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Lifestyle management improves quality of life and depression in overweight and obese women with polycystic ovary syndrome
Lifestyle management improves quality of life and depression in overweight and obese women with polycystic ovary syndrome Rebecca L. Thomson, Ph.D.,a,b Jonathan D. Buckley, Ph.D.,a Siew S. Lim, MND.,b Manny Noakes, Ph.D.,b Peter M. Clifton, Ph.D.,b Robert J. Norman, Ph.D.,c and Grant D. Brinkworth, Ph.D.b a
Australian Technology Network Centre for Metabolic Fitness & Nutritional Physiology Research Centre, Sansom Institute for Health Research, University of South Australia; b Preventative Health Flagship, Commonwealth Scientific and Industrial Research Organisation, Food and Nutrition Sciences; and c Research Centre for Reproductive Health, Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia
Objective: To assess the impact of adding exercise to dietary restriction on depressive symptoms and health-related quality of life (HRQOL) in women with polycystic ovary syndrome (PCOS). Design: Analysis of depression and quality of life outcomes from a randomized, controlled prospective clinical intervention that evaluated the effects on a range of health outcomes in women with PCOS. Setting: Clinical research unit. Patient(s): One hundred four overweight/obese PCOS women (aged 29.3 0.7 years; body mass index [BMI] 36.1 0.5 kg/m2). Intervention(s): Randomized to one of three 20-week lifestyle programs: diet only, diet and aerobic exercise, or diet and combined aerobic-resistance exercise. Main Outcome Measure(s): Depression and PCOS-specific HRQOL. Result(s): Forty-nine women completed the intervention (diet only ¼ 14, diet and aerobic exercise ¼ 15, diet and combined aerobic-resistance exercise ¼ 20). By week 20 all groups achieved weight loss and had improvements in depression and PCOS-specific HRQOL scores, except for body hair domain score. There was no difference between treatments for all outcomes. Conclusion(s): This study demonstrated that dietary restriction alone and combined with exercise had similar benefits for improving depression and HRQOL scores in overweight and obese women with PCOS. (Fertil Steril 2010;94:1812–6. 2010 by American Society for Reproductive Medicine.) Key Words: Weight loss, exercise, diet, depression, quality of life
Health-related quality of life (HRQOL) is a multidimensional concept encompassing physical, psychological, and social aspects of health, and its assessment allows the effects of a disease or treatment to be quantified (1, 2). Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, presenting in 7% of this population (3). The symptoms typically associated with PCOS include menstrual dysfunction, infertility, changes in physical appearance (excessive hair growth, obesity, and acne), and possible increased risk of diabetes and cardiovascular disease, all of which can also have adverse effects on HRQOL (4–8). Previous studies have shown that these clinical features promote psychological morbidity reflected by loss of self-esteem, emotional stress, and poor body image, which lead to an increased likelihood of Received May 15, 2009; revised October 20, 2009; accepted November 2, 2009; published online December 11, 2009. R.L.T. has nothing to disclose. J.D.B. has nothing to disclose. S.S.L. has nothing to disclose. M.N. has nothing to disclose. P.M.C. has nothing to disclose. R.J.N. has nothing to disclose. G.D.B. has nothing to disclose. Supported by the National Health and Medical Research Council of Australia, grant number: 401817, Canberra, Australia National Territory, Australia. Rebecca L. Thomson was funded by a postgraduate scholarship from the South Australia Department of Health. Reprint requests: Grant D. Brinkworth, Ph.D., CSIRO Food and Nutrition Sciences, PO Box 10041 BC, Adelaide, South Australia 5000, Australia (FAX: 61-8-8303-8899; E-mail: [email protected]).
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experiencing depressive symptoms (9–15) and reduced HRQOL (8, 13–16). Weight loss and lifestyle management have been shown to improve mood states and reduce depressive symptoms in overweight and obese women without PCOS (17–19). However, there is limited evidence evaluating the effects of PCOS treatments on psychological well-being and whether these can be improved after weight loss. Two studies by Clark et al. (20, 21) investigated the effect of 6-month lifestyle modification aimed at improving diet and increasing exercise in obese infertile women, some of whom had PCOS, and reported improved self-esteem and reduced depression and anxiety scores after a 6–10 kg weight loss. Two pilot studies have also investigated the effects of dietary restriction on psychological outcomes in obese women with PCOS (22, 23), with one observing a trend for improvements in HRQOL after 24 weeks on a low-carbohydrate ketogenic diet (23). Another study reported that a 16-week high-protein diet significantly improved depression and self-esteem, whereas despite similar weight loss (7–8 kg), the high-carbohydrate diet did not (22). This provided evidence that although weight loss is important, dietary composition may also be an influencing factor. These studies suggest a potential for weight loss to improve psychological outcomes, but further studies are needed in this area. There is also evidence that exercise independently provides a number of psychological benefits, including improvements in mood, self-image, body satisfaction, overall quality of life and psychological well-being, and reduced symptoms of depression and
Fertility and Sterility Vol. 94, No. 5, October 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/$36.00 doi:10.1016/j.fertnstert.2009.11.001
anxiety (24–28). To date no study has evaluated the effects of exercise training on depression and HRQOL outcomes in overweight and obese women with PCOS, despite the increasing prevalence of this condition in the community. The aim of this study was to assess the impact of adding exercise to an energy-restricted weight loss program on depressive symptoms and HRQOL in overweight and obese women with PCOS.
MATERIALS AND METHODS Participants One hundred four sedentary overweight and obese women with PCOS were recruited by public advertisement and from general practitioner and specialists clinics. Polycystic ovary syndrome was diagnosed according to the Rotterdam criteria (29), by the presence of two of the following three criteria: [1] biochemical (elevated testosterone (T) [ > 2.0 nmol/L] and free androgen index [>5.4]) or clinical (hirsutism assessed by Ferriman-Gallwey score >8) hyperandrogenism; [2] menstrual irregularity (oligo/anovulation [cycle length <21 days or >35 days]); and [3] presence of polycystic ovaries (PCO) by transvaginal or transabdominal ultrasound examination (30). Potential participants were excluded if they were using fertility treatments or oral contraceptives, were smokers, pregnant, breastfeeding, or had a history of cardiovascular, liver, kidney, or respiratory disease, diabetes, uncontrolled hypertension (>140/90 mm Hg), or cancer. Subjects were also excluded if they had any reproductive disorders unrelated to PCOS, thyroid abnormalities (hypothyroidism and hyperthyroidism), or nonclassic adrenal hyperplasia. All experimental procedures were approved by Human Ethics Committees of the Commonwealth Scientific and Industrial Research Organisation and the University of South Australia and participants provided written informed consent.
Study Design The data analyzed for this study were obtained from a subset of women who completed psychological-based outcomes from a large randomized controlled trial that concurrently evaluated the effects of a hypocaloric diet with and without exercise training on metabolic and reproductive outcomes (31). Women were randomized to one of three 20-week lifestyle interventions: diet only (DO, consisting of a 6,000 kJ/day energy restricted highprotein meal plan), diet and aerobic exercise (DA, consisting of 5 walking/ jogging sessions per week), or diet and combined aerobic-resistance exercise (DC, consisting of 3 walking/jogging and 2 strength training sessions per week). At baseline (week 0), the midpoint (week 10), and end of the intervention (week 20) participants attended the clinic after an overnight fast during which height (baseline only) and body weight were measured using a stadiometer (SECA, Hamburg, Germany) and electronic digital scales (Mercury, AMZ 14, Tokyo, Japan), respectively. Participants completed a validated PCOS questionnaire (PCOSQ) and the Center for Epidemiologic Studies Depression Scale (CES-D) to assess HRQOL and depression, respectively. Participants were required to fill out exercise and diet logs and exercise sessions were monitored during the study.
