Disordered eating and night eating behavior in young women with Polycystic Ovary Syndrome

doi:10.21203/rs.3.rs-1959239/v1

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Disordered eating and night eating behavior in young women with Polycystic Ovary Syndrome

https://doi.org/10.21203/rs.3.rs-1959239/v1

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Purpose

The most prevalent endocrine abnormality in women, polycystic ovarian syndrome (PCOS), is accompanied with symptoms that are related to metabolism, reproduction, and mental health. Eating disorders are well known as a contributing factor to obesity in women. However, there is limited data regarding eating disorders in women with PCOS. The aim of this study is to investigate the prevalence of disordered eating in young women with PCOS and to analyze the possible influencing factors associated with disordered eating.

Methods

The women aged 18–25 years with and without PCOS (n:110 for each group) were included in this study. Eating Disorder Examination Questionnaire (EDE-Q), Night Eating Questionnaire (NEQ), Beck anxiety, and Beck depression inventories were performed by all patients.

Results

Disordered eating and night eating syndrome (NES) were found more frequently in women with PCOS than in controls (25.5% vs 2.7%; 17.3% vs 2.7%, respectively, p < 0.001). Anxiety and depression scores were also higher in patients with PCOS than in the control group (p = 0.002, p = 0.001; respectively). PCOS diagnosis (OR:7.1, CI:1.49–33.4, p = 0.014), high Homeostasis model assessment of insulin resistance (HOMA-IR) (OR:0.68, CI:0.47–0.98, p = 0.04), and being overweight (BMI ≥ 25 kg/m²) (OR:1.2, CI:1.09–1.38, p = 0.001) were found as independent factors for disordered eating according to EDE-Q global score (≥ 4).

Conclusion

Disordered eating and NES were more common in young women with PCOS than in controls. PCOS diagnosis, high HOMA-IR, and being overweight may be independent factors associated with disordered eating in women. Screening for disordered eating and night eating syndrome, especially in young women with PCOS may be recommended to help with weight management.

Polycystic ovary syndrome (PCOS)

disordered eating

night eating syndrome

anxiety

depression

Polycystic ovary syndrome (PCOS), one of the most common endocrinopathies, affects 6–10% of women, according to different classifications of PCOS worldwide [1, 2]. It is known that most women with PCOS have difficulty controlling their weight compared to healthy women. In the long term, weight gain is associated with insulin resistance and other risk factors such as subfertility, disordered mental health, type 2 diabetes, and cardiovascular disease [3, 4].

The lifetime prevalence of eating disorders in the normative population is relatively low, ranging between 0.3% and 2% [5]. Recent evidence supports that eating disorders are more common (11%) in women with PCOS than in healthy women [6, 7]. Although structural and functional disturbances associated with non-homeostatic nutrition have been supported with central nervous system imaging, the factors related to a high prevalence of eating disorders in women with PCOS have not been elucidated [8]. Anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and other specific feeding and eating disorders, such as night eating syndrome (NES), are examples of eating disorders that are characterized by abnormal eating or weight problems. Earlier diagnosis and treatment of eating disorders in PCOS women are required due to tendency to persistent weight gain during the follow-up period [9]. Moreover, psychiatric comorbidities like mood and anxiety disorders mostly present with eating disorders [10].

Recently, the Androgen Excess-PCOS society and international evidence-based guidelines have recommended screening for eating disorders in women with PCOS [11, 12]. There are few studies investigating the prevalence of eating disorders and the contributing factors in young women with PCOS.

The aim of the present study was to compare the prevalence of disordered eating and night eating syndrome in young women with and without PCOS and to investigate the possible factors associated disordered eating.

This prospective study carried out in a tertiary center from January 2020 to February 2021. The Helsinki Declaration's principles guided the conduct of this research and the ethics committee permitted (No:164/11.12.2019) All participants provided their informed consent. The study involved women between the ages of 18 and 25 who had been diagnosed with PCOS and were visiting a gynecological clinic. Healthy women who went to the policlinic for routine check-ups made up the control group. Non-classical congenital adrenal hyperplasia (NCCAH), Cushing's disease, pregnancy or breastfeeding, hyperprolactinemia, oncological treatment, and utilization of hormonal therapy in the three months before the research, a history of psychotic illnesses, bipolar disorders, organic mental disorders, and intellectual disability were the exclusion criteria. Women who had hirsutism or irregular menstruation were also not included in the control group.

