Welcome back to my 3-part blog series on PCOS & eating disorders! If you are reading this and wondering what in the world PCOS is, you may want to read Part 1 and come back. You can expect more research and more myth-busting about diet culture!
Unsurprisingly, PCOS and eating disorders share a similar onset age range of adolescent years surrounding menarche (age of first menstrual cycle). This age varies based on the individual. PCOS and EDs are both lifelong battles that can be alleviated with specialized treatment and symptom management. In a 2024 review on the prevalence of PCOS and EDs, authors found: “Those with PCOS were 3-to-6-fold more likely to have an ED and higher odds ratios (ORs) of an elevated ED score compared with controls” (Lalonde-Bester, S., Malik, M., Masoumi, R., Ng, K., Sidhu, S., Ghosh, M., & Vine, D., 2024).
So… Why is the connection between PCOS and EDs so strong?
Based on what we currently understand about these two conditions, there are physiological and social aggravators that can make it common to struggle with both. From a social lens, someone with PCOS is often recommended to cut out multiple food groups in the pursuit of lowering inflammation. Dairy and gluten are typically the first to go, with some online nutritionists even recommending folks avoid certain fruits. Dairy and gluten are often major components of a normal, balanced diet so trying to cut them out (even with the best intentions!) can often lead to a slippery slope of restriction and not meeting one's needs. The research remains conflicting on whether removing gluten and dairy from your diet alleviates PCOS symptoms. Some studies report improved insulin resistance and serum male hormone levels when consuming low-fat/fat-free dairy (Azadi-Yazdi, M., Karimi-Zarchi, M., Salehi-Abargouei, A., Fallahzadeh, H., & Nadjarzadeh, A., 2017), whereas others report higher acne risk with low-fat/fat-free dairy consumption (Burris, J., Rietkerk, W., & Woolf, K., 2013).
As for gluten-free diets for PCOS, the argument you’ll typically see is that gluten is the root of inflammation. Not only is this harmful for disordered eating, but it’s also ignoring what we know about the human body. Oleska Prokopovych, RD, MAN(c) wrote an article regarding PCOS and gluten where she states: “In general, eating gluten could cause an acute inflammatory response in the body for some people. Acute inflammation is a beneficial function of a healthy body. It’s an immune reaction to help protect the body and may be caused by infection, but also non-infectious factors like consuming glucose, alcohol, toxins, or fatty acids (Bruzzese, V, et al., 2020; Hannoodee, Sally, and Dian Nasuruddin, 2022; Hollon, Justin, et al., 2015, Chen, Linlin, et al., 2018, as cited in Prokopovych, 2023). When evaluating research, it is important to assess the possible confounding variables and sample size before making bold claims. Research is so important but it's also important to recognize you may have experiences that differ from the literature. Even if research shows some people have improved PCOS symptoms with low-fat dairy, this will not be true for everyone, and you may find improvements with full-fat dairy! This is why it is so important to work with a Registered Dietitian to learn about the evidence and then try things on to see what works and doesn't work for you.
PCOS sufferers are also often recommended low-calorie diets due to weight stigma prevalent in the medical community and society. Dieting, especially very low calorie diets (VLCD), can increase the risk of binge eating and a cascade of other eating disorder symptoms. In a 2015 study of 24 women, participants logged their food and the average energy intake (calories) was around 1400 kcal which is inadequate for a human adult! I recently attended an EDRD Pro webinar from Kimmie Singh, RD on “Unpacking PCOS and Eating Disorders.” This presentation was so informative and engaging that I wanted to dive deeper on the NPN blog.
From the webinar, I learned more about the physiological forces behind PCOS and binge eating. Any eating disorder can be present with PCOS, however, research depicts a strong correlation between PCOS and Binge Eating Disorder (BED). The Physiology & Behavior Jounal reports binge eating behaviors in PCOS sufferers with up to 60% prevalence (Pehlivanturk-Kizilkan et al., 2024). Folks with PCOS may experience dysregulated hunger hormones, high androgens, and insulin sensitivity, further driving binge eating behaviors on a physiological level (Singh, 2024). Disordered eating behaviors can serve to fulfill someone’s serotonin needs, if they are lacking this brain chemical in any way. Research studies have identified a lower serum (blood) serotonin level and “disturbed stress response” in people with PCOS (Benson et al, 2009). Food, amongst other ritualistic behaviors, can provide our brains with serotonin (which is completely normal and safe!).
Considering that PCOS is a metabolic disorder, your hunger and fullness hormones, ghrelin and leptin, may seem out of whack compared to years before onset. Another component of metabolism is blood sugar and the hormone that transports blood sugar to cells: insulin. In the following quote from the Neuropsychiatric Diease and Treatment Journal, the authors captured the restriction cycle in PCOS perfectly: “Altered insulin levels may contribute to weight gain, which is associated with increased distress regarding weight status, initiating the dieting cycle: starting a diet, staying on it for a while with some weight loss, however dietary restraint promotes disinhibition and overeating, leading to binge eating and long-term weight gain through various metabolic and dietary processes, and the cycle repeats” (APA, 2013; Mustelin, Kaprio, Keski-Rahkonen, 2018; Neumark-Sztainer, Wall, Story, Standish, 2012, as cited in Krug, Giles, & Paganini, 2019). The graphic below was inspired by the cycle described in that quote, seen in EDs and PCOS alike.
