A prospective 12-month structured weight loss intervention in women with severe obesity and polycystic ovary syndrome: Impact of weight loss on eating behaviors

Abstract

Introduction
The knowledge regarding eating behavior and disorders in women with polycystic ovary syndrome (PCOS) and severe obesity is limited. This study aimed to assess eating behavior and lifestyle factors in women with severe obesity (BMI ≥35 kg/m ² ), with and without PCOS, and the effect of weight loss on these behaviors.

Material and Methods
A prospective clinical trial with participants screened for PCOS using National Institutes of Health criteria. Participants completed the Food Frequency Questionnaire, International Physical Activity Questionnaire, Three‐Factor Eating Questionnaire, and Questionnaire of Eating and Weight Patterns‐revised, and were evaluated regarding binge eating disorder using DSM‐5 criteria before and after a 12‐month weight loss intervention. Clinicaltrials.gov : NCT01319162.

Results
246 women were included (PCOS n = 63, age 33.0 ± 8.4, BMI 39.9 ± 4.7; non‐PCOS n = 183, age 37.7 ± 8.7, BMI 39.6 ± 4.3). Women with PCOS showed elevated baseline scores in cognitive restraint eating (50.0 [33.3–63.2]) compared to women without PCOS (38.9 [27.8–55.6]; p = 0.012). No differences were observed between groups in emotional and uncontrolled eating. In both groups, cognitive restraint eating was negatively correlated with energy intake (PCOS: r = −0.315, p < 0.05; non‐PCOS: r = −0.214, p < 0.001), while uncontrolled eating displayed a positive correlation with energy intake (PCOS: r = 0.263, p = 0.05; non‐PCOS: r = 0.402, p < 0.001). A positive correlation was found between emotional eating and energy intake only in women without PCOS ( r = 0.400, p < 0.001). Baseline self‐reported energy intake and physical activity did not differ between groups. At 12‐month follow‐up, women with PCOS reported reduced fat intake. Women without PCOS reported reduced energy intake, carbohydrates and sugar, increased protein, reduced scores for emotional and uncontrolled eating, and heightened scores for cognitive restraint eating. Comparing changes from baseline to follow‐up, differences were found between groups in cognitive restraint, intake of fat, carbohydrates, and sugar. The mean weight loss was 12–14 kg, with no between‐group difference ( p = 0.616).

Conclusions
Women with severe obesity and PCOS showed elevated cognitive restraint eating behaviors compared to women without PCOS. Although significant weight loss was seen in both groups, alterations in eating behavior more favorable for weight loss were only seen in women without PCOS.

Full text

Acta Obstet Gynecol Scand. 2024;00:1–10.
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1wileyonlinelibrary.com/journal/aogs
Received: 25 Febru ary 2024
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Revised: 18 April 2024
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Accepted: 19 April 2024
DOI: 10.1111/aogs.14867
ORIGINAL RESEARCH ARTICLE
A prospective 12- month structured weight loss intervention
in women with severe obesity and polycystic ovary syndrome:
Impact of weight loss on eating behaviors
Josefin Kataoka1,2 | Elisabet Stener- Victorin3 | Johanna Schmidt4,5 | Ingrid Larsson6,7
This is an op en access arti cle under the ter ms of the Creative Commons Attribution-NonCommercial-NoDerivs License, whi ch permits use a nd distribution in
any medium, provided the original work is properly cited, the use is no n-commercial and no modi ficat ions or adaptat ions are made.
© 2024 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by Joh n Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics
and Gynecology (NFOG).
Abbreviations: BMI, bod y mass ind ex; PCOS, polyc ystic ovary s yndrome; VLED , very lo w energy diet .
1Institute of Neuroscien ce and Physiolog y,
Depar tment of Physiology, Sahlg renska
Academy, University of Got henburg,
Gothenburg, Sweden
2Depar tment of Obstet rics and
Gynaecology, Sah lgrenska University
Hospit al, Got henburg, Sweden
3Depar tment of Physiology and
Pharma colog y, Karolinska Inst itute,
Stockho lm, Sweden
4Instit ute of Clinical Sciences , Sahlgrenska
academy, Universi ty of Got henbu rg,
Gothenburg, Sweden
5Göteborgs IVF- klinik, Goth enbur g, Sweden
6Depar tment of Medicine, Sahl grensk a
University Hospital, Gothenburg , Sweden
7Instit ute of Medicine, Sahlgrenska
Academy, University of Got henburg,
Gothenburg, Sweden
Correspondence
Josefin Katao ka, Sahlgrens ka Unive rsity
Hospit al, Diagnosvägen 14, Gothenburg
416 50, Sweden.
Email: josefin.kataoka@gu.se
Funding information
Novo Nordisk Fonden, Grant/Award
Number : NNF19OC0 056647 an d
NNF22OC0072904; Diabetesfonden,
Grant /Award Number: DIA 2021- 633;
Göteborgs Läkaresällskap, Grant/
Award Number: GLS 961123; Strategic
Research Programme (SR P) in Diabetes
at Karolinska Institutet; Vetenskapsrådet,
Grant /Award Number: 2018- 02872 and
2022- 005520; Regional Agreement on
Medical Training and Clinical Research
between the Stockholm C ounty Council
and the Karolinska Inst itutet A LFMedN,
Grant /Award Number: 20190079
Abstract
Introduction: The knowledge regarding eating behavior and disorders in women with
polycystic ovary syndrome (PCOS) and severe obesity is limited. This study aimed
to assess eating behavior and lifestyle factors in women with severe obesity (BMI
≥35 kg/m2), with and without PCOS , and the effect of weight loss on these behaviors.
