Effect of ketogenic diet and hypocaloric Mediterranean diet on metabolic and endocrine parameter in women suffering from Polycystic Ovary Syndrome

ABSTRACT

PCOS is the most prevalent female endocrine disorder and is characterized by polycystic ovaries, hyperandrogenism, and protracted anovulation. In PCOS, obesity, low-grade chronic inflammation, and insulin resistance (IR) frequently coexist. The Mediterranean diet (MD) and Ketogenic diet act as an anti-inflammatory eating plan that is high in complex carbohydrates, fiber, and monounsaturated fat, whereas the Keto diet is high in fat content. PCOS is associated with obesity, low-grade chronic inflammation, insulin resistance, and hormonal imbalances. The aim of the present study was to measure the metabolic and endocrine effects of a ketogenic and hypocaloric Mediterranean diet in women with polycystic ovarian syndrome. For this purpose, 80 participants were divided into two groups. Group 1 was on the ketogenic diet and Group 2 was on the Mediterranean diet for 9 weeks. The result of the present study showed that significant weight was reduced among the keto group (−10.9 kg) as compared to the Mediterranean group (−5.1 kg). Total cholesterol and Low-Density Lipoprotein among the keto group was 181. 5 ± 22.2 and 85.3 ± 16.2 U/L whereas, in the Mediterranean group 190.3 ± 22.7 and 91.3 ± 15.9 U/L were observed. Blood glucose levels among the Keto and Mediterranean groups reduced significantly 83.47 ± 5.81 and 91.7 ± 5.8 (mg/dl). C-peptide, LH, and FSH also improved more significantly as compared to the Mediterranean group respectively. This study revealed that a ketogenic diet is superior to a hypocaloric Mediterranean diet for lowering Triglyceride, Cholesterol, LDL, blood glucose, insulin, C peptide, HOMA-IR, LH/FSH, Serum Albumin, Facilitating Hormone, and Sex hormone-binding globulin levels. Females having PCO may improve health with the ketogenic diet

KEYWORDS:

• PCOS
• body weight
• ketogenic Diet
• hypocaloric Mediterranean diet

Introduction

Polycystic ovary syndrome (PCOS) is one of the most prevalent hormonal disorders in women of childbearing age. It is characterized by irregular menstrual cycles, sexual dysfunction, scalp dermatitis, and polycystic ovarian morphology (PCOM). PCOS has a variety of phenotypes and is diagnosed when Rotterdam criteria are met: Clinical hyperandrogenism (hirsutism, acne, seborrhea, and alopecia) and/or high circulating androgen levels; ultrasound-detected ovarian cysts; and oligo-amenorrhea with oligo-anovulation. In clinical practice, the Ferriman-Gallwey score is a useful instrument for assessing hirsutism, which is frequently associated with biochemical hyperandrogenism. PCOS frequently coexists with obesity, insulin resistance (IR), associated compensatory hyperinsulinemia, and a low-grade chronic inflammatory status. Although numerous studies have been conducted to investigate the association between metabolic alterations and PCOS, it is still unknown why PCOS-afflicted women are frequently obese.^[1] Specifically, obesity and obesity-related low-grade inflammation contribute to the development of IR by exacerbating metabolic and reproductive outcomes. Hyperinsulinemia and IR may increase androgenic activity, while high androgen levels may reduce IR through body composition changes, creating a vicious cycle that worsens this pathological condition. In PCOS women, metabolic and endocrine disorders raise the risk of metabolic syndrome, type 2 diabetes, and infertility. Polycystic ovarian syndrome (PCOS) is an endocrinopathy in women whose causes are unknown, unlike its effects on fertility and health. Pathophysiological processes affecting PCOS based on gonadotropins and steroid hormones genes. Genetics have been shown to cause PCOS in some people. Pathophysiological functions of genes synthesize proteins involved in PCOS before hyperandrogenism, including GnRHR, FSH, FSHR, LHCGR, CYP19A1, HSD17B, AR, and SHBG, which have been shown to affect human PCOS. Primary cause of PCOS is hormonal abnormalities, and PCOS people have irregular menstrual cycles. PCOS causes hyperandrogenism and gonadotropin secretion abnormalities due to steroidogenesis pathways and hypothalamic – pituitary–ovarian axis disruptions.^[2]

