Interview With Martha McKittrick on PCOS Nutrition

In celebration of PCOS Awareness Month, Martha McKittrick, a registered dietitian and certified diabetes educator, shares her expertise on PCOS and how nutrition plays a role. Martha has had a special interest in PCOS since 2000, and can be considered one of the pioneers in the field. She has been published in peer-reviewed journals and has lectured across the country is on the Health Advisory Board for the PCOS challenge and advocates for PCOS annually on Capitol Hill.


Georgie Kovacs 1:43

So, we are here to talk about PCOS and you are quite the expert and we're really at the forefront of the PCOS discussion. So tell us your background and how you got into PCOS.

Martha McKittrick 1:55

So, I'm going to be showing my age here a lot. I've been a registered dietician for over 25 years, and I've had a strong clinical background. I worked in a major New York City Hospital for many years. But, I've always liked to have my fingers in a lot of different pots. So I've always had my own practice for really 20 years. So I was working for Web MD, I was running a message board again about 20 years ago, and a woman had kind of written in and said, "You know, I'm having trouble losing weight, I'm having all these symptoms. I'm eating really healthy, eating low fat, I'm exercising, I can't lose weight." And so I said to her, "do you have any medical issues?" And she was like, "Yeah, I have PCOS."

And so I'm always like, really curious about stuff. So I researched it. And at the time, I was also working with a weight loss doctor in New York City, Dr. Louis Aroni. He's pretty well known. And I asked him what's up with PCOS, and he said, women tend to be insulin resistant, and it can be more difficult to lose weight. So at that point, we were in the fat free era, you know, when everything's fat free. So I said to this woman, "Look, try a little more protein, a little more fat and cut down on the carbs." And she was actually able to lose weight. And her symptoms got better for the first time in years. And then she introduced me to her physician, who was a doctor at Mount Sinai. And I get really interested in this whole kind of condition. And I started lecturing for the PCOS Association, across the United States with a lot of doctors and I just found it a really interesting condition that just not much was known about. So that's kind of how I got into it. And ever since then, I've been specializing in it.

Georgie Kovacs 3:35

So when you started out, if I'm not mistaken, you know, PCOS was viewed in somewhat of a different way. And some of the things that I believe you were starting to talk about, like the insulin resistance and whatnot more publicly, seem to be a bit controversial, and I think you were trying to publish some papers and had some difficulty about it. So tell us about that.

Martha McKittrick 3:56

At that point, it was really believed to be a reproductive condition versus a metabolic condition. And because I was so interested, I wanted to publish a paper on PCOS with insulin resistance and nutrition, and I wrote it all up, but I tried to approach a nutrition journal, I won't say the name. I wrote the article and they denied it. Because they said PCOS is a reproductive condition. It's not a condition of insulin resistance. And they photocopied an article from a medical journal from like 1950 or something that said, Stein Leventhal condition (what it used to be called) is a reproductive condition and they said, it has nothing to do with insulin resistance. So I showed this doctor who I was working with who was very published And he wrote a letter for me with all these references and told them they were wrong. It's highly likely that this has something to do with insulin resistance. So, long story short, they let me publish the article but it just goes to show this wasn't even that long ago, it was probably in the year 2000, that it was believed to be a purely reproductive condition. Interesting.

Georgie Kovacs 5:12

So I guess maybe we start with what is PCOS? Because from what I've seen, even the criteria differ, there are a few different ones. There are a bunch of reproductive endocrinologists and others who got together to develop guidelines. But what's interesting is whenever I've been to recent conferences, even those guidelines aren't referenced. So there seems to be a series of guidelines. So maybe you can help educate the audience on what it is and maybe some of the disagreements clinicians may have so that if they're trying to get diagnosed and treated, they better understand that challenge.

