem
Fewer previous weight loss Self-monitoring weight and diet
attempts
Higher autonomy/autonomous Eating less than 1500 kcal/day
motivation
Higher self-motivation
Eating five times/day
Weight loss
Table 1. Behavioral and Psychological Correlates of Weight Management Success
(continued)
Higher weight loss
expectations
Lower initial weight loss
Lower social support
Lower physical activity
Poorer mental health
Lower self-efficacy
More previous weight
loss attempts
Greater body dissatisfaction
Lower education
Younger age
Weight loss intervention attrition
6
Lower appearance evaluation
Lower body image satisfaction
Higher self-motivation
Higher self-regulation
More realistic weight gain
expectations
Do not overestimate recommended weight gain
Higher knowledge of GWG
Not ‘‘eating for two’’
Lower depressive symptoms and
disorders
Lower stress
Higher levels of social support
More use of helpful coping strategies
Higher overall body dissatisfaction
Feeling more attractive earlier in pregnancy
Feeling more fat in late pregnancy
Internal motivation and self-efficacy
GWG, gestational weight gain.
Reproductive- aged women
Pregnancy
Prevention of excess weight gain
Weight loss
Table 1. (Continued)
Weight loss intervention attrition
Internal motivation and self-efficacy Higher baseline internal weight
locus of control
Higher self-motivation
Higher psychological distress
Higher self-regulation
Higher food cravings
Weight loss maintenance
POLYCYSTIC OVARY SYNDROME
stimulus control, relapse prevention) interventions for weight
management.98 Please see Table 2 for a list of behavioural
strategies, their definitions, and some common examples.
Lifestyle and behavioral management of obesity
in reproductive-aged women
Young adults (18–35 years) are underrepresented in traditional intensive weight loss programs. However, higher attrition (67% vs. 95%), poorer adherence (52% vs. 74%), and
weight loss (-4.3 vs. -7.7 kg) are reported compared with
older adults.99 There is also limited research assessing weight
loss or weight gain prevention in young women. In a recent
systematic review of eight studies of moderate-to-poor quality,
significant weight loss was reported for the intervention
compared with the control group for nearly two third of the
studies. However, variability in study interventions makes it
difficult to identify successful program components to translate to clinical interventions.100 In additional weight loss
research, a program in young adults reported that an individualized behavioral, dietary, and physical activity weight loss
program resulted in 6.6 kg weight loss and 88% completion
rate over 20 weeks.99 This program modified previous interventions to incorporate greater focus on self-monitoring, reduced program intensity (11 sessions over 20 weeks), and
tailoring of session content to incorporate issues relevant to
this age group (e.g., fast food and alcohol consumption, time
management, social eating).99 Conversely, in n = 203 young
women (age 17–37 years) randomized to a general or prescriptive weight loss intervention over 12 weeks, prescriptive
advice was associated with greater weight loss (4.2 – 0.4 vs.
0.6 – 0.2 kg, p < 0.001) but greater attrition (48% vs. 31%,
p < 0.05).59 These conflicting findings highlight the difficulty
in reconciling program efficacy, clinically meaningful weight
loss, program effectiveness, and translatability.
