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. References 1. Hickey M, Doherty DA, Atkinson H, et al. Clinical, ultrasound and biochemical features of polycystic ovary syndrome in adolescents: Implications for diagnosis. Hum Reprod 2011;26:1469–1477. 2. Teede HJ, Joham AE, Paul E, et al. 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