OBGYN Palladino Presentation - PCOS Nutrition Interventions
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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.
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OBGYN Palladino Presentation - PCOS Nutrition Interventions
- 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
- 3. PathophysiologyofPCOS 3 Alex Rotstein, Raginin Srinivasan, Erin Wong McMaster Pathophysiology Review (MPR), 2013
- 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
- 10. Survey Demographics 10 0 10 20 30 40 50 60 70 66% 45% 8% 4% Setting for Care 71% 23% 6% Population Setting Urban Suburban Rural N=205 N=141
- 11. Multidisciplinary Specialties Involved 59% 41% Multidisciplinary Status Yes No 11 Specialty # Involved % Involved Dietitian/Nutritionist 94 71% Physician 89 67% Nurse 63 48% Fertility Specialist 46 35% Mid-Level Providers 37 28% Social Worker 37 28% Psychologist 34 26% N=132
- 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%)
- 15. Ideal Involvement of Providers Specialty N Highly Involved Involved Neutral Occasionally Involved Never Involved Dietitian 110 59% 30% 6% 3% 2% Endocrinologist 109 48% 36% 6% 7% 3% Gynecologist 110 45% 43% 5% 5% 2% Fertility Specialist 97 30% 33% 14% 13% 9% Exercise Physiologist 95 18% 40% 18% 9% 15% Health Psychologist 105 11% 45% 21% 15% 8% 15
- 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
- 19. Challenges for Dietitians Insurance Lack of knowledge on PCOS Lack of physician referrals Patient follow-through 19
- 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
- 23. Acknowledgments 23 Dr. Melissa Olfert Dr. Melanie Clemmer Dr. Pamela J. Murray Dr. Rajesh Naz Dr. Michael Vernon Olfert Research Lab
- 24. Questions 24
Notas del editor
- 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/
- http://www.pathophys.org/pcos/Alex Rotstein, RagininSrinivasan, Erin WongMcMaster Pathophysiology Review (MPR), 2013
- 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
- Improved menstrual function/ovulation
- Mention: Survey = Objective 1 + 2 Focus Groups = Objective 3
- 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