Andrea Myers
KNH 404
11/27/12
Case Study: Polycystic Ovarian Syndrome
I. Understanding the Disease and Pathophysiology
1. Define PCOS, and describe the etiology of this disease.
PCOS is Polycystic Ovary Syndrome. It is a health problem that can affect a
woman’s menstrual cycle, fertility, hormones, insulin production, heart, blood
vessels and physical appearance. Women with PCOS have an elevated level of
androgens (male hormones), an irregular or no menstrual cycle and they may or
may not have many small cysts in their ovaries. It is the most common hormonal
reproductive problem in women of childbearing age, affecting an estimated 5-10%
of that population. The cause of PCOS is unknown, though there is ongoing research
in the areas of genetics (many with PCOS have a mother or sister with PCOS) and the
body’s ability to make insulin (many with PCOS make too much insulin).
i. Nutrition Therapy and Pathophysiology; pg. 501
2. Outline the diagnosis criteria for PCOS.
There is not a well-defined diagnostic criteria for PCOS, which can make to
diagnosis of this rather common disease confusing for clinicians. According to the
most recent diagnostic criteria set by the Androgen Excess Society, a woman must
show signs of hyperandrogenism (clinical or biochemical), ovarian dysfunction
(oligomenorrhea or anovulation and/or polycystic ovarian morphology) and the
exclusion of other androgen excess related disorders.
i. http://www.nurse-practitioners-and-physician-assistants.advanceweb.com/
3. Describe the medical complications associated with PCOS.
Medical complications associated with PCOS include Infrequent or absent
menstrual cycles, ovarian cysts, infertility because of not ovulating, hirsutism, acne,
oily skin, dandruff, pelvic pain, weight gain, type 2 diabetes, high cholesterol, high
blood pressure, male pattern baldness, thinning hair, anxiety, depression, sleep
apnea, skin tags and unusual darkening on patches of skin.
i. Nutrition Therapy and Pathophysiology; pg. 501
ii. http://www.womenshealth.gov/publications/our-publications/fact-sheet/ polycysticovary-syndrome.cfm
4. Using the history and physical for Gracie, identify the signs and symptoms that are
consistent with PCOS. Are the any other typical signs and symptoms that Gracie does not
have?
The signs and symptoms that Gracie exhibits that are consistent with PCOS
include weight gain, hirsutism, sleep apnea, absent menstrual cycles, high blood
pressure, high cholesterol, acne, skin tags, acanthosis nigricans, thinning hair,
dandruff and incidences of miscarriage. The only typical symptom that Gracie does
not exhibit is pelvic pain and ovarian cysts.
i. Nutrition Therapy and Pathophysiology; pg. 501
5. PCOS is often associated with many of the same signs and symptoms as metabolic
syndrome. Define metabolic syndrome and outline any differences between this condition
and PCOS.
Metabolic syndrome is a group of risk factors that increase one’s risk for heart
disease and other health problems such as diabetes or stroke. The main differences
between metabolic syndrome and PCOS are that both men and women can be
afflicted with metabolic syndrome, while only women can have PCOS, and here are
slight differences in symptoms including the fact that high triglyceride levels are a
common symptom of metabolic syndrome and not of PCOS.
i. Nutrition Therapy and Pathophysiology; pg. 303
6. What are the long-term complications of PCOS?
Some of the long-term complications of PCOS include infertility, endometrial
hyperplasia, an increased incidence of miscarriage, coronary artery disease,
hypertension, hypercholesterolemia, obesity, insulin resistance and type 2
diabetes.
i. http://www.pharmacytimes.com/publications/issue/2004/2004-06/2004-06-7973
II. Understanding the Nutrition Therapy
7. Briefly, what are the primary nutritional treatment goals for PCOS?
The primary nutritional treatment goals for PCOS are not specified by one
specific diet. Recommendations for women afflicted with PCOS suggest that they
should focus on balance and moderation in their diets. Some key points to
remember for those with PCOS are to consume a wide variety of whole foods, to aim
to eat 25-30 g. of fiber per day, to limit simple sugars, to limit salt intake to less than
2400 mg./day, to limit unsaturated fats, and to eat protein and or fat with every
meal and snack of the day (to help stabilize blood glucose levels).
i. http://www.mckinley.illinois.edu/handouts/pcos.htm
III. Nutrition Assessment
A. Evaluation of Weight/Body Composition
8. Gracie’s waist measures 36 inches. Calculate her waist-to-hip ratio and explain the
implications of this anthropometric measurement in the diagnosis of metabolic syndrome.