Material and Methods: A prospective clinical trial with participants screened for
PCOS using National Institutes of Health criteria. Participants completed the Food
Frequency Questionnaire, International Physical Activity Questionnaire, Three- Factor
Eating Questionnaire, and Questionnaire of Eating and Weight Patterns- revised, and
were evaluated regarding binge eating disorder using DSM- 5 criteria before and after
a 12- month weight loss intervention. C l i n i c a l t r i a l s . g o v : NCT01319162.
Results: 246 women were included (PCOS n = 63, age 33.0 ± 8.4, BMI 39.9 ± 4.7;
n o n - P C O S n = 183, age 37.7 ± 8.7, BMI 39.6 ± 4.3). Women with PCOS showed el-
evated baseline scores in cognitive restraint eating (50.0 [33.3–63.2]) compared to
women without PCOS (38.9 [27.8–55.6]; p = 0.012). No differences were observed
between groups in emotional and uncontrolled eating. In both groups, cognitive
restraint eating was negatively correlated with energy intake (PCOS: r = −0.315,
p < 0.05; non- PCOS: r = −0.214, p < 0.001), while uncontrolled eating displayed
a positive correlation with energy intake (PCOS: r = 0.263, p = 0.05; non- PCOS:
r = 0.402, p < 0.001). A positive correlation was found between emotional eating
and energy intake only in women without PCOS (r = 0.400, p < 0.001). Baseline
self- reported energy intake and physical activity did not differ between groups.
At 12- month follow- up, women with PCOS reported reduced fat intake. Women
with out PCOS report ed re duced ener gy intake, ca rbohydr at es an d sug ar, increased
protein, reduced scores for emotional and uncontrolled eating, and heightened
scores for cognitive restraint eating. Comparing changes from baseline to follow-
up, differences were found between groups in cognitive restraint, intake of fat,

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KATAOKA et al.
1 | INTRODUCTION
Polycystic ovary syndrome (PCOS) is a common endocrine disorder,
with a prevalence of approximately 10% in women of fertile age.1
The condition is characterized by hyperandrogenism and insulin re-
sistance, leading to a spectrum of symptoms including reproductive
disturbances such as oligo- anovulation and infertility,2 hirsutism,
metabolic disturbances, including hyperinsulinemia, type 2 diabetes,
obesity, hyperlipidemia, and hypertension,3,4 as well as psychiatric
disorders such as anxiety and depression.5
The prevalence of obesity (BMI ≥30 kg/m2) in Sweden is 16%,
with a predominance of severe obesity among women compared to
men.6 A strong association exists bet ween PCOS and obesit y, wit h a
50 %–70 % pr evale nce of ob e s i t y in Am e r ic an wom en wit h PCO S7 and
a 34% prevalence of obesity in a Nordic population of women with
PCOS.8 The reasons for the association between PCOS and obesit y
remain unclear, but it has been shown that women with PCOS have
a higher rate of weight gain than women without PCOS, especially
in early adulthood.9 However, previous studies have identified com-
parable resting metabolic rate, energy intake, and physical activity
in women with and without PCOS of fertile age across normal- and
overweight categories.10,11 Nevertheless, a higher prevalence of dis-
ordered eating and binge eating disorders (BEDs) has been obser ved
in women with PCOS.12
Lifestyle treatment, including dietary modifications, physical ac-
tivity, and behavioral adjustments, is regarded as the first- line thera-
peutic approach for weight management, aimed at both weight loss
and maintenance of a healthy body weight in women with PCOS.13
In women with PCOS, such interventions are considered beneficial
in alleviating symptoms associated with PCOS and preventing meta-
bolic complications associated with PCOS over time.14 Despite this,
there are few studies examining dietary intake, physical activity, and
eating behavior in women with severe obesity (BMI ≥35 kg/m2) and
PCOS during obesity treatment.
This study aimed to investigate self- reported eating behavior,
energy intake, and physical activit y before and after a 12- month
weight loss intervention in a cohort of women with severe obesit y,
with and without PCOS, and to compare the results within and be-
tween the two groups.
2 | MATERIAL AND METHODS
2.1 | Design setting and participants
This is a prospective clinical trial carried out between 2011 and 2017,
at the Regional Obesity Center at Sahlgrenska University Hospital,
Gothenburg, Sweden, to which the par ticipants had been referred
for weight loss treatment. Women aged 18–50 years were invited to
the present study. Before initiation of a weight loss intervention, all
individuals that consented to participate underwent screening for
PCOS using the National Institutes of Health (NIH) criteria, requir-
ing both oligo- /anovulation and the presence of clinical and/or bio-
chemical hyperandrogenism, with the exclusion of other endocrine
disorders. The diagnostic procedure for PCOS has been described
in detail earlier.15 Subsequently, before the start of treatment and
at 12 months, patients under went anthropometric assessments and
laboratory sampling and responded to self- administered question-
naires regarding eating behavior, dietary intake, and physical activ-
ity. The same questionnaires were completed by the participants
at both baseline and follow- up. At baseline, based on PCOS status,
participants were categorically assigned to two groups: PCOS and
non- PCOS.