Weight management is one of the key therapeutic options for PCOS, since obesity worsens the clinical presentation.^[1] Worldwide 20% of women of reproductive age are afflicted.^[3] PCOS is more common among South Asian women, and especially among Pakistani women (52%) than it is among European women (20–25%) in the United Kingdom.^[4,5] It is difficult to diagnose PCOS because it is usually only diagnosed after other medical conditions that cause irregular menstrual cycles and extra androgenic hormones have been ruled out.^[6,7] Polycystic ovarian syndrome (PCOS), which impairs fertility and metabolism, is a leading cause of infertility in women. Oral contraceptives are typically prescribed to PCOS patients for menstrual problems and hirsutism/acne.^[8,9] Hyperinsulinemic syndrome is treated with oral diabetes sensitizers like pioglitazone as well as metformin. Although insulin sensitizers remain this same gold standard for managing PCOS, no non-pharmacological method has been shown to be better to others.

Beyond Mediterranean diet and ketogenic diet, few data exist on the dietary consumption of women with PCOS using the seven-day food records, the “gold standard” for nutritional assessments. Using a multiple-choice food questionnaire and a four-day food record, Douglas et al., (2006) estimated the dietary intake of women with PCOS and found that, despite similar intakes of total energy, macro- and micronutrients, PCOS women had a significantly higher intake of high glycemic index foods (primarily white bread and fried potatoes) than age- and BMI-matched controls.^[10] The Mediterranean diet and the ketogenic diet both seem to help with metabolic issues related to weight and type 2 diabetes.^[11]

When conducting a clinical evaluation to determine whether or not a patient has PCOS, the goal of treating polycystic ovary syndrome (PCOS) is to improve the patient’s quality of life by tackling the underlying hormonal problems that contribute to the condition, as well as digestive as well as gynecological concerns, and by helping the patient achieve and maintain a healthy body weight. According to a consensus declaration on PCOS from around the world, treatment should initially focus on changing one’s lifestyle through changes in nutrition and exercise.^[12,13] The medicinal use of ketogenic diets has been shown to be effective in treating a variety of illnesses in recent years. These diseases include polycystic ovary syndrome, insulin, skin issues, cancer, neural diseases, as well as the decrease of risk factors for respiratory and heart diseases.^[6,14] The macros of a ketogenic diet are relatively low protein, high fat, and low or no carbs.^[15] The percentages of fat, protein, and carbohydrates in the food range from 55–60%, 30–35%, and 5–10%, correspondingly. In particular, the carbohydrate content of a regular meal of 2000 kcal should not go above 20–50 g.^[16] Obesity, the LH/FSH ratio, fasting glucose, and testosterone levels all improved in PCOS women who adopted a ketogenic diet limited in carbohydrates. Blood levels of free testosterone were reduced due to elevated SHBG and diminished activation of androgen synthesis due to LCKD. Possible weight reduction from following a ketogenic (low-carb) diet for an extended period of time. In particular, a ketogenic isocaloric diet has been shown to be effective against cancer,^[17] seizures,^[6] diabetes type 2, and obesity.^[18,19] Infertility, irregular menstrual cycles, hirsutism, and polycystic ovarian morphology are all symptoms of polycystic ovary syndrome.^[20] It effects 4–20% of women globally who are of reproductive age. and 52% in Pakistan.^[3] Hypocaloric Mediterranean diet acts as an anti-inflammatory diet and it may help in improve disturbed hormones and metabolic complications. Ketogenic diet also play’s role in balanced endocrine and metabolic parameters, by improve the insulin resistance through ketogenesis and sparing of lean muscle, thus both diet plays role in improve PCOS and its complication. The goal of this study is to determine whether hypocaloric Mediterranean or the ketogenic, more beneficial effect on metabolic and hormonal factors in women with polycystic ovary syndrome.