Martha McKittrick 5:47

Yeah, that's part of the whole thing. I mean, first of all, I think just the name is super confusing. Polycystic Ovary Syndrome, right. So just the name is confusing because when you hear the word ovary, you think mainly that it is a reproductive condition. But it's really a metabolic condition. It's hormonal and it's reproductive. So it really encompasses more: it's a hormonal condition, it encompasses everything, even mental health. There are much higher rates of depression and anxiety with PCOS. Because, think about it, hormones affect like every system in the body, you know, risk of heart disease, risk of diabetes. So I think number one, I think the name is super confusing. The diagnostic criteria has been kind of debated and there are a couple sets of diagnostic criteria. And again, it's part of the problem. The ones right now that mainly are being used are the Rotterdam criteria. And basically a woman has to meet two out of three of the following. So it would be irregular periods number one. Number two would be high levels of androgens, or clinical signs. The clinical signs could be acne, excess hair growth or hair loss. And then the last one would be Polycystic apparent ovaries on ultrasound. So basically a woman has to meet two out of three of those. And if she does, she could meet the criteria for PCOS. Now there are some other organizations which think it should be three out of three, not two out of three. So that's partly where the confusion comes from. But I think the majority of health professionals at this point are using the Rotterdam criteria.

Georgie Kovacs 7:31

Now you've talked about insulin resistance. Would you say that? I've heard like even in the book, The Period Repair Manual, Dr Lara Briden talks about a lot of causes, with insulin resistance as just one of the many, like one could be getting off the pill and things like that. So can you talk maybe a little bit about insulin resistance and how much it plays a role versus other things that could cause PCOS.

Martha McKittrick 8:09

It gets a little confusing and if you go to a physician and you say, "what type of PCOS do I have? Do I have post pill PCOS?" They'll look at you like you have five heads, right? Because I think your average Western physician is not going to know about post pill PCOS. The thing is, we don't know what causes PCOS. And because it's a syndrome, it can be kind of hard to diagnose like if you have high cholesterol, we know if your cholesterol is over 200 or 220. If you have diabetes, if your hemoglobins are over 6.5.

With PCOS things kind of change. And so we don't know what causes it. We believe there's a very strong genetic component to it. Then there are certain drivers of it and it's even believed that something like endocrine disease disruptors could play a role in causing PCOS. And in trauma, actually, you know, they're finding some studies where young girls who've had trauma in their life have some kind of problem with the HPA axis, which could cause PCOS. So, stress could be a possible driver of it.

And then insulin resistance they believe is a very large driver of it. And I've read different statistics: I've read as high as 95% of all women with PCOS have some degree of insulin resistance. And this statistic I got from their most recent, I think the paper you were referencing, it was international guidelines that came out in 2018. But they say up to 95% of all women can have insulin resistance. I've heard other statistics that say 80%.

This particular paper also said up to 75% of lean women can have some degree of insulin resistance. So the degrees of that Insulin resistance will vary tremendously. Some women will have very, very mild insulin resistance and other women will have a lot of insulin resistance. So we can talk about how do you know if you have it or not, we can get into that. But insulin resistance is a huge driver of PCOS. And then it's also believed that stress and inflammation play an important role.

And they believe that many women with PCOS have low grade inflammation that can be causing symptoms of PCOS, so the kind of big ones I say really would be insulin resistance is probably the biggest one, or the one that has the most effect.

Inflammation can be a big one. There's a smaller subset of women who might have stress as their driver. And this type is often called adrenal type of PCOS or an adrenal driver, because when you have a lot of stress in your life, you increase the hormone cortisol, which is made in the adrenal glands, and that can also increase production of DHA which gets converted to DHS. And if you have high levels of DHS, which is the precursor to testosterone, that could show you might have more of an adrenal driver or a stress driver.

So, we have insulin resistance, we have inflammation, we have the stress component. And then you know, obviously, it's a hormone imbalance and abnormality in hormones is also kind of like a driver. So, I think these are important because there is no one size fits all treatment to PCOS. I guess my kind of gripe with this whole, you know, types of PCOS.

And I think it's awesome that we're trying to individualize treatment and help women take charge. But I think sometimes it gets put into too neat of a little box. Like you might take some of these quizzes on the internet. I can give you an example actually. So I had a client who took spinning classes. She loved her spinning classes and would look forward to them. She took them three times a week. It made her feel energized and put her in a good mood. She just felt great after taking them. And then she took a quiz online that turned out she had "inflammatory type PCOS" and the guidelines for her type of PCOS online were that you should avoid any kind of really intense exercise, including high intensity interval training and spinning wasn't good for you. You need to be doing yoga and walking.

So this woman got really upset because that's what she loves, spinning, and she had no ill effects from it. I mean, it would be a different story if she took a spinning class and she came home and she said, you know, oh my god that kicked my butt and she couldn't move for two days. So, she stopped her favorite kind of exercise and she got all demoralized and didn't even want to exercise anymore, because she wasn't allowed to take a spinning class as per the internet.

