How Diet Can Be Used to Manage PCOS with Kathryn Goebel, MD

Podcast Transcript

John Horton:

Hey there, and welcome to another episode of Nutrition Essentials, an offshoot of our popular Health Essentials Podcast. I'm John Horton, your host.

Polycystic ovary syndrome, better known as PCOS, is a complicated hormonal disorder in women that's often misunderstood. It comes with symptoms and side effects that can be troubling, to say the least. As women with PCOS search for solutions, they often find gobs of dietary advice online. Today, we're going to spend some time talking about what recommendations should be ignored and which are worth pursuing for the healthiest possible outcome.

As always, we have registered dietitian Julia Zumpano with us to answer our nutrition questions. To learn more about PCOS, we're joined by a specialist from Cleveland Clinic's Ob/Gyn and Women's Health Institute. Julia, who's with us today?

Julia Zumpano:

Thanks, John. Our guest is Dr. Kathryn Goebel. She's an Ob/Gyn with a specialty in PCOS care. She works with her patients to create individualized treatment plans to better manage their condition — and diet is a huge part of that process. I'm looking forward to comparing notes with her to help women with PCOS feel at their best.

John Horton:

Well, Julia, between you and Dr. Goebel, I'm sure we're about to hear some great advice. Let's get started.

Welcome to the podcast, Dr. Goebel. We appreciate you setting aside some time to chat about diet and PCOS, a condition that seems to be getting a lot more attention of late.

Dr. Kathryn Goebel:

Thanks. Happy to be here.

John Horton:

One of the reasons why there's more talk about PCOS is that it's being diagnosed much more frequently. By some estimates, it's now believed that up to 13% of women may have PCOS, which is up pretty significantly from a few decades ago. Do we know why we're seeing such an increase, Dr. Goebel?

Dr. Kathryn Goebel:

I really think there's probably two things going on. I think there probably is a true increase in the incidence of PCOS, probably tied to the obesity epidemic. If you look at 25 years ago, the obesity rate in adults was about 30%. Now, it's above 40%. In adolescents, it's now above 20%. This is really important for PCOS because most women will start having PCOS symptoms when they're adolescents.

I think also, though, we're just seeing a lot more people talking about it. You've got celebrities — Victoria Beckham, Florence Pugh, Bebe Rexha, Leah Michelle — all talking about their struggles with PCOS really publicly over the last few years. There's also a lot of social media influencers, particularly on Instagram, who are talking about health and wellness in the context of PCOS.

I'll say anecdotally, 15 years ago, when I would diagnose someone with PCOS, they might not have ever heard of it and they'd really have a lot of questions. Now, I'm seeing more young women come in and say, "Hey, I have these symptoms, it sounds like I might have PCOS. Can you test me for it? Is that what's going on?"

Julia Zumpano:

That's fascinating how much the exposure has evolved. That's one of the blessings of our technology and the world we live in these days.

For a little background, Dr. Goebel, can you please give us an overview of what PCOS is and what it means to live with that condition?

Dr. Kathryn Goebel:

Sure. Really, at the root, PCOS is a hormonal imbalance problem primarily caused by high testosterone levels. Not boy-level testosterone, but testosterone levels that are high enough to change the signal to the ovary to release an egg on time every month. Because if you're not releasing an egg on time every month, then you're not going to get regular periods. That can cause both women to have periods that can be really unpredictable, sometimes heavier, especially if they're skipping cycles. It can also obviously cause fertility problems. If you're not releasing an egg, you're not likely to be getting pregnant on your own.

Many women will also have cosmetic effects of the high levels of testosterone. These can be really bothersome. Increased acne, increased hair growth, particularly on the face, the chest, the back. It really can cause a lot of body image issues. Some studies suggest that women, if you look at who are the same level of overweight, same body mass index, those that have PCOS have more anxiety, more depression, more eating disorders.

In addition to the testosterone — and really, what we're going to be focusing on today — is the fact of the insulin disorder that is part of PCOS. The high insulin levels and the insulin resistance can actually contribute to the higher testosterone levels. They basically feed back and make each other worse. We know that women who have insulin resistance are at higher risk for diabetes, they're at higher risk for heart disease because of the damage of the blood sugar to these tiny blood vessels in the system. High cholesterol. The combination of insulin resistance and cardiovascular disease — sometimes, it's called metabolic syndrome — women with PCOS are at higher risk for this.

John Horton:

Dr. Goebel, do you find that there's still, though, a lot of misunderstanding that really just fuels worry about living with PCOS?

Dr. Kathryn Goebel:

Oh, for sure. Again, when we're looking at, OK, now, I have this diagnosis of PCOS, what does that mean to me? Am I going to be able to get pregnant and successfully have a family? What is that going to mean for my ability to lose weight and maintain good fitness throughout my life? What is it going to mean for my health when I'm older, as far as my cardiovascular risks? Am I going to definitely be diabetic by the time I'm 50? There's a lot I think of fear of, "OK, now, I have this diagnosis. What do I do with this?"