Material and methods

Design and settings

The Study was carried out at Gynnastic Health Center to determine the effect of the Keto and Mediterranean diet on Metabolic as well as endocrine parameters among females suffering from polycystic ovary syndrome. In a pre – post intervention study, a 45 days program was designed for people with polycystic ovary syndrome.

Study population

A total of 80 women suffering from polycystic ovarian syndrome aged between 18 and 45 years were included. The entire population was divided into two groups. Group 1 consisting of 40 women’s completed a treatment of ketogenic treat whereas group 2 consisting of 40 women’s completed a treatment of hypo calorie Mediterranean treatment. The inclusion criteria consist of premenopausal obese women between the age of 18 to 45 years, having BMI >30 kg/m² and having issue in conceiving and those excluded from the study who were <18 years and >45 years, post-menopausal or having comorbidities. Data regarding age, Anthropometric parameters, lipid profile, metabolic parameters and endocrinal parameter were recorded at baseline and after 45 days of treatment.

Ketogenic diet

The “mixed ketogenic” diet required a daily protein consumption that was split between isolated whey protein powder, which is made from milk and has a high biological value and complete amino acid profile but almost no carbohydrates or fat, and animal protein sources like meat, fish, or eggs. Protein consumption was calculated at 1.1–1.2 g/kg/day optimum body weight. The maximum daily carbohydrate consumption was set at 30 g, and the total daily calorie intake was set at about 600 kcal. As a result, the diet was a very-low-calorie ketogenic diet, which caused a sharp decrease in calories with the goal of losing weight mostly from the FM. The daily lipid need was set at 30 g, with the additional lipid quotas coming from meat, fish, oil-dried nuts, and oilseeds, and being mostly consumed in the form of 10 g of extra virgin olive oil consumed during the evening meal. Also, patients were instructed to take potassium and magnesium supplements and drink at least 2 L of water every day.^[21]

Mediterranean diet

According to the Mediterranean-style food pyramid, the MD diet was low in red and processed meat and high in whole grains (pasta, bread, and whole wheat), eggs, chicken, fish, vegetables, legumes, fruits, and olive oil as the major condiment. The initial assigned energy intake of the MD diet was established based on the person’s habitual energy intake assessed by a qualified nutritionist during a face-to-face interview. Body weight and the nutritionists’ clinical judgment were adjusted for to account for a potential underreporting that is common in overweight/obese people. About 55% of the energy came from carbohydrates, primarily whole wheat, 25% from fat (PUFA from olive oil, almonds, and pistachios), and 20% from protein (especially fish and legumes). All participants were also instructed to continue their regular physical activity throughout the trial, though compliance with this instruction was not tracked. The nutritionist monitored MD compliance through counseling every 2 weeks and follow-up phone calls every two to 3 days.^[22]

Parameters

Anthropometric parameter, Lipid profile test, Hormonal test, HbA1c test, HOMA IR, Serum albumin, LH and FSH.

Method

Questionnaire-

based, education and awareness session at the start of trial and biochemical analysis by relevant method, 18–45 years old premenopausal women, overweight or obese (until BMI 49.9 kg/m2), and those women who were not on any special kind of diet were selected. Study design: This was a randomized controlled research study divided into two groups, the ketogenic diet group and the Mediterranean group based on a ratio of 1:1. The participants were followed up to a period of 45 days. The data regarding Anthropometric parameters, metabolic parameters and endocrinal parameters were recorded at data 0 and after 45 days of the treatment.^[21]

Anthropometric and biochemical parameters

Anthropometric data consist of body weight, height, waist circumference, hip circumference, waist to hip ratio. For Biochemical parameters blood samples were collected with the help of hospital labortary (The University of Lahore, Teaching Hospital, Lahore, Pakistan) assistant to determine the blood glucose level, insulin, HOMA IR, Serum albumin, LH, FSH. Testosterone level and SHBG at baseline and after 45 days of treatment.^[21] Study protocol: For this 80 participants being overweight and obese were divided in to two groups. Group 1 was asked to consume modified ketogenic diet up to 45 days whereas group 2 was asked to consume modified Mediterranean diet up to 45 days. The data was recorded on day 0 and day 45 of treatment.

