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Cited by 88Ovarian function and disordersDiabetes, Cardiovascular Risks, and LipoproteinsDiet, Metabolism, and Disease

PCOS and nutritional approaches: Differences between lean and obese phenotype

Open access
Barrea, Luigi, Frias-Toral, Evelyn, Verde, Ludovica, Ceriani, Florencia, Cucalón, Gabriela, Garcia-Velasquez, Eloisa, Moretti, Dino, Savastano, Silvia +2 more·2021·Metabolism Open
DOI 10.1016/j.metop.2021.100123PMC PMC8479825
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Abstract

Polycystic Ovary Syndrome (PCOS) is an endocrine/metabolic disorder with an ever-increasing prevalence. It has various clinical characteristics; the cardinals are androgen excess, oligo-anovulatory infertility, polycystic ovaries, insulin resistance (IR), and cardiometabolic alterations. These disturbances are a consequence of PCOS's complex etiology. PCOS is mainly related to women with obesity; however, there are many PCOS lean patients too. Even though they share some aspects in their metabolic profiles, each group has individual differences in body composition and other parameters. Thus, in order to achieve successful therapeutic strategies, they should be tailored to these details. The authors reviewed PubMed's updated and related publications about body composition and nutritional strategies for PCOS lean and obese patients. As previous reports have determined, dietary patterns are essential in PCOS treatment. Several diets have been studied to control and improve IR, infertility, and cardiometabolic dysfunctions in PCOS. This review will explain the specific features in metabolic characterization and body composition among these patients. Finally, the diverse nutritional strategies used in women with PCOS will be analyzed depending on their lean or obese phenotype.

AI snapshot

Written from the paper’s full text.

TL;DR

This narrative review compares metabolic/body-composition features and nutritional approaches in lean versus obese PCOS phenotypes. It concludes that treatment should be phenotype-tailored: weight loss of at least 5–10% for obese PCOS, weight maintenance plus nutrient adequacy for lean PCOS, with the Mediterranean diet proposed as a favorable anti-inflammatory pattern.

Key findings

  • PCOS prevalence is estimated at 10–15% worldwide; obesity is reported in 25–70% of women with PCOS, but a significant proportion have normal BMI (≤25 kg/m²). Lean and obese PCOS share hyperandrogenemia, insulin resistance, oxidative stress, and chronic inflammation, and non-obese PCOS may carry metabolic risk similar to obese PCOS because of similar visceral adipose tissue (Satyaraddi et al.: 81 patients, 42 obese and 39 non-obese).
  • Nutritional goals differ by phenotype: obese PCOS should target weight loss of at least 5–10%, while lean PCOS should maintain weight and ensure adequate vitamins/minerals. The Mediterranean diet is highlighted for anti-inflammatory effects and association with decreased body weight; other studied diets include low saturated fat weight-loss, low GI, KEMEPHY, and very low carbohydrate diets.
  • In the reviewed dietary studies, Marsh et al. found low-GI versus healthy diet produced greater improvement in insulin sensitivity, lower fibrinogen, and improved menstrual regularity; Paoli et al. reported KEMEPHY in 14 PCOS women reduced BMI from 28.84 to 25.49 kg/m² with 9.43 kg weight loss; Le Donne et al. reported weight losses of 8.1, 8.5, and 9.8 kg for diet only, diet plus myo-inositol, and diet plus myo-inositol plus D-chiro-inositol, respectively.
  • Vitamin D supplementation may improve reproductive function, glucose metabolism, and lipid profile in PCOS; 25(OH)D is described as an independent predictor of total fat mass, and a suggested intake of 600–800 IU/day depending on age and gender is mentioned. Inositol stereoisomers are used to improve insulin resistance and reduce CVD risk factors, and bariatric surgery in severe obesity improved androgen levels, menstrual cycles, insulin sensitivity, and blood pressure.

Methods

  • Narrative review of updated and related PubMed publications about body composition and nutritional strategies for lean and obese patients with PCOS.
  • The paper discusses Rotterdam 2003 diagnostic criteria, body-composition assessment methods (CT, MRI, DEXA), and includes a table of reviewed studies assessing different dietary compositions in PCOS.
  • No systematic review, meta-analysis, or formal risk-of-bias methodology is stated.