Depression and HRQOL Questionnaires Depression was assessed using the CES-D (32), which is a self-reported scale that measures the presence and severity of depressive symptoms occurring in the past week. The scale consists of 20 items with a 4-point rating scale ranging from 0 (rarely, less than 1 day) to 3 (most of the time, 5–7 days). The items include questions about depressed mood, feelings of guilt, worthlessness, helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance. Total scores above 16 are considered high and indicative of the presence of mild depression (33). The HRQOL was measured using a validated self-administered PCOSQ (34–36). The PCOSQ includes 26 questions (items) from 5 HRQOL areas or domains: emotions (7 items), hair growth (5 items), body weight (5 items), infertility problems (5 items), and menstrual problems (4 items). Each item has a seven-point scale (a score of 7 denotes no problem or difficulty and 1
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indicates maximum HRQOL impairment). The mean score of all items within a domain provides a domain score, with lower scores indicating a greater negative impact.
Data Analysis Statistical analysis was performed using SPSS for Windows 17.0 (SPSS, Chicago, IL). Values are reported as mean SE. An a-level of significance was set at P%.05. Data were checked for normality before analysis and non-normally distributed data were transformed by taking the square root (CES-D) or by rank transformation (PCOSQ). Baseline differences between groups were determined by one-way analysis of variance (ANOVA). The effect of the intervention on weight, CES-D, and PCOSQ scores was determined by repeated measures ANOVAwith time as the within-subject factor and treatment group as the between-subjects factor. When there was a significant main effect, post-hoc analysis using Bonferroni corrections for multiple comparisons were performed where appropriate to determine differences between group means across time. Clinically relevant changes in HRQOL measures were defined as a medium effect size (P>.5), which has previously been suggested as an appropriate method (37). A reduction of R5 units is considered a clinically significant improvement for CES-D scores as it qualifies as a middle to large effect size (37, 38) and has been used in other studies (39, 40). Correlation analysis using Pearson’s correlation coefficient and Spearman’s rank order correlation were used to determine relationships between variables with Bonferroni adjustments for multiple comparisons (P¼.008).
RESULTS Participants Of the 104 women who were recruited for the study, 10 withdrew before commencement, therefore 94 women started the study (DO, n ¼ 30; DA, n ¼ 31; DC, n ¼ 33; aged 29.3 0.7 years; body mass index [BMI] 36.1 0.5 kg/m2). Fifty-two completed the study, with 49 women completing all psychological-based outcomes that were included in the current investigation (DO, n ¼ 14; DA, n ¼ 15, DC, n ¼ 20). The average compliance for exercise was 79%. There were no differences in baseline weight, CES-D, and PCOSQ scores between treatment groups (Table 1) or between women who completed the study and women who dropped out in any of the measures (P>.08). There was a significant reduction in body weight (DO, 8.9 1.6 kg; DA, 11.0 1.7 kg; DC, -8.7 1.3 kg; P%.001), with no difference between the groups (P¼.5).
Depression Scale There was no relationship between baseline CES-D scores and weight. During the intervention there was a significant time effect for CES-D scores (P<.001), such that scores significantly decreased by week 10, but with no further change by week 20 (Table 1). There was no differential effect of treatment (P>.86). Despite no significant reduction in CES-D scores by week 20, there was a significant correlation between the change in CES-D score and weight loss from week 0–20 (r ¼ 0.31, P¼.03), with greater weight loss associated with greater reductions in CES-D score.
HRQOL Questionnaire At baseline the emotion score correlated with glucose (r ¼ 0.40, P¼.005) and the body hair score correlated with T (r ¼ 0.40, P¼.004), indicating that higher glucose and T were related to worse domain scores (data not shown). All groups experienced significant improvements in PCOSQ domain scores by week 20 (P%.001), except for body hair score (P¼.10), with no difference between treatments (PR.10). The improvements in emotion, body weight, and menstrual problems domain were clinically significant. The changes in the emotion and body weight score were related to the
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TABLE 1 Depression scores from the center of epidemiologic studies depression scale (CES-D) and polycystic ovary syndrome questionnaire (PCOSQ) for women with polycystic ovary syndrome at baseline and after 10 and 20 weeks of diet only (DO), diet and aerobic exercise (DA), or diet and combined aerobic-resistance exercise (DC).
CES-D DO DA DC PCOSQ Emotion score DO DA DC Body hair score DO DA DC Weight score DO DA DC Infertility problems score DO DA DC Menstrual problems score DO DA DC
Week 0
Week 10
Week 20
Time
Time 3 treatment
18.2 2.5 18.6 2.2 13.4 1.7
13.0 2.7a 10.6 1.8a 9.3 1.5a
16.6 3.3 14.0 2.4 12.8 1.8
< .001
.86
4.1 0.4 4.3 0.2 4.8 0.2
4.6 0.3a 5.2 0.2a 5.2 0.2a
4.7 0.4a 4.9 0.3a 5.3 0.2a
< .001
.33
3.1 0.4 3.1 0.3 3.3 0.3
3.4 0.4 3.2 0.3 3.3 0.3
3.3 0.3 3.4 0.3 3.5 0.3
.10
.69
1.9 0.2 1.9 0.2 2.2 0.2
2.5 0.3a 3.4 0.3a 3.2 0.2a
2.9 0.3a 3.3 0.3a 3.5 0.3a
< .001
.10
4.4 0.5 4.5 0.4 4.5 0.3
4.7 0.6a 5.4 0.4a 5.1 0.3a
4.8 0.5a 5.3 0.4a 5.2 0.3a
< .001
.54
3.5 0.3 3.8 0.3 3.7 0.3
3.7 0.4a 4.4 0.3a 4.4 0.2a
4.1 0.4a 4.4 0.3a 4.6 0.3a
.001
.15
Note: Values are mean SE; n ¼ 49. a Significantly different from week 0 (P%.001) as determined by repeated measures ANOVA and pairwise comparisons with Bonferroni corrections. Thomson. Quality of life and depression in PCOS. Fertil Steril 2010.
change in weight (r ¼ 0.35 and r ¼ 0.43, respectively; P%.01). There was an inverse relationship between the change in menstrual problems score and improvements in average cycle length (r ¼ 0.41, P¼.01) (data not shown).
