Ethnicity, Obesity and the Prevalence of Impaired Glucose Tolerance and Type 2 Diabetes in PCOS: A Systematic Review and Meta-Regression
Open accessAbstract
BACKGROUND: Our prior meta-analyses demonstrated an increased prevalence of impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM) with polycystic ovary syndrome (PCOS), but with substantial clinical heterogeneity. OBJECTIVE AND RATIONALE: We aimed to update our previous review to quantify the prevalence of IGT and T2DM in PCOS with only quality studies (good and fair quality). We also aimed to examine the contribution of parameters including ethnicity, obesity and method of diagnosing T2DM in explaining the observed heterogeneity in IGT and T2DM prevalence in PCOS. SEARCH METHODS: We conducted a literature search (MEDLINE, CINAHL, EMBASE, clinical trial registries and hand-searching) up to June 2016 to identify studies reporting the prevalence of dysglycemia (IGT and T2DM) in women with and without PCOS. We included studies where women with PCOS (defined according to original National Institute of Health) were compared to women without PCOS for the end-points of the prevalence of IGT or T2DM. We excluded case reports, case series, editorials, and narrative reviews. Studies where PCOS was diagnosed by self-report, or where IGT or T2DM were measured by fasting glucose, only were excluded. We assessed the methodological quality of the included studies using a priori criteria based on the Newcastle-Ottawa Scaling (NOS) for non-randomized studies. Data are presented as odds ratio (OR) (95% CI) with random-effects meta-analysis by Mantel-Haenszel methods. We assessed the contribution of demographic and clinical factors to heterogeneity using subgroup and meta-regression analysis. OUTCOMES: We reviewed 4530 studies and included 40 eligible studies in the final analysis. On meta-analysis of quality studies, women with PCOS had an increased prevalence of IGT (OR = 3.26, 95% CI: 2.17-4.90) and T2DM (OR = 2.87, 95% CI: 1.44-5.72), which differed by ethnicity (for IGT, Asia: 5-fold, the Americas: 4-fold and Europe: 3-fold), was higher with obesity, and doubled among studies using self-report or administrative data for diagnosing diabetes. The ethnicity-related difference retained its significance for Asia and Europe in BMI-matched subgroups. Clear contributors to heterogeneity did not emerge in meta-regression. WIDER IMPLICATIONS: Our findings underscore the importance of PCOS as a cause of dysglycemia with a higher prevalence of IGT and T2DM. They support the relevance of ethnicity and obesity and emphasize the need for accurate diagnostic methods for diabetes. PROSPERO REGISTRATION NUMBER: CRD42017056524.
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PCOS is linked with increased prevalence of cardiometabolic risk factors, including dyslipidemia, hypertension, chronic inflammation, impaired glucose tolerance, and overweight and obesity.
“PCOS is linked with increased prevalence of cardiometabolic risk factors, including dyslipidemia [10,11,12,13], hypertension [13,14,15], chronic inflammation, and impaired glucose tolerance [16,17], as well as overweight and obesity [18,19].”
From Moving beyond Weight: A Narrative Review of the Dietary and Lifestyle Management for Reducing Cardiometabolic Risk in Polycystic Ovary Syndrome (PCOS) (2023) · cites this paper as [16]
Evidence suggests that PCOS is associated with greater risk of metabolic diseases such as type 2 diabetes in the long term.
“Notwithstanding their own perceptions of risk, evidence suggests that PCOS is associated with greater risk of metabolic diseases such as type 2 diabetes in the long term [117,118].”
From Providing lifestyle advice to women with PCOS: an overview of practical issues affecting success (2021) · cites this paper as [117]
Additional comorbidities can occur in adolescents with PCOS that might be independent of overweight status.
“Additional comorbidities can occur in adolescents with PCOS that might be independent of overweight status.”
From Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls (2019) · cites this paper as [211]
These comorbidities include impaired glucose tolerance and type 2 diabetes.
“These comorbidities include impaired glucose tolerance and type 2 diabetes [125, 126, 210, 211].”
From Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls (2019) · cites this paper as [211]
Women with polycystic ovary syndrome (PCOS) have an increased risk for impaired glucose tolerance (IGT).
“A meta-analysis from 2018 showed an increased risk for impaired glucose tolerance (IGT) and increased risk for type 2 diabetes mellitus (T2DM), with three times increased odds of IGT (Kakoly et al., 2018).”
From Type 2 diabetes mellitus in women with polycystic ovary syndrome during a 24-year period: importance of obesity and abdominal fat distribution (2020) · cites this paper as Kakoly et al., 2018
The increased risk for overt T2DM in women with PCOS is not significant when groups are matched for BMI.
“The risk for IGT was increased regardless of whether women with PCOS and controls were matched for BMI or not, while on the other hand, the increased risk for overt T2DM was not significant if the groups were matched for BMI (Kakoly et al., 2018).”
From Type 2 diabetes mellitus in women with polycystic ovary syndrome during a 24-year period: importance of obesity and abdominal fat distribution (2020) · cites this paper as Kakoly et al., 2018
The odds of impaired glucose tolerance are three times higher in women with PCOS.
“A meta-analysis from 2018 showed an increased risk for impaired glucose tolerance (IGT) and increased risk for type 2 diabetes mellitus (T2DM), with three times increased odds of IGT (Kakoly et al., 2018).”
From Type 2 diabetes mellitus in women with polycystic ovary syndrome during a 24-year period: importance of obesity and abdominal fat distribution (2020) · cites this paper as Kakoly et al., 2018
The increased risk for impaired glucose tolerance in women with PCOS is present regardless of whether women with PCOS and controls are matched for BMI.
“The risk for IGT was increased regardless of whether women with PCOS and controls were matched for BMI or not, while on the other hand, the increased risk for overt T2DM was not significant if the groups were matched for BMI (Kakoly et al., 2018).”
From Type 2 diabetes mellitus in women with polycystic ovary syndrome during a 24-year period: importance of obesity and abdominal fat distribution (2020) · cites this paper as Kakoly et al., 2018
Women with PCOS have an increased risk or prevalence of type 2 diabetes mellitus (T2DM).
“Women with PCOS have an increased prevalence of T2DM.”
From Type 2 diabetes mellitus in women with polycystic ovary syndrome during a 24-year period: importance of obesity and abdominal fat distribution (2020) · cites this paper as Kakoly et al., 2018
Only two studies in the 2018 meta-analysis examined women with a mean age above 50 years.
“Most of the studies included in the meta-analysis were cross-sectional and included mainly women around the age of 30 years and younger, and only two of the included studies examined women with a mean age above 50 years (Kakoly et al., 2018).”
From Type 2 diabetes mellitus in women with polycystic ovary syndrome during a 24-year period: importance of obesity and abdominal fat distribution (2020) · cites this paper as Kakoly et al., 2018
Most studies in the 2018 meta-analysis were cross-sectional and included mainly women around the age of 30 years and younger.
“Most of the studies included in the meta-analysis were cross-sectional and included mainly women around the age of 30 years and younger, and only two of the included studies examined women with a mean age above 50 years (Kakoly et al., 2018).”