John Horton:

Yeah, that's a lot to take in. Everything you just listed off, are huge life issues. You can see where it would really become something that weighs on folks.

Dr. Kathryn Goebel:

For sure.

John Horton:

I've seen a lot where they describe PCOS as “metabolic chaos,” which is just a great term.

Dr. Kathryn Goebel:

For sure.

John Horton:

It makes sense then that adjusting what you eat may help offer some balance within your system to maybe help manage the condition. I know we have a lot to cover, but let's start with the importance of choosing food based on what it means for your blood sugar levels.

Dr. Kathryn Goebel:

Right. If you think about, like I said, with insulin resistance, that means you have, at baseline, a higher insulin level. Making those food choices to not drive those insulin levels higher and to not have those big spikes really can be very important because if we can reverse any of those changes ... we know even losing 10% of your body weight in PCOS sometimes can get your periods to go back to normal without any other hormonal treatment. There's really that balance of the insulin, your sugar levels, and then how that interplays with your testosterone production — it's all interconnected. One area that we do have control over, that glucose metabolism and the insulin, is what we put in our mouths.

Julia Zumpano:

Just to piggyback off that, when we think about trying to maintain lower levels of insulin, we're looking at dietary changes that include reducing, first of all, sugar-containing foods and refined carbs because we want to pick and choose foods that are not providing us any nutrition first. Sugar-sweetened beverages, sweets, desserts, baked goods, things of that sort. Then, simple carbohydrates that are considered things like white bread, white pasta, white rice, white crackers. Again, we don't have to avoid them completely, but really, significantly limiting those foods and coming up with more complex carbohydrates to replace them with.

The difference between a simple and a complex carb is that simple carbs are broken down very immediately and quickly into glucose or sugar, which then leads to a rise in insulin. Where complex carbohydrates provide fiber, maybe a little protein. That slows down the rate of glucose in the bloodstream, causing much less of a spike, and therefore, much less of a reaction of insulin.

John Horton:

That makes total sense, with what you just said. If you eat some of these sugary goods, these baked goods, all those little things that too many of us, we crave a lot, that it's going to cause a spike in your blood sugar.

Walk us through how that affects PCOS and how that rise in blood sugar then leads to these symptoms, or what's happening?

Dr. Kathryn Goebel:

Well, like I said, the worse your insulin resistance is, the worse the testosterone imbalance is going to be as well. For somebody who has PCOS and is having some maybe milder symptoms, if they were to gain a significant amount of weight and follow a simple carb diet that really is causing a lot of insulin spikes and prolonged high insulin levels and then gaining weight, their testosterone balance is likely to get worse. Their symptoms, with their acne and their hair growth, are likely to get worse. Their irregularity of their menstrual cycle is likely to get worse as well.

Conversely, we know that a lot of these changes are reversible with dietary changes, and with weight loss and a healthy lifestyle. That can improve even the hormonal effects, like the regularity of the period, just by changing those lifestyle choices.

Julia Zumpano:

One thing I want to note, too, is that we know that these foods can be addicting. We know that they can be hard to cut back on. I call them “hyper-palatable foods.” They're designed for us to want to consume them, want to consume large amounts of them and continue to purchase them again. It is difficult to initially get away from these foods, but as you reduce your intake of these refined sugars and processed foods and manage your blood sugars, the management of your blood sugars will aid you in less cravings. If you can better manage your blood sugars, your cravings will improve. As you decrease the foods, and in some cases, some people need to initially eliminate them to get things settled down and managed, it will really help your appetite and your craving towards these foods.

That balance is really key for success. We never want to say we want to eliminate anything from the diet, we know all foods can fit. But initially, cutting those out, and then slowly adding them back in. Then, again, combining foods with a healthy fat and some protein can really help your blood sugar reaction and help minimize the amount of insulin you're producing after consuming those foods.

Dr. Kathryn Goebel:

Yeah, absolutely. Because if you eat something that is just a pure simple carbohydrate meal, two hours later, your sugar's going to have crashed and you're going to be looking in the break room to see if there's donuts. If you're having a healthy, well-balanced protein, fat in your diet that's going to maintain those steady blood sugars, you're not going to have those crashes and spikes and those cravings.

And also, for somebody who is able to really minimize or cut down on the sugars at the beginning of this change in their diet, amazing how very sweet fruit tastes when you haven't been eating the processed foods and the really, really artificial sugars that really just affect our taste buds and what tastes good to us.

John Horton:

It's amazing. As you guys have been going over all this, it really stands out just how complex this is and the layers that we're dealing with here. One thing leads to another leads to another, and they all work together to complicate these problems.