DISCUSSION This study demonstrated that a moderate energy-restricted diet in overweight and obese women with PCOS improved depression and HRQOL scores; however, exercise provided no additional benefit to that seen with diet alone. Previous research suggests that exercise independently improves psychological outcomes (24–28). We have previously shown that the addition of exercise did not result in any additional improvements in PCOS-related symptoms, which could potentially explain why no differences were seen (31). In addition, previous studies, which have shown psychological benefits of exercise, used other psychological instruments, largely focusing on anxiety and mood, whereas the PCOSQ has a broader focus and emphasis on symptomatology of PCOS. In addition, despite the absence of any statistically significant differences between treatment groups at baseline, the DC group appeared to have less psychological disturbances that could have potentially lessened any differential changes between the groups. However, after adjusting for these differences, there was still no additional effect of exercise on the outcomes assessed. For CES-D, there was a significant improvement at week 10, which was considered clinically significant, but no further changes
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were detected by week 20, despite having statistical power of 0.7 to detect a change in depression scores from week 10–20 (P<.05). It is unclear why participants did not continue to reduce depressive symptoms as they continued to lose weight and improve other PCOS symptoms during the later half of the intervention; however, this observation agrees with the findings of other studies in obese women, which found that diet-induced weight loss results in an improvement in psychological outcomes in the short-term, but was not maintained over the long term (41, 42). There are a few possible explanations for the lack of continued reduction in depression scores. The enthusiasm and motivation resulting from active participation in a supervised weight loss program during the early phases of the study may have been difficult to sustain over the long term (43, 44). Although participants in the present study successfully achieved dietary and lifestyle changes, as demonstrated by continued weight loss throughout the intervention, the emotional response to these modifications may have lessened over time, reducing any impact on depressive symptoms. Due to work and family commitments young women have a high perceived time pressure, which can be a fundamental barrier to healthy eating and physical activity participation (45–47) and may result in the development of a perception that the recommended behavioral changes to achieve optimum lifestyle habits are not feasible (48). In the general overweight population weight loss improves HRQOL (18, 19, 49, 50). However, to date only two other studies have assessed HRQOL in response to a treatment intervention in
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women with PCOS. The first observed improved psychological health after 6 months of laser treatment that improved facial hirsutism severity, along with alleviated depression and anxiety symptoms in women with PCOS (51). However, in the present study, we observed no change in the body hair domain score of the PCOSQ, which was not unexpected as at least 20 weeks are required before any reductions in hirsutism after weight loss are observed (52– 54). Hahn et al. (55) also showed marked improvements in HRQOL and emotional distress associated with weight loss after metformin treatment. At the commencement of the study participants demonstrated moderate to severe impairments in HRQOL as assessed by PCOSQ. The most severely affected HRQOL domain was that related to perceptions of weight, which agrees with the findings of previous studies (7–9, 35, 56). In addition, on average CES-D scores were relatively high (>16), indicating the presence of mild depression (33). To date there have been inconsistent results when identifying specific features of PCOS that may contribute to impaired psychological health. A biochemical explanation is plausible, although the relationship between T levels and depression in PCOS remains controversial, with inconsistent results reported (7, 11, 15) and no association observed in the current study. Psychosocial variables are also likely to influence the relationship, in particular the presence of appearance-related aspects of PCOS, such as excessive hair growth, obesity, and acne, as these physical characteristics are known to negatively affect a woman’s feeling of attractiveness (57) and body satisfaction (7, 11). Obesity has also been suggested as the primary mediatory of reduced HRQOL in PCOS (7, 12, 55, 58) and many women with PCOS have reported frustration with the inability to lose weight, leading to poor body image and low
self-esteem (34). These findings are not surprising given that obesity itself profoundly affects HRQOL independently of the presence of other clinical symptoms in otherwise healthy populations (59). This study was limited by the high drop-out rate, and the lack of a nondieting control group limits the ability to determine the specific effects of dieting and lifestyle management. The women who completed the study may have represented a group of highly motivated individual volunteers who achieved substantial weight loss and this could have potentially biased the observed effects and might limit the generalizability of the findings. However, this study did provide an opportunity to examine the impact of lifestyle management on these outcomes in women with PCOS and will provide direction for further investigations. This is an area of importance where there is currently a lack of data describing these effects and additional research is needed. To our knowledge this is the first study to evaluate the effect of exercise when added to a weight loss program on HRQOL and depressive symptoms in overweight and obese women with PCOS. Exercise was shown to provide no additional improvement in depression or HRQOL to that seen with diet alone. Further studies are required to determine whether the observed effects are attributable to the achievement of weight loss or to involvement in an intensive, clinically supported lifestyle modification program. Acknowledgments: The authors gratefully acknowledge Julia Weaver for assisting with trial management; Lindy Lawson and Rosemary McArthur for their assistance in the nursing activities; Gemma Williams, Xenia Cleanthous, and Julianne McKeough for their dietetic guidance; Mark Mano, Cathryn Seccafien, and Candita Sullivan for laboratory assistance; and Kylie Lange for statistical advice.
REFERENCES 1. Colwell HH, Mathias SD, Pasta DJ, Henning JM, Steege JF. A health-related quality-of-life instrument for symptomatic patients with endometriosis: a validation study. Am J Obstet Gynecol 1998;179:47–55. 2. Naughton MJ, McBee WL. Health-related quality of life after hysterectomy. Clin Obstet Gynecol 1997;40: 947–57. 3. Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet 2007;370:685–97. 4. Sonino N, Fava GA, Mani E, Belluardo P, Boscaro M. Quality of life of hirsute women. Postgrad Med J 1993;69:186–9. 5. Paulson JD, Haarmann BS, Salerno RL, Asmar P. An investigation of the relationship between emotional maladjustment and infertility. Fertil Steril 1988;49: 258–62. 6. Downey J, Yingling S, McKinney M, Husami N, Jewelewicz R, Maidman J. Mood disorders, psychiatric symptoms, and distress in women presenting for infertility evaluation. Fertil Steril 1989;52: 425–32. 7. McCook JG, Reame NE, Thatcher SS. Health-related quality of life issues in women with polycystic ovary syndrome. J Obstet Gynecol Neonatal Nurs 2005;34: 12–20. 8. Ching HL, Burke V, Stuckey BG. Quality of life and psychological morbidity in women with polycystic ovary syndrome: body mass index, age and the provision of patient information are significant modifiers. Clin Endocrinol (Oxf) 2007;66:373–9. 9. Barnard L, Ferriday D, Guenther N, Strauss B, Balen AH, Dye L. Quality of life and psychological well being in polycystic ovary syndrome. Hum Rep 2007;22:2279–86.
Fertility and Sterility
10. Hollinrake E, Abreu A, Maifeld M, Van Voorhis BJ, Dokras A. Increased risk of depressive disorders in women with polycystic ovary syndrome. Fertil Steril 2007;87:1369–76. 11. Weiner CL, Primeau M, Ehrmann DA. Androgens and mood dysfunction in women: Comparison of women with polycystic ovarian syndrome to healthy controls. Psychosom Med 2004;66:356–62. 12. Hahn S, Janssen OE, Tan S, Pleger K, Mann K, Schedlowski M, et al. Clinical and psychological correlates of quality-of-life in polycystic ovary syndrome. Eur J Endocrinol 2005;153:853–60. 13. Himelein MJ, Thatcher SS. Depression and body image among women with polycystic ovary syndrome. J Health Psychol 2006;11:613–25. 14. Elsenbruch S, Hahn S, Kowalsky D, Offner AH, Schedlowski M, Mann K, et al. Quality of life, psychosocial well-being, and sexual satisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003;88:5801–7. 15. Rasgon NL, Rao RC, Hwang S, Altshuler LL, Elman S, Zuckerbrow-Miller J, et al. Depression in women with polycystic ovary syndrome: clinical and biochemical correlates. J Affect Disord 2003;74:299–304. 16. Himelein MJ, Thatcher SS. Polycystic ovary syndrome and mental health: a review. Obstet Gynecol Surv 2006;61:723–32. 17. Kaukua J, Pekkarinen T, Sane T, Mustajoki P. Healthrelated quality of life in obese outpatients losing weight with very-low-energy diet and behaviour modification: a 2-y follow-up study. Int J Obes Relat Metab Disord 2003;27:1072–80. 18. Fontaine KR, Barofsky I, Andersen RE, Bartlett SJ, Wiersema L, Cheskin LJ, et al. Impact of weight
19.
