Improving insulin resistance is a cornerstone of all effective treatments of PCOS, however, is it necessary to go extreme and restrictive to obtain these results? Let's see in this episode of PCOS Answers Podcast.

Caitlin Johnson, RD (00:00) Welcome to the PCOS Answers Podcast with Caitlin Johnson, your functional medicine dietitian. This podcast is a private podcast only available through the PCOS app. It will provide practical science-based answers to all of your PCOS questions and every episode will leave you with something you can do today to help your PCOS. I'm so glad you're here. Welcome to another episode of the PCOS Answers Podcast. Caitlin Johnson, RD (00:29) Now, if you've been diagnosed with PCOS for any length of time, you've likely had a doctor tell you that you need to lose weight. And that suggestion usually comes with no helpful advice at all on how to do that or with incredibly unhelpful information that isn't evidence based or sustainable. I can't tell you how many different things I've heard women tell me that their doctor told them to do in order to lose weight with PCOS. Now, there's a good reason why this is something that doctors typically recommend both for helping with symptoms, helping with overall health, your longevity, and also with ovulation and fertility. It is true that evidence shows 5% to 10% body weight reduction. Caitlin Johnson, RD (01:15) So weight loss of 5% to 10% of your body weight can help you ovulate and it can actually help you conceive. Now, a lot of women with PCOS either ovulate, really infrequently or don't ovulate at all. So this is a really great goal just to get yourself ovulating naturally. Now, other doctors may kind of dangle something out in front of you like, hey, we can try IUI or IVF, but not until you obtain a certain amount of weight loss. So while this recommendation comes with some good science behind it, it doesn't typically come with really helpful advice. Caitlin Johnson, RD (01:51) And we are just left out in the wind, right, for the picking for any diet, culture or fitness expert to come in and say this is the only way that's ever going to be effective for you to lose weight and keep it off. So I am here to tell you, even though there's a lot of debate these days over the most effective way to treat PCOS with diet and lifestyle, that there are some things to consider with popular diets and there are some things to consider in terms of pulling the best from different ways of eating and making a sustainable plan for you. Truly, a simple search on the internet will give you as many ways to try and lose weight as the number of pounds we need to actually lose. Probably more, okay, probably more different diets and fads and exercise routines than the pounds we have to lose. But diet, culture and the landscape of fitness, we literally have too many options and we're making it too difficult on ourselves. Caitlin Johnson, RD (02:49) So while 5% to 10% weight loss is actually a great thing to pursue, it can be a really frustrating recommendation. I want to talk a little bit about is weight loss important for those of us that don't need to lose weight and does weight loss help with every different kind of key measure for hormone change? There was a study that was done in Saudi Arabia, this was published in August of 2020 and they basically looked at the ratios of LH to FSH. LH is luteinizing hormone. FSH is follicle stimulating hormone. Caitlin Johnson, RD (03:24) It's really normal for women with PCOS to have too high of LH numbers. This is the thing that pulses from your brain and basically tells your ovary, hey, it's time to Ovulate. Now, they were looking in obese versus nonobased women. Were there changes in this LH to FSH ratio? And what they saw was that weight was not something that impacted this high LH to FSH ratio. Caitlin Johnson, RD (03:50) It didn't matter if you were overweight or whether you were a normal weight. Weights didn't impact LH and FSH ratios. Since there are people that are abnormal weight and people who are overweight with PCOS, we can't see that weight loss is going to be a great solution for everyone because it won't impact this LH to FSH ratio. This particular hormonal abnormality is one of the reasons why it's more difficult for women with PCOS to Ovulate. Weight loss doesn't help every hormonal abnormality. Caitlin Johnson, RD (04:24) Now, weight loss does impact insulin resistance and improving insulin resistance can impact weight loss. So maybe this is a little bit of a better area to start looking at. One of insulin's main jobs is to shuttle blood sugar from the blood into the cell. So blood sugar becomes cell sugar or essentially energy for the cell to do its jobs. The problem with PCOS is we get so much of this message that there is energy available, take it in that we stop listening to that message, we stop recognizing that message and doing that job really efficiently. Caitlin Johnson, RD (05:00) So our body becomes insulin resistant, yet most of your tissues in your body will become insulin resistant. Your ovaries will not, okay? So they get more and more and more of this message. The energy is available. And part of what that does is it shifts what your ovary does with that blood sugar. Caitlin Johnson, RD (05:17) It changes the output from being estrogen, a hormone that actually helps with follicle development, to test testosterone, a hormone that basically stops follicle development. So chronically high levels of insulin can cause chronically high levels of testosterone instead of the estrogen that we need. So our follicles don't develop, and one doesn't get kind of tapped on the shoulder and thrown into the game as the egg for the cycle that's going to get ovulated. So there are some really popular strategies right now to impact insulin levels, and these are dietary strategies. Two of the most popular are the Ketogenic diet and intermittent fasting. Caitlin Johnson, RD (06:00) And I want to talk about both of these and consider, could these be effective ways