Limitations

  • The paper states there is still no consensus on the best nutritional treatment for PCOS, the exact dietary macro- and micronutrient combination needed is undetermined, and more robust evidence and randomized trials are needed, especially for vitamin D. It also notes a lack of evidence on lifestyle intervention effects on glucose tolerance, lipid profiles, and clinical reproductive outcomes such as quality of life and treatment satisfaction.
  • Evident from the text: this is a narrative review rather than a systematic review, and several cited dietary studies are small or heterogeneous (e.g., n=14 in Paoli et al.; n=43 in Le Donne et al.), limiting generalizability.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.metop.2021.100123

Cites

78 of 78 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 118 cited sources checked · 0 supported · 0 flagged

  • Findingnone given

    An increase in the frequency of body weight control methods has been observed in obese women who have undergone bariatric surgery.

    “Notably, an increase in the frequency of body weight control methods has been observed, so health personnel must evaluate this aspect in their follow-up visits.”
    Quote in the paperNot a substantial claim
  • Findingnone given

    Some of these diets achieved significant weight loss in obese PCOS patients.

    “Some of them have reached a significant weight loss in those PCOS obese patients.”
    Quote in the paperSubstantial claim
  • Premisecitation

    Androgens promote visceral fat accumulation and IR by inhibiting lipolysis and promoting lipogenesis.

    “In turn, androgens promote visceral fat accumulation and IR by inhibiting lipolysis and promoting lipogenesis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] Rosenfield, 2016, The pathogenesis of polycystic ovary syndrome (PCOS): the hypothesis of PCOS as functional ovarian hyperandrogenism revisited, Endocr Rev source

      Not checked in the free run.

  • Premisecitation

    A primary alteration in β-cell function has been suggested as a weight-independent pathophysiological component in women with PCOS.

    “A primary alteration in β-cell function has been suggested as a weight-independent pathophysiological component in women with PCOS [41].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] Messer, 2012, Pancreatic β-cell dysfunction in polycystic ovary syndrome: the role of metformin, Endocr Pract source

      Not checked in the free run.

  • Interpretationcitation

    Excess body fat may be an essential determinant of IR in PCOS.

    “This finding supports the hypothesis that excess body fat may be an essential determinant of IR in PCOS [35].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] Tosi, 2015, Total body fat and central fat mass independently predict insulin resistance but not hyperandrogenemia in women with polycystic ovary syndrome, J Clin Endocrinol Metab source

      Not checked in the free run.

  • May combine two claims. 40
  • Classified as probably not a substantial claim. 21
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingnone given

    In obese women who have undergone bariatric surgery, improvements in androgen levels, menstrual cycles, insulin sensitivity, and blood pressure have been found.

    “In obese women who have undergone bariatric surgery, an improvement has been found by reducing androgen levels and menstrual cycles, insulin sensitivity, and blood pressure.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Vitamin D signaling through the vitamin D receptor improves insulin receptor mRNA genomic input, initiating insulin synthesis and discharge and restraining pro-inflammatory cytokines related to IR pathogenesis.

    “The insulin receptor mRNA genomic input is improved by Vitamin D signaling through vitamin D receptor (VDR) [47]. This action initiates insulin synthesis and discharge. It also restrains some pro-inflammatory cytokines directly related to the IR pathogenesis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] Barrea, 2021, Vitamin D in obesity and obesity-related diseases: an overview, Minerva Endocrinol (Torino)

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Obese and lean women with PCOS, compared with controls, are metabolically worse and have more visceral adiposity.

    “A study by Satyaraddi et al. shows that obese and lean women with PCOS, compared to the control group, are metabolically worse and have more visceral adiposity”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Satyaraddi, 2019, Body composition, metabolic characteristics, and insulin resistance in obese and nonobese women with polycystic ovary syndrome, J Hum Reprod Sci source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Non-obese PCOS presents a metabolic risk similar to that of obese PCOS because they have a similar amount of visceral adipose tissue.

    “concluding that non-obese PCOS presents a metabolic risk similar to that of obese patients because they present a similar amount of visceral adipose tissue [12].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Satyaraddi, 2019, Body composition, metabolic characteristics, and insulin resistance in obese and nonobese women with polycystic ovary syndrome, J Hum Reprod Sci source

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  • May combine two claims. The quote only partly states this claim.

    Premisecitation

    Satyaraddi et al. in a case-control study with 81 patients with PCOS (42 obese and 39 non-obese) using DEXA concluded that both obese and non-obese women with PCOS, compared to age controls with the same BMI, were metabolically worse and had more visceral adiposity.

    “Satyaraddi et al. in a case-control study with 81 patients with PCOS (42 obese and 39 non-obese), evaluated the disposition of fat using DEXA and concluded that both obese and non-obese women”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Satyaraddi, 2019, Body composition, metabolic characteristics, and insulin resistance in obese and nonobese women with polycystic ovary syndrome, J Hum Reprod Sci source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Low saturated fat weight-loss diet, low GI diet, KEMEPHY diet, and very low carbohydrate diet have been studied in PCOS.