Yes, I think those guidelines are super helpful, especially with insulin resistance ones, but I think you have to listen to your own body. That's my biggest message to women with PCOS is stop falling prey to every single thing you read on the internet and listen to your body. I could get into the whole gluten and dairy thing and talk for hours on that subject.

But that's a whole other thing. Because you read online, "Oh, if you stop eating dairy" and these poor women stop having their plain Greek yogurt. And they stop having their Ezekiel bread, because they can't or they're not supposed to do that. And they get upset. They feel deprived and that's not a good thing. But some women might feel better cutting that stuff out. So here's where you have to listen to your body.

Georgie Kovacs 13:48

Let's talk about the path of how someone gets to a registered dietician and the role you play. So we women may not necessarily see their primary care doctor every year plus the OB GYN. As I've gotten older, I do see both. But when I was younger, I certainly did not. Not everyone remembers to see their OB GYN, but typically, I would assume that's your first place of diagnosis.

I've heard there's a lot of difficulties even to get diagnosed. So can you tell us what you tend to see and what advice you would give to women who are starting on this path of just trying to figure out what's going on with them and some of the challenges they should be prepared with? Because the other thing is because on our website, we have a page on Endometriosis and other on PCOS and other on thyroid conditions.

And it's, you know, just really helping women to understand the high level pieces and a lot of the symptoms even overlap. So we can't even say if you have this you definitely have this diagnosis. So just knowing women are having these things happening and they're trying to go to their clinician, and unfortunately here more often than not they are dismissed or thrown on birth control without looking at all the things that can happen. So, tell us about that beginning of the journey and what they can do.

Martha McKittrick 15:06

It actually takes the average woman a couple years to get diagnosed with PCOS and 50% of women who have PCOS are undiagnosed. Those are just a couple of statistics. I think the biggest thing you can do is be really proactive and do your research and there's an organization among the Health Advisory Board called the PCOS Challenge and they have some great information out there. They're really advocates for PCOS and if you go to their website, they have a whole list of questions and diagnostic criteria and symptoms. Get a notebook, get a file, start writing stuff down, start doing research.

I think if you go into your doctor's appointment, armed with some research and armed with good questions and write down your symptoms and get reputable sites to get information from, I think they'll be more likely to work with you. You also cannot be on the birth control pill to get tested for PCOS. Unfortunately, what I see sometimes is a woman might be on the pill and she'll go and she'll get her bloodwork done or she'll get a sonogram done. And the doctor will say, "Oh, your hormones are normal, you know, you have no cysts on your ovaries." Well, she's on the pill, she's not going to have abnormal hormones to be diagnosed with PCOS.

So make sure if, when you're getting checked for PCOS, that you are not on birth control pill, that you're having all the tests done, that you're having the sonogram, the ultrasound done of your ovaries, because in order to be diagnosed, you need to have bloodwork done. You need to have the ultrasound done of your ovaries and then your doctor needs to talk about your symptoms with you. I mean, if you have hirsutism, which is hair growth, you're probably getting lasered or having electrolysis and your doctor might look at you and not see anything and not think it's an issue but you've got to tell the doctor hey, these are all my symptoms. I think going into the doctor's office, you need to be very organized because the doctor might only have 10 minutes for you and you've got to just get everything down. So you don't want to walk in and feel flustered. Just I'd say be organized and just try to take charge.

Georgie Kovacs 17:17

Tell us about the pill and how being on it does not help with diagnosis. Because I do know that, for example, you could develop PCOS like symptoms once you get off the pill. But what does the pill do so that people understand why it would create challenges in getting diagnosed?

Martha McKittrick 17:37

Well, I mean, the pill is a very personal issue. I mean, what when I was young, I actually was on the pill for many years because I had irregular periods and I mean, I don't have PCOS, but the doctor just said, "Hey, you have irregular periods go on the pill." It never occurred to me to question "Oh, should I really be on the pill?" I think for a lot of women, the first line treatment for PCOS, let's just say you're diagnosed.