Study population

PCOS is defined as having at least two of the following: polycystic ovarian morphology (PCOM), oligo- or anovulation/amenorrhea, biochemical (total testosterone level 2.6 nmol), or clinical hyperandrogenism (Ferriman-Galwey score 12) [13]. PCOM is identified as having 12 or more follicles with a diameter of 2 to 9 mm or a larger ovarian volume (>10 mL) in one of the ovaries. A 10-MHz vaginal or 6-MHz abdominal probe (Mindray: DC—T6; Shenzhen Mindray Bio-Medical Electronics Co., Ltd.; Shenzhen, China) was used for ovarian ultrasonography.

The homeostasis model assessment of insulin resistance (HOMA-IR), which is more practical than the oral glucose tolerance test in day-to-day practice, has been used to evaluate the insulin resistance in patients, despite its limited applicability due to changes in beta-cell function over time [14]. HOMA-IR was calculated as fasting insulin (IU) x fasting glucose (mg/dl) /405, according to Matthews et al [15].

Psychiatric measures

All inventories were completed by the patients.

The Eating Disorder Examination Questionnaire

A 28-item self-report questionnaire titled the Eating Disorder Examination Questionnaire (EDE-Q) is used to assess the psychopathology of eating disorders over the previous 28 days [16]. It was developed from the Eating Disorder Evaluation Interview, which is considered the 'gold standard in evaluating eating disorders. It consists of a global score and four subscales: Dietary restraint (DR), Eating concern (EC), Weight concern (WC), and Shape concern (SC). The Turkish version of the scale was shown to be valid and reliable in the adolescent population [17].

Night Eating Questionnaire

The Night Eating Questionnaire (NEQ) is used to determine whether night eating behavior is present [18]. This 14-item Likert-type survey examines nocturnal eating, morning anorexia, daytime desire patterns, mood, and sleep issues. The screening studies were advised to use a cut-off score of 25, as higher values indicate higher levels of psychopathology. Atasoy et al. tested the scale's reliability and validity in Turkish [19].

Beck Depression Inventory

The Beck Depression Inventory (BDI) was used in order to determine the severity of depression [20]. It consists of 21 items, each of which is given a 4-point rating (from 0 for no symptoms to 3 for severe symptoms). When the total score is between 0 and 63, depression is categorized as nonexistent or minimal (10), mild to moderate (10–18), moderate to severe (19–29), and severe (63). (30-63). The BDI has good psychometric qualities and is valid and trustworthy [21].

Beck Anxiety Inventory

The scale consists of 21 components, each of which can be rated from 0 to 3, for a total score of 63 [22]. Total scores represent the level of anxiety and are divided into four categories: minimum anxiety (scores of 7 or lower), mild anxiety (scores of 8 to 15), moderate anxiety (16 to 25), and severe anxiety (26-63). Ulusoy et al. assessed the validity and reliability of the Turkish BAI adaption [23].

Statistical analysis

SPSS version 24 (IBM, Armonk, NY, USA) was used to conduct all statistical analyses. Means and standard deviations or the median were used to provide the descriptive results for continuous data (minimum-maximum). The Kolmogorov-Smirnov test was used to look into the normality analysis of the variables. Parametric variables between PCOS group and controls were compared using the Mann-Whitney U test or Student's t test. The chi-square test was applied to examine differences between categorical variables. Potential factors associated with disordered eating was investigated with binary logistic regression. Statistical significance was defined as p<0.05.

Socio-demographic and clinical characteristics

In all, 220 women between the ages of 18 and 25 were enrolled in this study, 110 of whom had PCOS and 110 of whom did not. Table 1 displays the sociodemographic and clinical characteristics of two groups. In comparison to controls, the PCOS group had significantly higher BMIs and waist-to-hip ratios (p = 0.001, p = 0.008, respectively). In comparison to the control group, a significantly larger percentage of women with PCOS were either overweight or obese (29.1% vs. 10% for the overweight group and 17.3% vs. 1.8% for the obese group, respectively). Patients with PCOS had higher HOMA-IR scores than those in the control group (median 1.9 vs. 1.7, respectively; p = 0.015).

