often leads to women seeking in vitro fertilization (a multi-billion-dollar industry). As we’ve seen, women with PCOS who do become pregnant are at increased risk of obstetrical complications such as gestational diabetes, pregnancy-induced hypertension (high blood pressure), and pre-eclampsia.
Though they are not part of the formal definition of PCOS, obesity leading to metabolic syndrome and insulin resistance leading to type 2 diabetes have been frequently noted in patients and affect an estimated 50 to 70 percent of women with PCOS. The close link to obesity and type 2 diabetes suggests that all three conditions have the same underlying root cause. All three are now understood as metabolic diseases, putting women with PCOS at high risk later in life for cardiovascular disease, strokes, and cancer.
Perhaps the most important associated disease is a history of weight gain that often precedes the diagnosis of PCOS. Of the obese women referred to one clinic, 28.3 percent were diagnosed with PCOS.41 PCOS can be more common as severity of the obesity increases, but more importantly, weight loss has also been proven to reduce testosterone, improve insulin resistance, and decrease hirsutism (more on this later).
Figure 3.1. The three metabolic diseases have a root cause
PCOS, obesity, and type 2 diabetes are variable manifestations of the same underlying problem. But what is that problem? To start answering this question, we need to know what causes obesity. Once we figure that out, we can gain a clue as to the root cause of PCOS.
GABRIELLA
Gabi’s story is a simple, clear-cut case of PCOS, but there’s always a twist. In early 2016, Gabi decided to start a family. She had been dating Hugo for many years, and now they were going to marry. She stopped taking the birth control pill, which she had used consistently since age 18.
Once off the pill, Gabi did not have a period for many months. For the first time in her life, she developed acne, and she also gained 8 pounds (4 kilograms). Gabi saw her doctor for a check-up, expressing her concerns. Besides her weight gain, she had headaches that lasted for days and that she could manage only by taking painkillers constantly. Her bloodwork showed increased androgen (male hormone) levels, which explained the acne and missed periods. An internal ultrasound confirmed multiple small ovarian follicles and the diagnosis of PCOS. Her doctor informed her it would be difficult to get pregnant, though not impossible. She felt devastated and discouraged.
At this point, Gabi asked for my help. She had been my patient and friend in Mozambique since 2009, and she knew I’d experienced the same situation. Like me, Gabi was a young, thin woman with PCOS. At 138 pounds (62 kilograms) and 5 feet 6 inches (1.7 meters) tall, she had a BMI of 23, which was perfectly normal. I reassured her that PCOS is a reversible condition related to hyperinsulinemia and insulin resistance and that the treatment was changing her diet. We discussed the diet of low-carbs and high healthy fats, which she knew from South Africa as the Banting Diet. She started immediately.
The next month her menstrual cycle went from 73 to 56 days. Considering that a normal menstrual cycle comes every 25–30 days, she had improved tremendously, but there was still work to be done. In just one month, her headaches were nearly gone, she stopped taking painkillers, and her skin cleared up. After two months on the new diet, Gabi felt less bloated, finally lost some weight, and started to ovulate. She continued on the low-carb diet and stopped snacking completely, even on “low-carb-friendly” foods. She also began some 24-hour intermittent fasting.
By January 2017, just over four months into her new way of eating, Gabi’s menstrual cycle had almost completely reverted to normal. Almost. She was late by a couple of weeks. Out of curiosity, she did a urine pregnancy test, which came out positive. She did a blood test right away. In Mozambique, doing a blood test is as easy as driving to the lab, ordering the test, and paying for it. This test, which is meant to be more accurate than the urine test, came back negative. She was devastated.
But something was not right. Her breasts were swollen and she had serious back and muscle cramps. Two other urine pregnancy tests were positive. We were worried. Could it be an ectopic pregnancy? Did she have a miscarriage? The very next day, she was able to get an appointment in nearby South Africa with her sister’s gynecologist. That blood test and an internal ultrasound confirmed she was five weeks pregnant and all was well! Low-carb works. Insulin resistance is reversible.
I encouraged Gabi to stick with her low-carbohydrate diet during pregnancy to prevent gestational diabetes, knowing that women with PCOS are more prone to this and other gestational conditions. She and the baby remained healthy and well throughout the pregnancy, and Beautiful Banting Baby was born in October 2017.
What We Know about Obesity
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THE WORLD HEALTH Organization defines obesity as a state of “abnormal or excessive fat accumulation.” Today, it is a worldwide epidemic affecting all ages, genders, and ethnicities, and it’s worsening with each successive generation. My 93-year-old grandmother never met an obese person until recently. She knew of no overweight kids in her school, family, or social circles. My 60-year-old mother had almost no overweight classmates. When I went to school, I had a few overweight classmates. They weren’t unusual, but they weren’t common either. My children, however, have many overweight and even obese little buddies.
Worldwide, obesity has nearly tripled since 1975. By absolute numbers, the United States is the most obese country in the world, followed closely by China and India. By proportion of population, 50.8 percent of the Cook Islands in Oceania is obese, followed by Qatar at 42.3 percent and the United States at 33.7 percent, according to a 2017 report of obesity rates by country.1
Obesity is commonly classified by the Body Mass Index (BMI), which compares weight to height but ignores factors such as muscle mass, age, and fat distribution. This definition limits the BMI’s overall accuracy, but it is generally a simple and useful measure.
Figure 4.1. Body Mass Index2
Ironically, the overriding concern of the 1970s was global hunger and the difficulty of increasing food production to avoid mass worldwide starvation. Yet, today we live with a global obesity epidemic that kills more people than does starvation. This slow-motion surge toward rampant obesity was completely unforeseen and has shocked most public health authorities. The resulting health consequences are dire. Having a BMI in the obese or extremely obese range is a risk factor for many serious health ailments, including PCOS, as well as the following:
•Heart disease
•Stroke
•Lung disease
•Diabetes
•Cancer
•Non-alcoholic fatty liver disease
•Gall bladder disease
•Osteoarthritis
•Pancreatitis
So