to help ovulation? I always get asked about the ketogenic diet and intermittent fasting for PCOS, and for good reason. There is evidence that both of these dietary patterns can lower insulin resistance. Okay. They increase insulin sensitivity, meaning you don't make as much insulin less insulin, less testosterone, better ovulation. Caitlin Johnson, RD (06:26) Makes sense, right? So let's start with a ketogenic diet. Basically, this diet was created because we realized that blood circulation of ketones and using that instead of blood sugar could lower the incidence of seizures in children that had many, many epileptic seizures. Now it's becoming much more popular in adults that just want to lose weight to hop on the Ketogenic diet, it was not designed for adults that just want to lose weight, but there's nothing new under the sun. This diet has been reimagined a number of times. Caitlin Johnson, RD (07:03) I remember it most popularly in the 90s called the Atkins Diet, but now it's popular just under the name keto. It essentially promotes low carbohydrate consumption. And when I say low, I mean less than 30 grams per day. That's like less than one piece of fruit. In order to get enough energy, though, when you're eating that low carbohydrates, you have to increase your amount of fat and protein. Caitlin Johnson, RD (07:28) So this eating pattern essentially shifts your body into a metabolic burning state called ketosis. You're no longer using blood sugar as your main source of energy. You're using ketones. Ketosis is not an efficient way to get calories from your food. So this inefficiency is actually helpful for weight loss. Caitlin Johnson, RD (07:49) It takes more energy to get the energy from the food, and so you actually burn calories trying to get the energy from your food. That may sound a little funky, but it's actually really efficient. It means that you lose weight with this pattern of eating without really having to try too hard. But even in a state of ketosis, you have to eat less calories than you're burning, even with that metabolic inefficiency on your side for weight loss, you still have to eat in a calorie deficit. That's something hard to obtain when most people eat high amounts of things like bacon, and cream cheese on this diet. Caitlin Johnson, RD (08:28) So even though eating in a keto kind of style with lower carbohydrates and higher fat and protein can be really helpful for weight loss and for insulin reduction, it doesn't really pass the test, in my opinion, of being something that's sustainable. Okay? As soon as you eat a bagel or a cookie or a handful of chips, your body gets pulled out of ketosis. And that metabolic state takes days to enter, so it will take you days to get back into. All the while, you'll be eating tons of fat and high amounts of calories. Caitlin Johnson, RD (09:04) There's, like, no wiggle room in this diet, which is really frustrating. The other thing that is hard for me in terms of giving this diet a pass for women of reproductive age that are trying to ovulate and potentially because they're trying to ovulate, I'm assuming they may want to get pregnant. This diet is devoid of many, many nutrients that we really need for proper development, for antioxidant status, for lots of things for you and future baby. So with the lack of sustainability, the fact that most people that eat this diet tend to overeat calories, even though they're in a state of ketosis and don't really obtain that long term weight loss that they're trying to obtain and the fact that it's devoid of a lot of nutrients. It really is a hard sell, even though it does improve insulin resistance. Caitlin Johnson, RD (09:59) The other thing. Caitlin Johnson, RD (10:00) Thing is that most studies on this Keto Diet are either done in small children for epilepsy or are done in adult males. They're not done in women with PCOS women of reproductive age, and they aren't done typically looking at long-term intake of this diet. And news flash, if you can't be on a diet for the rest of your life, whatever benefits you're going to obtain from that diet, you're not going to have forever. The benefits are going to go away as soon as you stop eating that way. So let's talk a little bit about intermittent fasting. Caitlin Johnson, RD (10:33) If you've been alive in the past five years, which if you're listening to this, I know you have been, you've heard of intermittent fasting. It's just a fancy way of saying time-restricted eating. This is not new. And frankly, if you are live and listening to this, you've done it before. Do you stop eating between dinner and breakfast? Caitlin Johnson, RD (10:52) Most nights. Yeah, me too. That's an overnight fast. That's a time restricted eating. Intermittent fasting crowd takes us to an entirely new level with way more restriction over those eating hours and increasing those fasting hours. Caitlin Johnson, RD (11:08) But essentially that's intermittent fasting. Most people that intermittent fast do one of two things. They do something called a 16 eight, where they only eat in an eight hour window of the day and fast for 16 hours, or they choose to fast for a full 24 hours period, usually one to two days per week. Now, among those two different categories I just gave you, there's wiggle room. Maybe that eight hour fasting window is from noon to 08:00 p.m.. Caitlin Johnson, RD (11:35) Maybe it's from 10:00 A.m. To 06:00 p.m.. Maybe you are more extreme and you only for like 6 hours, and you fast for more like 18 hours. So there's variations. However, the point of intermittent fasting like the Ketogenic Diet is really to lower insulin levels. Caitlin Johnson, RD (11:57) And for most people, for weight loss. When you eat in less hours of the day, or you eat for less hours of a total week, your body has less time that it's making insulin. You don't make as much insulin when you're not eating insulin's. Job is to shuttle that food from your blood into your cell. If you're not eating, there's not as much blood energy, blood sugar