Table 1

*Participant characteristics of the women with PCOS and control group*
Variables	PCOS (n\(=\)110)	Non-PCOS (n\(=\)110)	P value
Age (y)	21.1 ± 2.3	21.4 ± 2.4	0.38
BMI (kg/m²)	25.7 ± 5.3	21.6 ± 3.1	< 0.001
WC (cm)	80.4 ± 11.8	72.1 ± 9.1	< 0.001
HC (cm)	104.4 ± 11.7	96.9 ± 7.9	< 0.001
Waist to hip ratio	0.77 ± 0.06	0.74 ± 0.06	0.008
BMI category			< 0.001
Underweight (< 18.5)	11 (10%)	15(13.6%)
Healthy weight (18.5–24.9)	48 (43.6%)	82 (74.5%)
Overweight (25.0-24.9)	19 (29.1%)	2 (10%)
Obese (< 30)	32 (17.3%)	11(1.8%)
Menstrual periods in a year	7 ± 3.8	12 ± 0	< 0.001
HOMA-IR	1.9 (0.6–14)	1.7 (0.5–6.4)	0.015
Smoker	8 (7.3%)	17 (17.7%)	0.02
Education level			0.22
Year 12 or less	59 (54.2%)	50 (45.5%)
University	51 (45.8%)	60 (54.5%)
Student	17 (15.6%)	0	-
Worker	22.7%	26.4%	0.64
Marital status-married			0.09
Single	94 (85.5%)	83 (75.5%)
Married	16 (14.5%)	27 (24.5%)
Income			0.37
No paid job	83 (75.5%)	79 (71.8%)
Subsistence wage	12 (10.9%)	12 (10.9%)
Middle income	15 (13.6%)	16 (14.5%)
High income	0	3 (2.7%)
PCOS, polycystic ovary syndrome; BMI, body mass index; WC, waist circumference; HC, hip circumference; HOMA-IR, Homeostatic Model Assessment for Insulin Resistance.

EDE-Q, NEQ, anxiety, and depression scores

Table 2 shows the results of the two groups in terms of EDE-Q, NEQ, BAI, and BDI. According to global EDE-Q scores, the PCOS group had notably more disordered eating than the control group did (25.5% vs 2.7%, p < 0.001). Additionally, PCOS women were more likely to experience night eating syndrome than healthy women (17.3% vs 2.7%, p < 0.001).

Table 2

*EDE-Q, NEQ, anxiety, and depression scores for women with and without PCOS*
	PCOS (n=\(110)\)	Control group (n=\(110)\)	P*
Dietary restraint (n, %)	24 (21.8%)	7 (6.4%)	0.002
Weight concern (n, %)	31 (28.2%)	5 (4.5%)	< 0.001
Shape concern (n, %)	52 (47.3%)	7 (6.4%)	< 0.001
Eating concern (n, %)	18 (16.4%)	2 (1.8%)	< 0.001
Global score (n, %)	28 (25.5%)	3 (2.7%)	< 0.001
NEQ	19.3 ± 7.9	16.2 ± 4.9	< 0.001
Beck anxiety score	22 (0–60)	14 (0–52)	0.002
Beck depression score	15 (0–54)	10 (0–42)	0.001
Eating Disorder Examination Questionnaire, EDE-Q; Night Eating Questionnaire, NEQ
The number (%) of the patients with EDE-Q domain scores’ ≥4 was given. NEQ scores was shown as mean ± standard deviation, Beck anxiety and depression scores were shown as median (minimum-maximum)

EDE-Q global scores and BMI were found to be strongly correlated (r = 0.69, p < 0.001). HOMA-IR, NEQ scores, and W/H ratio showed a moderate correlation with EDE-Q global scores (r = 0.33, r = 0.44, r = 0.34; correspondingly, p0.001). There was a minimal correlation between anxiety or depression scores and EDE-Q global scores (r = 0.25, r = 0.26, respectively, p < 0.001). BMI < 25, PCOS status, and high HOMA-IR were found to be independent variables for increased disordered eating (OR: 7.06, p = 0.014; OR: 1.2, p < 0.001; OR:0.68, p = 0.04; respectively) (Table 3).

Table 3

*Logistic regression of the variables related to disordered eating in women*
	OR	CI	P
BMI (≥ 25 kg/m²)	1.2	1.1–1.38	0.001
Smoking	1.8	0.41–8.22	0.42
Marital status	0.84	0.26–2.73	0.77
PCOS status	7.06	1.49–33.4	0.014
Hyperandrogenism	0.93	0.29–2.95	0.90
HOMA-IR	0.68	0.47–0.98	0.04
Education	0.60	0.22–1.60	0.31
Anxiety	0.99	0.95–1.03	0.56
Depression	1.02	0.97–1.07	0.49
BMI, Body mass index; HOMA-index: HOMA-IR, Homeostatic Model Assessment of Insulin Resistance

In this study, we demonstrated that young women with PCOS (18–25 years old) had greater rates of disordered eating and night eating syndrome than healthy women (25.5% vs. 2.7%; 17.3% vs. 2.7%, respectively, p < 0.001). Three independent risk factors for disordered eating were discovered: the presence of PCOS, being overweight, and having a high HOMA-IR (OR:7.06, 1.2, 0.68, respectively). The prevalence of disordered eating was higher in our group than in prior studies which has been reported as 7.4–12.2% [7, 24, 25]. As self-reported diagnoses have mostly been the basis of studies to date, the findings may underestimate the incidence of disordered eating or eating disorders. Similar to our study, an Australian cohort of women with PCOS was found to have a higher prevalence of disordered eating disorders when compared to women without PCOS [26]. The average total and subscale values of the EDE-Q were shown to be higher in women with PCOS than in the overweight/obese women (p < 0.05) [27]. However, Michelmore KF et al. found no difference in eating disorders between young women with PCO and without PCO [28].

