Question from Jenny:  Was your weight maintenance/loss formula for  PCOS women only? (Jenny was referring to a recent post I did on PCOS) .  At 5′1″ and 123 lbs (and a longtime dieter) I’d have to eat 730 calories a day to lose 1/2 lbs a week. Is that right?

Answer from Martha: No, Jenny - that calorie level would be too low for you. The formula I used in that post was mainly geared towards women with PCOS. Women with PCOS tend to be insulin resistant and may have a more difficult time losing weight. Despite the fact that you say you are a chronic dieter, you are not obese by any means and likely are not insulin resistant (nor do you have PCOS - right?). Therefore your caloric needs would not be that low to lose weight. You would end up slowing your metabolism if you only ate 730 calories a day.

So assuming you are exercising moderately, you should need about 1750 calories to maintain your current weight (14 calories/pound) or 1440-1600 calories if you are not exercising (12-13 calories/pound). Therefore to lose 1/2 pound a week, you would subtract 250 calories a day from these levels: 1200 - 1500 calories a day.

 Keep in mind that this is just a formula and needs to be fine tuned to meet the individuals needs. Taking your calories too low will actually slow your metabolism. I am going to write a post in the next few days on the topic of eating too few calories.

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Irregular periods? Trouble losing weight? Weight gain in the abdominal area? Hair growth on your face and/or body (where hair shouldn’t be growing)? Experiencing hair loss? If you are experiencing some of these symptoms, you may have a common hormone abnormality called polycystic ovarian syndrome (PCOS). It affects between 7-10% of women. Many women don’t even know they have it. If you have any of the above symptoms, take this PCOS quiz.

I have been working with women with PCOS for the past 10 years. Approximately 10-15% of my clients have PCOS. Check out my previous post for more info on PCOS. Through my experiences in working with these women, I have found the following lifestyle recommendations to be helpful to women with PCOS.

Lifestyle recommendations for PCOS:

 • No one diet works for everyone. Each plan must be tailored to suit the individual. In my experience, I have found that women with PCOS who are very insulin resistant, especially if they are obese, often have an easier time losing weight and feel better on a lower carb diet. However this doesn’t mean that every women with PCOS needs to be on a very low carb diet.  (Pic on the right is of me lecturing on Diet and PCOS to staff members at Reproductive Medical Associates - RMA- in NYC).

• Do not think of this as a short-term diet but rather a healthy eating plan to be followed for the long term. I don’t even like to use the word “diet” as it implies deprivation and something short- term.

• A priority in treating insulin resistance is weight loss. This is more important than the macronutrient composition of the diet. Even losing 5-10% of body weight will help decrease symptoms of PCOS.

• Exercise is a key factor in decreasing insulin resistance. The ideal program includes an aerobic and resistance training component. The resistance training component should focus on light weights and more repetition. 

• All calories count – whether from protein, fat or carbohydrate. This must be emphasized as it is common to see women who feel they can eat unlimited amounts of protein and fat as long as they keep the carbohydrate intake low. A hypo caloric diet must be adhered to if weight loss is to occur.

Use the following formula to determine your caloric needs:

For weight maintenance
- 10 calories per pound for women who are obese, very inactive, or chronic dieters 
- 13 calories per pound for women over age 55 who are very active
- 15 calories per pound for very active women
- If you tend to have a difficult time losing weight and are obese, very inactive, or a chronic dieter, it is possible that you may need to use 8 or 9 calories per pound.

For weight loss 
- To lose 1 lb a week, subtract 500 from maintenance caloric level
- So if your maintenance caloric needs are 2000, you should consume 1500 calories a day to promote a one pound weight loss a week.

• Select lower glycemic index carbohydrates (ie. whole grains, fruit, vegetables, legumes, milk) instead of higher glycemic index carbohydrates such as rice, potato, white bread.

• Consume balanced meals that contain protein/fat and carbs. This will help to control blood sugar, keep you feeling full longer and ward of carbohydrate cravings. For example, a slice of whole grain toast with some natural peanut butter may be a better choice for breakfast as compared to a bowl of cereal with fat free milk for some women. The higher fat and protein content of the peanut butter may satiate you more than the higher carbohydrate content of the cereal.

• Very low fat diets are not recommended as they can lead to increased cravings. In addition, they can worsen insulin resistance. On the other hand, you should not go overboard with your consumption of fats as they are high in calories. For example, 1 T. of olive oil contains 120 calories.