    “Other diets that have been studied are the low saturated fat weight-loss diet, low GI diet [16], the ketogenic Mediterranean with phytoextracts (KEMEPHY) diet [17], and the very low carbohydrate diet.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [16] Marsh, 2010, Effect of a low glycemic index compared with a conventional healthy diet on polycystic ovary syndrome, Am J Clin Nutr source

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    • cites [17] Paoli, 2020, Effects of a ketogenic diet in overweight women with polycystic ovary syndrome, J Transl Med source

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  • May combine two claims.

    Premisecitation

    PCOS occurs in lean women as well as in obese women.

    “It is important to note that PCOS is not exclusive to obese women; it also occurs in lean women.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Satyaraddi, 2019, Body composition, metabolic characteristics, and insulin resistance in obese and nonobese women with polycystic ovary syndrome, J Hum Reprod Sci source

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    Premisecitation

    Insulin hypersecretion is the probable underlying mechanism in PCOS and is present in both lean and obese subjects.

    “Insulin hypersecretion is the probable underlying mechanism in this scenario, present in both lean and obese subjects [42].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [42] Vrbíková, 2002, Insulin sensitivity and beta-cell function in women with polycystic ovary syndrome, Diabetes Care source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Faghfoori et al. recommend a dietary treatment that impacts IR control and metabolic functions through a hypocaloric diet, low simple sugars and refined carbohydrates, and promotion of low glycemic index foods.

    “according to Faghfoori et al., it is recommended to carry out a dietary treatment that has an impact on the control of IR, metabolic functions from a hypocaloric diet, with a low contribution of simple sugars and refined carbohydrates, promoting the intake of foods with a low glycemic index (GI) [14].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Faghfoori, 2017, Nutritional management in women with polycystic ovary syndrome: a review study, Diabetes Metab Syndr source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Adiponectin expression is down-regulated by obesity.

    “It has been proposed that adiponectin expression is down-regulated by obesity [43].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43] Stefan, 2002, Adiponectin--its role in metabolism and beyond, Horm Metab Res source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Reduction of saturated and trans fatty acid intake is sought, and attention should be paid to possible deficiencies such as vitamin D, chromium, and omega-3.

    “Likewise, the reduction of the contribution of saturated and trans fatty acids will be sought, and attention should be paid to possible deficiencies such as vitamin D, chromium, and omega-3 [14].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Faghfoori, 2017, Nutritional management in women with polycystic ovary syndrome: a review study, Diabetes Metab Syndr source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Mediterranean diet can be an adequate dietary treatment for PCOS due to its anti-inflammatory effect and its relationship with decrease in body weight.

    “it has been postulated that the Mediterranean diet (MD) can be an adequate dietary treatment for PCOS due to its anti-inflammatory effect and its relationship with the decrease in body weight [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Barrea, 2019, Adherence to the Mediterranean diet, dietary patterns and body composition in women with polycystic ovary syndrome (PCOS), Nutrients source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisenone given

    Environmental factors such as eating habits play an essential role in preventing and treating women with PCOS.

    “It seems clear that environmental factors such as eating habits play an essential role in preventing and treating women with PCOS.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    The obese phenotype of PCOS differs from the lean phenotype based on BMI being above or below the normal limit for age and ethnicity.

    “In practice and research studies, the obese phenotype of PCOS differs from lean based on BMI, that is, if it is above or below, respectively, the limit considered normal for age and ethnicity [30].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [30] Toosy, 2018, Lean polycystic ovary syndrome (PCOS): an evidence-based practical approach, J Diabetes Metab Disord source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    A healthy diet with adequate distribution of macronutrients seems to be a good option for PCOS.

    “a healthy diet with adequate distribution of macronutrients seems to be a good option [15].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] González, 2020, Inflammation triggered by saturated fat ingestion is linked to insulin resistance and hyperandrogenism in polycystic ovary syndrome, J Clin Endocrinol Metab source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Non-obese women with PCOS have lower insulin levels and IR associated with higher levels of sex hormone-binding globulin, but hyperinsulinemia remains a common finding.