20.
21.
22.
23.
24.
25.
26.
loss on health-related quality of life. Qual Life Res 1999;8:275–7. Lemoine S, Rossell N, Drapeau V, Poulain M, Garnier S, Sanguignol F, et al. Effect of weight reduction on quality of life and eating behaviors in obese women. Menopause 2007;14:432–40. Clark A, Thornley B, Tomlinson L, Galletley C, Norman R. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 1998;13:1502–5. Clark AM, Ledger W, Galletly C, Tomlinson L, Blaney F, Wang X, et al. Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod 1995;10:2705–12. Galletly C, Moran L, Noakes M, Clifton P, Tomlinson L, Norman R. Psychological benefits of a high-protein, low-carbohydrate diet in obese women with polycystic ovary syndrome—a pilot study. Appetite 2007;49:590–3. Mavropoulos JC, Yancy WS, Hepburn J, Westman EC. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutr Metab (Lond) 2005;2:35. DiLorenzo TM, Bargman EP, Stucky-Ropp R, Brassington GS, Frensch PA, LaFontaine T. Longterm effects of aerobic exercise on psychological outcomes. Prev Med 1999;28:75–85. Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. J Psychosom Res 1993;37:565–74. LaFontaine TP, DiLorenzo TM, Frensch PA, StuckyRopp RC, Bargman EP, McDonald DG. Aerobic exercise and mood: a brief review, 1985–1990. Sports Med 1992;13:160–70.
1815
27. Williams PA, Cash TF. Effects of a circuit weight training program on the body images of college students. Int J Eat Disord 2001;30:75–82. 28. Penedo FJ, Dahn JR. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Curr Opin Psychiatry 2005;18: 189–93. 29. The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;19:41–7. 30. Balen AH, Laven JSE, Tan S-L, Dewailly D. Ultrasound assessment of the polycystic ovary: international consensus definitions. Hum Reprod Update 2003;9:505–14. 31. Thomson RL, Buckley JD, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. The effect of a hypocaloric diet with and without exercise training on body composition, cardiometabolic risk profile, and reproductive function in overweight and obese women with polycystic ovary syndrome. J Clin Endocrinol Metab 2008;93:3373–80. 32. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401. 33. Zich JM, Attkisson CC, Greenfield TK. Screening for depression in primary care clinics: the CES-D and the BDI. Int J Psychiatry Med 1990;20:259–77. 34. Cronin L, Guyatt G, Griffith L, Wong E, Azziz R, Futterweit W, et al. Development of a health-related quality-of-life questionnaire (PCOSQ) for women with polycystic ovary syndrome (PCOS). J Clin Endocrinol Metab 1998;83:1976–87. 35. Guyatt G, Weaver B, Cronin L, Dooley JA, Azziz R. Health-related quality of life in women with polycystic ovary syndrome, a self-administered questionnaire, was validated. J Clin Epidemiol 2004;57:1279–87. 36. Jones GL, Benes K, Clark TL, Denham R, Holder MG, Haynes TJ, et al. The polycystic ovary syndrome health-related quality of life questionnaire (PCOSQ): a validation. Hum Reprod 2004;19:371–7. 37. Cohen J. Statistical power of analysis for the behavioural sciences. London: Academic Press, 1969
1816
Thomson et al.
38. Geerlings SW, Beekman AT, Deeg DJ, Van Tilburg W. Physical health and the onset and persistence of depression in older adults: an eight-wave prospective community-based study. Psychol Med 2000;30:369–80. 39. Beekman AT, Geerlings SW, Deeg DJ, Smit JH, Schoevers RS, de Beurs E, et al. The natural history of late-life depression: a 6-year prospective study in the community. Arch Gen Psychiatry 2002;59:605–11. 40. Steunenberg B, Beekman AT, Deeg DJ, Kerkhof AJ. Personality and the onset of depression in late life. J Affect Disord 2006;92:243–51. 41. Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc 2005;105:929–36. 42. Karlsson J, Hallgren P, Kral J, Lindroos A-K, Sj€ostr€om L, Sullivan M. Predictors and effects of long-term dieting on mental well-being and weight loss in obese women. Appetite 1994;23:15–26. 43. Wing RR, Epstein LH, Marcus MD, Kupfer DJ. Mood changes in behavioral weight loss programs. J Psychosom Res 1984;28:189–96. 44. Wadden TA, Steen SN, Wingate BJ, Foster GD. Psychosocial consequences of weight reduction: how much weight loss is enough? Am J Clin Nutr 1996;63:461S–5s. 45. Inglis V, Ball K, Crawford D. Why do women of low socioeconomic status have poorer dietary behaviours than women of higher socioeconomic status? A qualitative exploration. Appetite 2005;45:334–43. 46. Jabs J, Devine CM. Time scarcity and food choices: an overview. Appetite 2006;47:196–204. 47. Andajani-Sutjahjo S, Ball K, Warren N, Inglis V, Crawford D. Perceived personal, social and environmental barriers to weight maintenance among young women: a community survey. Int J Behav Nutr Phys Act 2004;1:15. 48. Ball K, Crawford D, Warren N. How feasible are healthy eating and physical activity for young women? Public Health Nutr 2004;7:433–41. 49. Kolotkin RL, Meter K, Williams GR. Quality of life and obesity. Obes Rev 2001;2:219–29. 50. Rippe JM, Price JM, Hess SA, Kline G, DeMers KA, Damitz S, et al. Improved psychological well-being,
Quality of life and depression in PCOS
51.
52.
53.
54.
55.
56.
57. 58.
59.
quality of life, and health practices in moderately overweight women participating in a 12-week structured weight loss program. Obes Res 1998;6:208–18. Clayton WJ, Lipton M, Elford J, Rustin M, Sherr L. A randomized controlled trial of laser treatment among hirsute women with polycystic ovary syndrome. Br J Dermatol 2005;152:986–92. Pasquali R, Antenucci D, Casimirri F, Venturoli S, Paradisi R, Fabbri R, et al. Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss. J Clin Endocrinol Metab 1989;68:173–9. Kiddy DS, Hamilton-Fairley D, Bush A, Short F, Anyaoku V, Reed MJ, et al. Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 1992;36:105–11. Gambineri A, Pelusi C, Genghini S, MorselliLabate AM, Cacciari M, Pagotto U, et al. Effect of flutamide and metformin administered alone or in combination in dieting obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 2004;60: 241–9. Hahn S, Benson S, Elsenbruch S, Pleger K, Tan S, Mann K, et al. Metformin treatment of polycystic ovary syndrome improves health-related quality-oflife, emotional distress and sexuality. Hum Reprod 2006;21:1925–34. Coffey S, Bano G, Mason HD. Health-related quality of life in women with polycystic ovary syndrome: a comparison with the general population using the polycystic ovary syndrome questionnaire (PCOSQ) and the short form-36 (SF-36). Gynecol Endocrinol 2006;22:80–6. Keegan A, Liao L-M, Boyle M. ‘‘Hirsutism’’: a psychological analysis. J Health Psychol 2003;8:327–45. Hashimoto DM, Schmid J, Martins FM, Fonseca AM, Andrade LH, Kirchengast S, et al. The impact of the weight status on subjective symptomatology of the polycystic ovary syndrome: a cross-cultural comparison between Brazilian and Austrian women. Anthropol Anz 2003;61:297–310. Stunkard AJ, Faith MS, Allison KC. Depression and obesity. Biol Psychiatry 2003;54:330–7.