And I'll get back to your question in a second. But let's just say you're diagnosed with PCOS and then your doctor is probably going to hand you a prescription for the pill. And you think that's your only choice, right? These physicians go online and when you're talking about the 2018 standards of care, the first treatment option for PCOS is the birth control pill. That's just number one, and a physician is going to read that and they're going to think this is what my patient needs. But you don't necessarily need to be on the pill. But if you choose to be on the pill, you need to understand there are some potential risks for it. In some cases, they can worsen insulin resistance, they can affect the gut microbiome, which by the way, I forgot that's another kind of root cause of PCOS is alterations in the gut microbiome which we can come back to, but you need need to understand there are some potential health risks of being on the pill, there are some nutrient deficiencies that can occur. And why would you want to go on the pill?

Some women have very, very, very bad like hirsutism or very bad acne that it can be difficult to be controlled with diet and lifestyle. Let's just say you clear acne by getting to the root cause of your PCOS, which may be insulin resistance. So if you do everything you can, from a diet and lifestyle standpoint, maybe do a trial of cutting out dairy because dairy is linked to acne and PCOS. There are studies behind that.

So I'm on board with that, and maybe take certain supplements. Maybe you don't need to be on the pill, maybe your skin is going to clear up and maybe your cycle will start to regulate. So you don't need to be on the pill because you have acne. But let's just say you've tried everything and you are absolutely miserable. Then maybe you do want to go on the pill to cure your acne for example. Oftentimes women can start to ovulate, get their periods on their own by doing diet and lifestyle and that's really what I'm trying to help women do is just take control that naturally, but you know, keep it in mind if it's okay if you have to take a medication and I think that's one of the things about social media.

On one hand, I think it's fantastic. Now women know they don't have to take medications, but some women want to and it's okay, like if you take spironolactone, which is a diuretic, but it's often used off label for PCOS to help with acne and to help with hair growth. If it makes your quality of life better because you no longer have this hair growth or your skin's gotten better then that's okay.

You know, you shouldn't feel ashamed no matter what you do. But to get back to your first question when you're on the pill, it will change your hormones and it does help to lower androgens, so that would affect your bloodwork. So if you're on the pill, chances are you might have a lower testosterone level, maybe some of your symptoms will get better. Sometimes acne improves and you may start to get a period, but it's not really a period because the pill suppresses ovulation. It's just a bleed, but everybody calls it a period. So you'll get like this kind of fake cycle. But you know, for some women, it works. For other women, it also causes depression. There are a lot of side effects of the pill that are not really talked about. And if you go on the pill and you see a big change in your mood, and depression and all that, you should probably get off.

Georgie Kovacs 21:43

Those are really valid points, and I appreciate you reminding women not to be hard on themselves, and it's their power to choose because that's what this is really all about. Unfortunately, there aren't enough answers for women and we all just do the best we can and we have to really help each other through that. So we talked about some of the side effects of having PCOS, but we haven't really covered what is really the impact of PCOS. So yes, you may have hair growth, yes, you may have issues with weight loss, and things like that, but what what else? Help everybody understand the other impacts of it.

Martha McKittrick 22:28

With decreased ovulation, some women have trouble getting pregnant, although you should not feel that it's hopeless. I have tons of clients who have gotten pregnant with PCOS. If you have trouble, you could be assisted with some kind of reproductive physician. Metabolic concerns are probably even more serious.

There is a greatly increased risk of type two diabetes; it's believed that 50% of women will get type two diabetes by the age of 40. Because PCOS tends to be a metabolic condition for many women, not for all. For some, it's more of a reproductive issue. So, they don't have as great a risk for diabetes, but a lot of women do. And there's also an increased risk of heart disease, increased risk of endometrial cancer, and then there's a huge impact on mood and anxiety disorders and all that. So, you have your symptoms, which can be devastating for some women, like the hair loss, the hair growth, acne, that can be horrible, trouble getting pregnant, but then there's the more metabolic problems as well. So there's a lot and you know, the name Polycystic Ovary Syndrome.

You don't know that when you hear that name. You just think, "Oh, I have cysts on my ovaries." These cysts are teeny, teeny, teeny little, they call them as pearls, like little tiny white dots on your ovaries. It's not like you have this massive cyst. But that's what people think about you telling somebody “PCOS.” It's a hormone condition that can affect your entire body.

Georgie Kovacs 24:17

We talked about the fact that you're a registered dietician. So let's talk about diet. And I'm sure you're involved in so many different aspects, but I know nutrition is such a key. And I know nutrition impacts mood and things like that. So a person is diagnosed and when do they come to you? And what is the role someone like you can play in their life and how do you help?