    “While non-obese women have lower insulin levels and IR [38] associated with higher levels of sex hormone-binding globulin [39], hyperinsulinemia remains a common finding in this population [40].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [38] Unluer, 2013, Comparison of HbA1c levels in obese and non-obese polycystic ovarian patients, Clin Exp Obstet Gynecol

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    • cites [39] Silfen, 2003, Early endocrine, metabolic, and sonographic characteristics of polycystic ovary syndrome (PCOS): comparison between nonobese and obese adolescents, J Clin Endocrinol Metab source

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    • cites [40] Dahan, 2019, Relationship among obesity, insulin resistance, and hyperinsulinemia in the polycystic ovary syndrome, Endocrine source

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  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    International recommendations indicate that weight control is one of the main treatment strategies for PCOS because obesity worsens the clinical presentation of the syndrome.

    “International recommendations indicate that weight control is one of the main treatment strategies for PCOS since obesity worsens the clinical presentation of this syndrome [13].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Teede, 2018, Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome, Hum Reprod source

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  • May combine two claims.

    Interpretationcitation

    Low adiponectin levels in PCOS are likely related to IR, but not to testosterone.

    “Low adiponectin levels in PCOS are likely related to IR, but not testosterone [44].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [44] Toulis, 2009, Adiponectin levels in women with polycystic ovary syndrome: a systematic review and a meta-analysis, Hum Reprod Update source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    More elevated adhesion to the Mediterranean diet is related to larger Phase Angle as evidence of cell stability, a positive effect of MD on PCOS.

    “Also, a more elevated adhesion to the MD related to larger Phase Angle has been published as evidence of cell stability, as another positive effect of MD on PCOS [19].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Barrea, 2017, Mediterranean diet and Phase Angle in a sample of adult population: results of a pilot study, Nutrients source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Beyond obesity, metabolic abnormalities in PCOS include dyslipidemias, IR, hyperinsulinemia, and glucose intolerance.

    “Beyond obesity, the metabolic abnormalities found in PCOS include dyslipidemias, IR, hyperinsulinemia, and glucose intolerance [36].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] Vryonidou, 2015, Mechanisms IN endocrinology: metabolic syndrome through the female life cycle, Eur J Endocrinol source

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  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    This type of inflammation and hyperandrogenism are linked to saturated fat.

    “This type of inflammation and hyperandrogenism are linked to saturated fat.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Hyperinsulinemia affects the ovary selectively, which persists insulin sensitive, while liver and skeletal muscle evidence IR.

    “Hyperinsulinemia affects the ovary selectively, which persists insulin sensitive, while liver and skeletal muscle evidence IR.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Premisenone given

    Androgens oppose the effects of insulin on subcutaneous fat stores, while hyperandrogenemia promotes the accumulation of visceral fat.

    “Androgens oppose the effects of insulin on subcutaneous fat stores, while hyperandrogenemia promotes the accumulation of visceral fat.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Higher adherence to the Mediterranean diet has been proven effective in preserving skeletal muscle mass in healthy women, likely due to anti-inflammatory and antioxidant properties of micronutrients or their direct role in muscle metabolism.

    “Higher adherence to this nutritional approach has also been proven to be effective in preserving the skeletal muscle mass in healthy women, likely due to the potential anti-inflammatory and antioxidant properties of micronutrients or through their direct role in muscle metabolism and physiology, such as with magnesium and potassium [56].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [56] Barrea, 2019, Association between Mediterranean diet and hand grip strength in older adult women, Clin Nutr source

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  • May combine two claims.

    Premisecitation

    Obesity is reported in 25-70% of women with PCOS, but a significant proportion of patients have PCOS despite having a normal BMI (≤25 kg/m2).

    “Obesity is reported in 25–70% of women with PCOS, but a significant proportion of patients have it despite having a normal BMI (≤25 kg/m2) [36].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] Vryonidou, 2015, Mechanisms IN endocrinology: metabolic syndrome through the female life cycle, Eur J Endocrinol source

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  • May combine two claims.

    Premisecitation

    Marsh et al. 2010 found that a low-GI diet versus a healthy diet in PCOS produced greater improvement in insulin sensitivity, lower fibrinogen, and improved menstrual regularity, with no significant differences in other outcomes.

    “Low-GI vs healthy diet: Greater improvement in insulin sensitivity, lower fibrinogen, improved menstrual regularity.No significant differences in other outcomes”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [16] Marsh, 2010, Effect of a low glycemic index compared with a conventional healthy diet on polycystic ovary syndrome, Am J Clin Nutr source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Lean PCOS women had more diminished HDL and HDL2 levels than women with normal ovarian function, while obese PCOS individuals also presented increased triglyceride levels.

    “Lean PCOS women had more diminished HDL and HDL2 levels than their counterparts with normal ovarian function, while obese PCOS individuals also presented increased triglyceride levels [53].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [53] Diamanti-Kandarakis, 2007, Pathophysiology and types of dyslipidemia in PCOS, Trends Endocrinol Metabol source

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  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisereasoning

    Visceral fat gives more IR than subcutaneous abdominal fat due to its increased lipolytic response to catecholamines.