2.2 | Anthropometry and biochemistry
Body height, weight, and waist circumference were measured ac-
cording to standard protocol at baseline and at 12 months. BMI was
calculated by kg/m2.16
carbohydrates, and sugar. The mean weight loss was 12–14 kg, with no between-
group difference (p = 0 .616) .
Conclusions: Women with severe obesity and PCOS showed elevated cognitive re-
straint eating behaviors compared to women without PCOS. Although significant
weight loss was seen in both groups, alterations in eating behavior more favorable for
weight loss were only seen in women without PCOS.
KEYWORDS
dietar y intake, eating behavior, obesity, polycystic ovar y syndrome, weight loss
Key message
In severe obesity, women with PCOS have more conscious
control over their eating than those without PCOS. Weight
loss interventions led to substantial and comparable
weight loss in both groups; however, altered eating behav-
iors were specifically noted among women without PCOS.
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KATAOKA et al .
2.3 | Eating behavior
The 21- item Three- Factor Eating Questionnaire (TFEQ- R21)17 is
a questionnaire assessing eating behavior divided into three sub-
scales that cover different eating behavior domains: emotional
eating (EE), cognitive restraint eating (CR), and uncontrolled eat-
ing (UE). EE subscale assess eating as a response to emotions,
cognitive restraint eating subscale assess consciously choosing
to restrict food intake to lose or maintain weight and uncon-
trolled eating subscale assess loss of control regarding eating.
Raw scores were transformed into scaled scores of 1–100, where
higher scores for each subscale indicate greater emotional eating,
greater cognitive restraint eating, and greater emotional eating
characteristics.
2.4 | Binge eating disorder
The identification of BED was done according to the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM- 5)
criteria,18 based on questions from the Questionnaire of Eating and
Weight Patterns- revised (QEWP- r), which has been translated and
validated in the translated version.19
2.5 | Dietary intake
Dietar y intake was assessed with a validated semi- quantitative
Food Frequency Questionnaire (FFQ) and covered habitual dietary
intake over the last 3 months when completing the FFQ.20 Energy
and nutrient calculations were done with the food database from the
Swedish Food A gency.21
2.6 | Physical activity
To assess physical activity, the shor t version of the International
Physical Activity Questionnaire (IPAQ)22 was used. IPAQ is a vali-
dated questionnaire with nine items, measuring recalled physical
activity during the last 7 days with information on the time spent
walking, activities of vigorous or moderate intensity, and sedentary
activity/sitting. Answers were given in hours and minutes.
2.7 | Intervention
All participants started the 12- month weight loss intervention
with a 12- week period of a ver y low- energy diet (VLED), which
has been described in detail before.15 The VLED regimen con-
sisted of a liquid diet with a calorie intake of 450–800 kcal per
day. 23 Subsequently, so li d fo ods were gr adually intro du ce d wi thin
the context of an energy- reduced diet, with caloric content ad-
justed to achieve a reduction of 30% from the estimated energy
requirements for weight maintenance. The reintroduction of solid
foods followed a step- based pattern, starting with one meal at a
time, starting with breakfast, and continuing with VLED at the
other meals during the day. After 6 weeks, the next meal was re-
introduced, and af ter another 6 weeks, the third meal was rein-
troduced. By that time, the par ticipants had no meals left with
VLED. D ieta ry ad vice within the framewo rk of an en er gy- reduced
diet included more foods with low energy density, e.g. vegeta-
ble s, fru it s, and foo ds with high s atiation effect s, e.g . wh ole- grain
cereals. Counseling regarding physical activity was given during
the whole treatment period and was individualized in relation to
the preferences of the participants. Appointments were sched-
uled once a month for all par ticipants with either a study nurse
or a dietician. These appointments included weight assessments
and su pport fo r both dieta r y modif ic ation s and increase d physica l
activity.
2.8 | Statistical analyses
Statistical analyses were performed using SPSS 27.0 software.
Normally distributed data was presented as mean ± SD, and skewed
data was presented as median and IQ range. Between- group com-
parisons of women with and without PCOS were conducted using a
Student's t- test for normally distributed variables or Mann–Whitney
U- test for skewed variables, adjusting for age with an analysis of co-
variance (ANCOVA). The chi- squared test was used when comparing
the proportions of BEDs.
Changes from baseline to 12 months within groups were as-
sessed using a paired t- test and Wilcoxon signed- rank test, and
independent samples t- test for comparing changes between the
groups. Correlations were determined using the Spearman cor-
relation test. The results were considered statistically significant
at p < 0.05.
3 | RESULTS
At baseline, a total of 246 women characterized by severe obesity
volunteered to participate in the study (PCOS n = 63, non- PCOS
n = 183). The characteristics of the included participants are shown
in Table 1. Women with PCOS were younger (PCOS 33.0 ± 8.4 years,
non- PCOS 37.7 ± 8.7 years; p < 0.001) compared to women with-
out PCOS. No differences in BMI were observed between the
two groups (PCOS 39.9 ± 4.7 kg/m2, non- PCOS 39.6 ± 4.3 kg/m2;
p = 0.787; Table 1).
At 12 months, a total of 72 women (PCOS, n = 21; non- PCOS,
n = 68) had completed the follow- up assessments. Compared to
baseline, women with PCOS lost 12.5 ± 9.3 kg, p < 0.001, and women
without PCOS lost 14.0 kg ± 12.5, p < 0.001, with no difference
between groups (p = 0.616). The percentage of weight loss was
11.5 ± 8.4% for women with PCOS and 12.3 ± 10.5% for those with-
out PCOS.