Statistical analysis

SPSS version 24.0 was used to record the data and analyze the results. A paired sample t-test was used to compare the results of the study at the start and at the end. A p-value ≤.05 was thought to be significant and results are expressed as the mean ± standard deviation.

Result and discussion

Polycystic ovary syndrome (PCOS) is among the most prevalent hormonal disorders, affecting 5–10% of reproductive-aged women. Despite decades of research, the cause of PCOS remains obscure. Oxidative stress is now understood to play a pivotal role in the pathophysiology of a variety of diseases, including PCOS. Diet appears to play an important role in regulating the clinical presentation and laboratory findings of individuals with PCOS. Diet of low-glycemic fruits and vegetables and small amounts of low-fat dairy, lean red meat, poultry, fatty acids, legumes, whole grains, and seeds can be eaten in moderation.^[23]Although intracellular reactive oxygen species (ROS) production and propagation are controlled by highly complex antioxidant enzymatic and non-enzymatic systems, it is essential to devise strategies for the prevention and dietary treatment of PCOS by understanding the mechanisms of oxidative stress.^[24] In the present study, a highly significant reduction (p < .001) was recorded for keto treatment as compared to the Mediterranean group in anthropometric parameters. The result of this study showed that significant weight reduction among the keto group (−10.9 kg) as compared to the Mediterranean group (−5.1 kg). The body Mass Index of the Keto group at baseline and after treatment was 34.5 ± 4.6 and 31.2 ± 4.1 kg/m².whereas, in the Mediterranean group at baseline and after treatment was 33.6 ± 3.9 and 33.2 ± 3.8 kg/m². The mean energy intake among the Keto group at baseline and after treatment of the study was 1659.55 ± 71.25 and 1567.48 ± 73.4 (kcal) whereas for the Mediterranean group it was 1678.44 ± 58.38 and 1629.5 ± 63.8 (kcal) as shown in Table 1. Similar results were observed by Barrea et al., who mentioned that keto diet contain high fat content which may give satiating feeling also help in reducing food craving.^[25] The Mediterranean diet is nutritious and balanced, emphasizing whole grains, vegetables, fruits, and lean meats. It may not be intended for weight reduction, but it has been linked to heart disease and stroke prevention.^[26] So, the Mediterranean group’s slight BMI decline is beneficial. In the short run, the keto diet may be more successful in weight reduction than the Mediterranean diet. Nonetheless, individual reactions to diets may vary widely, and long-term sustainability is vital when selecting a diet.^[26]

Table 1. Anthropometric measurement of Keto group and Mediterranean group.

Parameters	Keto Group		p-value	Mediterranean Group		P-value
	Pre	Post		Pre	Post
Weight (kg)	95.5±10.0	84.6±9.6	0.000**	96.6±10.4	91.5 ± 10.2	0.035*
Body mass index (kg/m^2)	34.5 ± 4.6	31.2± 4.1	0.001*	33.6 ± 3.9	33.2± 3.8	0.487
Waist circumference	99.86 ± 10.6	88.7± 9.7	0.000*	100.42±11.4	97.85±10.9	0.049*
Hip circumference	122.78±12.46	113.6±11.2	0.000**	122.37±12.55	117.4 ± 11.9	0.016*
Waist to Hip ratio	0.8 ±0.05	0.77 ± 0.047	0.001*	0.82 ± 0.04	0.80 ± 0.039	0.045*
Energy (Kcal)	1659.55±71.25	1567.48±73.4	0.000**	1678.44±58.38	1629.5± 63.8	0.032*