    “Due to its increased lipolytic response to catecholamines, visceral fat gives more IR than subcutaneous abdominal fat.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Most studies report a decrease in HDL cholesterol and an increase in triglyceride levels in PCOS, the same lipid profile associated with IR.

    “Most studies report a decrease in HDL cholesterol and an increase in triglyceride levels, the same lipid profile that is known to be associated with IR.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    A lipid-stimulated proinflammatory status may cause the characteristic IR, hyperandrogenism, and dyslipidemia frequently found in PCOS women.

    “A lipid-stimulated proinflammatory status may cause the characteristic IR, hyperandrogenism, and dyslipidemia frequently found in PCOS women.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Premisenone given

    Inflammation and IR are often associated with PCOS.

    “As stated before, inflammation and IR are often associated with PCOS.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Paoli et al. 2020 found that the KEMEPHY diet in PCOS improved testosterone, DHEAs, LH, and FSH, with weight loss of 9.43 kg and BMI at the end of intervention of 25.49 kg/m2.

    “Improvement in levels:Testosterone, DHEAs, LH, FSH.Weight loss: 9,43 kgBMI at the end of intervention: 25,49 kg/m2”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] Paoli, 2020, Effects of a ketogenic diet in overweight women with polycystic ovary syndrome, J Transl Med source

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  • May combine two claims.

    Premisecitation

    Excessive weight has a significant impact on the PCOS phenotype because it is associated with a greater prevalence of menstrual and hormonal irregularity, and hirsutism.

    “Also, excessive weight has a significant impact on the PCOS phenotype since it is associated with a greater prevalence of menstrual and hormonal irregularity, and hirsutism [1].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] Orio, 2016, Obesity, type 2 diabetes mellitus and cardiovascular disease risk: an uptodate in the management of polycystic ovary syndrome, Eur J Obstet Gynecol Reprod Biol source

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  • May combine two claims.

    Premisecitation

    Le Donne et al. 2019 found that diet alone, diet plus MI, and diet plus inositols in PCOS produced weight loss of 8.1, 8.5, and 9.8 kg respectively and significant fat mass lost for group 1.

    “Weight loss: 8.1, 8.5 and 9.8 kg for Group 1,2,3 respectively and significant fat mass lost for Group 1”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [64] Moran, 2013, Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines, J Acad Nutr Diet source

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  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing). May combine two claims.

    Premisecitation

    Decreased vitamin D levels and IR are independent body size characteristics in PCOS patients.

    “Some publications state that decreased vitamin D levels and IR are independent body size characteristics in PCOS patients.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [48] Muscogiuri, 2012, Low levels of 25(OH)D and insulin-resistance: 2 unrelated features or a cause-effect in PCOS?, Clin Nutr source

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    • cites [49] Davis, 2019, Associations between vitamin D levels and polycystic ovary syndrome phenotypes, Minerva Endocrinol source

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    • cites [54] Frias-Toral, 2021, Polycystic ovary syndrome and obesity: clinical aspects and nutritional management, Minerva Endocrinol (Torino)

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  • May combine two claims.

    Premisecitation

    In the general population, low-calorie diets with fat modifications, Mediterranean diet, ketogenic diet, and reduction in dietary GI in addition to overall calorie reduction to induce weight loss may have a positive effect on IR.

    “In the general population, research evaluating the effects of varying dietary recommendations differs from low-calorie diets with fat modifications, MD, ketogenic diet (KD) and reduction in the dietary GI in addition to overall calorie reduction to induce weight loss may have a positive effect on IR (Table 1) [64,65].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [64] Moran, 2013, Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines, J Acad Nutr Diet source

      Not checked in the free run.

    • cites [65] Muscogiuri, 2016, Current insights into inositol isoforms, Mediterranean and ketogenic diets for polycystic ovary syndrome: from bench to bedside, Curr Pharmaceut Des source

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  • May combine two claims.

    Premisereasoning

    In the ovary, hyperinsulinism cooperates with LH to up-regulate androgen generation, causing premature luteinization of granulosa cells and complicating hyperandrogenism.

    “In the ovary, hyperinsulinism cooperates with LH to up-regulate androgen generation. These effects cause premature luteinization of granulosa cells complicating hyperandrogenism.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Nutrition is a major modifiable environmental risk factor for several non-communicable diseases and plays an essential role in their prevention and initial treatment.