One thing that kept coming up was weight gain, which I know is a real common side effect of PCOS. It seems like those extra pounds do worsen the symptoms that come with the condition and can lead to some of these other issues, too. Can you walk us through a little more of this complicated relationship between PCOS and weight gain?

Dr. Kathryn Goebel:

Sure. Like you said, it is complicated because being overweight or obese can help trigger these metabolic changes that can cause a lot of the symptoms of PCOS.

John Horton:

The body just doesn't work the same.

Dr. Kathryn Goebel:

Exactly.

John Horton:

If you have the extra weight, there's a lot going on.

Dr. Kathryn Goebel:

But when you're somebody who has chronically high insulin levels, it can make it harder to lose weight as well. Then, when you look at the compounding effect of the body image issues in women with PCOS, it's really a setup for very disordered eating.

Some women will experience binge-eating. It is much more common in women than in men. Even for those who don't meet the diagnosis of a binge-eating disorder, what is extremely common is what I just call “emotional eating.” Emotional eating is basically consuming these processed high-sugar, high-fat foods, and really, it's trying to buffer your feelings. You're eating not because of hunger but because of what you're feeling. This is modeled particularly to women from a very early age. Think of every after-school sitcom that you watched as a kid. The main character broke up, they were shown eating a pint of ice cream.

John Horton:

A pint of ice cream, yeah.

Dr. Kathryn Goebel:

Look at today on social media, the whole little treat culture. Most of the time, those are food … and sugary treats, fatty treats. There's the whole subset of “mommy wine culture.” It's treating yourself with something that maybe is not in your best interest nutritionally to brighten the monotony of parenting, as a consolation for a bad day, to reward yourself for getting through a task. Then, the other effect of alcohol use as well is that we know that alcohol lowers your inhibition and increases the risk for binge-eating as well.

Julia Zumpano:

I think those are two great points. In my patients, I see a lot of emotional and binge-eating. It's hard to decipher the difference between the two. Usually, I ask a couple screening questions. When you suffer from binge-eating disorder, it's usually when you're consuming large amounts of food and you feel out of control. You feel like you don't have control of your eating. Then, usually, it's unfortunately followed by feelings of guilt, or depression, or even worse feelings from when you began. And even more uncomfortable feelings from a gut perspective or how you're physically even feeling uncomfortable. If that occurs more than three times a week, we usually classify that as binge-eating disorder.

The emotional eating piece may not necessarily include a full binge, but it may just be that any time you're stressed, you're grabbing chocolate or you go through the drive-thru. Whatever your vice might be, you're feeding your emotion, whether it be good or bad, with food as a soothing technique.

What we try to do is, we try to come up other ways to soothe. We replace the food with another soothing event or distracting event. Soothing may be taking a hot bath, maybe simply taking some deep breaths. Distraction could be calling a friend or going on a walk. There is a whole list of options we have, and of course, you can come up with your own. Anything that will either distract you away from that emotion or soothe you in a non-food-related way.

Even from when I see children, I try to encourage parents not to reward their children with food. If you're going to reward your child for good behavior, starting with good habits when they're young is rewarding them with maybe an extra TV show or a friend gets to come over, whatever it might be, but just not a food-related treat.

Dr. Kathryn Goebel:

Yeah. The other thing I find really helpful for my patients who struggle with emotional eating is food journaling. I think, again, there's lots of different ways to do food journaling that work for different people. Personally, I like it very simple. Just write down the food just before you put it into your mouth. Because even if that just gives you that split-second pause, "Am I eating because I'm hungry, or am I eating because I'm bored, I'm angry, I'm frustrated, I'm lonely, or there's some other feeling?"

Even if it's not immediately someone is ready to change their behaviors, that food journaling can help them see, "OK, when is it that I'm not having the willpower that I want over my eating? Am I an evening snacker?” Does it make sense: "Well, maybe when I put the baby to bed, should I brush my teeth before I come back downstairs so I'm not having that mental cue of it's still time to be eating?" For moms with young kids, are you eating the grilled cheese crusts and the little cookies that are leftover on the tray every time instead of putting it in the garbage? That food that you're not thinking about, unplanned eating, can really add up because a lot of the times, those are not good, healthy choices. I think really starting with that food journaling to see, "What am I eating? When am I eating it?" Just being more mindful about our eating.

Julia Zumpano:

I love the idea of food journaling. I recommend that all the time. Regardless of what your health goal is, I think it's very eye-opening. It gives you ideas of your food trends, your timing, et cetera.

One thing I do encourage is taking it a step further. When you're writing down what you're eating to also note your emotion. Then, you can also note if there are times of your day you feel that emotion, if there's certain emotions you crave certain foods with. And also, sometimes, it could just be justifying to write down how you feel. Because actually, what we're trying to do is express or release that feeling, and we may feel like we're trying to do that through eating. But if you're able to write it down or journal it, you may be able to just release or express that feeling in that way and you may be less inclined to serve that emotion with food.

