Role of the dietitian in multidisciplinary treatment of polycystic ovary syndrome

1. Melissa Olfert, DrPH, MS, RD (Chair)
Pamela J. Murray, MD, MHP
Melanie Clemmer, PhD
1
Role of the Dietitian in
Multidisciplinary Treatment of
Polycystic Ovary Syndrome
Wendy Thompson

2. Outline
• Introduction/Background
• Study Objectives
• Study Design
• Methodology
• Results
• Conclusions
• Future Research
• Questions
2

3. The Significance of the PCOS
3
National Institutes of Health Office of Disease Prevention, 2012
4 Billion Dollars!
Does NOT include
co-morbidities

4. PathophysiologyofPCOS
4
Alex Rotstein, Raginin Srinivasan, Erin Wong
McMaster Pathophysiology Review (MPR), 2013

5. How is PCOS Diagnosed?
NIH 1990 Rotterdam 2003 AE-PCOS Society 2006
• Hyperandrogenism
• Chronic Anovulation
---Both criteria needed
• Hyperandrogenism
• Oligo-and/or anovulation
• Polycystic ovaries
---2 of 3 criteria needed
• Hyperandrogenism
• Ovarian dysfunction
---Both criteria needed
First developed and most
commonly used criteria
today
Formulated to expand on NIH
diagnostic definition
Formulated to provide an
evidence-based definition
5
*All possible related disorders must be ruled out
NIH Evidenced Based Methodology Workshop on PCOS, 2012; Shannon et al. 20122
~ 50-75% will visit multiple
clinicians before it is identified2

6. Health Implications of PCOS
• Obesity
• Type 2 Diabetes
• CVD
• Infertility
• Depression/Anxiety
• Dermatological Symptoms
• Metabolic Syndrome
• Hypothyroidism
• Eating Disorders
• Obstructive Sleep Apnea
• Endometrial/Ovarian
Cancer
6
Sirmans & Pate, 2014; Daniilidis A. & Dinas K., 2009

7. PCOS Treatment
• Lifestyle intervention =
first line treatment1-3
• Support medical
management
• Weight loss is best achieved
though multidisciplinary
lifestyle management4
• Requires ongoing support for
long-term success5-6
7
Teede et al, 20111; Humphreys & Costarellil, 20082; Jeanes et al, 20093; Moran et al, 20094; Himelein, 20065; Stankiewicz, 20066
Physical
Activity
Diet
Smoking
Cessation
Stress

8. Benefits of Weight Loss in PCOS
• Potential Benefits
Include1-3:
•  insulin levels
•  testosterone
•  risk for CVD and
diabetes
• Improved dermatological
symptoms
• Improved fertility
8
• Weight loss of 5% to
10% can improve
metabolic and
reproductive aspects
of PCOS1-2
• Does not reverse
PCOS, but helps
control associated co-
morbidities3
Teede et al, 20111; Farhat et al, 20112; Barthelmess & Naz, 20143

9. Nutritional Interventions
Current diet recommendations:
• Energy for weight
maintenance or loss1-2
• Moderate to low glycemic
index1-3
•  Carbohydrates2 (35-40%)3
• Evenly distribute energy
intake1,3
• 4-5 meals/snacks per day
• General healthy guidelines
9
Moran et al, 20131; Academy of Nutrition and Dietetics, Nutrition Care Manual, 20142, Grassi, The Dietitian’s Guide to PCOS, 20073
No optimum dietary
composition1

10. Current Utilization and
Knowledge of Dietitians
• Interview-Guided
Questionnaire (N=53)1
• 26% of overweight were
referred to RD
• Patients reported diet
advice from
endocrinologist to be
useful, but inadequate
• Survey Report (N=206)2
• 15% saw a dietitian
• 3% over 2 visits with RD
• Knowledge of Dietitians
• Survey (N=105)2
• Only 34% felt well
informed
• 64% believed there was
an insufficient evidence
base for the dietary
management of PCOS
10
Humphreys & Costarellil, 20081; Jeanes et al, 20092
There has been no
published research on the
current utilization or
knowledge of dietitians
and PCOS in the USA