• Select healthy fats. Limit saturated and trans fats as these fats can increase risk of heart disease by raising LDL cholesterol. Substitute unsaturated fat for saturated fat and trans fats. Monounsaturated fats found in found in nuts and nut butters, avocado, olive and canola oil are especially healthy. Include omega 3 fats (found in fatty fish, canola oil, leafy greens and walnuts) in the diet to decrease risk of heart disease. These fats may also improve insulin resistance.  
• Identify problem behaviors and work on making permanent behavior changes. Make small changes at a time. Food records have proven to be a very useful tool in identifying problem behaviors as well as helping you to limit your calories. Who wants to write down that they had 5 chocolate chip cookies? Check out this link for more info on food records.

• Pay attention to how your body feels after eating various foods. Which foods set off cravings or decrease energy levels? Which foods make you feel energized? This is very important to help you determine what kind of eating plan will work best for you.

• Suggested vitamin / mineral supplements: B complex if you are taking metformin,  multivitamin with minerals,  calcium 1000 mg – 1500 mg  (if unable to consume enough from the diet). I would also recommend 1-2 grams of omega 3 fatty acids from a supplement if you are not eating fatty fish at least 3 times a week.

• Practice stress management. Being stressed can raise cortisol levels, which in turn, can worsen insulin resistance. I’m sure we have all heard of high cortisol levels linked to “belly fat”. And, no - those pills such as cortislim don’t lower cortisol levels nor do they get rid of belly fat!

• Get adequate sleep. Being sleep deprived can worsen insulin resistance, make weight loss more difficult and can intensify your carb cravings.

For more helpful info on PCOS, check out this book:  A Patient’s Guide to PCOS: Understanding–and Reversing–Polycystic Ovary Syndrome by Walter Futterweit 
I wrote the 2 chapters on diet and PCOS. Numerous meal plans are included.  

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Question from Linda: I have PCOS (polycystic ovarian sydrome) and am trying to follow a lower carb diet. However, I’m having trouble finding something low carb to eat for breakfast. My favorite breakfast foods - cereal and bagels - are loaded with carbs. Help!

Answer from Martha: You are right - most breakfast foods are high in carbs. However with a little creativity, you can find lower carb breakfast choices. But first, here is a little info on diet and PCOS.

Low glycemic index diet and PCOS
Many of the symptoms of PCOS (irregular periods, hair growth, hair loss, acne, etc.) may be caused by high levels of insulin. Eating foods that rapidly turn to sugar will increase blood levels of insulin. So I often recommend that women with PCOS follow a lower glycemic index diet to help lower insulin levels. In addition, many women with PCOS find that they feel better and have an easier time losing weight when they follow a diet plan that has a lower glycemic index. 

So what is a low glycemic index diet?
Basically, this type of diet contains  meals and snacks that include moderate amounts of higher fiber carbs as well as protein and a little fat. This combination of nutrients allows for a slower rise of glucose, less insulin secretion and then a slower drop of glucose. It can help you feel full longer, have fewer cravings and sustained energy levels.

Even if you don’t have PCOS, you might want to try some of the following suggestions for breakfast. They are a lot healthier and lower in calories than a jumbo bagel, a donut or a giant cup of oatmeal loaded with granola, brown sugar and raisins.

Suggestions for low glycemic index calorie controlled breakfast choices:

* These breakfast choices were taken from the chapters I wrote on diet and pcos for Dr. Walter Futterweit’s book: A Patient’s Guide to PCOS.

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I often recommend nuts as snacks for my clients, whether they are trying to lower their cholesterol, lose weight, have PCOS ( as nuts a great low carb snack) or just trying to eat healthier. Nuts are nutritious, filling and contain heart healthy fats. Consumption of nuts have been linked to a decreased risk of heart disease and diabetes.

The down side of nuts - they are high in calories. Some people have the discipline to eat one portion of nuts. However other people, such as myself, don’t have this control. Have you ever found yourself sitting with a full can of cashews in front of the television only to find the can suddenly half empty? How many times have you found your hand reaching into the nut bowl at your local bar? I am guilty of that one…

I have a hard time finding mini bags of nuts in local stores. Most small bags are 1.5 - 2 oz. This translates into  approximately 250-320 calories. The little bags of nuts at Starbucks are 550 calories!