John Horton:

Yeah, you guys have really just portrayed so well the complicated relationship all of us seem to have with food and weight, and how that goes together. With PCOS, it seems like it's exacerbated even more.

For Julia, with someone with PCOS, what should they be looking to put on their plate? What should they be filling out their food journal with if they want to try to keep the condition under control?

Julia Zumpano:

Sure. No surprises here, same theme. We're looking for whole foods. High-fiber foods and good sources of lean protein. Just whole grains, fresh fruits and vegetables, nuts and seeds, beans or legumes. Lean meats, such as chicken, turkey, lean beef or pork, fish or seafood. Then, healthy fats, such as extra virgin olive oil or avocados. A really good balance of whole foods, making sure you're getting tons of fiber and tons of healthy fat because fiber and fat are what put the brakes on your sugars. Your blood sugars will really be best managed if you're consuming enough fiber and healthy fat with meals. And, of course, protein. But those three nutrients are essential for the management of blood sugars. And a lot of times, people aren't consuming enough healthy fat and protein, which is what causes them to crave carbohydrates. Carbohydrates aren't bad. They're our body's main source of energy. We certainly need carbohydrates, but we need the right kinds. The kinds that are packed in fiber. That will lead to the best blood sugar management and the best outcome. And bonus, all of these foods are considered anti-inflammatory, which we'll talk in a minute about the benefits of eating an anti-inflammatory diet for PCOS and just overall disease prevention and management.

John Horton:

Yeah. One thing, too, I think we need to emphasize is just … you had mentioned whole foods. The flip side of that is staying away from ultra-processed foods.

I read something where they talked about the JERF concept, which I'd never heard before and I really liked. I guess that stands for “just eat real food”?

Julia Zumpano:

Yeah, I love that concept. Certainly, yeah. We know to avoid those packaged foods, those things that call to us. Potato chips and cookies and crackers and pretzels and sugar-sweetened beverages and alcohol and high amounts of caffeine. Those are all stimulant foods, and they're going to cause you to want to consume them more. They may even skew your thought process around, "OK, it's OK to have these," and you'll just consistently get in this bad habit of a loop on consuming these foods. Then, your blood sugar is all out of whack, and our body's in this metabolic distress, as we're talking about. Really, feeding your system to have managed blood sugar and success around managing your food choices.

Dr. Kathryn Goebel:

I think this is where meal planning really is super-duper helpful. If your pantry is full of all of those super processed foods, and you come in the door at 6 pm and you're hungry, you're not going to make the best choices. This is about sitting down and saying, "OK, how am I going to feed myself and my family this week? How can I make choices that are good ahead of time? Can I make a healthy dinner and make an extra portion that I can bring to work tomorrow for lunch?" As opposed to when everyone in the office is like, "Oh, do you want to order lunch today?" How can you make as much of those food decisions ahead of time instead of in the moment?

Julia Zumpano:

I completely agree. Planning ahead is essential. Really, that grocery shopping trip is where it begins. When you're grocery shopping, that's when you really want to make sure you fill your cart with all of those foods you should be consuming, the foods we just spoke about. Planning your meals ahead so you have everything. Planning for those nights, that just life happens and you just had no time to cook dinner. Well, what are you going to do? What is a 10- to 15-minute meal you can pull together and still feel really good about? It's really essential to have a stockpile of good food, healthy foods in your freezer and your fridge so you have no excuse to stray.

John Horton:

I want to ask here, too, if you go search online, there are no shortage of sites where you see where something's labeled as the magic food, this will cure your PCOS or make everything go away. There's no magic item that's going to take care of everything, right?

Dr. Kathryn Goebel:

Nope.

Julia Zumpano:

Absolutely not.

Dr. Kathryn Goebel:

No. Really, it's going to be what are those day-in, day-out choices that you're making. Like we had said, I don't think there is any food that is inherently evil and bad, but I think you need to look at your overall eating plan. Is there a little bit of room for joy in your eating? Absolutely. But do you need to have that in the context of a well-planned, well-balanced diet that's really going to meet what your health goals are? Yes.

Julia Zumpano:

I also think a little bit of a mindset is important here. Just really embracing a new lifestyle, a healthier way of eating, embracing what that means to your body. Embracing the fact that you're making and taking an initiative to improve your health and feel better. Hopefully and ideally, as you do that, the weight will just naturally, hopefully, come down. You'll feel better. You'll feel better. Your blood sugars will be better managed, you'll have better self-image.

I think that's really important, too, is the mindset piece around it. I think if we walk into a plan knowing and feeling deprived from the beginning, that plan's not going to be sustainable. I think it's important to not deprive yourself, but really look at it in the form of “I'm treating myself.”

John Horton:

I love that mindset, that mindset idea. I know my wife will get me to eat more cucumbers because she cuts them up real long and they're cucumber fries. All of a sudden, they taste better.