Figure 2: The Restriction Cycle (aka Restrict-Binge Cycle) seen in PCOS & EDs
A different, weight-neutral approach for PCOS
Another reason that patients with PCOS may have disordered eating is due to body image distress. When the sweeping recommendation on repeat is to shrink your body size, you may grow to see your body as abnormal. Eating disorders and body image concerns can coincide, affecting self-perception and worth. In a 2024 review of 38 studies: “Those with PCOS were 3–6-fold more likely to have an ED and higher odds ratios (ORs) of an elevated ED score compared with controls (Lalonde-Bester, S., Malik, M., Masoumi, R., Ng, K., Sidhu, S., Ghosh, M., & Vine, D., 2024). Symptoms of Binge Eating Disorder and Bulimia Nervosa frequently overlap with PCOS, wreaking havoc on blood sugar. Taking a weight-neutral approach to PCOS means helping people focus on symptom management, lab improvement, and quality of life while protecting their relationship with food and body. Over time I hope we will see even more research on the psychological and physical gains of a weight-neutral approach for PCOS. And, of course, we need to promote the gravity of reproductive health beyond being “just a women’s issue!” which leads to a lack of funding and research in this area. Discrimination of race and body size seeps its way into healthcare far too often. Both PCOS and eating disorders are a snapshot of a broader fight for social justice.
To wrap things up, the connection between PCOS and eating disorders can be fairly complicated, so don’t try to find a “solution” or “fix” for everything you’re dealing with! By making small behavioral tweaks with the guidance of a specialized healthcare professional, you can manage your symptoms sustainably. Remember, everyone’s journey with PCOS and eating disorders is different, so getting advice that honors both diagnoses is key. I cannot recommend Kimmie Singh, RD, Angela Grassi, RD, and Julie Duffy Dillon, RD enough for PCOS nutrition resources. If you have any questions or want to chat about your experience, contact us! At New Paths Nutrition, we’re here to help answer all that feels fuzzy about nutrition and encourage you to find your best relationship with food. Feel free to comment below with any of your PCOS & ED experiences. I’d love to hear your perspective!
References:
Azadi-Yazdi, M., Karimi-Zarchi, M., Salehi-Abargouei, A., Fallahzadeh, H., & Nadjarzadeh, A. (2017). Effects of Dietary Approach to Stop Hypertension diet on androgens, antioxidant status and body composition in overweight and obese women with polycystic ovary syndrome: a randomised controlled trial. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association, 30(3), 275–283. https://doi.org/10.1111/jhn.12433
Benson, S., Arck, P. C., Tan, S., Hahn, S., Mann, K., Rifaie, N., Janssen, O. E., Schedlowski, M., & Elsenbruch, S. (2009). Disturbed stress responses in women with polycystic ovary syndrome. Psychoneuroendocrinology, 34(5), 727–735. https://doi.org/10.1016/j.psyneuen.2008.12.001
Burris, J., Rietkerk, W., & Woolf, K. (2013). Acne: the role of medical nutrition therapy. Journal of the Academy of Nutrition and Dietetics, 113(3), 416–430. https://doi.org/10.1016/j.jand.2012.11.016
Krug, I., Giles, S., & Paganini, C. (2019). Binge eating in patients with polycystic ovary syndrome: prevalence, causes, and management strategies. Neuropsychiatric disease and treatment, 15, 1273–1285. https://doi.org/10.2147/NDT.S168944
Lalonde-Bester, S., Malik, M., Masoumi, R., Ng, K., Sidhu, S., Ghosh, M., & Vine, D. (2024). Prevalence and Etiology of Eating Disorders in Polycystic Ovary Syndrome: A Scoping Review. Advances in nutrition (Bethesda, Md.), 15(4), 100193. https://doi.org/10.1016/j.advnut.2024.100193
Pehlivanturk-Kizilkan, M., Akgül, S., Güven, A. G., Düzçeker, Y., Derman, O., & Kanbur, N. (2024). Binge eating symptomatology in adolescents with polycystic ovary syndrome. Physiology & behavior, 279, 114532. https://doi.org/10.1016/j.physbeh.2024.114532
Phy, J. L., Pohlmeier, A. M., Cooper, J. A., Watkins, P., Spallholz, J., Harris, K. S., Berenson, A. B., & Boylan, M. (2015). Low Starch/Low Dairy Diet Results in Successful Treatment of Obesity and Co-Morbidities Linked to Polycystic Ovary Syndrome (PCOS). Journal of obesity & weight loss therapy, 5(2), 259. https://doi.org/10.4172/2165-7904.1000259
Prokopovychr, O. (2023). “PCOS and gluten: What you need to know”. Dietitian Success Center, from https://dietitiansuccesscenter.com/pcos-and-gluten/
Sachdeva, G., Gainder, S., Suri, V., Sachdeva, N., & Chopra, S. (2019). Comparison of the Different PCOS Phenotypes Based on Clinical Metabolic, and Hormonal Profile, and their Response to Clomiphene. Indian journal of endocrinology and metabolism, 23(3), 326–331. https://doi.org/10.4103/ijem.IJEM_30_19
Singh, K (2024). Unpacking PCOS and Eating Disorders [Webinar]. EDRD Pro.
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