Martha McKittrick 24:48

I'm sure a lot of your listeners can attest to this. You know, you get diagnosed, finally, after years and maybe seen four different physicians finally get those diagnoses and you're so excited and now think, "what can I do to help myself, eat less, exercise more and lose weight?" That's what you're told. Or, you know, if you hadn't gained weight, you probably wouldn't have this kind of thing or lose weight and then you can get pregnant so it's all about the weight. The woman's almost blamed. It's your fault because of your weight, which is not true.

About 30% of women who have PCOS are lean and they're not overweight. So, what are they gonna do? Having excess weight on you can worsen insulin resistance, it can worsen inflammation, but even lean women have been found to have higher inflammatory markers, and they have insulin resistance. So it's not just about weight. I think a woman has to be proactive and understand that nutrition and lifestyle should be the first line treatment for PCOS, not pills, because nutrition and lifestyle can attack insulin resistance, it can detect inflammation, and it can help improve gut health.

And it can also help with hormone balance with the adrenal androgens. So that's where you want to start. And I'm really big on nutrition and lifestyle. Yes, I am a registered dietician, but to me, you know, something like getting enough sleep, or stress management is important too. These things are just as important as eating a healthy kind of diet. In being active, and I think a lot of women here read online, like I told you my story about the woman who took the spin classes, they're confused, like, they just don't know what kind of exercise I should be doing? It's just super confusing.

Can I do high intensity? Should I just do low intensity? Should I weight train? Will I get too bulky? What should I do? So I help them with all that. I just kind of look at the woman as an individual and I try to help her understand her root cause or root causes of PCOS. And it could be a couple: a woman could have insulin resistance, she could have some inflammation and she could have some GI issues, she could have some gut health issues. She could also have stress issues. So it could be all four really. I think we have to not put women in a little box, like this is what you do with this type and this type and this type. You must look at the overall picture.

And sometimes it'd be kind of tricky to figure out your root cause because, for example with inflammation, yes, you can have your inflammation markers checked, but chances are, they're going to be normal. But that doesn't mean you don't have inflammation in your body. There are a lot of other signs of inflammation, you know, it could be a lot of fatigue, it could be feeling achy, there is a lot that could indicate you have inflammation.

So the same thing with insulin resistance: you could get your fasting insulin levels checked and they're totally normal. But that does not mean you don't have insulin resistance. There are other ways to judge. The best test would be a two hour glucose tolerance test with insulin levels. But a lot of doctors don't do that. I often just judge by signs and symptoms: do you have a lot of trouble losing weight? Do you have excess fat stored around the abdominal area? Do you have skin tags? Do you have dark patches of skin? I might do a waist to hip ratio and if it's greater than point eight, that's a sign of insulin resistance. If you have pre-diabetes, it's highly suggestive of insulin resistance. So there are a lot of other ways to check.

Do some research on social media: there are some great dietitians to follow. You want to find a dietitian who specializes in PCOS because not all dietitians know about it. So you want to find a specialist and you want to be careful if somebody's saying to you, "all women need to avoid this or all women need to do this." There's a no one size fits all approach for PCOS. There's the root cause difference.

There's lifestyle, there's activity level, there's genetics, there's gut microbiome, there's so many things, there's food sensitivities, so there's never a one size fits all approach. So you know, do some research with somebody who specializes in it, and you need a plan tailored to you, you need to sit down with your coach with a nutritionist and talk about: your concerns, you need to talk about your problem areas what your food cravings, you know, your sleep your exercise, need to have a discussion for like an hour and just really talk about what's going on. And then you need to work with the dietician to get a plan for you.

And the plan should really encompass everything: it's your compass. I always talk about sleep with my clients. Sleep is such an important piece for us. And you need to talk about stress and you need to figure out what kind of exercise is best for you. I'm a huge fan of yoga. They've done a lot of studies on yoga with PCOS. But don't be afraid to weight train. You need a plan tailored for you. And then you need to go through your lifestyle.

Some of my clients, especially New York, hate to cook and they just don't want to cook. So then you need someone who is going to help you if you don't cook. How can you plan a meal plan? How can you get healthy foods? If you hate to cook, and you're given a million recipes, it might work for a week, but it's not going to work anymore. How are you going to handle your carbohydrate cravings? What can you do about it? A lot of these problems can be solved, but you need to work with me to get some help.