Dr. Kathryn Goebel:

I load cucumbers with salt for my kids to eat them and they'll eat them up. It's little tricks that you do. And of course, I can't say it enough, is just taking that ownership of your health. Be in the driver's seat of changing your outcome.

John Horton:

Julia, you did a little foreshadowing for us when you brought up anti-inflammatory foods. Let's spend a little bit of time talking about why those are so important for managing PCOS.

Julia Zumpano:

For me, from a food perspective, inflammation happens all around the body. We know that there's acute inflammation or chronic inflammation. When our body's in a state of distress or metabolic distress, we have inflammation. When our blood sugars are out of whack, when our insulin level is high, when we have a little extra weight on us, those are all markers for inflammation.

We can feed that inflammation by the food we're choosing to have. All those ultra-processed sugary foods are only going to support that inflammatory process to continue or worsen. Or we can try to suppress that inflammation by the food choices we make. By choosing foods that are high in omega-3 fatty acids, like fatty fish and chia seeds and flax seeds and hemp seeds. And choosing whole foods, like fruits and vegetables and grains that provide us those anti-inflammatory compounds that can stop that inflammatory process, or at least slow it down.

Dr. Kathryn Goebel:

It's really important to remember that when we're looking at the insulin resistance side of PCOS, we're looking at chronically high sugar levels and insulin levels, which are causing damage to the blood vessel linings. That's that long-term, what we call endothelial damage or damage to blood vessel linings, that causes heart diseases, and organ issues such as kidney disease as well, that can go along with diabetes, high blood pressure, high cholesterol — all of those things that are part of that metabolic syndrome.

The pro-inflammatory environment in there is something that, like I said, food is one more tool that we have to counteract some of these challenges to our bodies.

John Horton:

It seems like it is very much a day-in and day-out thing. We all like that instant relief, it's an instant solution. But when you're talking about inflammation, it is what you're eating day, after day, after day that sets your body up for how it's responding.

Julia Zumpano:

Absolutely, absolutely. You have a cookie here and there randomly, not going to be a big deal.

John Horton:

Yeah, you have one little spike and it comes back down.

Julia Zumpano:

Right. If you're eating a whole foods, well-balanced diet, that's where we can have that treat and be OK. Our body will adjust and respond. But if we are consuming it day after day, day in and day out, and it's leading to that metabolic distress, that insulin resistance — as Dr. Goebel said perfectly, what it does to the inside of our arteries and the lining of our blood vessels, and the reaction that we can have from a cardiovascular standpoint and our other organs is where we see that significant inflammation when you're eating these ultra-processed, highly processed, high sugary foods, fast foods, convenient foods on a day-to-day basis.

Something else to note, too, I think we tend to demonize things like sweets or snack foods. There's a lot of sweets and snack foods that can be considered more healthy than others. You can still incorporate those a little bit more regularly, as long as you're choosing more on the healthier side. Something like a homemade oatmeal raisin cookie with all homemade ingredients, no synthetic ingredients. Maybe you reduce the sugar and use some apple sauce or a banana. Maybe you roast some potatoes or cut them really thin and you make your own chips, or kale chips, or whatever you can do to incorporate that snacky food that you might want. There are ways that we can incorporate the flavor the desire of the texture of the food we're looking for and still make it healthy.

John Horton:

When we're looking at them, setting up our eating plan, everybody likes diets because it gives you a little bit of a game plan, are there certain diets that stand out as being ideal for someone with PCOS?

Julia Zumpano:

I think just a blood sugar management diet would be the most ideal. Just really, the key point here is a good balance of macronutrients each time you eat. Adequate fiber, protein and healthy fat.

Now, when you look at inflammation and we're talking about that a lot, we know the Mediterranean diet is a naturally anti-inflammatory diet. It's high fiber.

John Horton:

It's the answer for everything it seems like.

Julia Zumpano:

Yeah.

Dr. Kathryn Goebel:

The nice thing about the Mediterranean diet is we know it's so anti-inflammatory with the fishes, with the olive oils, with all the healthy fats. But it's also a deeply satisfying diet. It doesn't feel like a diet that you're cheating yourself out of eating good stuff. There are lots of great, beautiful, delicious meals that are part of a Mediterranean diet.

The other thing that we can talk about here a little bit is intermittent fasting because that's something that gets a lot of attention when we're looking at glycemic index diets, PCOS, insulin resistance. I think intermittent fasting can be helpful, but I think it needs to be considered carefully. Because when you think about really what intermittent fasting is meant to be, it's meant that you are to consume a day's worth of a healthy, beautiful, well-balanced diet within a restricted number of hours. The reason for that is to affect your insulin level.