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KATAOKA et al.
3.1 | Eating behavior
At baseline, women with PCOS had higher scores of cognitive re-
straint eating compared to women without PCOS (p = 0.012;
Figure 1). However, no significant differences were found between
the groups in emotional eating or uncontrolled eating (Table 1). The
prevalence of BED did not differ bet ween the PCOS and non- PCOS
groups (PCOS: 11.5%; non- PCOS: 17.5%, p = 0.27).
Among women with PCOS who completed the 12- month follow- up,
no significant difference was obser ved in self- reported eating behavior
compared to baseline. Conversely, women without PCOS reported re-
ductions in uncontrolled eating and emotional eating and increased cog-
nitive restraint eating compared to baseline (Table 2). At the 12- month
follow- up, none of the 21 wome n wit h PCOS received a diagnosi s of BED,
whi le four out of the 68 wom en without PCOS wer e dia gn os ed with BED.
3.2 | Dietary intake and physical activity
At baseline, there was no difference in self- reported energy intake,
macronutrients or micronutrients, or physical activit y levels be-
tween women with and without PCOS (Table 1).
Among women with PCOS who remained at 12- month follow- up,
a reduced intake of energ y percent (E%) fat was found compared to
baseline (Table 2). Women without PCOS reported a reduction in
PCOS (n = 63)
Non- PCOS
(n = 183)
p- value
crude
p- value adjusted
for age
Age (years) 33.0 ± 8.3 37. 9 ± 8.21 <0.001
Weight (kg) 111.0 ± 16. 8 110.7 ± 14 .6 0.893 0.872
BMI (kg /m2)39.9 ± 4.7 3 9.7 ± 4.3 0.715 0.763
Waist circumference (cm) 115. 5 ± 12.8 114.9 ± 10.2 0.697 0.358
Physical activity
Sedentary behavior
(min/day)
360 (120–60 0) 300 (120–555) 0.195 0.213
Medium/vigorous activity
(min/week)
136 (90–184) 124 (83–165) 0.194 0.354
Walking (min/week) 771 (0–1268) 758 (0–1163) 0.730 0.679
Dietary intake
Energy (kcal/day) 2692 ± 1181 264 8 ± 1081 0.787 0.423
Protein, E% 16.3 ± 2.6 16. 2 ± 3.0 0.796 0.771
Fat, E% 39. 0 ± 5.3 38.8 ± 5.6 0.733 0.878
Carbohydrates, E% 43.4 ± 5.6 4 3.7 ± 6.3 0.757 0.770
Sugar, E% 19.8 ± 5.9 19.9 ± 5.9 0.900 0.806
Alcohol, E% 1.0 ± 1.3 1.1 ± 1.8 0 .673 0 .944
Fiber (g) 23.6 ± 12 .9 22.5 ± 10.4 0.499 0.142
Iron (mg) 14.7 ± 6.2 14.8 ± 5.7 0. 895 0.663
Vitamin C (mg) 142. 2 ± 7 7. 4 130.0 ± 82.0 0. 313 0.230
Vitamin D (μg) 8.4 ± 3 .9 7. 6 ± 3.6 0.163 0.050
Note: Values are presented as mean ± SD, except for physical activit y, which is presented as
median and IQ range. Comparisons between groups were made with an independent sample
t- test and Mann–Whitney U- test, with adjustment for age with ANCOVA; p < 0.05 was considered
statis tically significant. Bold shows statistically signific ant p- values.
Abbreviations: BMI, body mass index; E%, energ y percent; IQ range, interquartile range; PCOS,
polycystic ovary syndrome; SD, standard deviation.
TABLE 1 Baseline characteristics in
women with severe obesity with and
without PCOS.
FIGURE 1 Eating behavior domains at baseline in women with
severe obesity with and without PCOS. ns, non- significant; PCOS,
polycystic ovar y syndrome.
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KATAOKA et al .
energy intake, E% carbohydrates, and sugars, increased E% protein,
and reduced iron intake compared to baseline (Table 2). No statisti-
cally significant changes in micronutrients were found within groups
at 12- month follow- up or in change between groups (Table 2).
Fur therm or e, at 12- mo nt h follow- u p, women wi th PCO S repo rted
increased time spent on medium- to- vigorous activity, while women
without PCOS reported reduced time spent walking (Table 2).
3.3 | 12- month follow- up
From baseline to follow- up, a difference in cognitive restraint eat-
ing was found with a higher increase in that score in the non- PCOS
group compared with the PCOS- group (p = 0.0 04), for fat intake,
where women with PCOS decreased fat intake more (p = 0.024),
and in carbohydrate intake and sugar intake, where women without
PCOS decreased their intake more, with both nutrient s (p = 0.017)
compared to women with PCOS.
3.4 | Weight change categories
All participants, independent of PCOS status, were divided into two
weight change categories: <5% or weight gain, and ≥10% (Table 3).
Within the ≥10% weight loss group, weight loss was −24.5 ± 9.8%,
and in the <5% weight loss or weight gain group, weight loss was
−0.3 ± 4.0% (Table 3). Women in the ≥10% weight loss group re-
ported higher cognitive restraint eating (p = 0.002), lower emotional
TABLE 2 Eating behavior, dietary intake, and physical activity in women with severe obesity with and without PCOS at baseline and after
a 12- month weight loss intervention.