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Australian Technology Network Centre for Metabolic Fitness & Nutritional Physiology Research Centre, Sansom Institute for Health Research, University of South Australia; b Preventative Health Flagship, Commonwealth Scientific and Industrial Research Organisation, Food and Nutrition Sciences; and c Research Centre for Reproductive Health, Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia
Objective: To assess the impact of adding exercise to dietary restriction on depressive symptoms and health-related quality of life (HRQOL) in women with polycystic ovary syndrome (PCOS). Design: Analysis of depression and quality of life outcomes from a randomized, controlled prospective clinical intervention that evaluated the effects on a range of health outcomes in women with PCOS. Setting: Clinical research unit. Patient(s): One hundred four overweight/obese PCOS women (aged 29.3 0.7 years; body mass index [BMI] 36.1 0.5 kg/m2). Intervention(s): Randomized to one of three 20-week lifestyle programs: diet only, diet and aerobic exercise, or diet and combined aerobic-resistance exercise. Main Outcome Measure(s): Depression and PCOS-specific HRQOL. Result(s): Forty-nine women completed the intervention (diet only ¼ 14, diet and aerobic exercise ¼ 15, diet and combined aerobic-resistance exercise ¼ 20). By week 20 all groups achieved weight loss and had improvements in depression and PCOS-specific HRQOL scores, except for body hair domain score. There was no difference between treatments for all outcomes. Conclusion(s): This study demonstrated that dietary restriction alone and combined with exercise had similar benefits for improving depression and HRQOL scores in overweight and obese women with PCOS. (Fertil Steril 2010;94:1812–6. 2010 by American Society for Reproductive Medicine.) Key Words: Weight loss, exercise, diet, depression, quality of life
Health-related quality of life (HRQOL) is a multidimensional concept encompassing physical, psychological, and social aspects of health, and its assessment allows the effects of a disease or treatment to be quantified (1, 2). Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, presenting in 7% of this population (3). The symptoms typically associated with PCOS include menstrual dysfunction, infertility, changes in physical appearance (excessive hair growth, obesity, and acne), and possible increased risk of diabetes and cardiovascular disease, all of which can also have adverse effects on HRQOL (4–8). Previous studies have shown that these clinical features promote psychological morbidity reflected by loss of self-esteem, emotional stress, and poor body image, which lead to an increased likelihood of Received May 15, 2009; revised October 20, 2009; accepted November 2, 2009; published online December 11, 2009. R.L.T. has nothing to disclose. J.D.B. has nothing to disclose. S.S.L. has nothing to disclose. M.N. has nothing to disclose. P.M.C. has nothing to disclose. R.J.N. has nothing to disclose. G.D.B. has nothing to disclose. Supported by the National Health and Medical Research Council of Australia, grant number: 401817, Canberra, Australia National Territory, Australia. Rebecca L. Thomson was funded by a postgraduate scholarship from the South Australia Department of Health. Reprint requests: Grant D. Brinkworth, Ph.D., CSIRO Food and Nutrition Sciences, PO Box 10041 BC, Adelaide, South Australia 5000, Australia (FAX: 61-8-8303-8899; E-mail: [email protected]).
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experiencing depressive symptoms (9–15) and reduced HRQOL (8, 13–16). Weight loss and lifestyle management have been shown to improve mood states and reduce depressive symptoms in overweight and obese women without PCOS (17–19). However, there is limited evidence evaluating the effects of PCOS treatments on psychological well-being and whether these can be improved after weight loss. Two studies by Clark et al. (20, 21) investigated the effect of 6-month lifestyle modification aimed at improving diet and increasing exercise in obese infertile women, some of whom had PCOS, and reported improved self-esteem and reduced depression and anxiety scores after a 6–10 kg weight loss. Two pilot studies have also investigated the effects of dietary restriction on psychological outcomes in obese women with PCOS (22, 23), with one observing a trend for improvements in HRQOL after 24 weeks on a low-carbohydrate ketogenic diet (23). Another study reported that a 16-week high-protein diet significantly improved depression and self-esteem, whereas despite similar weight loss (7–8 kg), the high-carbohydrate diet did not (22). This provided evidence that although weight loss is important, dietary composition may also be an influencing factor. These studies suggest a potential for weight loss to improve psychological outcomes, but further studies are needed in this area. There is also evidence that exercise independently provides a number of psychological benefits, including improvements in mood, self-image, body satisfaction, overall quality of life and psychological well-being, and reduced symptoms of depression and
Fertility and Sterility Vol. 94, No. 5, October 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/$36.00 doi:10.1016/j.fertnstert.2009.11.001
anxiety (24–28). To date no study has evaluated the effects of exercise training on depression and HRQOL outcomes in overweight and obese women with PCOS, despite the increasing prevalence of this condition in the community. The aim of this study was to assess the impact of adding exercise to an energy-restricted weight loss program on depressive symptoms and HRQOL in overweight and obese women with PCOS.
MATERIALS AND METHODS Participants One hundred four sedentary overweight and obese women with PCOS were recruited by public advertisement and from general practitioner and specialists clinics. Polycystic ovary syndrome was diagnosed according to the Rotterdam criteria (29), by the presence of two of the following three criteria: [1] biochemical (elevated testosterone (T) [ > 2.0 nmol/L] and free androgen index [>5.4]) or clinical (hirsutism assessed by Ferriman-Gallwey score >8) hyperandrogenism; [2] menstrual irregularity (oligo/anovulation [cycle length <21 days or >35 days]); and [3] presence of polycystic ovaries (PCO) by transvaginal or transabdominal ultrasound examination (30). Potential participants were excluded if they were using fertility treatments or oral contraceptives, were smokers, pregnant, breastfeeding, or had a history of cardiovascular, liver, kidney, or respiratory disease, diabetes, uncontrolled hypertension (>140/90 mm Hg), or cancer. Subjects were also excluded if they had any reproductive disorders unrelated to PCOS, thyroid abnormalities (hypothyroidism and hyperthyroidism), or nonclassic adrenal hyperplasia. All experimental procedures were approved by Human Ethics Committees of the Commonwealth Scientific and Industrial Research Organisation and the University of South Australia and participants provided written informed consent.
Study Design The data analyzed for this study were obtained from a subset of women who completed psychological-based outcomes from a large randomized controlled trial that concurrently evaluated the effects of a hypocaloric diet with and without exercise training on metabolic and reproductive outcomes (31). Women were randomized to one of three 20-week lifestyle interventions: diet only (DO, consisting of a 6,000 kJ/day energy restricted highprotein meal plan), diet and aerobic exercise (DA, consisting of 5 walking/ jogging sessions per week), or diet and combined aerobic-resistance exercise (DC, consisting of 3 walking/jogging and 2 strength training sessions per week). At baseline (week 0), the midpoint (week 10), and end of the intervention (week 20) participants attended the clinic after an overnight fast during which height (baseline only) and body weight were measured using a stadiometer (SECA, Hamburg, Germany) and electronic digital scales (Mercury, AMZ 14, Tokyo, Japan), respectively. Participants completed a validated PCOS questionnaire (PCOSQ) and the Center for Epidemiologic Studies Depression Scale (CES-D) to assess HRQOL and depression, respectively. Participants were required to fill out exercise and diet logs and exercise sessions were monitored during the study.