The difficulty that young adults may experience in weight
loss interventions also reinforces the focus toward weight
gain prevention as a preferred obesity management strategy
in this high-risk group. A community-based model may be a
preferable approach for weight gain prevention, as primary
healthcare involvement is less necessary in the absence of
chronic disease. Community-based approaches to fostering
healthy lifestyles form part of an overall, multi-pronged approach to obesity prevention.101 These include the Healthy
Lifestyle Program (HeLP-her), which is a low-intensity,
community-based lifestyle intervention that is designed to
prevent weight gain in women of childbearing age.102 The 4month intervention is based on Social Cognitive Theory and
incorporated goal setting, self-monitoring, social support,
problem solving, and relapse prevention training. Both short(4 months) and long-term (12 months) outcomes were positive, with intervention group women reporting no weight gain
compared with weight gain in a comparison group that received a single lecture-style healthy lifestyle education session.102 On expansion of this program to a rural setting
involving 649 reproductive-aged women across 41 Australian towns,103 participants who successfully initiated and
continued behavior change (to prevent weight gain) reported
realistic program expectations, applied program messages
readily, reported high intrinsic motivation, self-efficacy, and
self-awareness, and perceived minimal environmental and
social barriers in qualitative research.57 These findings sug-
7
gest that promoting women’s motivation and self-efficacy,
and reducing socio-contextual barriers may help promote
healthy weight.43
Lifestyle and behavioral management of obesity
in pregnancy
Pregnancy-related lifestyle and behavioral interventions
have targeted prevention of excess GWG, and reduction of
postpartum weight retention. Hill et al.74 meta-analyzed behavior change techniques associated with effective GWG interventions, and found that the provision of information,
motivational interviewing, self-monitoring, providing rewards
contingent on successful behavior (e.g., encouragement for
meeting physical activity goals), and goal setting (although the
ideal goal types, timing and context as not yet clear) appear to
be key strategies.104 Although it is possible that behavior
change techniques can be used to prompt women to higher
levels of motivation, the psychosocial (e.g., depression, stress,
body image, social support, coping skills) and cognitive (e.g.,
knowledge of and attitudes about GWG) factors outlined
earlier may influence a woman’s motivation and confidence to
manage diet and physical activity behaviors.105
HeLP-her was expanded to an antenatal intervention delivered during pregnancy for women at risk of developing
gestational diabetes.106 To our knowledge, it is the only
community-based approach to preventing excessive GWG
that has been conducted. The antenatal intervention was
successful at promoting lower total GWG (to 28 weeks’
gestation) and reducing postpartum weight retention (at 6
weeks postpartum) when compared with the single-session
comparison group.106 This suggests promise for communitybased interventions in preventing excessive GWG. These
should be collaborative and multi-center in approach, capitalize on existing social connections, and motivate women to
be active agents in their own behavior change.
The management of obesity during pregnancy and postpartum should also include the provision of support to optimize the
uptake of breastfeeding as it is associated with postpartum
weight loss,107 in addition to reduced maternal risk of breast
malignancy,108 improvements in risk factors for cardiovascular
disease and type 2 diabetes,109 and infant health benefits.110
However, breastfeeding continuation is challenging, with <50%
of Australian women reporting any breastfeeding at 6 months
postpartum,111 which is further worsened in obesity.112 A
combined education and support program delivery with an individual or group approach may improve breastfeeding uptake
and continuation, as reported in a recent systematic review.113
Lifestyle and Behavioral Management of Obesity
in Women with PCOS: Existing and Proposed
Models and Clinical Implications
Evidence-based clinical practice guidelines for weight
management and models of care in PCOS state that lifestyle
management should be recommended for general health
benefits, prevention of excess weight gain, and modest
weight loss.20 Lifestyle management is also important to
highlight for lean women with PCOS given that longitudinal
weight gain is higher2 and that weight gain prevention programs are less clinically intensive. In keeping with this, the
evidence-based guidelines also recommended that prevention of weight gain should be recommended in PCOS.
8
Aim
Setting SMART (specific, measurable, achievable, Increased motivation and self-efficacy.
relevant, timely) outcomes (e.g., weight loss) or
behavioral (e.g., minutes of physical activity)
goals.
Monitoring weight and/or behaviors (e.g., foods
Increased self-awareness and
eaten, physical activity).
accountability.
Changing the environment so that it cues healthy Increased environmental cues for
rather than unhealthy behaviors.
healthy behaviors, making it easier
to make healthier choices.
Recognizing, understanding, and changing
Increased cognitive cues for healthy
unhelpful thinking patterns.
behaviors, making it easier to make
healthier choices.
Definition
Purchasing more fruits and vegetables and less unhealthy snack
foods.
Keeping a food diary or weighing self weekly.
To build up to walking to work (3 km) three times a week by
the end of the month.
Example
Changing thinking from ‘‘I’ve eaten a piece of chocolate cake
and blown my diet, I might as well finish the cake now and
start fresh tomorrow’’ to ‘‘One piece of chocolate cake won’t
hurt, I’ll go back to eating healthily for the rest of the day.’’
Problem solving Recognizing problems interfering with behavior
Reducing barriers to healthy behaviors. Recognizing that getting home from work hungry is a barrier to
change, generating options, choosing the best
preparing a healthy evening meal. Generating a list of
option, and monitoring the outcome.
options for managing this (e.g., eating a snack before leaving
work, preparing slow cooker meals that are ready on arrival
etc). Choosing the best option (e.g., slow cooker meals) and
keeping track of whether this solves the problem and leads to
healthier evening meals.