From Type 2 diabetes mellitus in women with polycystic ovary syndrome during a 24-year period: importance of obesity and abdominal fat distribution (2020) · cites this paper as Kakoly et al., 2018
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Update on PCOS: consequences, challenges, and guiding treatment
Hoeger, K. M., Dokras, A., & Piltonen, T. (2021) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgaa839 · Cited by 610 · see citing works
Deconstructing a Syndrome: Genomic Insights Into PCOS Causal Mechanisms and Classification
Dapas, M., & Dunaif, A. (2022) · Endocrine Reviews · doi:10.1210/endrev/bnac001 · Cited by 300 · see citing works
Polycystic ovary syndrome and risk of type 2 diabetes, coronary heart disease, and stroke
Zhu, T., Cui, J., & Goodarzi, M. O. (2021) · Diabetes · doi:10.2337/db20-0800 · Cited by 226 · see citing works
Beyond fertility: polycystic ovary syndrome and long-term health
Cooney, L. G., & Dokras, A. (2018) · Fertility and Sterility · doi:10.1016/j.fertnstert.2018.08.021 · Cited by 270 · see citing works
Diabetes: A metabolic and reproductive disorder in women
Thong, E. P., Codner, E., Laven, J. S. E., & Teede, H. (2020) · The Lancet Diabetes & Endocrinology · doi:10.1016/s2213-8587(19)30345-6 · Cited by 242 · see citing works
Self-citationLim, S., Smith, C. A., Costello, M. F., MacMillan, F., Moran, L., & Ee, C. (2019) · BMC Endocrine Disorders · doi:10.1186/s12902-019-0434-8 · Cited by 105 · see citing works
Self-citationMelin, J., Forslund, M., Alesi, S., Piltonen, T., Romualdi, D., Spritzer, P. M., Tay, C. T., Pena, A., Witchel, S. F., Mousa, A., et al. (2024) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgad465 · Cited by 78 · see citing works
Self-citationProviding lifestyle advice to women with PCOS: an overview of practical issues affecting success
Ee, C., Pirotta, S., Mousa, A., Moran, L., & Lim, S. (2021) · BMC Endocrine Disorders · doi:10.1186/s12902-021-00890-8 · Cited by 70 · see citing works
Self-citationForslund, M., Landin-Wilhelmsen, K., Trimpou, P., Schmidt, J., Brännström, M., & Dahlgren, E. (2020) · Human Reproduction Open · doi:10.1093/hropen/hoz042 · Cited by 66 · see citing works
The evolutionary biology of endometriosis
Dinsdale, N., Nepomnaschy, P., & Crespi, B. (2021) · Evolution, Medicine, and Public Health · doi:10.1093/emph/eoab008 · Cited by 53 · see citing works
Knowledge of PCOS in physicians-in-training: identifying gaps and educational opportunities
Chemerinski, A., Cooney, L., Shah, D., Butts, S., Gibson-Helm, M., & Dokras, A. (2020) · Gynecological Endocrinology · doi:10.1080/09513590.2020.1746761 · Cited by 45 · see citing works
Transtheoretical model-based mobile health application for PCOS
Wang, L., Liu, Y., Tan, H., & Huang, S. (2022) · Reproductive Health · doi:10.1186/s12978-022-01422-w · Cited by 38 · see citing works
Characterization of polycystic ovary syndrome among Flo app users around the world
Jain, T., Negris, O., Brown, D., Galic, I., Salimgaraev, R., & Zhaunova, L. (2021) · Reproductive Biology and Endocrinology · doi:10.1186/s12958-021-00719-y · Cited by 37 · see citing works
Marinkovic-Radosevic, J., Cigrovski Berkovic, M., Kruezi, E., Bilic-Curcic, I., & Mrzljak, A. (2021) · World Journal of Diabetes · doi:10.4239/wjd.v12.i7.932 · Cited by 35 · see citing works
The impact of ageing and menopause in women with polycystic ovary syndrome
Helvaci, N., & Yildiz, B. O. (2022) · Clinical Endocrinology · doi:10.1111/cen.14558 · Cited by 32 · see citing works
Amini, L., Mojab, F., Jahanfar, S., Sepidarkish, M., Raoofi, Z., & Maleki-Hajiagha, A. (2020) · Complementary Therapies in Medicine · doi:10.1016/j.ctim.2019.102245 · Cited by 30 · see citing works
Pirotta, S., Joham, A., Grieger, J. A., Tay, C. T., Bahri-Khomami, M., Lujan, M., Lim, S. S., & Moran, L. J. (2020) · Seminars in Reproductive Medicine · doi:10.1055/s-0041-1726866 · Cited by 29 · see citing works
Self-citationPhimphasone-Brady, P., Palmer, B., Vela, A., Johnson, R. L., Harnke, B., Hoffecker, L., Coons, H. L., & Epperson, C. N. (2022) · F&S Reviews · doi:10.1016/j.xfnr.2021.11.004 · Cited by 20 · see citing works
Medical Treatment and Comorbidity in Polycystic Ovary Syndrome: An Updated Review
Glintborg, D., & Andersen, M. (2020) · Current Opinion in Endocrine and Metabolic Research · doi:10.1016/j.coemr.2020.02.014 · Cited by 20 · see citing works
Sheikh, J., Khalil, H., Shaikh, S., Hebbar, M., Zia, N., Wicks, S., Jayaprakash, S., Narendran, A., Subramanian, A., Malhotra, K., et al. (2023) · BJOG: An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.17428 · Cited by 18 · see citing works
Herbert, S., & Woolf, K. (2023) · Nutrients · doi:10.3390/nu15245069 · Cited by 15 · see citing works
“PCOS is linked with increased prevalence of cardiometabolic risk factors, including dyslipidemia [10–13], hypertension [13–15], chronic inflammation, and impaired glucose tolerance [16,17], as well as overweight and obesity [18,19].”