Insulin is essentially a storage hormone. It says, "Take my blood sugar and store it in my cells for later." If you have your insulin going all day long because you're snacking all day long, you're sipping on your iced coffee that has sugar on it all morning long, your insulin is running all that time, so you're constantly in storage mode. The goal, then, is to minimize the number of hours that those insulin levels are high.

We've talked about a little bit, women with PCOS are a little bit more prone to disordered eating and to binge-eating. Intermittent fasting can be, for some people, a slippery slope to a very disordered eating. It's not designed to be a cycle of starvation and binge-eating. You really need to think about it as, this is what you eat in a day, which is a normal, healthy amount of food, a well-balanced diet, just considering the hours in which you eat it.

John Horton:

Yeah. Is there a target that's ideal then to look for if you're going to intermittent fast, to limit it to a certain timeframe and not go too far?

Dr. Kathryn Goebel:

Yeah, there's a lot of different opinion on this, and you can speak to this as well. A lot of people will say, "OK, what is actually manageable for me?" For a lot of people, the eight-hour window is very manageable. If you're somebody who does not wake up hungry and is fine with just your black coffee or tea in the morning, then if you eat from noon to 8 pm, that's very reasonable. You can still be social and eat with your family, and all of those things. If you're someone who really needs to eat when you wake up, maybe that needs to be shifted earlier. I don't know that there's a magic number for every person, every disease process. But really, I think it requires, especially for those of us that have a family that we want to eat with, it requires a lot of forethought so that you're not feeling that deprivation. Because what happens when someone is on a diet where they feel deprived? They don't stick with it.

John Horton:

Yeah.

Julia Zumpano:

I agree. I even start people at a 12-hour window. Let's just start with 12 hours. Let's just make sure we're cutting off at 8 and we're eating at 8. Or we're cutting off at 7 and eating at 7. Depending on the person's lifestyle, when they wake up, when they sleep, et cetera. Then, I build from there. I may go from 12 hours, to then 10 hours, and then eight hours in your eating window. Some people just hang out at 12 or 10, but they're still maybe making huge improvements if they're eating a good amount of calories after 8 pm.

I think it's important to note that studies have shown that even a 12-hour window has shown nutritional benefit and blood sugar management benefits. Of course, as you fast a little longer, you're going to get a little bit more benefit from eating in a 10-hour window or eight-hour window, but we want to start where it's reasonable. Usually, start with a 12- to 10-hour eating window, and then advance to an eight if that's something you're willing to do.

I also think it's important to note when you wake up and when you go to sleep, I do try to pair that window. If you're always getting up at 5 and you're waiting until noon to eat, I think that's way too long.

John Horton:

Yeah.

Julia Zumpano:

I think it's really important to try to ... I like to shave off four hours on either end. If you're going to do four hours after you wake up and stop eating four hours before you go to bed, assuming you're going to sleep eight hours, which would be ideal. That's usually my methodology of thought.

That's what I love about time-restricted eating is that it's very, very flexible. Also, a trick that I do is I always give people one non-fasting day a week because then they just don't have to worry about it. Or even two, two non-fasting days a week. They just don't have to worry about it and they can maybe enjoy their weekend, or whatever, without having to worry about the timing that they're eating.

Dr. Kathryn Goebel:

Right.

John Horton:

Dr. Goebel, you mentioned that slippery slope because we've talked about how, with PCOS, it can maybe open the door to disordered eating. If you are going to play around with intermittent fasting and try that, how do you know whether or not you've hit that slope and you're starting to slide a little bit? Are there some signs that you advise your patients to look for just to make sure they're still on solid ground with their diet and nutrition?

Dr. Kathryn Goebel:

For sure. I think really what is super helpful, even more so for when you're planning this timed eating, is planning ahead of time, really. Saying, "OK, this is my schedule for the week. This day, this 10-hour window might work better. I might have to shift it the next day because of an exercise routine or when my kids need to eat because of sports." Like we said, on the weekend, maybe things need to be a little bit more lax because of things that are going on.

I think where you start running into trouble is when you get into the mindset of, "I can eat whatever I want, as long as I stop by this time."

John Horton:

Yeah.

Dr. Kathryn Goebel:

That is where we see people really running into that scarcity mentality of, "I need to eat all the food before 7 pm, so I'm just going to gorge myself."

I'm going to get into flirting with those binge-eating behaviors. I really think it needs be … look at what is a day's worth of a healthy diet for you? What hours are you going to choose to eat it within? But it is not a free-for-all during those restricted hours.

Julia Zumpano:

Right. That's why sometimes, when you have that 12-hour window, too, you can space your meals a little bit more spread out. Consume three meals, and then really better manage your blood sugars and not feel restricted. I think it's that restriction piece that people don't like.

Dr. Kathryn Goebel:

Right.

Julia Zumpano:

Whether they're restricted in timing or food, and then it creates this, "Oh, I'm never going to be able to have this until just now, so I have to consume as much as I can as possible." It's just that restrictive mind.