Time
Planning how to allocate time to specific activities. Ensuring enough time for healthy
Recognizing that spending 3 hours each night watching TV
management
behaviors.
does not leave enough time for healthy behaviors. Reducing
evening TV time and not commencing TV until after going
for a walk.
Significant others walking regularly with the participant or
Social support
Involving significant others in treatment.
Facilitating ongoing support for
committing to not bringing unhealthy foods into the home.
healthy behavior change outside of
treatment sessions and after
completion of treatment.
Maintaining healthy behaviors and not Speaking to manager about reducing workload to reduce stress
Coping skills
Learning strategies for managing difficult
(problem focused coping) or going to yoga as a way of
relying on unhealthy behaviors to
situations and negative emotions. Often divided
managing stress (emotion-focused coping) instead of eating
cope with difficult situations and
into problem-focused coping (i.e., doing
in response to stress.
negative emotions.
something to address the problem) and
emotion-focused coping (i.e., doing something
to reduce the negative emotions).
Relapse
Recognizing that lapses/slips are a part of behavior Preventing lapses from becoming
Detecting weight gain early and implementing strategies to
prevention
change.
relapses.
manage this (e.g., recommencing food diary and meal
strategies
planning).
Motivational
An active, client-directed counseling approach that Initiating and maintaining intrinsic
Clinician prompting the client to generate their own reasons for
interviewing/
aims at exploring and resolving ambivalence
motivation for change.
wanting to change health behaviors (rather than telling the
enhancement
about behavior change.
client why they should change).
Psychological
Optimal psychological health incorporating
Promoting psychological well-being
Increasing self-care activities such as sleep, relaxation, and
well-being
and minimizing psychosocial
social activities.
intrapersonal (e.g., self-efficacy, selfbarriers to health behavior change.
acceptance) and interpersonal (e.g., positive
relationships) functioning.
Cognitive
restructuring
Stimulus
control
Self-monitoring
Goal setting
Strategy
Table 2. Behavioral Strategies, Definitions, and Examples
POLYCYSTIC OVARY SYNDROME
This multidisciplinary approach is consistent with national and international evidence-based recommendations for
long-term weight management in the general population.114
Although intensive interventions (e.g., Diabetes Prevention
Program) have resulted in long-term clinically meaningful
weight losses and reductions in comorbidities, these highintensity programs are rarely feasible in real-world settings.115
Alternative approaches, such as the Counterweight approach,
are recommended as for primary care.114 This less intensive
program (11 visits over 24 months) resulted in 32% of attenders
maintaining a weight loss ‡5% over 24 months and is more
clinically feasible and cost-effective for implementation.116
A similar moderate-intensity approach is recommended for
women with PCOS who are overweight or obese. This should
incorporate both a specific structured weight loss component
and a separate phase focusing on weight maintenance. Successful structured weight loss programs exist in PCOS that
report weight loss of 4.2–7.7 kg over 3–12 months and improvements in body composition, reproductive hormones,
menstrual cyclicity and ovulation, insulin resistance, risk factors for type 2 diabetes and cardiovascular disease, quality of
life, and self-esteem.23,117 Although these interventions are
effective for intervention completers, high attrition is commonly reported with drop-out rates of up to 46%.16 These
programs focused solely on dietary or physical activity counseling and prescriptions with either no behavioral component
or an undefined behavioral component delivered by a dietitian
or an exercise physiologist.30 Outcomes are likely to be improved with the inclusion of behavioral and psychological
strategies. These should include goal setting, self-monitoring,
cognitive restructuring, problem solving and relapse prevention, target improved motivation, social support, coping skills,
and psychological well-being and also include behavioral
change techniques such as motivational interviewing, selfmonitoring, and time-management strategies. PCOS management may also require differing health expertise in a shared
interdisciplinary healthcare model, including referral to allied
health professionals such as psychologists, dietitians, or exercise physiologists, where appropriate, based on individual
presentation and circumstances.20
In the context of pregnancy, this model of care would also
benefit from midwives assisting in implementation of lifestyle management. Prior research highlighted that midwives
see themselves as central in providing lifestyle behavior education to pregnant women,118 and the majority provide
counseling on GWG, diet, and physical activity.119 As previously discussed, the consideration of appropriate support
for optimizing breastfeeding uptake and continuation is also
crucial given that obesity is associated with poorer breastfeeding success and that obesity is increased in PCOS.112
