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Abstract
Background Polycystic ovary syndrome (PCOS) in adolescents causes appearance changes such as hirsutism, alopecia, acne and long-term complications, such as metabolic syndrome and infertility. This study aimed to compare physical activity status and food patterns, as prominent predictive factors, in adolescents with and without PCOS.
Methods This study was a cross-sectional study conducted on 400 adolescents at health centres affiliated with Golestan University of Medical Sciences. The data collection tools include a demographic questionnaire, a standard adolescents’ Physical Activity Status Questionnaire and a Nutritional Status Questionnaire. SPSS V.20 software was used to analyse the data.
Results The mean age of participants was 19.16±3.18. The results of the study showed that height, weight and menstrual status were significantly different between the two groups (p<0.05). The calorie intake in affected adolescents was high, and the physical activity status was unfavourable (p<0.05).
Conclusion Adolescents with PCOS have been found to have different physical activity levels, nutritional patterns and calorie intake compared to non-affected individuals. This is a critical issue, as high caloric intake and insufficient physical activity can exacerbate the development of PCOS in adolescents.
- Polycystic Ovary Syndrome
- Adolescent Health
Data availability statement
Data are available upon reasonable request from the coresponding author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Polycystic ovary syndrome is a heterogeneous condition with variable phenotypic expressions that affects women’s health.
WHAT THIS STUDY ADDS
Among the contextual characteristics, it seems that girls affected by PCOS tend to have higher weight and height measurements than those who are not affected. Additionally, unhealthy eating habits and insufficient physical activity are more common among teenagers with PCOS. These girls also experience longer intervals between menstrual cycles and shorter durations of menstruation compared with non-affected individuals.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
It is suggested that by increasing awareness and providing training, steps can be taken to prevent and treat complications of this syndrome in teenagers.
Introduction
One of the prevalent endocrine diseases in women during childbearing age is polycystic ovary syndrome (PCOS).1 This syndrome is a heterogeneous condition with variable phenotypic expressions that have significant differences in diagnostic criteria.2 Although the aetiology of this syndrome is not completely understood, factors such as genetic predisposition, increased insulin secretion, insulin resistance, obesity, environmental and chemical pollution, environmental factors, nutrition and physical activity are effective in its occurrence. The role of genetics and lifestyle is undeniable.3–6 Although PCOS can occur at any age, it mostly begins in the adolescent period.7 8 Adolescence is one of the most critical periods of life, and the occurrence of chronic disorders during this period can affect the future of adolescents’ health and well-being.9 The detection of PCOS during adolescence is challenging because of the overlap with the physiological events of puberty. The diagnosis of PCOS in adolescent girls should be based on the two main criteria of irregular menstrual cycles and hyperandrogenism (clinical and/or biochemical symptoms).10 Since adolescents with this syndrome may be exposed to disorders, such as obesity, metabolic syndrome, insulin resistance, type 2 diabetes, infertility, cancer, heart diseases and mental disorders, identifying the risk factors and managing this syndrome during this period is very important.11 12
Studies have shown that, compared with healthy people, women with PCOS consume foods with a high glycaemic index, high fat (saturated fat and polyunsaturated fat) and high total energy intake.13 14 In a study on obese or overweight women with PCOS in Iran, the authors found that these women consumed more fat, carbohydrates, caffeine and fewer vitamins and minerals than healthy people.14 Since no study has been conducted on the dietary patterns and lifestyle of adolescent girls with PCOS, this study is designed to compare the physical activity status and dietary patterns of adolescents with and without PCOS.
Materials and methods
This cross-sectional study was conducted in health centres affiliated with the Gorgan University of Medical Sciences in Iran between February 2021 and October 2021. This article was written in compliance with the Declaration of the World Medical Association of Helsinki on Ethical Research Conduct.
Overall, 400 adolescents, who had PCOS (n=200) and without PCOS (n=200), were referred to health centres affiliated with the Gorgan University of Medical Sciences in Iran between February 2021 and October 2021 and included in this study through a simple random sampling method.
The inclusion criteria for the study were adolescent girls aged between 12 and 24 who have health literacy, no history of chronic diseases that affect the regularity of the menstrual cycle, such as endocrine disorders and genetic problems, and have had at least 2 years since the start of their menstruation. The Rotterdam criteria were used to diagnose PCOS in this study.15 These criteria include anovulation, hyperandrogenism and polycystic ovaries. Polycystic ovaries are defined as having at least 12 follicles measuring 2–9 mm in diameter or an ovarian volume >10 mL in at least one ovary. The presence of at least two clinical-biochemical criteria was used to confirm the diagnosis. All girls were subjected to sonographic and laboratory examinations and the results were reviewed by gynaecologists. If the gynaecologist’s final diagnosis was confirmed, the teenagers were placed in the affected group, and if the diagnosis was not confirmed, they were placed in the non-affected group. Adolescents in both groups completed three questionnaires. The questionnaires were completed by the self-reporting method.