11. Proposed Benefits of Dietitians
11
Geier et al, 2012
100%
76% 71% 61%
% of Patients Seen by
Providers
Only study that has
assessed potential
benefits of dietitians

12. Study Objectives
• Objective 1: To investigate the current trends
and future implications for multidisciplinary
treatment of PCOS across different providers
• Objective 2: To explore the role, importance and
challenges for RDs in multidisciplinary PCOS
treatment
12

13. Study Design
Phase 2: Focus Group Series
(N=9)
Phase 1: Survey
(N=261)
13

14. Timeline of Project
14
PHASE 1:
Survey Tool
Development
February -
April 2013
WVU's IRB
Approval
March 2013
Survey
Recruitment
March - June
2013
Survey Open
May 15th -
July 15th,
2013
Survey Data
Analysis
August -
November
2013
PHASE 2:
Focus Group
Planning
November -
January
WVU's IRB
Addendum
Approval
Early January
2014
Focus Group
Recruitment
January 2014
Focus Groups
Conducted
Late January
2014
Focus Group
Data Analysis
February
2014

15. Survey Recruitment
Survey
Participants
N=261
LISTSERVs:
•SAHM
•NASPAG
•SART-ASRM
•EmbryoMail
LinkedIn Groups
Direct Emails
15Inclusion Criteria:
• Health Care Provider
• Currently Treat PCOS
Phase 1

16. Focus Group Recruitment
16
Focus Group
Participants
N=9
US Survey
Participants
(n=22)
Additional PCOS
Experts (n=12)
Referrals
(n=4)
Inclusion Criteria:
• Health Care Provider
• Currently Treat PCOS
Phase 2

17. Survey Design
• Development:
• 30 Questions
• Basic Demographics
• Current Facility
• Future Implications
• Developed based on reviewing
existing literature and clinics
• Expert reviewed
• Implementation:
• Qualtrics
• Open for 2 months 17
Phase 1

18. Focus Group Methodology
• Development:
• 7 Major questions1
• Expert review
• Implementation:
• Held via teleconference1
• 2-3 note takers and facilitator
• Audio recorded
• Similar providers were placed
together to promote group
cohesiveness2-3 and
compatibility4-5 18
Phase 2
Stewart & Shamdasani, 19901; Cartwright et al, 19682; Terborg et al, 19763; Haythorn et al, 19564; Sapolsky, 19605

19. Survey Data Analysis
• Quantitative
• Numerical Data
• Mean, Median, Mode, Standard
Deviation
• Qualitative
• Assessed for themes and
categorized accordingly using
Excel (clustering)
• Frequencies 19
Phase 1

20. Focus Group Data Analysis
• Braun & Clarke’s Thematic Analysis1-2
• Identify, analyze and report patterns (themes) within data
• Guide to Thematic Analysis2
1. Become familiar with the data – transcribe, clean, & compile data
2. Generate initial codes – assign participant ID numbers &
categories
3. Search for themes – create code-list
4. Review themes – rearrange as needed
5. Define and name themes – code and sort data
6. Producing the report – synthesize data
20
Phase 2
Boyatzis, 19981; Braun & Clark, 20062

21. Survey Results
21
Phase 1

22. Survey Sample
22
59%
20%
5%
3%
3%
3%
7%
Provider Type
Physicians
Dietitians
Fertility Specialist
Researchers
Midlevel Providers
Educator/Counselors
Other
N=210
64%
36%
Location
USA
Other
N=184

23. Geographical Demographics
0
10
20
30
40
15%
36%
22%
27%
%ofparticipants
USA Regions
0
5
10
15
20
25
30
35
5%
10%
5%
10%
34%
24%
12%
%ofparticipants
World Regions
23
N=74
N=41