John Horton:

The forbidden fruit theory. Whatever you can't have is all of a sudden even better.

Julia Zumpano:

Exactly, exactly. All of a sudden, I can't eat a minute past 7, so I have to consume everything before then. Well, if you're tight on time, I usually tell people, "Why don't you just push it until 8 this day?"

Dr. Kathryn Goebel:

Right.

John Horton:

Yeah.

Julia Zumpano:

Instead of just feeling like you have to shove everything in, let's just add an hour and be OK with it.

John Horton:

Be flexible and live your life-

Julia Zumpano:

…yes.

John Horton:

...and make sure you fit it in there. Don't overly worry if you're a half-hour over or something happens one day.

Julia Zumpano:

Flexibility is key. It's so important when it comes to sustaining healthy eating habits. You have to be flexible. Then, that leads to better metabolic flexibility. We want our body to be able to respond in a good way to that flexibility, not negatively affecting us.

Dr. Kathryn Goebel:

Those really restrictive thoughts about eating, again, that is what we see in disordered eating. We see that if you're thinking about food all the time, and you're having that, "OK, I have to eat all this food quickly in a small amount of time." Is there shame associated with that? Like I said, there's a lot of those patterns. That's why, like I said, that intermittent fasting or timed eating can be a great tool for some people. Certain personality types, you have to be aware of monitoring, what is your thinking around your food? Are you starting to have those really compulsive thoughts about food, and what you need to eat, when you need to eat it? Is that becoming a challenge for you? In which case, that might not be the best approach for you.

John Horton:

Yeah. This seems like a good time, too, to bring up the whole concept of all the restrictive diets that you see, those fad diets that Dr. Google seems to throw out there a lot. Those are not ideal for people to seek out as a solution to issues with PCOS, right?

Julia Zumpano:

No, it's more restrictive. It's the same concept we're following. More restriction leads to a little bit more of that emotional eating piece.

John Horton:

Yeah.

Julia Zumpano:

Restrictive eating, it's just an emotional and physical rollercoaster. I think just having a well-balanced diet, a whole foods-based diet, managing your blood sugars throughout the day, finding an eating plan, meaning which foods you enjoy, and will and can consume on a regular basis, is ideal. If that follows more of a high protein profile, or a higher fiber profile, it can sway. But still, whole foods, still managing blood sugars through the balance of your macronutrients, and not anything overly restricted. No fads, nothing where you're feeling like, "OK, I can follow this for a month, but after a month I'm done." If you have that mentality, it's not the right plan.

John Horton:

People will lean on those fad diets as a quick weight loss thing or something like that, but it seems like they lead to trouble eventually.

Dr. Kathryn Goebel:

What's going to happen is when you have these very restrictive diets, yeah, you might lose some weight fairly quickly, but these are not things that you can maintain.

John Horton:

Yeah.

Dr. Kathryn Goebel:

Because you're depriving yourself, you're not getting enough calories in some of these diets. Or you're just not getting the nutrients that you need. Like Julia said, we really want to focus on a well-balanced, colorful diet. Plenty of fruits and vegetables, protein sources, healthy fats. Which is really, again, a very satisfying diet. It's just about making those good choices.

If you're on a very restrictive diet, you're unlikely to maintain it. We know from lots and lots of years of study of people doing this yo-yo dieting, they often, once they stop, will then end up heavier than they were before. Which not only is problematic from the metabolic part from PCOS, if they have that increased weight gain, but also from a self-esteem standpoint. If someone is struggling with all of these feelings that they're powerless over their diet, if they're failing at these fad diets, it really is just not good for your overall wellness.

Julia Zumpano:

I completely agree.

John Horton:

Yeah. I'm glad you brought that up because from everything we've talked about today, PCOS being an emotional rollercoaster is very much out there. It seems like it affects people on so many levels.

Dr. Goebel, in your experience, if someone does start adjusting their diet and makes some of these healthier changes, do they start seeing a lot of these symptoms fade and they're better able to manage the condition?

Dr. Kathryn Goebel:

Yeah, there's two ways to think about this. There's, OK, can we actually get your metabolic syndrome to reverse? Can we get enough of an anti-inflammatory effect? Can we get weight loss? Can we get the insulin levels down? Which is then going to help with our testosterone levels as well.

But there's also, like we were talking about, there's the emotional part of it. Can we work on ... if you're able to maintain a healthy diet, if you are taking care of your body and moving it in a way that feels good to you, getting some cardiovascular exercise, doing weight training, sleeping well. Minimizing the caffeine, staying hydrated. All of the things that just make us feel good in our bodies, is that going to be able to help with your self-esteem component?

Then, that feeds right back into if you're feeling good about yourself, you're less likely to be emotional eating. I think for those for whom emotional eating or binge-eating is really a problematic part of their diet, I think doing the work with a registered dietitian, a life coach, a psychiatrist or a therapist. I think really getting to the root of for somebody who is eating not for hunger reasons — what other ways can you buffer those feelings? How can you work through that?