PCOS (n=21) Non- PCOS (n=68)
p- valueb
0 mån 12 mån p- valuea0 mån 12 mån p- valuea
n = 16 n = 56
Weight (kg) 106.1 ± 13.1 93.6 ± 13.2 <0.001 110.9 ± 15.3 96 .9 ± 16 .2 <0.001 0.796
BMI (kg /m2) 38.4 ± 2.3 33.8 ± 3.8 <0.001 39.4 ± 4.3 34.5 ± 5.4 <0.001 0.827
Waist circumference (cm) 113.2 ± 10.7 102.1 ± 11.2 <0.001 114 .4 ± 11. 0 102.8 ± 12.3 <0.001 0 .941
Eating behavior
Uncontrolled eating 40.7 (29.6–63.0) 55.56 (33.1–77.8) 0. 656 44.4 (25.9–63.0) 38.9 (18.5–52.8) 0.033 0.084
Cognitive restraint 50.0 (41.7–66.7) 61.1 (5 0. 0– 61.7) 0.231 38.9 (33.3–50.0) 66.7 (50.0–83.3) <0.001 0.004
Emotional eating 61.1 (44.4–83.3) 55.6 (33.3–77.8) 0.474 61.1 (38.9–83.3) 50.0 (26.4–66.7) 0.002 0.532
Dietary intake n = 14 n = 48
Energy (kcal/day) 2372 ± 850 1938 ± 740 0 .120 2719 ± 971 2094 ± 653 <0.0 01 0.704
Protein (E%) 16.9 ± 2 .9 17. 8 ± 1.5 0.372 15.7 ± 2.8 18.1 ± 4.1 <0.001 0. 519
Fat (E%) 41.9 ± 6.8 37.9 ± 3.3 0.041 39.3 ± 4.8 40.2 ± 7. 2 0.373 0.024
Carbohydrates (E%) 40.4 ± 7.2 43.0 ± 4.0 0.101 43.4 ± 6.1 40.3 ± 8.3 0.012 0.017
Sugar (E%) 17. 0 ± 5.4 18.7 ± 3.7 0.250 20.1 ± 6.0 1 7. 4 ± 7. 0 0.006 0.017
Alcohol (E%) 0.7 ± 1.0 1.0 ± 2 .0 0. 5 41 1.4 ± 2.1 1.1 ± 1.7 0.070 0.070
Fiber (g) 19.7 ± 8.7 1 9.8 ± 7.8 0.969 23.3 ± 10.9 23.6 ± 11.0 0.419 0.766
Iron (mg) 12.9 ± 4.3 11.6 ± 3.6 0.284 14. 8 ± 4.6 13.3 ± 3.8 0.010 0.766
Vit C (mg) 93.2 ± 36.5 10 9.1 ± 54.7 0.195 146.3 ± 111.6 138.7 ± 78.5 0.301 0.301
Vit D (μg) 7. 1 ± 2.7 6.3 ± 2.3 0.1 74 7. 5 ± 3.4 6.9 ± 3.4 0.162 0.162
Physical activity n = 16 n = 56
Sedentary behavior
(min/day)
480 (210–615) 3 00 (225–435) 0.343 360 (120–6 00) 360 (120–480) 0.043 0. 8 51
Medium/vigorous activity
(min/week)
101 (71–135) 183 (0–530) 0.041 135 (78–181) 180 (0–30 0) 0.129 0.234
Walking (min/week) 899 (65–1399) 178 (60–298) 0.121 86 3 (315–1261) 165 (64–420) <0.001 0.914
Note: Values are presented as mean and ± SD for anthropomet rics and energy intake, and median and IQ range for eating behavior and physical
activity. Bold shows statistically signific ant p-values.
Abbreviations: CR, cognitive res traint; E%, energy percent ; EE, emotional eating; IQ r ange, interquar tile range; PCOS , polyc ystic ovary syndrome; SD,
standard deviation; UE, uncontrolled eating.
ap- value within group, paired samples t- test for anthropometric s and energy int ake, and W ilcoxon signed- rank test for eating behavior and physical
activity.
bp- value of change b etween groups at 12 months was analy zed with Mann–Whitney U- t e s t .
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KATAOKA et al.
eating (p = 0.047), and more time spent in sedentary activity
(p = 0.037) compared to those in the <5% weight loss group. No dif-
ferences were found between the two weight change categories for
emotional eating (Table 3).
3.5 | Correlations
At baseline, within both groups, a negative correlation was found be-
tween cognitive restraint and energy intake (r = −0.315, p < 0.05 [PCOS
group], r = −0.214, p < 0.001 [non- PCOS group]), whereas uncontrolled
ea tin g dem o nst r ate d a pos iti ve corre lat i on with en erg y i ntak e (r = 0.263,
p < 0.05 [PCOS group], r = 0.402, p < 0.001 [non- PCOS group]; Table 4).
A positive correlation was found between emotional eating and en-
ergy intake only in women without PCOS (r = 0.400, p < 0.001; Table 4).
Furt her mor e, ther e wa s a nega tive corr elati on between rep orte d E% fat
at baseline and weight change in the PCOS- group (r = −0.470, p < 0.05).
In women without PCOS, a negative correlation was found between
baseline sedentary behavior/sitting time and weight change (r = −0. 268,
p < 0.05) and a negative correlation between baseline uncontrolled eat-
ing and weight change (r = −0.298, p < 0.05; Table 4).