24. Participant Settings
24
0
10
20
30
40
50
60
70
66%
45%
8%
4%
Setting for Care
71%
23%
6%
Population Setting
Urban
Suburban
Rural
N=205
N=141

25. Multidisciplinary Specialties
Involved
59%
41%
Multidisciplinary
Status
Yes
No
25
Specialty # Involved % Involved
Dietitian/Nutritionist 94 71%
Physician 89 67%
Nurse 63 48%
Fertility Specialist 46 35%
Mid-Level Providers 37 28%
Social Worker 37 28%
Psychologist 34 26%
N=132

26. Strengths and Weaknesses of the
Current System
34%
30%
10%
0
10
20
30
40
%ofProviders
Needs Improvement
26
* Wait-Time, Cost,
InsuranceN=88
21% 21% 20%
17%
0
5
10
15
20
25
%ofProviders
Current Strengths
N=87

27. Potential Barriers for Future
Multidisciplinary Clinics
27
Money and resources
(30%)
Insurance/reimbursement
(26%)
Difference of
opinions (16%)
Time
(12%)
N=76

28. Potential Advantages for
Multidisciplinary Clinics
28
Increased
access to
more disciplines
(10%)
Better communication
between providers (15%)
Better results & long-term
outcomes (18%)
Convenience & efficiency (30%)
Comprehensive and integrated care (32%)
N=82

29. Ideal Involvement of Providers
Specialty N
Highly
Involved
Involved Neutral
Occasionally
Involved
Never
Involved
Dietitian 110 59% 30% 6% 3% 2%
Endocrinologist 109 48% 36% 6% 7% 3%
Gynecologist 110 45% 43% 5% 5% 2%
Fertility
Specialist
97 30% 33% 14% 13% 9%
Exercise
Physiologist
95 18% 40% 18% 9% 15%
Health
Psychologist
105 11% 45% 21% 15% 8% 29

30. Survey Conclusions
• Multidisciplinary clinics could provider greater convenience,
access to care, and ultimately lead to a better prognosis for
patients with PCOS
• The most common barriers identified included
money/resources, insurance, and difference of opinions
• 90% of responders believed that dietitians should be either
highly involved or involved
30
Phase 1

31. Focus Group Results
31
Phase 2

32. Focus Group Demographics
• Dietitians
• PCOS (4)
• Physicians
• Adolescent/Internal
Medicine
• Pediatric
Endocrinologist (2)
• Other
• LN/CNS
• Health Psychologist
32
67%
33%
Multidisciplinary
Clinic
Yes
No 71%
29%
Gender
Female
Male

33. Focus Group Questions
Participants’
Treatment
Facility
• “Describe any nutritional interventions that you provide to your patients”
• “How are dietary interventions and patient care communicated between
providers?”
Utilization of
Nutritional
Interventions
• When is dietary intervention warranted for a patient with PCOS?
• How accessible are nutritional interventions for the majority of PCOS patients?
Challenges and
Changes
• “What are some of the challenges for getting dietitians more involved with
PCOS?”
• “Do you feel like providers know and understand the value of nutritional
interventions for PCOS patients?”
• In your career, have you seen any shift in the awareness or interest of PCOS?
33
Phase 2

34. Nutritional Interventions Provided
Physicians
• Basic diet history
• Brief nutrition education
Psychologist
• Motivational interviews
to facilitate changes
• Explore
emotional/mindless
eating
• Clarify information
--“Dietitian provides the
education but the
psychologist gets the
change.”
34

35. Nutrition Interventions
Tasks of the RD
• Individualized treatment
• Assess food coping
mechanisms
• Explore emotional or
disordered eating habits
• Help understand
condition
Specific Interventions
• Managing insulin
resistance
• General healthy eating
guidelines
• Sensible dietary
supplementation
• Correct nutrient
deficiencies
• Assist in treatment 35

36. Communication Differences
Solo Providers
• Limited opportunity
• No face to face
communication
• Only email and progress
notes
• Confidentiality barriers
• Not ideal, but still effective
Multidisciplinary
• More verbal
communication
• More integration of care
• Little formal case
management
• Varies by setting
36“In an ideal world, there would be PCOS treatment clinics all around the world
and all the providers would have the opportunity to converse about each
patient.”