Depression and HRQOL Questionnaires Depression was assessed using the CES-D (32), which is a self-reported scale that measures the presence and severity of depressive symptoms occurring in the past week. The scale consists of 20 items with a 4-point rating scale ranging from 0 (rarely, less than 1 day) to 3 (most of the time, 5–7 days). The items include questions about depressed mood, feelings of guilt, worthlessness, helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance. Total scores above 16 are considered high and indicative of the presence of mild depression (33). The HRQOL was measured using a validated self-administered PCOSQ (34–36). The PCOSQ includes 26 questions (items) from 5 HRQOL areas or domains: emotions (7 items), hair growth (5 items), body weight (5 items), infertility problems (5 items), and menstrual problems (4 items). Each item has a seven-point scale (a score of 7 denotes no problem or difficulty and 1
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indicates maximum HRQOL impairment). The mean score of all items within a domain provides a domain score, with lower scores indicating a greater negative impact.
Data Analysis Statistical analysis was performed using SPSS for Windows 17.0 (SPSS, Chicago, IL). Values are reported as mean SE. An a-level of significance was set at P%.05. Data were checked for normality before analysis and non-normally distributed data were transformed by taking the square root (CES-D) or by rank transformation (PCOSQ). Baseline differences between groups were determined by one-way analysis of variance (ANOVA). The effect of the intervention on weight, CES-D, and PCOSQ scores was determined by repeated measures ANOVAwith time as the within-subject factor and treatment group as the between-subjects factor. When there was a significant main effect, post-hoc analysis using Bonferroni corrections for multiple comparisons were performed where appropriate to determine differences between group means across time. Clinically relevant changes in HRQOL measures were defined as a medium effect size (P>.5), which has previously been suggested as an appropriate method (37). A reduction of R5 units is considered a clinically significant improvement for CES-D scores as it qualifies as a middle to large effect size (37, 38) and has been used in other studies (39, 40). Correlation analysis using Pearson’s correlation coefficient and Spearman’s rank order correlation were used to determine relationships between variables with Bonferroni adjustments for multiple comparisons (P¼.008).
RESULTS Participants Of the 104 women who were recruited for the study, 10 withdrew before commencement, therefore 94 women started the study (DO, n ¼ 30; DA, n ¼ 31; DC, n ¼ 33; aged 29.3 0.7 years; body mass index [BMI] 36.1 0.5 kg/m2). Fifty-two completed the study, with 49 women completing all psychological-based outcomes that were included in the current investigation (DO, n ¼ 14; DA, n ¼ 15, DC, n ¼ 20). The average compliance for exercise was 79%. There were no differences in baseline weight, CES-D, and PCOSQ scores between treatment groups (Table 1) or between women who completed the study and women who dropped out in any of the measures (P>.08). There was a significant reduction in body weight (DO, 8.9 1.6 kg; DA, 11.0 1.7 kg; DC, -8.7 1.3 kg; P%.001), with no difference between the groups (P¼.5).
Depression Scale There was no relationship between baseline CES-D scores and weight. During the intervention there was a significant time effect for CES-D scores (P<.001), such that scores significantly decreased by week 10, but with no further change by week 20 (Table 1). There was no differential effect of treatment (P>.86). Despite no significant reduction in CES-D scores by week 20, there was a significant correlation between the change in CES-D score and weight loss from week 0–20 (r ¼ 0.31, P¼.03), with greater weight loss associated with greater reductions in CES-D score.
HRQOL Questionnaire At baseline the emotion score correlated with glucose (r ¼ 0.40, P¼.005) and the body hair score correlated with T (r ¼ 0.40, P¼.004), indicating that higher glucose and T were related to worse domain scores (data not shown). All groups experienced significant improvements in PCOSQ domain scores by week 20 (P%.001), except for body hair score (P¼.10), with no difference between treatments (PR.10). The improvements in emotion, body weight, and menstrual problems domain were clinically significant. The changes in the emotion and body weight score were related to the
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TABLE 1 Depression scores from the center of epidemiologic studies depression scale (CES-D) and polycystic ovary syndrome questionnaire (PCOSQ) for women with polycystic ovary syndrome at baseline and after 10 and 20 weeks of diet only (DO), diet and aerobic exercise (DA), or diet and combined aerobic-resistance exercise (DC).
CES-D DO DA DC PCOSQ Emotion score DO DA DC Body hair score DO DA DC Weight score DO DA DC Infertility problems score DO DA DC Menstrual problems score DO DA DC
Week 0
Week 10
Week 20
Time
Time 3 treatment
18.2 2.5 18.6 2.2 13.4 1.7
13.0 2.7a 10.6 1.8a 9.3 1.5a
16.6 3.3 14.0 2.4 12.8 1.8
< .001
.86
4.1 0.4 4.3 0.2 4.8 0.2
4.6 0.3a 5.2 0.2a 5.2 0.2a
4.7 0.4a 4.9 0.3a 5.3 0.2a
< .001
.33
3.1 0.4 3.1 0.3 3.3 0.3
3.4 0.4 3.2 0.3 3.3 0.3
3.3 0.3 3.4 0.3 3.5 0.3
.10
.69
1.9 0.2 1.9 0.2 2.2 0.2
2.5 0.3a 3.4 0.3a 3.2 0.2a
2.9 0.3a 3.3 0.3a 3.5 0.3a
< .001
.10
4.4 0.5 4.5 0.4 4.5 0.3
4.7 0.6a 5.4 0.4a 5.1 0.3a
4.8 0.5a 5.3 0.4a 5.2 0.3a
< .001
.54
3.5 0.3 3.8 0.3 3.7 0.3
3.7 0.4a 4.4 0.3a 4.4 0.2a
4.1 0.4a 4.4 0.3a 4.6 0.3a
.001
.15
Note: Values are mean SE; n ¼ 49. a Significantly different from week 0 (P%.001) as determined by repeated measures ANOVA and pairwise comparisons with Bonferroni corrections. Thomson. Quality of life and depression in PCOS. Fertil Steril 2010.
change in weight (r ¼ 0.35 and r ¼ 0.43, respectively; P%.01). There was an inverse relationship between the change in menstrual problems score and improvements in average cycle length (r ¼ 0.41, P¼.01) (data not shown).