4 | DISCUSSION
This study found higher levels of cognitive restraint eating behav-
ior in women with severe obesity and PCOS. This behavior was
associated with lower energy intake, whereas uncontrolled eating
was associated with higher energy intake in both women with and
withou t PCOS . Aft er a wei gh t lo ss interv en ti on with cli ni cally signifi -
cant and similar weight loss in both groups, altered eating behaviors
were noted only in women without PCOS. Those who lost ≥10% in
weight, independent of PCOS status, after the 12- month interven-
tion reported higher cognitive restraint eating behavior and less
emotional eating.
In this study, women with PCOS demonstrated elevated cog-
nitive restraint eating behavior at baseline in comparison to their
counterparts without PCOS, while scores for emotional and uncon-
trolled eating were similar between the t wo groups. Cognitive re-
straint eating behavior entails a heightened preoccupation with the
type and quantity of food consumed to influence bodyweight and
shape, representing an eating behavior that promotes weight loss or
weight maintenance.24 Notably, earlier research on eating behavior
in women with PCOS has found inconsistent results. Larsson et al.10
found no dif ferences in eating behavior between women with and
without PCOS, while Basar et al.25 showed elevated cognitive re-
straint eating in women with PCOS. It is relevant to note that both
of these studies included women with a mean BMI ranging from
over weight to obe sit y bu t not severe ob esi ty.10, 25 Thus, the result of
the present study is supported by the study of Basar et al.,25 which
shows that cognitive restraint eating behavior is more prevalent in
women with severe obesity and PCOS compared to women with
severe obesity without PCOS. One plausible explanation for the el-
evated cognitive restraint eating in women with severe obesity and
PCOS could be attributed to the perception of being overweight and
the multiple weight loss attempts that have been shown in women
with PCOS26 that may contribute to an increased awareness of
weight- related concerns.
The prevalence of BED in the general population ranges from
1%–2% to 14%–19% in populations with severe obesity,27 which is
in line with our results. In the present study, no difference in BED
could be found between PCOS and the non- PCOS groups. This
stands in contrast to previous studies, indicating a higher preva-
lence of any eating disorder, including BED, in women with PCOS.12
However, studies specifically addressing BEDs in women with PCOS
are limited.
A substantial variation in self- reported energy intake was noted,
as re fl ec te d by lar ge standard de vi ations in both grou ps , wi th no sta-
tistically significant differences between groups. Previous studies
in women with PCOS have reported similar levels of energy intake
>10%
(n = 29)
<5% or gain
(n = 16) p- value
Weight loss (%) −24.5 ± 9. 8 −0.3 ± 4.0 <0.001
Energy intake (kcal/day) 1985 ± 615 2253 ± 761 0.205
Moderate/vigorous activity
(min/week)
180 (0–570) 165 (0–345) 0.155
Walking (min/week) 200 (60–420) 190 (71–592) 0 .618
Sedent ary behavior (min/day) 360 (165–480) 150 (41–570) 0.037
Uncontrolled eating 33.3 (14.8–59.3) 48.2 (27.8–63.9) 0.231
Cognitive restraint 72.2 (61.1–83.3) 55.6 (44.4–66.7) 0.002
Emotional eating 38.9 (13.9–61.1) 61.1 (33.3–83.3) 0.047
Note: Values are presented as mean ± SD, except for physical activit y and eating behavior, which
is presented as median and IQ range. Comparisons between groups were made with independent
samples t- test for weight loss and energ y intake, and Mann–Whitney U- test physical ac tivit y and
eating behavior. p < 0.05 was considered statistically significant. Bold shows statistically significant
p-values.
Abbreviations: E%, energy percent; IQ range, interquartile r ange; PCOS, polyc ystic ovary
syndrome; SD, standard deviation.
TABLE 3 Energ y intake, eating
behavior, and physical ac tivit y for all
women at 12 months in relation to two
weight change categories.
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KATAOKA et al .
TABLE 4 Correlations between physical activity, dietary intake, and eating behavior at baseline with a 12- months weight change in women with severe obesity with and without PCOS.
PCOS (n= 63)
Moderate/vigorous
activity Walking Sedentary activity Energy intake Protein Fat Carbohydrates UE CR EE
Weight change (n= 16) 0.221 −0.039 −0.405 −0.014 0.201 − 0. 470*0 .369 − 0.191 −0.151 −0.054
Moderate/vigorous activity −0.150 −0. 219 0.557** −0.314*−0.181 0.348** −0.036 0.080 −0.290*
Walking 0.119 −0 .100 0.368** −0.001 −0.206 0.41 2** 0.082 0.755**
Sedentary activity 0.055 0.116 0.153 −0.23 0 0.295*−0 .122 0.301*
Energy intake −0.3 07*0.242 −0.036 0.263*− 0.315*−0.072
Protein −0.078 −0.424** 0.024 −0.089 0.209
Fat −0.843** 0.196 0.119 0.018
Carbohydrates − 0.18 3 −0 .107 −0.137
UE −0.077 0.614**
CR −0.033
Non- PCOS (n= 183)
Moderate/vigorous
activity Walking Sedentary
Energy
intake Protein Fat Carbohydrates UE CR EE
Weight change (n= 56) −0.038 −0.156 −0.268*−0 .138 0.089 −0.009 −0.075 −0.298*0.205 −0 .161
Moderate/vigorous activity 0.127 − 0. 161*0.455** −0.144 −0.168*0.236** 0.092 0.010 0.051
Walking 0.033 0.198** 0.219** 0.136 −0.172*0.446** −0.009 0. 659**
Sedentary activity −0.010 0.054 0.13 5 −0.152 0.162*−0.070 0.052
Energy intake −0.355** 0.222** 0.022 0.402** − 0. 214** 0.40 0**
Protein 0.044 −0.497** −0 .185*0.18 0*−0.177*
Fat −0.845** 0. 267** −0.018 0.185*
Carbohydrates − 0.132 −0.087 −0.015
UE −0.131 0.621**
CR −0.081
Note: Values are presented as the correlation coefficient r. Correlation analyses were made with the Sp earman correlation tes t, and p < 0.05 was considered statistically significant. Bold shows statistically
significant p-values.