BackgroundXing, N.-N., Ren, F., & Yang, H. (2024) · Food & Nutrition Research · doi:10.29219/fnr.v68.9835 · Cited by 13 · see citing works
Beyond counting sheep: Exploring the link between polycystic ovary syndrome and sleep health
Jafar, N. K. A., Bennett, C. J., Moran, L. J., & Mansfield, D. R. (2023) · Seminars in Reproductive Medicine · doi:10.1055/s-0043-1777724 · Cited by 12 · see citing works
Self-citationLim, S., Wright, B., Savaglio, M., Goodwin, D., Pirotta, S., & Moran, L. (2021) · Seminars in Reproductive Medicine · doi:10.1055/s-0041-1735575 · Cited by 10 · see citing works
Scannell, N., Villani, A., Moran, L., & Mantzioris, E. (2025) · Proceedings of the Nutrition Society · doi:10.1017/s0029665124007584 · Cited by 12 · see citing works
“Approximately 30% of women with PCOS have impaired glucose tolerance and 7.5% have T2DM (40) with the degree of risk to the onset of T2DM varying from between three to five-fold, contingent upon obesity and ethnicity (41) .”
InfluentialSelf-citationPolycystic Ovary Syndrome and Exercise: Evaluation of YouTube Videos
Atigan, A., & Atigan, A. (2023) · Cureus · doi:10.7759/cureus.35093 · Cited by 7 · see citing works
- Authors
- Kakoly, N. S., Khomami, M. B., Joham, A. E., Cooray, S. D., Misso, M. L., Norman, R. J., Harrison, C. L., Ranasinha, S., Teede, H. J., & Moran, L. J.
- Affiliations
- Monash University (AU)
- Monash Health (AU)
- The University of Adelaide (AU)
- Corresponding author
- Moran, L J
- ORCID
- Venue
- Human Reproduction Update
- Publisher
- Oxford University Press (OUP)
- Published
- 2018-03-26
- Volume
- 24
- Issue
- 4
- Pages
- 455-467
- ISSN
- 1355-4786 (ISSN-L)
- 1460-2369
- OpenAlex
- W2792351428
- Cited by
- 384
- References
- 76
- Citations by year
- 2026: 46 · 2025: 44 · 2024: 55 · 2023: 61 · 2022: 51 · 2021: 54 · 2020: 36 · 2019: 28 · 2018: 8
- FWCI
- 4.75
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Human Reproduction Update (publishedVersion)
- PubMed (publishedVersion)
- Monash University Research Portal (Monash University) (submittedVersion, other-oa)
- Adelaide Research & Scholarship (AR&S) (University of Adelaide) (submittedVersion)
- Funders
- National Health and Medical Research Council
- 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 › Obstetrics and Gynecology › Gestational Diabetes Research and Management
- Keywords
- polycystic ovary syndrome, impaired glucose tolerance, type 2 diabetes, ethnicity, obesity, body mass index, Asian women, European women, quality of evidence, meta-regression, subgroup analysis, quality of life domains
- MeSH terms
- Diabetes Mellitus, Type 2, Ethnicity, Female, Humans, Obesity, Polycystic Ovary Syndrome, Prevalence, Glucose Intolerance
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