On the other hand, the exclusion criteria for the study were the unwillingness of participants to continue the study for any reason, failure to complete the questionnaire and lack of access to adolescent information after three follow-ups by phone.
Covariates
Age, weight, height, body mass index (BMI), menarche, interval between two mensurations, length of menstruation, education, family history of PCOS and smoking were obtained from self-administered questionnaires. The education level was defined as under-diploma, diploma and university. Family history of PCOS and smoking was defined as yes or no questions.
Sample size
The sample size was calculated according to the study of Maya et al using the formula given below.16 Therefore, taking into account 10% attrition, the sample size was selected as 400 girls (
=1.96; p=0.04; d=0.2).
Data collection instrument
The data collection tools include a demographic questionnaire, Adami and Cordera’s nutritional status and an international Physical Activity Status Questionnaire.
Demographic questionnaire
The demographic questionnaire includes participants' characteristics like age, weight, height, BMI, education, family history of PCOS, smoking, menstrual status, duration of bleeding and menstrual cycle intervals.
Adami and Cordera Qestionnaire
The nutritional status questionnaire was derived from the Mediterranean Region People’s Nutritional Status Questionnaire (Adam Cordera), which included individual eating patterns and habits. The first part calculates the number of calories consumed, and the second part, questions 1–7, are related to food patterns and questions 8–17 are related to the subjects’ eating habits.17 The validity and reliability of this questionnaire were reported to be 0.44 and 0.74 by Damirchi et al, respectively.18
Adolescent Physical Activity Standard Questionnaire
This questionnaire contains nine questions; each question has a value from one to five. The average of nine questions is considered a person’s physical activity score. The range of this score is from 1 to 5; score 1 indicates the lowest level of physical activity, and score 5 indicates the highest level of physical activity. A score of 3 and above is suitable, and scores of 1 and 2 indicate that physical activity is undesirable.19 In a meta-analysis, the validity and reliability of this questionnaire were reported as 0.27 and 0.75, respectively.20 The content, face validity and reliability were calculated to be 0.97 for Iranian teenagers.21
Data collection method
To conduct the study, the ethics code (IR.TUMS.FNM.REC.1400.190) was obtained from the Ethics Committee of the Faculty of Nursing and Midwifery and Rehabilitation School of Tehran University of Medical Sciences. Then, the necessary permission was obtained from the Health Department of Golestan University of Medical Sciences. There are 22 comprehensive health centres in Gorgan, and nine were selected by a simple random method. After visiting the comprehensive health service centres, introducing herself and providing explanations about the objectives of the research, the researcher checked the electronic files of the families with adolescents, called them and explained the research objectives. An effort was made to get their opinion on participating. They were also assured that their information would remain confidential in this research. Written informed consent was signed by all participants and demographic characteristics were filled out by teenagers.
Statistical methods
The collected data was entered into SPSS V.22 software, and then analyses were performed and compared in two groups. Descriptive statistical methods used in this study include frequency distribution tables, means and SD. In the descriptive statistics section, an independent t-test and a Mann-Whitney test were used to check the difference in quantitative variables between the two groups. The multivariate analysis of covariance was used to control for confounding and estimate the OR and 95% CI. The level of statistical significance in this study was considered to be 0.05.
Patient and public involvement
Patients were not involved in this study.
Results
The flow diagram of the study is shown in figure 1. 550 adolescents were assessed for eligibility, and finally, 400 teenagers were included in this study. The mean age of participants was 19.16±3.18. The demographic characteristics of participants are shown in table 1. The results of the independent t-test showed that the group with PCOS has significantly more weight, height and interval between two periods than the non-affected group (p<0.05), but their menstrual duration is significantly shorter than the other group (p<0.05), even after adjusting for other characteristic variables.
Flow diagram of the study. CONSORT, Consolidated Standards of Reporting Trials; PCOS, polycystic ovary syndrome.
Demographic characteristics in two groups of adolescents with and without PCOS and a logistic regression analysis of the study factors related to PCOS
The average calorie intake and physical activity in the two groups are shown in table 2. Based on the independent t-test, the calorie intake in the PCOS group was significantly higher, and the daily physical activity was lower than the control group (p=0.001). After adjusting for various characteristics of teenagers (age, weight, height, BMI, menarche, group (PCOS/control), interval between two mensurations and length of menstruation), multivariate analysis revealed that the OR for calorie intake and daily physical activity in the two groups was 3.54 (95% CI 1.98 to 3.82) and 2.61 (95% CI 1.31 to 3.76), respectively.
Distribution of daily physical activity and calorie intake among adolescents with and without PCOS
The distribution of eating habits and patterns among teenagers with and without PCOS based on the Adami and Quadra questionnaires is shown in table 3. Based on the findings of this table, among teenagers with PCOS compared with non-sufferers, unhealthy eating habits are more frequent, like skipping one of the daily meals to lose weight, the tendency to eat snacks in the evening, the tendency to consume more food at lunch than dinner and the tendency to watch TV while eating.