DISCUSSION This study demonstrated that a moderate energy-restricted diet in overweight and obese women with PCOS improved depression and HRQOL scores; however, exercise provided no additional benefit to that seen with diet alone. Previous research suggests that exercise independently improves psychological outcomes (24–28). We have previously shown that the addition of exercise did not result in any additional improvements in PCOS-related symptoms, which could potentially explain why no differences were seen (31). In addition, previous studies, which have shown psychological benefits of exercise, used other psychological instruments, largely focusing on anxiety and mood, whereas the PCOSQ has a broader focus and emphasis on symptomatology of PCOS. In addition, despite the absence of any statistically significant differences between treatment groups at baseline, the DC group appeared to have less psychological disturbances that could have potentially lessened any differential changes between the groups. However, after adjusting for these differences, there was still no additional effect of exercise on the outcomes assessed. For CES-D, there was a significant improvement at week 10, which was considered clinically significant, but no further changes
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were detected by week 20, despite having statistical power of 0.7 to detect a change in depression scores from week 10–20 (P<.05). It is unclear why participants did not continue to reduce depressive symptoms as they continued to lose weight and improve other PCOS symptoms during the later half of the intervention; however, this observation agrees with the findings of other studies in obese women, which found that diet-induced weight loss results in an improvement in psychological outcomes in the short-term, but was not maintained over the long term (41, 42). There are a few possible explanations for the lack of continued reduction in depression scores. The enthusiasm and motivation resulting from active participation in a supervised weight loss program during the early phases of the study may have been difficult to sustain over the long term (43, 44). Although participants in the present study successfully achieved dietary and lifestyle changes, as demonstrated by continued weight loss throughout the intervention, the emotional response to these modifications may have lessened over time, reducing any impact on depressive symptoms. Due to work and family commitments young women have a high perceived time pressure, which can be a fundamental barrier to healthy eating and physical activity participation (45–47) and may result in the development of a perception that the recommended behavioral changes to achieve optimum lifestyle habits are not feasible (48). In the general overweight population weight loss improves HRQOL (18, 19, 49, 50). However, to date only two other studies have assessed HRQOL in response to a treatment intervention in
Quality of life and depression in PCOS
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women with PCOS. The first observed improved psychological health after 6 months of laser treatment that improved facial hirsutism severity, along with alleviated depression and anxiety symptoms in women with PCOS (51). However, in the present study, we observed no change in the body hair domain score of the PCOSQ, which was not unexpected as at least 20 weeks are required before any reductions in hirsutism after weight loss are observed (52– 54). Hahn et al. (55) also showed marked improvements in HRQOL and emotional distress associated with weight loss after metformin treatment. At the commencement of the study participants demonstrated moderate to severe impairments in HRQOL as assessed by PCOSQ. The most severely affected HRQOL domain was that related to perceptions of weight, which agrees with the findings of previous studies (7–9, 35, 56). In addition, on average CES-D scores were relatively high (>16), indicating the presence of mild depression (33). To date there have been inconsistent results when identifying specific features of PCOS that may contribute to impaired psychological health. A biochemical explanation is plausible, although the relationship between T levels and depression in PCOS remains controversial, with inconsistent results reported (7, 11, 15) and no association observed in the current study. Psychosocial variables are also likely to influence the relationship, in particular the presence of appearance-related aspects of PCOS, such as excessive hair growth, obesity, and acne, as these physical characteristics are known to negatively affect a woman’s feeling of attractiveness (57) and body satisfaction (7, 11). Obesity has also been suggested as the primary mediatory of reduced HRQOL in PCOS (7, 12, 55, 58) and many women with PCOS have reported frustration with the inability to lose weight, leading to poor body image and low
self-esteem (34). These findings are not surprising given that obesity itself profoundly affects HRQOL independently of the presence of other clinical symptoms in otherwise healthy populations (59). This study was limited by the high drop-out rate, and the lack of a nondieting control group limits the ability to determine the specific effects of dieting and lifestyle management. The women who completed the study may have represented a group of highly motivated individual volunteers who achieved substantial weight loss and this could have potentially biased the observed effects and might limit the generalizability of the findings. However, this study did provide an opportunity to examine the impact of lifestyle management on these outcomes in women with PCOS and will provide direction for further investigations. This is an area of importance where there is currently a lack of data describing these effects and additional research is needed. To our knowledge this is the first study to evaluate the effect of exercise when added to a weight loss program on HRQOL and depressive symptoms in overweight and obese women with PCOS. Exercise was shown to provide no additional improvement in depression or HRQOL to that seen with diet alone. Further studies are required to determine whether the observed effects are attributable to the achievement of weight loss or to involvement in an intensive, clinically supported lifestyle modification program. Acknowledgments: The authors gratefully acknowledge Julia Weaver for assisting with trial management; Lindy Lawson and Rosemary McArthur for their assistance in the nursing activities; Gemma Williams, Xenia Cleanthous, and Julianne McKeough for their dietetic guidance; Mark Mano, Cathryn Seccafien, and Candita Sullivan for laboratory assistance; and Kylie Lange for statistical advice.
REFERENCES 1. Colwell HH, Mathias SD, Pasta DJ, Henning JM, Steege JF. A health-related quality-of-life instrument for symptomatic patients with endometriosis: a validation study. Am J Obstet Gynecol 1998;179:47–55. 2. Naughton MJ, McBee WL. Health-related quality of life after hysterectomy. Clin Obstet Gynecol 1997;40: 947–57. 3. Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet 2007;370:685–97. 4. Sonino N, Fava GA, Mani E, Belluardo P, Boscaro M. Quality of life of hirsute women. Postgrad Med J 1993;69:186–9. 5. Paulson JD, Haarmann BS, Salerno RL, Asmar P. An investigation of the relationship between emotional maladjustment and infertility. Fertil Steril 1988;49: 258–62. 6. Downey J, Yingling S, McKinney M, Husami N, Jewelewicz R, Maidman J. Mood disorders, psychiatric symptoms, and distress in women presenting for infertility evaluation. Fertil Steril 1989;52: 425–32. 7. McCook JG, Reame NE, Thatcher SS. Health-related quality of life issues in women with polycystic ovary syndrome. J Obstet Gynecol Neonatal Nurs 2005;34: 12–20. 8. Ching HL, Burke V, Stuckey BG. Quality of life and psychological morbidity in women with polycystic ovary syndrome: body mass index, age and the provision of patient information are significant modifiers. Clin Endocrinol (Oxf) 2007;66:373–9. 9. Barnard L, Ferriday D, Guenther N, Strauss B, Balen AH, Dye L. Quality of life and psychological well being in polycystic ovary syndrome. Hum Rep 2007;22:2279–86.
Fertility and Sterility
10. Hollinrake E, Abreu A, Maifeld M, Van Voorhis BJ, Dokras A. Increased risk of depressive disorders in women with polycystic ovary syndrome. Fertil Steril 2007;87:1369–76. 11. Weiner CL, Primeau M, Ehrmann DA. Androgens and mood dysfunction in women: Comparison of women with polycystic ovarian syndrome to healthy controls. Psychosom Med 2004;66:356–62. 12. Hahn S, Janssen OE, Tan S, Pleger K, Mann K, Schedlowski M, et al. Clinical and psychological correlates of quality-of-life in polycystic ovary syndrome. Eur J Endocrinol 2005;153:853–60. 13. Himelein MJ, Thatcher SS. Depression and body image among women with polycystic ovary syndrome. J Health Psychol 2006;11:613–25. 14. Elsenbruch S, Hahn S, Kowalsky D, Offner AH, Schedlowski M, Mann K, et al. Quality of life, psychosocial well-being, and sexual satisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003;88:5801–7. 15. Rasgon NL, Rao RC, Hwang S, Altshuler LL, Elman S, Zuckerbrow-Miller J, et al. Depression in women with polycystic ovary syndrome: clinical and biochemical correlates. J Affect Disord 2003;74:299–304. 16. Himelein MJ, Thatcher SS. Polycystic ovary syndrome and mental health: a review. Obstet Gynecol Surv 2006;61:723–32. 17. Kaukua J, Pekkarinen T, Sane T, Mustajoki P. Healthrelated quality of life in obese outpatients losing weight with very-low-energy diet and behaviour modification: a 2-y follow-up study. Int J Obes Relat Metab Disord 2003;27:1072–80. 18. Fontaine KR, Barofsky I, Andersen RE, Bartlett SJ, Wiersema L, Cheskin LJ, et al. Impact of weight
19.
20.
21.
22.
23.
24.
25.