Women with PCOS were mainly overweight or obese, so they appeared to be more prone to gaining weight than others. Since it was reported that there was no difference in resting metabolic rates between PCOS and healthy women after adjusting for age and BMI, other possible factors lead to more weight gain in women with PCOS than others [29]. It has been revealed that PCOS women had extensive corticolimbic activation in response to food stimuli and strong responses in several brain regions involved in insulin sensitivity, despite the lack of an established etiological link between PCOS and eating problems [30]. In correlation with this, another study on eating habits in adolescents has reported that girls with PCOS have poorer eating habits and consume more calories per day than the control group [31]. A meta-analysis found increased insulin sensitivity was found related to AN, while a negative, statistically significant association was found between BN/BED and insulin sensitivity [32]. Furthermore, it has been shown that having high levels of androgen is linked to a generalized increase in appetite and poor impulse control [33]. We did not observe a correlation between androgen levels and disordered eating.

The reported prevalence rates of night eating syndrome in the general population range from 1.5% to 5.7, with rates rising among overweight and obese people [34]. We found higher NEQ scores in women with PCOS than in controls in this study (p < 0.001). Lee et al. also reported higher NEQ scores in the PCOS group compared to the control group, but the percentage of night eating syndrome, which was 12.9% (NEQ score ≥ 25), did not differ between the two groups [25]. High NEQ scores in our study group may be related to the relatively younger age of the included women. NES has been shown to be more common in young adults, although other studies have shown no difference between different age groups [35, 36]. High levels of night eating scores in the young age group might be related to circadian rhythm shifts due to lifestyle, or high levels of sleep disturbances in young women may affect the rate of NES [37].

Many clinical features of PCOS, such as obesity, hyperandrogenism, hirsutism, and irregular menstrual cycles, may contribute to an increased prevalence of low health quality, high anxiety, and elevated depression scores in this population [38]. We detected high levels of anxiety and depression scores in the PCOS group compared to the control group (median 22 vs 14, p = 0.002; 15 vs 10, p = 0.001, respectively) although, a weak correlation between anxiety or depression and disordered eating was present. Greenwood et al. showed that BMI, hyperandrogenism, and depression symptoms predict disordered eating behaviours 5 years later [9].

Our study's strengths include the fact that it exclusively included young women between the ages of 18 and 25 as a specific age group. The diagnosis of PCOS or eating disorders was not self-reported, in contrast to the majority of prior community-based cohort studies. In light of this, more accurate findings about the prevalence of disordered eating may arise. Additionally, we investigated associations between PCOS, BMI, HOMA-IR, eating disorders, anxiety, and depression.

Our study has some limitations. First of all, the study group consisted only of patients from a tertiary center, so it may not represent the entire population in terms of socio-economic level or cultural characteristics. Disordered eating and other inventories were taken from the patients, so the diagnosis was not confirmed by a clinical interview. The number of patients in the non-PCOS overweight group was insufficient to compare the overweight and non-overweight groups in terms of disordered eating. Future studies are needed to investigate whether disordered eating is related to PCOS or insulin resistance, or obesity.

In summary, our results showed that disordered eating and night eating syndrome were more common in young women with PCOS than healthy women. Screening for eating disorders and NES in young women with PCOS may allow for early intervention, prevent further weight gain and worsening future morbidities in this group. An additional study can be conducted to investigate biochemical processes in women with eating disorders and PCOS and to clarify whether possible factors such as overweight or high insulin resistance influence the occurence of eating disorders in women with PCOS.

Author contributions SY and NGUS conceptualized and suggested a plan for the study. The data collection and input were carried out by SY and FKG. The data analysis and manuscript writing were done by SY. The manuscript was edited and finalized by SY, NGUS, and FKG.

Compliance with ethical standards

Conflict of interest Authors declare that they have no conflict of interest.

Funding

The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work.

Acknowledgments

The authors would like to thank all women who graciously volunteered to participate in this study.

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Disordered eating and night eating behavior in young women with Polycystic Ovary Syndrome

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Introduction

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Socio-demographic and clinical characteristics

EDE-Q, NEQ, anxiety, and depression scores

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