15-minute power-point to present the research of a two-phase informative study that collected survey and qualitative data through a series of focus groups regarding the current description and future implications of PCOS multidisciplinary clinics while emphasizing the role, importance, and challenges for dietitians.
1. 1
Nutrition Interventions:
Feedback from PCOS
Focused Practitioners
Wendy Thompson
Graduate Dietetic Intern
Davis College of Agriculture, Natural
Resources and Design
Melanie Clemmer, PhD
Pamela J. Murray, MD, MHP
Melissa Olfert, DrPH, MS, RD
2. • Multifaceted
• Many phenotypes
• ~60% obese
• 15-20% develop diabetes
prevalence in WV
Polycystic Ovary Syndrome (PCOS)
2
National Institutes of Health Office of Disease Prevention, 2012; Daniilidis A. & Dinas K., 2009
4. How is PCOS Diagnosed?
NIH 1990 Rotterdam 2003 AE-PCOS Society 2006
• Hyperandrogenism
• Chronic Anovulation
---Both criteria needed
• Hyperandrogenism
• Oligo-and/or anovulation
• Polycystic ovaries
---2 of 3 criteria needed
• Hyperandrogenism
• Ovarian dysfunction
---Both criteria needed
First developed and most
commonly used criteria
today
Formulated to expand on NIH
diagnostic definition
Formulated to provide an
evidence-based definition
4
*All possible related disorders must be ruled out
NIH Evidenced Based Methodology Workshop on PCOS, 2012;
Shannon et al. 20122
~ 50-75% will visit multiple
clinicians before it is identified2
5. PCOS Treatment
• Lifestyle intervention =
first line treatment1-3
• Support medical management
• Weight loss is best achieved
though multidisciplinary
lifestyle management4:
• Dietary
• Exercise
• Behavioral
• Requires ongoing support
for long-term success 5-6
5
Teede et al, 20111; Humphreys & Costarellil, 20082; Jeanes et al, 20093; Moran et al, 20094;
Himelein, 20065; Stankiewicz, 20066
Physical
Activity
Diet
Smoking
Cessation
Stress
6. Benefits of Weight Loss in PCOS
• Potential Benefits
Include1-3:
• insulin levels
• testosterone
• risk for CVD and
diabetes
• Improved dermatological
symptoms
• Improved fertility
6
• Weight loss of 5% to
10% can improve
metabolic and
reproductive aspects
of PCOS1-2
• Does not reverse
PCOS, but helps
control associated co-
morbidities3
Teede et al, 20111; Farhat et al, 20112; Barthelmess & Naz, 20143
7. Study Objective
To investigate the current trends and future
implications of multidisciplinary PCOS clinics while
emphasizing the role and challenges for dietitians.
7
8. Formative Study Design
Phase 2: Focus Groups
(N=9)
Phase 1: Survey
(N=261)
8
• Anonymous, Internet-
based
• 30 Questions
• Basic Demographics
• Current Facility
• Future Implications
• Teleconference
• 7 Major Questions
• Braun & Clarke’s
Thematic Analysis1
Braun & Clark, 20061
9. Survey Demographics
9
59%
20%
5%
3%
3% 3%
7% 0%
Provider Type
Physicians
Dietitians
Fertility Specialist
Researchers
Midlevel Providers
Educator/Counselors
Other
N=210
64%
36%
Location
USA
Other
N=184
12. Strengths and Weaknesses of the
Current System
34%
30%
10%
0
10
20
30
40
%ofProviders
Needs Improvement
12
* Wait-
Time, Cost, InsuranceN=88
21% 21% 20%
17%
0
5
10
15
20
25
%ofProviders
Current Strengths
N=87
13. Potential Barriers for Future
Multidisciplinary Clinics
13
Money and resources
(30%)
Insurance/reimbursement
(26%)
Difference of
opinions (16%)
Time
(12%)
14. Potential Advantages for
Multidisciplinary Clinics
14
Increased
access to
more
disciplines
(10%)Better
communication
between providers
(15%)
Better results & long-term
outcomes (18%)
Convenience & efficiency (30%)
Comprehensive and integrated care (32%)
17. Focus Group Demographics
• Dietitians
• PCOS (4)
• Physicians
• Adolescent/Internal
Medicine
• Pediatric
Endocrinologist (2)
• Other
• LN/CNS
• Health Psychologist
17
67%
33%
Multidisciplinary
Clinic
Yes
No
18. When is Dietary
Intervention Warranted
For PCOS?
• Always important to
discuss and provide
nutrition counseling
• Equally important
regardless of BMI
• Immediately upon on
diagnosis patients should
meet with RD
• First line treatment
How Accessible are
Dietary Interventions
for PCOS?
• Not very accessible!