available to get into the cell. Caitlin Johnson, RD (12:21) It can be efficient at insulin sensitivity, like increasing the amount of insulin sensitivity, lowering insulin resistance. But it isn't sustainable for most people that live real lives, that have jobs or families or somebody trying to conceive. Okay? Because we're trying to create safety for your body, a routine for your body. Your body having a way to say what happened yesterday is likely to happen tomorrow, and so it's safe for me to ovulate. Caitlin Johnson, RD (12:51) Eating in an intermittent fasting way may not create that safety that you're looking for with your body. I guess this is a double edged sword. I love and hate about this diet is that intermittent fasting doesn't limit food choices. As long as you eat within this eating window, any food is really fair game. Well, when you're trying to ovulate and have quality eggs and grow a baby, what you eat matters. Caitlin Johnson, RD (13:18) It really, really matters. So intermittent fasting doesn't get a pass in my mind. For somebody that's trying to ovulate and get pregnant and stay pregnant. Now, there is evidence in the literature that intermittent fasting can improve insulin sensitivity. This makes sense. Caitlin Johnson, RD (13:34) If you eat in a smaller window of time, your body makes less insulin over time, and over that large amount of time, less insulin means less testosterone, which means you might ovulate. The theory is there, and the science is kind of there. However, once again, we don't have studies in women with PCOS or even a lot of studies in women at all, and less of women in reproductive age. And you guessed it, not a single study on women with PCOS trying to get pregnant. So I want to tell you a little bit about things that I've seen from clients who have tried to intermittent fast or have done keto in the past. Caitlin Johnson, RD (14:13) Most of those women come to me in a very stressed out state in their body. Their levels of androgens that come from their adrenal glands, which is kind of your stress organ, are off the charts. It also is something that has really triggered past eating disorders, both in ways of restriction and binging. Even though you eat less carbs or you eat less total amount of time, or you burn fuel in a less efficient manner and potentially maybe lose weight. The other most compelling argument against doing a full on intermittent fast or going keto is that they really aren't necessary to improve insulin resistance. Caitlin Johnson, RD (14:55) You can do it so many other ways and they really aren't necessary to restore ovulation. I've seen in hundreds, thousands of women that just implement, really obtainable sustainable, delicious eating patterns and windows of time of eating that are really natural, be able to sustain and obtain ovulation without going so extreme, increasing quality fats and oils. I am here for that. Okay? There is some merit to not eating your last bites of food right before you lay down for insulin resistance improvement and really good digestion and rest for your gut overnight. Caitlin Johnson, RD (15:36) If you're somebody that stays up late and has a snack at 930 or 10:00 P.m. And eats breakfast at seven or 08:00 A.m., you're not even getting like a normal twelve-hour fast overnight. So something that you can do over the next month or so is giving yourself an extra hour every week. So let's go with a real-life example. Let's say you have your last snack right now at 09:30 P.m. Caitlin Johnson, RD (16:02) And you eat breakfast at 730. What if over the next week, we moved your last snack to 09:00 P.m. And breakfast to 08:00 A.m.? We just gained an extra hour of overnight fast without moving things really drastically. And then the next week, your last bite comes in by 830 and breakfast is at 08:30 a.m. Caitlin Johnson, RD (16:20) Hey. Now we have a twelve hour fast overnight and you can move that anywhere between a twelve-hour and a 14 hours fast overnight and enjoy some of the benefits of intermittent fasting without super strict hour requirements. Now, what if you have a night that you're up super late for whatever reason? Can you get hungry before bed? No big deal. Caitlin Johnson, RD (16:41) Eat when you're hungry. Okay, I'm not trying to advocate that you skip hunger signals. I'm just trying to say, hey mama, we can over time over the next three to four weeks, extend your fast overnight without being super restrictive and give your body some of the benefits of increased insulin sensitivity. Now that being said, this is not something to go crazy over. The other great thing about that is we're not even really changing what you're eating. Caitlin Johnson, RD (17:08) We're just saying, hey, extend your overnight fast. Now that's going to be really hard to do if staying up super late and you eat dinner early. So let's say you go to bed right now at midnight, but dinner is at seven. It's going to be hard to last those 5 hours without eating again. This is your full suggestion and begging from your functionally trained dietitian that we need to work on your circadian rhythm too, for you to be able to have an overnight fast that's long enough because you can't stay up super late and just expect yourself not to want to snack before bed. Caitlin Johnson, RD (17:44) Other added benefit of extending your overnight eating window is that if you're not eating between the hours of like eight and midnight, you're less likely to grab spicy Doritos, cheetos cereal, ice cream, whatever. That late night snack. I'm super hungry. I just want to munch on something. Craving thing is for you. Caitlin Johnson, RD (18:05) You're likely to eat less of it. So okay, I want to tell you a little bit more about this and I want to dive into two studies about breakfast in its effect on ovulation meal timing. Its effect on ovulation. But you're going to get that in part two of this podcast. So stay tuned for episode ten where we dig into breakfast innovation.

Ep 9: Keto, Intermittent Fasting, Breakfast and Ovulation