**= Highly Significant

*= Significant

^NS= Non Significant

A significant (p < .001) reduction was recorded for the triglyceride, cholesterol and LDL level whereas increase in HDL (U/L) was recorded for the keto group as compared to the Mediterranean group with (p < .05). The result implies that the keto diet may improve lipid profiles better than the Mediterranean diet. The Mean TG level (U/L) of Keto group before and after treatment was 136.5 ± 14.0 and 128.3 ± 12.6 as compared to Mediterranean treatment it was 137.2 ± 18.0 and 133.4 ± 17.5 (U/L). The Mean Cholesterol level (U/L) of Keto group before and after treatment it was 195.7 ± 25.4 and 181.5 ± 22.2 as compared to Mediterranean treatment it was 197.5 ± 24.8 and 190.3 ± 22.7. The mean HDL level of keto group was 43.9 ± 8.8 and 51.8 ± 9.2 whereas in Mediterranean it was 44.6 ± 8.7 and 47.8 ± 7.6. The Mean LDL (U/L) for Keto treatment 97.0 ± 17.3 and 85.3 ± 16.2 whereas in Mediterranean treatment was 96.4 ± 16.5 and 91.3 ± 15.9 as shown in Table 2. Similar results were observed by Fenton et al., who mentioned that When people consume low amounts of carbohydrates, the liver produces fewer triglycerides, which may be involved in raising HDL cholesterol levels. The research design does not enable us to establish causation, and other variables like exercise, drug usage, and metabolism may have affected the outcomes. The results contribute to the research on dietary approaches for cardiovascular health. Reducing cholesterol levels helps prevent cardiovascular disease.^[27] The keto diet is a high-fat, low-carbohydrate diet that induces ketosis, when the body uses fat instead of carbs for energy. The Mediterranean diet is plant-based and rich in fruits, vegetables, whole grains, nuts, and olive oil.^[12,28] This diet lowers LDL cholesterol and triglycerides, which raise heart disease risk. The keto and Mediterranean diets lower cholesterol.^[29]

A significant (p < .001) decrease was recorded for the Blood glucose, Insulin, HOMA-IR, C peptide level whereas an increase in serum albumin was recorded for the keto group as compared to the Mediterranean group (p < .05). The blood glucose level of the keto group before and after the treatment was 95.58 ± 6.88 (mg/dl) and 83.47 ± 5.81 (mg/dl). Whereas that of the Mediterranean group was 96.84 ± 7.62 (mg/dl) and 91.7 ± 5.8 (mg/dl) as shown in Figure 1. Same results were observed by Mobbs et al., who mentioned that the keto diet is a low carbohydrate, high fat diet. Low carbohydrate and moderate protein intake results in the production of small molecules known as “ketones.”

Figure 1. Average Blood glucose (mg/dl) distribution among keto and Mediterranean group.

These ketones are used for energy when the body does not produce enough glucose (blood sugar).^[30,31] and Esposito et al., mentioned that Mediterranean-style eating is rich in plant-based foods and limits processed ones, it can help reduce insulin resistance. This leads to better blood sugar management and lower A1C levels.^[32] The Mean Insulin of the Keto group was 36.84 ± 19.6 (mg/dl) and 20.7 ± 6.8 (mg/dl) whereas Mediterranean group was 37.82 ± 17.8 (mg/dl) and 31.6 ± 7.5 (mg/dl) as shown in Figure 2.

Figure 2. Average Insulin levels (mg/dl) among keto and Mediterranean group.

The Mean level of IR for Keto and Mediterranean group was 8.09 ± 4.06, 2.9 ± 1.03 and 9.02 ± 4.03, 7.04 ± 3.08 as mentioned in Figure 3.

Figure 3. Average HOMA IR level (mg/dl) among Keto and Mediterranean group.