Gracie’s hip to waist ratio:
Hip- 49”
Waist- 36”
Ratio: 36”/49”= 0.73
The implications of this measurement in the diagnosis of metabolic syndrome are in
Gracie’s favor. Gracie’s ratio is under 0.80, which means her fat accumulation is not
stored in the abdominal region (a risk factor of metabolic syndrome) and due to her
ratio of 0.73, she is less likely to have metabolic syndrome.
9. Calculate and interpret Gracie’s BMI.
BMI= weight (kg)/height^2 (m^2)
Gracie’s weight= 180lbs/2.2= 82kg
Gracie’s height= 65” x 2.54= 165cm= 1.65m
BMI: 82kg/1.65m^2 = 30 kg/m^2
Gracie’s BMI of 30 kg/m^2 indicates that she is obese.
10. Assess Gracie’s weight gain and explain the nutritional implications of the BMI and
overall weight gain. Is there a relationship among BMI, PCOS, and metabolic syndrome? If
so, explain.
Gracie’s weight gain of 40 lbs has pushed her BMI into the obese range. With her
high BMI, Gracie is a higher risk for high cholesterol, high triglycerides, type 2
diabetes, high blood pressure, heart disease, stroke, cancer (including uterine,
cervical, ovarian, breast, colon and rectum), sleep apnea, depression, gallbladder
disease, skin problems, osteoarthritis, fatty liver disease, metabolic syndrome and
gynecologic problems. The relationship among (high) BMI, PCOS and metabolic
syndrome is that they have very similar complications, and one is at a greater risk of
these complications if they are overweight or obese.
i. http://www.mayoclinic.com/health/obesity/DS00314/DSECTION=complications
B. Calculation of Nutrient Requirements
11. Calculate total daily energy requirements for Gracie based on a weight within the
normal BMI range and on her current weight. Which would you recommend as you plan
her nutrition therapy and why?
Normal BMI range- weight at 140lbs:
TEE= (10 x weight+ 6.25 x height- 5 x age – 161) AF
AF= 1.3 very light activity
TEE: (10 x 140lbs + 6.25 x 65” – 5 x 34) 1.3 = 2,127 kcal/day
Range: 2,100-2,200 kcal/day
Current weight:
TEE= (10 x weight+ 6.25 x height- 5 x age – 161) AF
AF= 1.3 very light activity
TEE: (10 x 180lbs + 6.25 x 65” – 5 x 34) 1.3 = 2,647 kcal/day
Range: 2,600-2,700 kcal/day
I would recommend that Gracie follow the 2,100-2,200 kcal/day plan, so that she
will be able to lose some weight and obtain a healthier BMI. If she were to follow the
2,600-2,700 kcal/day plan, she would maintain her undesirable obese status.
C. Intake Domain
12. Assess Gracie’s 24-hour recall for total kcal, % CHO, % PRO, and % FAT.
-See attached fitday sheet13. List four common nutritional recommendations for individuals with PCOS.
Four common nutritional recommendations for individuals with PCOS are to limit
processed foods and foods containing processed sugars, to add more whole grains
to the diet, to add more fruits and vegetables to the diet and to add more lean meats
to the diet. Essentially, a patient with PCOS should strive to eat a well-balanced diet
in moderation.
i. http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovarysyndrome.cfm#h
14. Compare Gracie’s intake to the current nutrition recommendations. List any nutrition
problems within the intake domain.
Gracie’s intake from her 24-hour recall, according to fitday, was 2,512 kcal, which is
412 more kilocalories than her current recommendations. She also had a diet high
in fat (with 46% of her calorie intake being from fat instead of the recommended
30%).
D. Clinical Domain
15. Evaluate Gracie’s lab results.
Abnormal Lab
Normal Value
Bilirubin
< 0.3 mg/dL
ALT
4-36 U/L
HDL-C
>55 mg/dL
TG
35-135 mg/dL
LDL
<130 mg/dL
Reason for
Nutritional
Abnormality
Implication
high- drug reactions,
Liver malfunctionmetabolic syndrome
hepatitis
high- medications,
Liver malfunctioneating fast food
hepatitis
low- high TG levels,
risk of CVD
overweight, lack of
physical activity,
medications
high- lack of physical risk of CVD
activity, overweight
high- obesity,
risk of CVD
inactivity, unhealthy
diet, genetics
i. http://labtestsonline.org/understanding/analytes
16. Evaluate each of the medications that Gracie is prescribed. Determine the function of
each medication, and identify any nutritional implications.
Medication
Function of Medication Nutritional Implications
YAZ 1 tablet PO
Oral Contraceptive
Hyperkalemia,
hypertriglyceridemia,
changes in glucose
tolerance
Glucophage 850mg PO
Diabetes management
depletion of vitamin B12
Aldactone 100mg/d PO
Lower blood pressure
avoid diet high in salt,
potassium, drink correct
amount of liquids
Vaniqua
Cream to reduce facial
n/a mostly skin reaction
hair
implications
i. http://www.rxlist.com/drugs/alpha_a.htm
17. Some medications are used “off-label” to treat PCOS. What does “off-label” mean? What
are the primary medications used to treat PCOS?