    “Nutrition is one of the major modifiable environmental risk factors for several non-communicable diseases and plays an essential role in their prevention and initial treatment [56].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [56] Barrea, 2019, Association between Mediterranean diet and hand grip strength in older adult women, Clin Nutr source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Lifestyle intervention improves body composition, hyperandrogenism, and IR in women with PCOS.

    “Lifestyle intervention has been helpful as it improves body composition, hyperandrogenism, and IR in women with PCOS.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [63] Goyal, 2017, Debates regarding lean patients with polycystic ovary syndrome: a narrative review, J Hum Reprod Sci source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Dyslipidemia is probably the most common metabolic disorder in PCOS, detected in 70% of patients according to NCEP guidelines.

    “Dyslipidemia is probably the most common metabolic disorder in PCOS detected in 70% of patients according to the National Cholesterol Education Program (NCEP) guidelines [52].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [52] Jacewicz-Święcka, 2020, Changes in metabolic profile in the women with a history of PCOS-A long-term follow-up study, J Clin Med source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The common denominator in PCOS seems to be ovarian hyperandrogenism, with IR and consequent hyperinsulinemia as a nonessential but common aggravating factor.

    “The common denominator in PCOS seems to be OH, with IR and consequent counterbalancing hyperinsulinemia, a nonessential but common aggravating factor in this pathophysiology.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Excessive adiposity in PCOS is associated with increased IR rates, resulting in aggravation of reproductive and metabolic abnormalities.

    “Excessive adiposity in PCOS is associated with increased IR rates, resulting in reproductive and metabolic abnormalities aggravation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Bariatric surgery changes PCOS complications such as ovulation rates, menstrual regularity, CVD, decreasing waist circumference, and total fat mass.

    “Bariatric surgery does appear to change the PCOS complications such as ovulation rates, menstrual regularity, CVD, decreasing waist circumference, and total fat mass.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [72] Broughton, 2017, Obesity and female infertility: potential mediators of obesity's impact, Fertil Steril source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the last couple of years, the women population presented lower intake of energy-dense nutrient-poor foods and soda drinks, and higher intake of fruits and legumes, thus higher adherence to the Mediterranean diet that could support a therapeutic role of the dietary pattern on PCOS.

    “In the last couple of years, there has been observed that women population presented lower intake of energy-dense nutrient-poor foods and soda drinks, and higher intake of fruits and legumes thus higher adherence to the MD that could support a therapeutic role that has the dietary pattern on PCOS [8,56].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [8] Barrea, 2019, Adherence to the Mediterranean diet, dietary patterns and body composition in women with polycystic ovary syndrome (PCOS), Nutrients source

      Not checked in the free run.

    • cites [56] Barrea, 2019, Association between Mediterranean diet and hand grip strength in older adult women, Clin Nutr source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Inositol stereoisomers (MYO-INS and DCI) are used for treatment of PCOS by improving insulin resistance and reducing CVD risk factors.

    “The stereoisomers of inositol such as Myo-inositol (MYO-INS) and D-chiro-inositol (DCI) are currently being used for the treatment of PCOS by improving IR and reducing CVD risk factors [51,76]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [51] Muscogiuri, 2016, Low 25 (OH) vitamin D levels are associated with autoimmune thyroid disease in polycystic ovary syndrome, Endocrine source

      Not checked in the free run.

    • cites [76] Muscogiuri, 2016, Inositols in the treatment of insulin-mediated diseases, Int J Endocrinol

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Physical exercise decreases waist circumference, weight, and total fat mass in women with PCOS.

    “decreasing waist circumference, weight, and total fat mass making exercise a positive non-pharmacological lifestyle change for PCOS [70]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [70] De Lima Nunes, 2019, Lifestyle interventions and quality of life for women with polycystic ovary syndrome: a systematic review and meta-analysis protocol, Medicine (Baltimore) source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Weight loss by 5-10% can improve insulin and testosterone levels and improve menstrual hormones.

    “Weight loss, by 5–10%, can improve insulin and testosterone levels and improve menstrual hormones [64,68].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [64] Moran, 2013, Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines, J Acad Nutr Diet source

      Not checked in the free run.

    • cites [68] Muscogiuri, 2021, Nutritional guidelines for the management of insulin resistance, Crit Rev Food Sci Nutr

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    IR, dyslipidemia, and hyperandrogenism might result from a lipid-induced pro-inflammatory state.

    “A healthy dietary pattern with satisfactory macronutrient distribution is essential in these patients since IR, dyslipidemia, and hyperandrogenism might result from a lipid-induced pro-inflammatory state.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    International guidelines for assessing and managing PCOS (2018) recommend variations in intensity and time of exercise as a lifestyle change to improve overall health in individuals with PCOS.