But I really feel like doing all these lifestyle changes that will just make you feel good in your body are going to not only help you from a metabolic and from a hormonal standpoint, but really just then help you to optimize what you have control over this condition.

Julia Zumpano:

I can't agree more. I think it's super important to understand your other lifestyle factors. Exercise makes you feel good. It increases endorphins. It helps relieve emotions. It's really important to whatever physical way you can move your body that makes you feel good, that's going to be key here. Getting enough sleep. Studies have shown when you don't sleep enough, we tend to eat poorly because we're searching for energy. We're searching for that energy boost. We're so tired, we're not making good choices because we don't care at that point. I think that it's really important to look at all three facets. Your sleep, your exercise and your nutrition, and then those can also help you manage emotion and stress.

John Horton:

Yeah. Dr. Goebel, you had mentioned earlier, too, PCOS and how it can affect family planning for people. How much of a role, then, does the dietary part come in that? When people are at that stage of their life and they're looking to get their condition under control?

Dr. Kathryn Goebel:

Sure. When you're looking at PCOS from a fertility standpoint, really the big problem is if you're not ovulating. If you're not releasing an egg because of this hormonal imbalance, that can really cause some fertility struggles for women.

Now, there are certainly hormonal treatments available to help with ovulation. But we also know, as I mentioned earlier, that weight loss in and of itself can help to restore ovulation and regulate those periods and help with fertility. There are some studies that suggest inositol, which is a supplement, can also be helpful to help regulate cycles as well. Magnesium, vitamin D, super important for insulin regulation as well. But also, the anti-inflammatory component. When you look at women who have a pro-inflammatory environment in their body, that's not good for fertility, for fertilization of embryos, implantation of embryos.

It's all really important. That's why you'll see a lot, in the fertility literature, particularly on social media, a lot of attention being paid to what are you putting in your body? What chemicals are you putting in your body? What artificial things are you putting in your body? Can you eat a cleaner diet when you're trying to conceive? Can you stop smoking? Can you stay hydrated? Can you make sure that you're getting all of these anti-inflammatory foods in? Again, that all plays back into the PCOS. Again, whether or not women end up needing hormonal help to get through, overcome that fertility struggle with the ovulation, certainly those diet and lifestyle changes can make a difference.

John Horton:

This has been such an informative discussion. It really illustrates how complex PCOS, and, like I say, how many layers that there are. If there's one thing, though, that you want people to take away from this chat as they map out their journey with PCOS, what would it be? Dr. Goebel, why don't you lead it off here?

Dr. Kathryn Goebel:

Sure. I like to think of PCOS management, looking at, to me, the three different facets of it. Regulation of menstrual cycles, whether that's for fertility or just for regulation of abnormal bleeding. Looking at the cosmetic effects. How is your skin? How is the abnormal hair growth? How is that affecting your self-worth and your body image? Then the long-term effects, your cardiovascular health, your risk for Type 2 diabetes. I really think that treatment goals for somebody who walks into my office and who's 18 is going to be very different than somebody who's 30 and trying to conceive. Very different from somebody who's in their late 40s and thinking about, "I've got a strong family history of Type 2 diabetes, I have PCOS. How can I optimize these things?"

While there may be medication options, there may be hormonal options that will apply to each of those situations, diet changes, lifestyle changes can be so important for a woman at every stage of management of PCOS, despite what her immediate treatment goals are.

Julia Zumpano:

On my end, I think it can be overwhelming to change your diet. There's so much information. Depending on where you're starting, a Mediterranean diet could be very daunting for you. I think it's important to take it in small steps. I usually recommend starting with one change at a time. It might just be that you're switching out your soda with a tea, an unsweetened black or herbal tea. Maybe it's that you're switching out your baked good in the morning at breakfast with some eggs or oatmeal. Maybe it's just choosing one change and then building upon that change to make it more manageable and more reasonable. We all know ourselves better than anyone else. Look inside, look at what you think will make the biggest impact and biggest improvement, but start one step at a time.

John Horton:

With everything both of you have said, I think anyone with PCOS should be leaving this feeling a little optimistic that there are things they can do to take control and help them move past the condition. And really, just live the way they want to live. Thank you very much for really laying that out for us and showing a path forward.

Julia Zumpano:

Thank you, Dr. Goebel, for joining us today. Really appreciate your expertise.

Dr. Kathryn Goebel:

It was my pleasure. Yeah, I think it's such an interesting and important topic. Again, so much that people can do on their own at home to really just feel better with this condition.

John Horton:

Dietary changes often can help steady the hormonal imbalances that come with PCOS. Focus on eating whole foods with high nutritional value to ease and manage PCOS symptoms and lower your risk of related health issues.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.