37. When is Dietary
Intervention Warranted
For PCOS?
• Always important to
discuss and provide
nutrition counseling
• Equally important
regardless of BMI
• Immediately upon on
diagnosis patients should
meet with RD
• First line treatment
How Accessible are
Dietary Interventions
for PCOS?
• Not very accessible!
37

38. Challenges for Dietitians
Insurance
Lack of PCOS knowledge
Lack of physician referrals
Patient follow-through
38

39. Lack of Referrals from Physicians
• Lack of insurance coverage
• Limited access
• Quick to write off as
uninterested or noncompliant
• Little confidence
• Value pharmacological
treatment
• Feel they have treatment
covered
• Not educated on the value
39
“Physicians are the gatekeepers”

40. Lack of Patient Follow-Through
• Lack of insurance coverage
• Not ready for change
• Practicality
• Stigma or punishment
• Overwhelmed
• Already know what the
dietitian is going to tell
them
40“It is just food – you are just going to
tell me to eat asparagus rather than a
snickers bar and I already know that.“

41. Importance of Involving RDs
• Access to adequate
lifestyle interventions
• Physicians should not
be fully responsible:
• Little to no training
• “They can only be the
experts on so many
things”
• Takes time
• “More than just handing
the patient a 1,200 kcal
diet plan”
41
CDC – NCHS, Ambulatory Health Care Data, 20101
Average length of visit = 18.7 minutes

42. Shift in Awareness
• More information in the lay press
• Patient-driven diagnosis
• Support groups
• Websites
• More awareness in medical community
• Providers still do not understand it
• “It’s starting to get mentioned but it
doesn’t get the attention it deserves.”
42
The better the clinician understands PCOS, the better
they are able to treat it!

43. Discussion
• Supports the findings:
• Multidisciplinary clinics provide access to more disciplines1,2
• Patients need dietitians for adequate lifestyle management3
• Strengthens the need for evidence on the benefits of dietitians1
• Uncovered the potential under-utilization of health psychologist
in addition to the RD3,4 for PCOS despite potential benefits1
• First study to gain insight from a mix of PCOS providers on
potential implications of multidisciplinary clinics and the
challenges of involving dietitians in the care of PCOS
43
Geier, 20121; Bekx, 20102; Humphreys, 20083; Jeanes, 20094

44. Limitations
• Small sample size
• Completion rate
• Missing equal
representation of disciplines
• Self-reported experience
• Not generalizable to the
entire population of
healthcare professionals
44

45. Conclusions
• PCOS patients require special attention with individualized, focused,
multidisciplinary care – ideally in one facility
• The most common challenges for dietitians include insurance, lack
of knowledge, and lack of physician referrals
• Dietitians and health psychologist are highly overlooked when it
comes to the care of PCOS
• Education for PCOS and lifestyle interventions need to be increased
across providers
45
“Often times, with PCOS, nutrition
counseling is treated like dermatology and it
needs to be treated more like psychology.”

46. Future Research Aims
• Assess factors influencing weight loss/maintenance
• Delivery methods
• Frequencies
• Long-term success
• Determine how to effectively educate:
• Dietitians on PCOS
• Physicians on the importance lifestyle interventions
• Development of a screening tool
46

47. Acknowledgments
Committee Members
Dr. Melissa Olfert
Dr. Pamela Murray
Dr. Melanie Clemmer
ORL Research Team
Jade White
Mackenzie Barr
Fellow Interns
Family and Friends
Study Participants 47

48. Questions
48