26.
loss on health-related quality of life. Qual Life Res 1999;8:275–7. Lemoine S, Rossell N, Drapeau V, Poulain M, Garnier S, Sanguignol F, et al. Effect of weight reduction on quality of life and eating behaviors in obese women. Menopause 2007;14:432–40. Clark A, Thornley B, Tomlinson L, Galletley C, Norman R. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 1998;13:1502–5. Clark AM, Ledger W, Galletly C, Tomlinson L, Blaney F, Wang X, et al. Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod 1995;10:2705–12. Galletly C, Moran L, Noakes M, Clifton P, Tomlinson L, Norman R. Psychological benefits of a high-protein, low-carbohydrate diet in obese women with polycystic ovary syndrome—a pilot study. Appetite 2007;49:590–3. Mavropoulos JC, Yancy WS, Hepburn J, Westman EC. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutr Metab (Lond) 2005;2:35. DiLorenzo TM, Bargman EP, Stucky-Ropp R, Brassington GS, Frensch PA, LaFontaine T. Longterm effects of aerobic exercise on psychological outcomes. Prev Med 1999;28:75–85. Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. J Psychosom Res 1993;37:565–74. LaFontaine TP, DiLorenzo TM, Frensch PA, StuckyRopp RC, Bargman EP, McDonald DG. Aerobic exercise and mood: a brief review, 1985–1990. Sports Med 1992;13:160–70.
1815
27. Williams PA, Cash TF. Effects of a circuit weight training program on the body images of college students. Int J Eat Disord 2001;30:75–82. 28. Penedo FJ, Dahn JR. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Curr Opin Psychiatry 2005;18: 189–93. 29. The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;19:41–7. 30. Balen AH, Laven JSE, Tan S-L, Dewailly D. Ultrasound assessment of the polycystic ovary: international consensus definitions. Hum Reprod Update 2003;9:505–14. 31. Thomson RL, Buckley JD, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. The effect of a hypocaloric diet with and without exercise training on body composition, cardiometabolic risk profile, and reproductive function in overweight and obese women with polycystic ovary syndrome. J Clin Endocrinol Metab 2008;93:3373–80. 32. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401. 33. Zich JM, Attkisson CC, Greenfield TK. Screening for depression in primary care clinics: the CES-D and the BDI. Int J Psychiatry Med 1990;20:259–77. 34. Cronin L, Guyatt G, Griffith L, Wong E, Azziz R, Futterweit W, et al. Development of a health-related quality-of-life questionnaire (PCOSQ) for women with polycystic ovary syndrome (PCOS). J Clin Endocrinol Metab 1998;83:1976–87. 35. Guyatt G, Weaver B, Cronin L, Dooley JA, Azziz R. Health-related quality of life in women with polycystic ovary syndrome, a self-administered questionnaire, was validated. J Clin Epidemiol 2004;57:1279–87. 36. Jones GL, Benes K, Clark TL, Denham R, Holder MG, Haynes TJ, et al. The polycystic ovary syndrome health-related quality of life questionnaire (PCOSQ): a validation. Hum Reprod 2004;19:371–7. 37. Cohen J. Statistical power of analysis for the behavioural sciences. London: Academic Press, 1969
1816
Thomson et al.
38. Geerlings SW, Beekman AT, Deeg DJ, Van Tilburg W. Physical health and the onset and persistence of depression in older adults: an eight-wave prospective community-based study. Psychol Med 2000;30:369–80. 39. Beekman AT, Geerlings SW, Deeg DJ, Smit JH, Schoevers RS, de Beurs E, et al. The natural history of late-life depression: a 6-year prospective study in the community. Arch Gen Psychiatry 2002;59:605–11. 40. Steunenberg B, Beekman AT, Deeg DJ, Kerkhof AJ. Personality and the onset of depression in late life. J Affect Disord 2006;92:243–51. 41. Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc 2005;105:929–36. 42. Karlsson J, Hallgren P, Kral J, Lindroos A-K, Sj€ostr€om L, Sullivan M. Predictors and effects of long-term dieting on mental well-being and weight loss in obese women. Appetite 1994;23:15–26. 43. Wing RR, Epstein LH, Marcus MD, Kupfer DJ. Mood changes in behavioral weight loss programs. J Psychosom Res 1984;28:189–96. 44. Wadden TA, Steen SN, Wingate BJ, Foster GD. Psychosocial consequences of weight reduction: how much weight loss is enough? Am J Clin Nutr 1996;63:461S–5s. 45. Inglis V, Ball K, Crawford D. Why do women of low socioeconomic status have poorer dietary behaviours than women of higher socioeconomic status? A qualitative exploration. Appetite 2005;45:334–43. 46. Jabs J, Devine CM. Time scarcity and food choices: an overview. Appetite 2006;47:196–204. 47. Andajani-Sutjahjo S, Ball K, Warren N, Inglis V, Crawford D. Perceived personal, social and environmental barriers to weight maintenance among young women: a community survey. Int J Behav Nutr Phys Act 2004;1:15. 48. Ball K, Crawford D, Warren N. How feasible are healthy eating and physical activity for young women? Public Health Nutr 2004;7:433–41. 49. Kolotkin RL, Meter K, Williams GR. Quality of life and obesity. Obes Rev 2001;2:219–29. 50. Rippe JM, Price JM, Hess SA, Kline G, DeMers KA, Damitz S, et al. Improved psychological well-being,
Quality of life and depression in PCOS
51.
52.
53.
54.
55.
56.
57. 58.
59.
quality of life, and health practices in moderately overweight women participating in a 12-week structured weight loss program. Obes Res 1998;6:208–18. Clayton WJ, Lipton M, Elford J, Rustin M, Sherr L. A randomized controlled trial of laser treatment among hirsute women with polycystic ovary syndrome. Br J Dermatol 2005;152:986–92. Pasquali R, Antenucci D, Casimirri F, Venturoli S, Paradisi R, Fabbri R, et al. Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss. J Clin Endocrinol Metab 1989;68:173–9. Kiddy DS, Hamilton-Fairley D, Bush A, Short F, Anyaoku V, Reed MJ, et al. Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 1992;36:105–11. Gambineri A, Pelusi C, Genghini S, MorselliLabate AM, Cacciari M, Pagotto U, et al. Effect of flutamide and metformin administered alone or in combination in dieting obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 2004;60: 241–9. Hahn S, Benson S, Elsenbruch S, Pleger K, Tan S, Mann K, et al. Metformin treatment of polycystic ovary syndrome improves health-related quality-oflife, emotional distress and sexuality. Hum Reprod 2006;21:1925–34. Coffey S, Bano G, Mason HD. Health-related quality of life in women with polycystic ovary syndrome: a comparison with the general population using the polycystic ovary syndrome questionnaire (PCOSQ) and the short form-36 (SF-36). Gynecol Endocrinol 2006;22:80–6. Keegan A, Liao L-M, Boyle M. ‘‘Hirsutism’’: a psychological analysis. J Health Psychol 2003;8:327–45. Hashimoto DM, Schmid J, Martins FM, Fonseca AM, Andrade LH, Kirchengast S, et al. The impact of the weight status on subjective symptomatology of the polycystic ovary syndrome: a cross-cultural comparison between Brazilian and Austrian women. Anthropol Anz 2003;61:297–310. Stunkard AJ, Faith MS, Allison KC. Depression and obesity. Biol Psychiatry 2003;54:330–7.
Vol. 94, No. 5, October 2010