Abbreviations: CR, cognitive res traint; E%, energy percent ; EE, emotional eating; PCOS, polycystic ovary s yndrome; UE, uncontrolled eating.
*p < 0.05; **p < 0.001.
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8
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KATAOKA et al.
when compared with women without PCOS.10 It is imp orta nt to note
that self- repor ted data on energy intake introduce the potential for
reporting bias. However, when utilizing the mean estimated energy
requirements for weight stability, according to the Mifflin St. Jeor
equation,28 the reported energy intake at baseline in both groups
was comparable with the energy requirements for the participants'
weight at the time, which implies a reasonably accurate reporting of
the energy intake at baseline.
The adherence during the strict VLED period was high due to
the average weight loss during that period (data not shown). In an-
other study on patients with psoriatic arthritis, we collected dat a on
participants' experiences of the VLED period and their return from
VLED to regular foods.29 The participants found the strict VLED pe-
riod easy to implement, while the return to regular foods was more
difficult.29 Although this is another patient group, it could be as-
sumed that difficulties regarding dietary change for weight loss are
similar regardless of diagnosis.
Baseline physical activity in both study groups falls below
the recommended levels outlined for adults by the World Health
Organization (WHO),30 which are also the recommendations for
women wi th PCOS.13 This observation is comparable with prior find-
ings indicating reduced physical activity in individuals with obesity31
and supports the inverse relationship documented between body
mass index (BMI) and physical ac tivit y.32
During the strict VLED period, energy intake is markedly re-
duced to facilitate significant and rapid weight loss, with the aim
of encouraging further behavioral changes for weight loss.23 Due
to this intervention, including VLED, both groups reduced sig-
nificantly in weight from baseline to follow- up. The important
finding was that women with PCOS responded to the weight loss
intervention similarly to women without PCOS, with compara-
ble average weight loss in both groups. Based on clinical experi-
ence, women with PCOS may say that due to having PCOS, they
have more difficulties losing weight than women without PCOS.
However, the present study shows that they respond to a weight
loss treatment as well as women without PCOS, and this infor-
mation may be used in discussions with women with PCOS and
obesity. A reduction in self- reported energy intake was seen only
in wome n with o ut PCOS. Th i s was as soc iat ed wit h an inc r eas ed in-
take of protein and a decreased intake of carbohydrates and sugar
at the 12- month follow- up. In women with PCOS, self- reported
energ y intake did not decrease significantly; however, a reduction
in E% fat was found. Although a reduction in E% sugar was found
in women without PCOS, both groups reported a ver y high sugar
intake both before and af ter weight loss intervention, with an al-
most double intake compared to recommendations from interna-
tional guidelines.33 Comparing changes between groups, women
with PCOS reduced fat intake more than women without PCOS,
whereas women without PCOS reduce their intake of carbohy-
drates and sugar more than women with PCOS. Previous studies
showed no difference in weight loss after a low- fat diet compared
to a low- carbohydrate diet,34 and indeed, the two groups in the
present study did not differ in weight loss.
Wan g et al .35 obs erve d red uced en erg y intake an d si gni fic ant but
modest weight loss in women with severe obesity, both in those with
and without PCOS, following a 6- month lifestyle intervention. This
study was a post- hoc analysis of a treatment group in a randomized
controlled study in women scheduled for infertility treatment, with
a dropout rate of 25% in the PCOS group and 20% in the non- PCOS
group, respectively.35 Caution is warranted in interpreting the find-
ing s, as the motivation for weight loss may be influen ced by th e con-
text of infertilit y treatment. However, the findings of the latter study
support our results that women with obesity and PCOS can reduce
their weight as well as women without PCOS. Although our study
had a longer follow- up, we also had a higher dropout rate compared
to the study of Wang et al.35
Alterations in eating behavior after intervention, characterized
by reductions in uncontrolled eating, emotional eating, and in-
creased cognitive restraint eating, and behaviors in favor of weight
loss, were exclusively obser ved in women without PCOS. Women
without PCOS also increased their cognitive restraint more com-
pared to those with PCOS. These result s are compar able with a pre-
vious study in women with overweight or obesity without PCOS,
who underwent a 12- week dietary intervention, resulting in modest
weight loss with improvements in all three domains of eating be-
havi or.36 Conversely, in a 12- month RCT in women with PCOS try-
ing to achieve pregnancy, the lifestyle intervention resulted in 5%
weight loss and the participants reported increased restraint eating
post- intervention.37 However, these studies used different eating
behavior questionnaires than the present study and did not compare
women with and without PCOS.
The reason why women with PCOS, in the present study, showed
no change in cognitive restraint eating while women without PCOS
did could be explained by the limited number of participants at fol-
low- up, resulting in a potential lack of statistical power.