Calorie content of nuts

Tips to control your portions of nuts:

1. Portion out nuts into small bags. This can help you to control your portion sizes.

2. Buy a type of nut you don’t love. For example, I don’t love soy nuts - but know they are healthy. I would buy those over almonds (which I would have trouble controlling my portion of)

3. Buy mini bags of nuts so they are already portion controlled. They are hard to find in stores. I find random  deli’s in NYC that sell mini bags (1 oz) of almonds and peanuts. I have also found that you can buy them online sometimes.

Purchase mini bags of nuts online:

1. Thanks to my client Viviam S. for telling me about real mini bags of nuts (1/2 oz portion for 80 calories). Great for a snack! She brought me in a sample that she got on an airplane. They are called King Nuts. Check out mini bags of Fancy Nuts and Peanuts. You can purchase these online.

2. Check out Planter’s on the Go nut packs. They contain 1 oz portions and are 160 calories. Unfortunately, I have only found them in a few random stores and you can’t purchase them on the Planters website. However, I did find that you can purchase them on Amazon.com at this link (only the peanut variety though). Make sure the nut pack you purchase is one ounce as many of the nut packs are 3 oz or more. Do an online search and you may be able to find where you can purchase them.

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You work out and have toned thighs and butt … however you have an annoying little (or big) roll of fat that hangs over your skin tight Seven jeans. Not a welcome sight for a city girl. This fat is  informally known as a muffin top. I heard this term for the first time several years ago when the really low rise pants came out. My girlfriend A. C. (full name not to be posted) was complaining about her muffin top. I had no idea what she was talking about. She educated me on this term. While A. C. certainly doesn’t have a muffin top,  I can see the resemblance of fat spilling over pants to the top of a muffin.

Why does fat get stored in this manner?
The location of fat storage is often due to genetics. Some women store excess body fat in their legs or hips while others store it in the abdominal area. Does your mother, grandmother, aunts or sisters have fat in this area? If so, it is likely that you will too. Other causes of abdominal fat can be due to stress (which causes an increase in cortisol levels) or high insulin levels (found in medical conditions such as PCOS and type 2 diabetes).

Dangers of  fat in the abdominal area
Women tend to carry their excess body fat in their hips, thighs, butts, legs and maybe arms (wings!), while men usually gather fat in the abdominal area. That being said, there are women who hold onto fat in the abdominal area.The most dangerous abdominal fat is the kind you can’t see - the fat inside the abdominal cavity that surrounds your internal organs. Chances are that if you can see abdominal fat on the outside, you also have it on the inside surrounding your organs. . Here are some of the dangers associated with excess abdominal fat:
- Increased risk of diabetes
- Increased risk of heart disease
- Psychological distress (not a “medical” risk - but upsetting!)

Tips to minimize your muffin top 
1. Studies have shown that aerobic exercise can help get rid of overall body fat, including fat in the abdominal area. I would recommend aerobic exercise (biking, spinning, running, speed walking, eliptical machine, stairmaster, swimming, etc.) at least 4 times a week for 45 minutes. In addition, try to walk as much as possible during the day.

 2. Spot reducing doesn’t work. While doing abdominal exercises can help to tighten muscles under your fat, it will not get rid of the fat.

3. Newer studies, including one by Kathryn Schmitz of the University of Pennsylvania School of Medicine,  have shown that strength training may prevent you from building belly fat. Check out this link for more details on the study.

Highlights of the study:
- She assigned 164 overweight or obese women aged 25-44 to one of two groups. One group did strength training sessions for one hour twice a week for the first year and for 45 minutes twice a week for the second year. The second group was simply given a brochure that recommended aerobic exercise.
- After two years the strength training group lost more body fat (3.7 percent) than the control group (0.1 percent) and gained less deep abdominal fat (7 percent) that the control group (21 percent)

4. Of course, you will also need to be careful with your diet. If you are consuming more calories than you burn off, you will continue to store body fat. I would recommend food records to keep tabs on your caloric intake. Check out my previous post on food records.

5. Eat a healthy diet that is low in refined sugars and processed grains. These foods can raise insulin levels which can contribute towards belly fat in some people. Focus on vegetables, lean protein, moderate amounts of heart healthy fats, fruits and whole grains. More about your caloric needs in a later post.