    “International guidelines for assessing and managing PCOS (2018) indicate that variations on intensity and time of exercise are recommended as a lifestyle change to improve overall health in individuals with PCOS [73]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [73] Pani, 2020, From prediabetes to type 2 diabetes mellitus in women with polycystic ovary syndrome: lifestyle and pharmacological management, Internet J Endocrinol

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    The Mediterranean diet (MD) leads to better results in PCOS individuals because of its anti-inflammatory effect and its relationship with decreased body weight.

    “However, the MD has been proposed as a possible eating guide that leads to better results in PCOS individuals because of its anti-inflammatory effect and its relationship with decreased body weight.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Vitamin D supplementation in women with PCOS improves reproductive function, glucose metabolism, and lipid profile.

    “Intervention studies of vitamin D supplementation in women with PCOS have shown improvements in reproductive function, glucose metabolism, and lipid profile by improving reproductive function [48,61,74,75]”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [48] Muscogiuri, 2012, Low levels of 25(OH)D and insulin-resistance: 2 unrelated features or a cause-effect in PCOS?, Clin Nutr source

      Not checked in the free run.

    • cites [61] Muscogiuri, 2014, Mechanisms in endocrinology: vitamin D as a potential contributor in endocrine health and disease, Eur J Endocrinol source

      Not checked in the free run.

    • cites [74] Muscogiuri, 2017, Vitamin D and chronic diseases: the current state of the art, Arch Toxicol source

      Not checked in the free run.

    • cites [75] Karamali, 2017, Effects of calcium, vitamins D and K co-supplementation on markers of insulin metabolism and lipid profiles in vitamin D-deficient women with polycystic ovary syndrome, Exp Clin Endocrinol Diabetes source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Physical exercise improves ovulation rates, menstrual regularity, and cardiovascular disease (CVD) in women with PCOS.

    “Physical exercise has been shown to improve several factors related to PCOS such as ovulation rates, menstrual regularity, CVD [9]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Orio, 2016, Oral contraceptives versus physical exercise on cardiovascular and metabolic risk factors in women with polycystic ovary syndrome: a randomized controlled trial, Clin Endocrinol (Oxf). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In women with PCOS who underwent laparoscopic bypass, androgen levels, menstrual cycles, insulin sensitivity, and blood pressure improved.

    “A study of women with PCOS who underwent laparoscopic bypass, lowering androgen levels and menstrual cycles, insulin sensitivity, and blood pressure demonstrated that obesity significantly impacts the pathophysiology of obesity-related infertility [72].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [72] Broughton, 2017, Obesity and female infertility: potential mediators of obesity's impact, Fertil Steril source

      Not checked in the free run.

53 of 53

  • The paper relies on this without support.

    There is still no consensus on what is the best nutritional treatment for PCOS.

    “There is still no consensus on what is the best nutritional treatment for PCOS.”

  • The paper relies on this without support.

    The exact dietary macro- and micronutrient combination needed for a good nutritional plan to improve PCOS clinical characteristics is undetermined.

    “Nevertheless, the exact dietary macro and micronutrient combination needed for a good nutritional plan to improve PCOS clinical characteristics are undetermined.”

  • The paper relies on this without support.

    The specific dietary composition that should be implemented in obese PCOS remains controversial.

    “The specific dietary composition that should be implemented remains quite controversial, which can be considered a challenge for clinicians.”

  • The paper relies on this without support.

    25(OH)D levels are an independent predictor of total fat mass in PCOS patients.

    “25(OH)D levels are an independent predictor of total fat mass in PCOS patients.”

  • The paper relies on this without support.

    Vitamin D plays a role in various metabolic pathways, including glucose metabolism.

    “Vitamin D plays a role in various metabolic pathways, including glucose metabolism.”

  • The paper relies on this without support.

    Lack of 25(OH)D may cause inflammatory responses, thus worsening insulin resistance.

    “the lack of 25(OH)D may cause inflammatory responses, thus worsening IR.”

  • The paper relies on this without support.

    The indications for bariatric surgery are not different in women with PCOS (BMI ≥40 kg/m2 or ≥35 kg/m2 and severe morbidity presence).

    “The indications for bariatric surgery are not different in women with PCOS (BMI ≥40 kg/m2 or ≥35 kg/m2 and severe morbidity presence.”

  • The paper relies on this without support.

    The immunomodulatory role of vitamin D is well documented.