In women with obesity and PCOS, a weight loss greater than 5%
has demonstrated improvement in symptoms of PCOS38; however,
most studies are small, and to date, international evidence- based
guidelines for PCOS do not recommend a specific percentage of
weight loss for women with PCOS to improve hormonal and met-
abolic variables.13 In the present study, categorizing participants
based on weight loss, individuals achieving 10% weight loss exhib-
ited higher cognitive restraint compared to those with <5% weight
loss or weight gain. Due to the limited number of par ticipants at fol-
low- up, categorization by PCOS diagnosis was not feasible. These
results may imply that substantial weight loss can foster behavioral
changes in favor of further weight loss, especially in women with
severe obesit y. This is supported by previous findings that indicate
that individuals achieving rapid weight loss, which is often the case
with treatment including VLED, are more likely to maintain long-
term weight loss.39
In both groups, cognitive restraint eating exhibited a nega-
tive correlation with energy intake at baseline. Uncontrolled eat-
ing correlated positively with energy intake in women without
PCOS, whereas this correlation was not evident in women with
PCOS. These results indicate that cognitive restraint eating can
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9
KATAOKA et al .
favor weight loss, whereas uncontrolled eating can be a barrier to
weight loss.
In women without PCOS, sedentar y behavior/sitting time and
uncontrolled eating were negatively correlated with weight loss;
thus, the higher the baseline sedentary behavior/sitting time and
uncontrolled eating, the greater the weight loss at 12 months. This
seems contradictor y but could be explained by the fact that more
unfavorable behaviors for weight loss at baseline give room for
larger behavioral changes during the intervention.
The strengths of this study include a relatively large baseline co-
hort with no statistically significant differences between the PCOS
and non- PCOS groups regarding anthropometric measures. Other
strengths were the usage of validated questionnaires and the struc-
tured weight loss inter vention with regular check- up visits, as well
as the long follow- up time of 12 months. Limitations include the
selected group of women with severe obesity, and therefore the
generalizabilit y to other age- and BMI groups is limited. Additionally,
self- reported dietary intake is another limitation, where partici-
pants may tend to both under- repor t and mis- report dietary intake.
However, average energy intake seems reasonable in relation to en-
ergy needs for the average baseline weight in both women with and
without PCOS.
The substantial dropout impedes the power of the study, po-
tentially explaining the absence of statistically significant changes.
High drop- out rates are common in weight loss interventions, and
this study falls within the upper interval, possibly caused by the fol-
low- up time of the study. Those dropping out of weight loss studies
tend to be those who lose less weight during the intervention or
those who are younger than 50 years,40 as wo me n we re in thi s study.
In women with PCOS specifically, drop- out from a weight loss inter-
vention is associated with more depressive symptoms, while higher
appointment attendance is associated with a greater adherence rate
and a greater weight loss.41
Notably, no difference in age, anthropometry, or metabolic pa-
rameters was observed between dropouts and completers in the
present study.15
5 | CONCLUSION
In this prospective study of women with severe obesity, those
with PCOS reported higher conscious control regarding eating
than women without PCOS, a behavior correlated with lower self-
reported energ y intake irrespective of PCOS status. A 1- year weight
loss program resulted in clinically significant weight loss in both
groups but did not elicit discernible effects on eating behavior in
women with PCOS. In contrast, the intervention induced alterations
in eating behavior among women without PCOS that may be favora-
ble for further weight loss or the maintenance of achieved weight
loss. To evaluate long- term effects of weight loss inter vention on
eating behavior, longer follow- up studies regarding eating behavior
after weight loss intervention is warranted in women with severe
obesity and PCOS.
AUTHOR CONTRIBUTIONS
Josefin Kataoka, Elisabet Stener- Victorin, J.S., and I.L. contributed
to conception and planning of the study, drafting, and revising of
the manuscript. Josefin Kataoka and Ingrid Larsson contributed to
analyzing and interpreting data. All authors approved the final ver-
sion of the manuscript.
FUNDING INFORMATION
The work was supported by the Vetenskapsrådet (project no.
2018- 02872 and 2022-0 05520); Novo Nordisk Foundation
(NNF19OC00566 47 and NNF22OC0072904 ESV); Diabetes
Foundation (DIA2021- 633); Strategic Research Programme (SRP)
in Diabetes at Karolinska Institutet; the Regional Agreement on
Medical Training and Clinical Research between the Stockholm
County Council and the Karolinska Institutet ALFMedN 20 190 079
(all ESV); and Göteborgs läkaresällskap Research grant for PhD stu-
dent (GLS 961123) (JK).
CONFLICT OF INTEREST STATEMENT
The authors have no conflict of interests to disclose.
ETHICS STATEMENT
The study was conducted following the Declaration of Helsinki and
was approved by the regional ethical review board of the University
of Gothenburg, Sweden, DNR- 106- 11. Date of approval was 2011-
03- 31. All participants gave oral and written informed consent be-
fore entering the study. The study was registered at Clini caltr ial. gov:
NCT01319162, March 18, 2011.
ORCID
Josefin Kataoka https://orcid.org/0000-0003-2465-7309
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How to cite this article: Kataoka J, Stener- Vic torin E,
Schmidt J, L arsson I. A prospective 12- month structured
weight loss intervention in women with severe obesity and
polycystic ovar y syndrome: Impact of weight loss on eating
behaviors. Acta Obstet Gynecol Scand. 2024;0 0:1-10.
doi:10.1111/aog s.14867
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