 Bottom line: Weight training is important to help lower your body fat, especially fat in the abdominal area. I see a lot of city girls at my gym spending tons of time on the eliptical machine (which seems to be a favorite) without getting great results. You would be better off adding in some weight training along with the cardio.

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I often receive emails and letters from nutrition students who are interested in observing a nutritionist in private practice “in action”. I also train dietetic interns at the hospital where I work (New York Presbyterian Hospital) and enjoy helping students gain experience for their future careers as registered dietitians.

I received a letter from Allison Scheinfeld,  a Health and Nutrition Science major at Brooklyn College, asking for the opportunity to observe me counsel a patient with PCOS.   She will be graduating in May 2008, and is looking for internships in the NYC area. She has a special interest in PCOS since she has this condition. I suggested Allison write an article on her experience with PCOS … and here it is! 

My diagnosis of PCOS
At 19, after suddenly gaining 25 lbs, I was diagnosed with Polycystic Ovary Syndrome.  I then finally knew the cause for all the effects of my mind and body.  It explained why I gained weight, why my skin had constant little red bumps, the uncontrollable hair on my neck, why I hadn’t gotten a menstrual period in over 8 months and why I always felt slightly anixous.  It was still not an easy diagnosis,  I had to take many tests for other syndromes/diseases.  My many endronologists thought maybe I had Cushings Syndrome or Diabetes.  Knowing the cause was only half the battle.  Then came all the questions. What treatment is right for me?  Can I conceive a child?  Will the acne disappear?  The main question for me was would I ever be 100% happy despite all my  obstacles?  I have found that the correlation between food and symptoms is the key.  Nutrition is the basic component of controlling PCOS and has led me to become a R.D student.   My endocrinologist recommended Ms. Kittrick as a R.D and I soon googled her website.  She has given me the opportunity to sit in on her counseling sessions with PCOS clients, and now an opportunity to share my store, and hopefully some tips to help any girls that have this syndrome.

 The following carbs work best for me
The question of carbohydrates is one that many PCOS women have.  The answer?  Good carbs.  Only whole grains, complex carbs.  The best bet for carbohydrates is sprouted whole grain.  It has a very low glycemic index, which slowly raises your blood sugar. They have sprouted whole grain bread, pasta, bagels, cereal, English muffins, etc.  I start every morning with a piece of sprouted grain toast with melted cheese.  I am still able to enjoy carbs without worrying that my skin will break out or my mood and energy will drop.   Other good options of whole grains are Wasa multigrain crackers and Kashi products (their Go Lean bars are great to carry in your bag for the middle of the day.)  You should note, it is still best to watch your portion sizes.  Even the “healthy” food can add weight and negative effects if eaten in large amounts.

 How to incorporate fruit into the diet
I am a big fan of fruit and fruit salad, but many fruits have high sugar content, which does not have positive effects on symptoms.  Green apples have the lowest sugar content of a fruit and I find that the crunch and the sweetness satisfy my sweet tooth.  Other good choices for fruit are grapefruits, oranges, peaches and pears.   As far as melons go, they should be consumed in moderation, due to their high glycemic index.  You can still enjoy watermelon, but just like the carbs, know good portion sizes.  I find that dried fruit (raisins, apricots, prunes) set off my cravings for other sweets.  So I only have those once in a while. It is best to have fresh fruit, I prefer organic, but it just personal preference.

 The sweet tooth
If I have a binge night where I eat way too much chocolate or a large amount of chocolate cake (it’s a love/hate relationship), my skin will react the very next morning.  When I do not keep things under control, not just the acne reacts.  The hirsutism, hair loss, bloating and the low “down in the dumps” moods all come into play.  There are many other options than bingeing on the seven-layer cake.  Tasti D Lite is close to being my savior, along with Skinny cow products which are great to keep in the freezer for those nights when you need that something.

 Other good choices
 Hummus (my favorite brand is Tribe, but my sister is more partial to Sabra) is a great choice for girls with PCOS.  It is low calorie, low carb and low sugar.  I put it on the Wasa crackers and it’s delicious.  I make lots of stir frys with olive oil and pepper.  Sometimes I use salad dressings to mix in.  Mushrooms, peppers, onions, bok choy, beets, etc.  Veggies are a great way to fill up without any reason to feel guilty.  Sweet potatoes have a low GI and are a good alternative to the “evil” white potato (which I 100% steer clear of.)