“Off-label” refers to when a drug is used in a different way than described in the
FDA-approved drug label. The primary medications used to treat PCOS are birth
control pills (which control menstrual cycles, reduce male hormone levels and help
clear acne), diabetes medications (which affects the way insulin controls blood
glucose, lowers testosterone production, may help ovulation return and slows the
growth of abnormal hair), fertility medications (which can stimulate ovulation).
i. http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovarysyndrome.cfm#k
18. List nutrition problems within the clinical domain using the diagnostic term.
NC-2.2 Altered nutrition-related laboratory values (TG, cholesterol)
NC-3.3 Overweight/obesity
NC-3.4 Involuntary weight gain
E. Behavioral-Environmental Domain
19. From Gracie’s history, are there any lifestyle factors that may impact the treatment of
her PCOS?
Some lifestyle factors that may impact the treatment of Gracie’s PCOS are that she
leads a stressful life with a newly adopted baby, a career and graduate school. Due
to these other aspects in her life, Gracie may not find time to take care of herself as
she should which could lead to her unhealthy eating, lack of exercise and could lead
to her not paying attention to her treatments, specifically her medications and
eating healthily.
20. While you are interviewing Gracie, she tells you that one of her friends with PCOS takes
fenugreek, cinnamon, and ginseng to control her blood glucose levels. Discuss any current
research regarding the use of cinnamon, ginseng, or fenugreek to lower blood glucose
levels.
There is some research concerning these herbal remedies and lowering blood
glucose levels, however they are not often used in Western culture. Taking these
herbs in large quantities (with the quantities being different depending on which
remedy is used). These remedies are more effective on type 2 diabetics and should
not be used with type 1 diabetics because it could cause life-threatening
hypoglycemia.
i. www.aaimedicine.com/jaaim/sep06/Blood_Sugar.pdf
21. What information would you recommend to your patient regarding the use of herbal
remedies in lowering blood glucose levels?
I would inform Gracie that while there is much speculation as to whether or not
cinnamon, ginseng, or fenugreek can help reduce blood glucose levels, there is not
clear evidence. I would suggest that she not try these herbal remedies, as her
glucose levels have been normal and she could induce hypoglycemia if she were to
start taking herbal remedies, it could be a costly endeavor and it could potentially
interfere with one of her medications. I would suggest that she stick to her new diet
plan and start an exercise regimen in order to keep blood glucose levels under
control.
i. www.aaimedicine.com/jaaim/sep06/Blood_Sugar.pdf
22. List any nutrition problems within the behavioral-environmental domain using the
diagnostic term.
NB-1.1 Food and nutrition-related knowledge deficit
NB-1.7 Undesirable food choices
NB-2.1 Physical inactivity
IV. Nutrition Diagnosis
23. Select two high-priority nutrition problems and complete PES statements for each.
-Excessive energy intake related to frequent consumption of high-fat, high
kilocalorie foods as evidenced by 24-hour dietary recall and obese BMI of 30
kh/m^2.
-Physical inactivity related to busy lifestyle and lack of access to facility as evidenced
by undesired weight gain of 40 lbs over ten years.
V. Nutrition Intervention
24. For each PES statement written, establish an ideal goal (based on signs and symptoms)
and an appropriate intervention (based on etiology).
-Goal: Reduce weight and BMI to normal range by reducing daily kilocalorie intake
from 2,500kcal to 2,100-2,200kcal/day and eating balanced meals containing 50%
CHO, 20% protein and 30% fat.
-Goal: Increase physical activity slowly, starting with 30 minutes 4 times/week and
working up to recommended 1 hour/day. Encourage family physical activities, such
as daily walks.
VI. Nutrition Monitoring and Evaluation
25. What nutritional parameters can be used to measure Gracie’s response to treatment?
Some nutritional parameters that can be used to measure Gracie’s response to
treatment include her weight, BMI, cholesterol levels, blood pressure and
triglyceride levels. These should be measured and analyzed at her next
appointment.
26. When should you schedule your next counseling session with Gracie, and what would
you evaluate?
I should schedule my next counseling session with Gracie for about two months
after her initial session. This way some improvements may be seen. I would evaluate
her weight, BMI, waist-to hip circumference, her lab values (including TG,
cholesterol, etc.) and a 24-hour recall or food diary provided by Gracie. If treatment
goes as planned, there should be a positive change in each of these aspects
evaluated.