Distribution of eating habits among teenagers with and without PCOS based on the Adami and Quadra Questionnaire
Discussion
The present study was conducted to compare the nutritional status and physical activity among adolescents with and without PCOS. The findings of this study showed that there is a statistically significant difference in terms of average height, weight and menstrual status between the two groups. The findings of this study in this section were consistent with the findings of Hashimpour et al,22 Kaewnin et al,23 Desai et al,24 and Pourhosseini et al,25. Among these, there were two studies whose results in the menstrual status section were different from the results of the present study. The groups with PCOS had menstrual intervals and durations within the normal range and did not differ from non-sufferers,26 27 which of course may be due to the difference in the frequency of participants (early adolescence and less diagnosis of this disorder) and the racial differences between the participants of the two studies.
Also, the results of the present study showed that the amount of physical activity in the group of PCOS was unfavourable, and it was significantly different from the non-affected group. In line with the results of the present study, the study of Shayan et al reported a direct relationship between regular daily exercise and the reduction of symptoms of this syndrome. So aerobic and regular daily exercise for 36 min was associated with a decrease in the incidence of this syndrome.28
The results of the present study were consistent with the results of the study by Huang et al and Saremi et al regarding the effect of physical activity on PCOS.29 30 The systematic study by Patten et al emphasised the importance of exercise for patients with PCOS.31 Therefore, exercise is probably effective in regulating sex hormones (follicle-stimulating hormone and free testosterone) and improving the complications of PCOS.32 By reducing body fat and increasing the secretion of a beta-endorphin hormone, exercise reduces the level of LH and, as a result, decreases testosterone.33 The protective effect of regular exercise against diseases such as cardiovascular diseases, type 2 diabetes and breast and colon cancers is well established.34 The anti-inflammatory effect of regular exercise may mediate the beneficial effect of exercise on health in individuals,35 thus improving PCOS. But unlike the results of the present study, the results of Lin et al’s study showed that there is no relationship between physical activity and PCOS.36 Among the reasons for the difference between the results of the studies, we can mention the difference in the sample size, the difference in the tools used and the difference in the threshold of exercise to produce an effect on PCOS.
According to the results of the present study, there is a significant difference in the calories consumed by the two groups. The average calorie intake in the PCOS group is higher than that of healthy teenagers. However, Kulshreshtha et al showed that the intake of calories in women with PCOS does not differ from that of healthy women if their weight is adjusted, and the difference between the two groups is in the consumption of junk and low-fibre foods in the affected group.37 Also, the results of Panjeshahin et al’s study showed that high fat intake from total calories (especially saturated fat and cholesterol) could increase the occurrence of this syndrome.38
The present study also examined the eating patterns of adolescents with and without PCOS. Our study showed that abnormal eating patterns are more common in adolescents with PCOS than in healthy adolescents. In line with the present study, Hajivandi et al showed in their qualitative study that Iranian adolescents with PCOS have a greater tendency to consume high-fat, salty, sweet foods and unhealthy snacks.39
According to the result of Jakubowicz et al’s study, getting high calories at breakfast along with reducing dinner helps improve insulin resistance and reduce the activity of inflammatory factors, which improves hyperandrogenism and speeds ovulation40, which is in line with our study. A systematic review reported that women with PCOS had lower adherence to appropriate dietary patterns and lower consumption of major food groups (grains, fruits, vegetables, proteins, seeds, nuts and dairy).41
Limitations and strengths of the study
The limitations of the research can be the non-cooperation of students with the researchers to be present in the sampling environment due to being at school and interfering with the working hours of the clinic, the lack of cooperation of parents and the strictness of the education system for the presence of researchers in the school. This work was done on teenagers for the first time and served as a screening method, and many teenagers became aware of their disease for the first time.
Conclusion
The results of the present study showed that physical activity status, nutritional patterns and the number of calories consumed are different between adolescents with PCOS and those without. The results of this study revealed that unhealthy eating patterns and insufficient physical activity are more common among adolescents with this syndrome. It is suggested that by improving the level of awareness of teenagers in this field and providing the necessary training, we take steps for the prevention and treatment of the complications caused by this syndrome in teenagers.
Data availability statement
Data are available upon reasonable request from the coresponding author.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants. The present study is the result of a dissertation for a master’s degree in midwifery approved by the Tehran University of Medical Sciences with an ethics code of IR.TUMS.FNM.REC.1400.190. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The author would like to thank and appreciate all the professors and research vice counsellors of the University of Tehran and Gorgan, the officials of health centres and dear adolescents who participated in this study.
References
Footnotes
Contributors Elham Ebrahimi and Sepideg Rezaei Ghamsari equally contributed to the conception and design of the research. Elham Ebrahimi and Sepideg Rezaei Ghamsari contributed to the acquisition and analysis of the data. Elham Ebrahimi and Bibihajar Zahmatkesh contributed to the interpretation of the data. Elham Ebrahimi and Shahla Faal Siahkal drafted the manuscript. All authors critically revised the manuscript, agreed to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.
Funding This work was supported by the Tehran University of medical sciences (TUMS) under Grant number 40011151002.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.