18
20. Importance of Involving RDs
• Access to adequate
lifestyle interventions
• Physicians should not
be fully responsible:
• Little to no training
• “They can only be the
experts on so many
things”
• Takes time
• “More than just handing
the patient a 1,200 kcal
diet plan” 20
21. Conclusions
• PCOS patients require special attention with
individualized, focused, multidisciplinary care – ideally in
one facility
• The most common challenges for dietitians include
insurance, lack of knowledge, and lack of physician
referrals
• Dietitians are highly overlooked when it comes to the
care of PCOS
• Education for PCOS and lifestyle interventions need to be
increased across providers 21
22. Did you ever wonder how your lifestyle
is affecting you?
Ask today about speaking with our Registered Dietitian
to discuss methods for:
Improving your nutritional status
Includes a nutrition assessment
Meeting your physical activity needs
Improving your BMI
Improving your fertility
Improving your overall health
WVU Center for Reproductive
Medicine Welcomes…
22
Hippokratia. 2009 Apr-Jun; 13(2): 90–92. PMCID: PMC2683463Long term health consequences of polycystic ovarian syndrome: a review analysisA Daniilidis and K Dinas http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2683463/to increased obesity and diabetesWV Statistics33.8% Obese4th highest rate in US13% Diabetes1st highest rate in USNational Institutes of Health Office of Disease Prevention as cited inAmerican Congress of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 108: Polycystic Ovary Syndrome. Obstet Gynecol. 2009;114(4):936–949. [PubMed]5 million in the USJust behind Louisiana, Mississippi, AlabamaAs of 2012 - http://fasinfat.org/lists/highest-rates-adult-obesity/ http://fasinfat.org/states/wv/
of women with PCOS Ovarian Dysfunction refers to oligo or-anovulation and/or polycystic ovarian morphologyClinical and/or biochemical signs of hyperandrogenismRelated disorders include congenital adrenal hyperplasia, Cushing’s syndrome, hyperprolactinemiahttp://prevention.nih.gov/workshops/2012/pcos/docs/PCOS_Final_Statement.pdfIn women, symptoms of hyperandrogenism frequently include acne, scalp hair loss (androgenic alopecia), excessive facial and body hair (hirsutism), high libido, and others. Collectively, these symptoms are known as virilization.Hyperadrogenemia – a condition of the blood where there is excess androgens that cause male featuresHyperandrogenism – is the collection of symptoms that result from hyperandrogenemia
Usually, weight loss does not extend beyond one year without ongoing support5-6Moran Lj, Pasquali R, Teede HJ,Hoeger KM, Norman RJ. Treatment of obesity in polycystic ovary syndrome: A position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. FertilSteril. 2009;92(6): 1966-1982.State the whole person
Table 1: Demographic characteristics of provider specialty – multiple selections possible (n=210)
N=135
Responders (n=88) were asked to list the top one or two items that their facility could improve upon. Incorporating more multidisciplinary involvement with more integration and/or communication (34%)Expanding on nutrition and/or exercise programs to support weight loss (30%)Responders (n=87) were also asked to list the top one or two items that their facility does well.
The most common potential barriers to future multidisciplinary clinics noted by responders (n=76)
When asked to discuss the potential advantages of multidisciplinary PCOS clinics the most common responses (n=82)
Ideal involvement of specialties in future multidisciplinary PCOS clinics, as rated by survey responders (N=113)Likert Scale
Boston, MassachusettsLas Vegas, NevadaPhiladelphia, Pennsylvania and around the world via web conferencingAtlanta, GeorgiaIndianapolis, IndianaSt. Louis, MissouriMadison, WisconsinLos Angeles, CaliforniaMinneapolis, Minnesota2/7 = male6/9 = worked in a multidisciplinary facilityMA, PANV, CAGAIN, MO, WI, MN
Lean PCOS OverlookedConsidered the first line treatment Insulin resistanceIncreased risk for diseaseOverweight and obese More symptomatic More obvious referralsAlthough all providers agreed that nutritional interventions are important for even women with PCOS, not all women with PCOS are getting lifestyle interventions. Providers stressed that the biggest barriers are most likely insurance coverage and physicians that do not refer out because they do not see the benefits of nutritional interventions.
Lack of MD referrals – “physicians are the gatekeepers”
*Average length of visit = 18.7 minutes = CDC – NCHS, Ambulatory Health Care Data, 20101One provider stated “The dietitian providers the nutritional information and the psychologist really gets the change”Only way most patients will get adequate lifestyle interventions and help understand their conditionhttp://www.cdc.gov/nchs/ahcd/physician_office_visits.htmPatients benefit from nutritional counseling so much more than handing out a diet plan because there is a large psychological and emotional component related to food that much be addressed.
“Often times, with PCOS, nutrition counseling is treated like dermatology and it needs to be treated more like psychology.”Just getting the conversation started at the primary care level