 Importance of exercise for women with pcos
Exercise is also extremely important when dealing with PCOS.  I could not live without my treadmill.  Since I took up running 3 years ago, my body and mind have definitely improved (and I lost the PCOS related 25 lbs.)  I recommend starting out with 1 or 2 miles like I did, and then slowly adding distance.  I can now run 6 miles straight which is a huge accomplishment for me, considering I could not even run a half a mile a couple of years ago.  As far as the hirsutism goes, I have tried all types of hair removal, and my conclusion is that threading (ancient Indian technique) is amazing.  It is less rough on the skin than wax, and lasts longer.

 Make good choices and get good results
To have Polycystic Ovary Syndrome is to constantly have an extra obstacle to deal with in life.  No one in the outside world, except for women who suffer from PCOS can know the difficulty and pain that goes along with this syndrome.   It is a physical, as well as emotional.   It is nice to know that you have the power to control many of your symptoms with a little self-control and planning of your meals.

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Polycystic ovarian sydrome (PCOS) is the most common abnormal hormonal condition of women of reproductive age and is the number one cause of infertility. It affects 7-10% of all women. Unfortunately, many women who have it do not know they have it. The diagnosis often slips by physicians as the condition can be tricky to diagnose. I have been specializing in PCOS for the past 8 years and often have the opportunity to help a woman get diagnosed with this condition. This will enable them to get the proper treatment.

Allison was a 30 year old female who came to my office seeking help in losing weight. She had experienced a rapid 30 pound weight gain in college which she has still not been able to lose. Allison reported sugar cravings, mood swings and carbohydrate cravings. She has tried many different diets but none have worked for her.

I obtained Allison’s diet history. Her diet was very low in fat and fairly high in carbs. She indulged her sugar cravings at least once a day. Her caloric intake was approximately 1700 calories a day. She was trying to exercise 2-3 times a week…when she was not too tired.

I frequently ask women who are overweight (especially in the abdominal area) about their menstrual history. It turns out the Allison had irregular periods and was put on the birth control pill in college. I also asked her if she had any symtoms of excessive hair growth - which she did. She said she thought the hair was due to her Italian ethnicity. Irregular periods, rapid weight gain and excessive hair growth (hirsuitism) can be symptoms of PCOS.

Problems:

1. I suspected Allison had PCOS. This could contribute towards her weight gain and difficulty losing weight, carb cravings and mood swings. It can also increase risk of diabetes, heart disease and endometrial cancer if not treated. I had Allison take a PCOS quiz. While this is not a “diagnositic” test, it is a useful tool to suggest a diagnosis of pcos.

2. Allison’s diet was too high in processed carbs and too low in protein and heart healthy fats and fiber.

3. She often went too long without eating. This contributed towards low energy levels, carb cravings and overeating at the next meal.

4. Allison was not exercising on a regular basis.

Solutions:

1. I gave Allison the names of several endocrinologists who specialize in PCOS. She met with one of them and was diagnosed with PCOS. She was relieved to know there was a reason for her difficulty losing weight, excessive hair growth and low energy levels / carb cravings.

2. I provided her with information on PCOS and insulin resistance. I also discussed the importance of a healthy diet in treating PCOS.

3. I explained that she would likely feel better and have more success in losing weight if she moderated her carbohydrate intake, selected lower glycemic index carbs and ate more frequent mini meals that included a high fiber carb, protein and fat. For example, snack on peanut butter and whole grain crackers rather than 2 hundred calorie packs of fat free cookies.

4. Increase her exercise to 4 times a week. In addition, I recommended that she walk to work (2 miles) at least 3 times a week. I explained the benefits of increasing physical activity: burning calories, speeding metabolism, stress management, lowering insulin levels, etc.

5. Keep a food record recording what she ate, the time she ate and how she felt. In additon to helping her keep track of her calories, this also showed her which meals made her feel better.

6. I also stressed the importance of calorie control. I often see people who think they can eat almost unlimited food as long as their carb intake is low. I recommended 1400 calories a day for Allison.

The good news, I have been meeting with Allison for follow-up appointments every 2 weeks. She has been able to lose 8 pounds in 7 weeks. She feels much more energetic and had fewer carb cravings. She has been meeting her exercise goals and says she feels like a new person.

Check out my website for more references on PCOS

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