The result of present study was also supported by previous studies^[30,32] The C peptide level of keto group and Mediterranean group was 2.72 ± 1.23 and 1.8 ± 0.86., 2.51 ± 1.15 and 2.21 ± 1.04 as shown in Figure 4. The result of serum albumin are shown in Figure 5. Current research suggests that obese people may benefit from ketogenic and Mediterranean diets. Previous study done by Rosenbum et al.^[33] mentioned that Keto diet also decrease in appetite-stimulating hormones such as insulin and ghrelin, when eating restricted amounts of carbohydrate and this diet also play hunger-reducing role of ketone bodies – the body’s main fuel source on the diet.^[33] Keto may have reduced hyperandrogenism symptoms because to its lower free testosterone levels. This diet boosts ovarian function and insulin resistance due to higher FSH and SHBG levels. FSH develops ovarian follicles, which generate oocytes. SHBG binds to testosterone, lowering its free form and improving insulin resistance.^[8,26] Ketogenic diet may have had superior endocrinal characteristics than Mediterranean. Further research is required to validate these results and determine the treatment’s long-term impact on reproductive and metabolic health.

Figure 4. Average C peptide (mg/dl) among keto and Mediterranean group.

Figure 5. Average Serum albumin level (mg/dl) among keto and Mediterranean group.

A highly significant (p < .001) decrease was recorded for the LH, LH/FSH, Free testosterone, Total testosterone level whereas an increase in FSH and SHBG was recorded for the keto group as compared to Mediterranean group with (p < .05). The Mean LH and FSH of the Keto group and Mediterranean treatment before and after the treatment was 13.69 ± 6.28 and 8.37 ± 5.18. 16.26 ± 8.48 and 12.56 ± 7.64, 4.89 ± 2.68 and 8.64 ± 3.79. 6.12 ± 3.78 and 8.32 ± 4.12 as shown in Table 3. With the help of the keto diet, the body enters into ketosis which not only improves weight loss but also hormoneslevels.^[22,34]

Table 2. Lipid profile of the keto and Mediterranean group.

Parameters	Keto Group		p-value	Mediterranean Group		P-value
	Pre	Post		Pre	Post
Triglyceride	136.5±14.0	128.3±12.6	0.000**	137.2±18.0	133.4±17.5	0.048*
Cholesterol	195.7±25.4	181.5±22.2	0.000**	197.5±24.8	190.3±22.7	0.032*
HDL	43.9±8.8	51.8±9.2	0.000**	44.6±8.7	47.8±7.6	0.053*
LDL	97.0±17.3	85.3±16.2	0.000**	96.4±16.5	91.3±15.9	0.022*

**= Highly Significant

*= Significant

NS= Non Significant

Table 3. Endocrinal parameters of the subjects before and after treatment.

Parameters	Keto Group			Mediterranean group
	Pre	Post	p-value	Pre	Post	p-value
Luteinizing Hormones (mUL/mL)	13.69±6.28	8.37±5.18	0.000**	16.26±8.48	12.56±7.64	0.002*
Foliclle Stimulating hormones (mUL/ml)	4.89±2.68	8.64±3.79	0.000**	6.12±3.78	8.32±4.12	0.037*
LH/FSH	2.7±2.3	1.09±1.3	0.000**	2.6±2.2	1.73±0.9	0.134*
Free testosterone	0.94±0.48	0.62±0.32	0.000**	0.96±0.46	0.81±0.38	0.045*
Total Testosterone	39.89±17.38	29.68±13.89	0.000**	40.09±17.67	34.25±14.9	0.050*
Sex Hormone binding globulin	40.59±15.68	59.86±19.89	0.000**	41.75±16.45	53.56±17.5	0.029*

**= Highly Significant

*= Significant

^NS= Non Significant

Conclusion

Women with PCOS who are overweight or obese showed a more significant improvement in anthropometric, metabolic and endocrine parameters after going on a Ketogenic diet. This was done with the goal of getting a decrease in body weight, total lipid profile, blood glucose level, insulin, C peptide, HOMA-IR, and a rise in serum albumin level. Luteinizing hormone, orLH/FSH, was also improved with the ketogenic diet as compared to the Mediterranean diet. Therefore, the fact that positive results were observed in a very brief period of time is a strength of our study, as is the fact that significantly more patients participated than in previous research. Based on our findings, we think that the ketogenic diet is the best way to treat this syndrome,^[35] .^[36]

Acknowledgement

The authors are highly thankful to The University of Lahore

Disclosure statement

No potential conflict of interest was reported by the author(s).