Although breastfeeding has been previously proposed to be
further worsened in PCOS,120 a recent community-based
cohort study reported that obesity but not PCOS status was
independently related to breastfeeding success.121
A specific structured weight maintenance and prevention
of weight gain approach is also required in women with PCOS
who are not overweight or obese, consistent with the previously reported Help-Her approach. This was also achieved
with minimal attrition (10%) and low program intensity (four
sessions over 12 months). This is consistent with weight
management research focusing on young adults that previously reported that reduced program intensity is preferable
9
Table 3. Key Recommendations for Weight
Management Interventions for Women
with Polycystic Ovary Syndrome
Weigh and measure women regularly
Education goals alone and unachievable goals are
generally unsuccessful. Encourage simple behavior
change (prioritization of healthy lifestyle, family support,
lifestyle and exercise planning, setting of small achievable goals)
A multidisciplinary approach using a shared interdisciplinary healthcare model
Less intensive and more clinically feasible and costeffective intervention
Separate weight loss and weight maintenance components
Strategies to maximize retention
Inclusion of behavioral and psychological strategies (e.g.,
motivational interviewing, goal setting, self-monitoring,
cognitive restructuring, problem solving, time management, relapse prevention)
Target improved motivation, social support, coping skills,
and psychological well-being
Refer to allied health professionals such as psychologists
(motivational interviewing, behavior management techniques, emotional health and motivation), dietitians
(tailored dietary advice, education, behavioral change
support), exercise physiologists (exercise motivation,
education), and/or midwives where appropriate
Optimizing breastfeeding uptake and continuation
Aim for at least 5%–10% weight loss in women who are
overweight, which will assist with symptom control.
Structured, low-intensity weight maintenance and
prevention of weight gain approach is also required in
women with PCOS who are not overweight or obese
PCOS, polycystic ovary syndrome.
beyond 3 months in this age group.99 This is also consistent
with the PCOS guidelines that recommend the use of behavioral change techniques for prevention of weight gain.20
Evidence-based guidelines for the Assessment and Management of PCOS20 also provide guidance on the optimal dietary
composition of lifestyle management. Dietary compositions such
as higher protein or lower glycemic index approaches have received increasing interest in PCOS due to their beneficial effects
on weight loss or maintenance122–124 related to potential beneficial effects on satiety.125,126 However, the systematic review
that informed the guidelines identified five studies that assessed
either monounsaturated fatty acid enriched, low carbohydrate,
low glycemic index, or high protein diets or diets consistent with
standard healthy eating principles.127 Weight loss improved the
features of PCOS regardless of dietary composition in the majority of studies, and the guidelines recommended that healthy
food choices should be used irrespective of diet composition for
weight loss (Level C evidence—Body of evidence provides some
support for recommendations but care should be taken in its
application) or prevention of weight gain (Level D Evidence—
Body of evidence of weak and recommendation must be applied
with caution). Table 3 summarizes the key recommendations for
weight management for women with PCOS.
Conclusions
Weight management through lifestyle intervention is crucial for PCOS management to improve fertility, pregnancy
10
BRENNAN ET AL.
complications, risk factors for diabetes and cardiovascular
disease, and psychological health. However, weight management programs in PCOS have focused predominantly
on dietary and physical activity interventions comprising
counseling and education provision. Few studies have incorporated lifestyle interventions, and behavioral theories
and strategies are poorly described. Development of these
strategies for PCOS should be informed by research in
reproductive-aged women and during pregnancy. Outcomes
are likely to be improved with the inclusion of behavioral
strategies, including goal setting, self-monitoring, cognitive restructuring, problem solving, and relapse prevention
strategies. There is a need for the development and evaluation
of evidence-based, effective, feasible, and cost-effective
lifestyle interventions to improve health and well-being in
PCOS.
Acknowledgments
L.M. is supported by a South Australian Cardiovascular
Research Development Program Fellowship; a program
collaboratively funded by the National Heart Foundation, the
South Australian Department of Health, and the South Australian Health and Medical Research Institute. The other
authors have nothing to declare.
Role of Funding Sources
There has been no financial support for this work.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Lisa Moran, PhD
Discipline of Obstetrics and Gynecology
The Robinson Research Institute
University of Adelaide
North Adelaide, 5005
Australia
E-mail: [email protected]
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