    “the immunomodulatory role is well documented”
8 of 8

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Most studies examining body composition in PCOS have relied on anthropomorphic measurements (BMI, waist circumference, waist-to-hip ratio) which are considered inaccurate compared with the current gold-standard of magnetic resonance imaging.

    “In addition, most of the studies examining body composition in PCOS have relied on anthropomorphic measurements (BMI, waist circumference, waist-to-hip ratio) which are considered inaccurate compared with the current gold-standard of magnetic resonance imaging [182].”

    From Polycystic Ovary Syndrome: An Evolutionary Adaptation to Lifestyle and the Environment (2022) · cites this paper as [182]

    Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • Studies comparing obese and lean women with PCOS have several methodological problems including small sample size, overlap of PCOS characteristics with normal pubertal changes, non-standardized diagnostic criteria, and limited generalizability due to a focus on a specific ethnic group.

    “Studies comparing obese and lean women with PCOS have several methodological problems including small sample size, overlap of PCOS characteristics with normal pubertal changes, non-standardized diagnostic criteria, and limited generalizability to the entire population due to a focus on a specific ethnic group [166,182].”

    From Polycystic Ovary Syndrome: An Evolutionary Adaptation to Lifestyle and the Environment (2022) · cites this paper as [182]

    The 'Nutritional approach to lean PCOS' section (page not provided) says that differences in diagnostic criteria across studies contribute to disparities in PCOS diagnosis. It does not identify overlap with normal pubertal changes, small sample sizes, or a focus on one ethnic group as general methodological problems in studies comparing lean and obese women. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Visceral WAT is associated with insulin resistance in women with PCOS leading to both metabolic and reproductive problems.

    “Visceral WAT is associated with IR in women with PCOS leading to both metabolic and reproductive problems [182].”

    From Polycystic Ovary Syndrome: An Evolutionary Adaptation to Lifestyle and the Environment (2022) · cites this paper as [182]

  • PCOS also occurs in women who are not obese and risk is related to visceral fat mass.

    “PCOS also occurs in women who are not obese and risk is related to visceral fat mass. 30 , 31”

    From Overweight, obesity and excessive weight gain in pregnancy as risk factors for adverse pregnancy outcomes: A narrative review (2022) · cites this paper as [31]

  • Reducing weight in women with PCOS can improve insulin resistance, hypertension, dyslipidemia, type 2 diabetes, and other related morbidities.

    “Reducing weight in women with PCOS can improve IR, hypertension, dyslipidemia, T2D, and other related morbidities, but ideal macronutrient distribution has not been standardized yet [1, 7, 11].”

    From Ketogenic Diet as Medical Prescription in Women with Polycystic Ovary Syndrome (PCOS) (2023) · cites this paper as [1]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Le Donne study is assigned the wrong reference number

    Minor

    Table 1 labels the Le Donne et al. 2019 study as reference [64], but reference [64] is a 2013 review by Moran et al. The Le Donne et al. 2019 study appears as reference [66].

  • Bariatric-surgery statement cites a ketogenic-diet study

    Minor

    The text attributes a 2017 gastric-surgery finding to reference [17], but that reference is a 2020 study of a ketogenic diet, not gastric surgery.

2 of 2

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2 of the 80 references couldn’t be matched to a known paper.

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Authors
Barrea, L., Frias-Toral, E., Verde, L., Ceriani, F., Cucalón, G., Garcia-Velasquez, E., Moretti, D., Savastano, S., Colao, A., & Muscogiuri, G.
Affiliations
  • Pegaso University (IT)
  • Federico II University Hospital (IT)
  • Universidad de la República de Uruguay (UY)
  • Escuela Superior Politecnica del Litoral (EC)
  • Kennedy Clinic Hospital (EC)
Corresponding author
Muscogiuri, Giovanna
ORCID
Venue
Metabolism Open
Publisher
Elsevier BV
Published
2021-12
Volume
12
Pages
100123
ISSN
2589-9368 (ISSN-L)
DOI
10.1016/j.metop.2021.100123
PMC
PMC8479825
OpenAlex
W3199299133
Cited by
86
References
80
Citations by year
2026: 16 · 2025: 18 · 2024: 23 · 2023: 15 · 2022: 11 · 2021: 3
FWCI
11.44
Type
journal article
Language
en
Open access
Licence
Locations
  • Metabolism Open (publishedVersion, cc-by-nc-nd)
  • Europe PMC (PubMed Central) (publishedVersion, other-oa)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diet, Metabolism, and Disease
Keywords
polycystic ovary syndrome, body composition, dietary intervention, dietary habits, insulin resistance, hyperandrogenism, cardiometabolic dysfunction, personalized treatment

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

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