Impact of promoting healthy lifestyle interventions among adolescents, young adults with polycystic ovarian disease in resource limited settings

Polycystic (PCOD) is a reproductive metabolic disorder caused by hormonal imbalances within women of fertile age. Mainstay for treating patients with PCOD includes pharmacological therapy and lifestyle modi(cid:976)ications. Lifestyle modi(cid:976)ications that play a key role in the management of PCOD are weight management, reduction in stress, physical activity, body mass index and dietary changes. There is sparse information regarding the impact of these interventional parameters among the PCOD women in the literature. This study aims to determine the impact of healthy lifestyle modi(cid:976)i-cations in the management of PCOD among young adults and adolescents. It was a prospective interventional study conducted in the Gynaecology outpa-tient department in Government General Hospital, Kadapa over the time of 6 months from June 2019 to November 2019. Counseling on lifestyle changes and implementation of healthy lifestyle interventions were given to the study population by using the standard questionnaire forms and post counseling changes were collected after 90 days of visit to the clinic. The statistical signif-icance was done by using the unpaired t-test and graph pad version 8.3.0. The total sample of 30 PCOD patients was compared to before patient counseling on lifestyle modi(cid:976)ications and after follow-up. The total population was categorized into 2 groups as adolescents (10%) and young adults (27%). The current study showed that there is a signi(cid:976)icant association between dietary intervention (p <0.0113) and physical activity scores (p<0.029) among the PCOD patients. In PCOD patient’s healthy lifestyle modi(cid:976)ications like dietary interventions and Physical activity serves as an effective treatment strategy adjunct to pharmacological therapy and improved the patient reproductive health.

A Polycystic Ovarian Disease (PCOD) is a reproductive metabolic disorder caused by hormonal imbalances within women of fertile age. Mainstay for treating patients with PCOD includes pharmacological therapy and lifestyle modi ications. Lifestyle modi ications that play a key role in the management of PCOD are weight management, reduction in stress, physical activity, body mass index and dietary changes. There is sparse information regarding the impact of these interventional parameters among the PCOD women in the literature. This study aims to determine the impact of healthy lifestyle modi ications in the management of PCOD among young adults and adolescents. It was a prospective interventional study conducted in the Gynaecology outpatient department in Government General Hospital, Kadapa over the time of 6 months from June 2019 to November 2019. Counseling on lifestyle changes and implementation of healthy lifestyle interventions were given to the study population by using the standard questionnaire forms and post counseling changes were collected after 90 days of visit to the clinic. The statistical significance was done by using the unpaired t-test and graph pad version 8.3.0. The total sample of 30 PCOD patients was compared to before patient counseling on lifestyle modi ications and after follow-up. The total population was categorized into 2 groups as adolescents (10%) and young adults (27%). The current study showed that there is a signi icant association between dietary intervention (p <0.0113) and physical activity scores (p<0.029) among the PCOD patients. In PCOD patient's healthy lifestyle modi ications like dietary interventions and Physical activity serves as an effective treatment strategy adjunct to pharmacological therapy and improved the patient reproductive health.

INTRODUCTION
Polycystic ovarian disease (PCOD) a multiple system metabolic disorder because of hormonal imbalances (Harwood et al., 2007). Its epidemiology ranges from 2-7.5% and 6.3% in Asian countries like India, China and Sri Lanka (Joshi et al., 2014). In most of the health care settings the classi ication of PCOD patients is mainly based upon the rotterdam criteria that needs existing symptoms like a) Chronic or oligo anovulation b) Presence of excess male sex hormones c) Polycystic ovaries when diagnosed on ultrasound. Aetiological features associated with the PCOD remain unclear, but evidence support genetic, environmental and lifestyle modi ications are important contributors for development of PCOD (Naderpoor et al., 2015). Treatment strategy for patients with PCOD is the combination of pharmacological therapy and lifestyle modi ications. However, lifestyle modi ications that play an important role as irst line treatment options include stress reduction, dietary changes, exercise management and blood pressure (Humphreys and Costarelli, 2008). There are little shreds of evidence on the impact of lifestyle modi ications like blood pressure, dietary intake, stress reduction and body mass index in PCOD patients. Many of the literature report a mutual association among healthy lifestyle and PCOD. Therefore, the key objectives of our study were to determine the impact of the lifestyle modi ications like BP, dietary intake, and Physical activity in PCOD patients in tertiary care hospital settings.

Study design
It is a prospective Interventional study.

Study period
Present work was carried out for a period of 6 months from June 2019 to November 2019.

Study site
The present study was conducted at Government General Hospital, at the out-patient department Kadapa.

Ethical approval
Institutional ethical committee approval was obtained Prior to initiation of the study and informed consent was taken from all the subjects included in the study.

Source of data
Entire required data was collected from the patients through medical case sheets and lab reports.

Sample size
During the study period of six months, the total sample size was 30 patients.

Inclusion criteria
Patients with age group 12-24 years (adolescents and young girls) diagnosed with PCOD were included in the study. All the adolescents and young adult patients receiving drug therapy for PCOD on a clinical basis were included in the study.

Exclusion criteria
Patients who did not give consent to participate in the study were excluded. Patients above the age of 25 years were excluded from the study. Patients who had been receiving the drug therapy for more than 3 years were excluded from the study due to chances of misleading the results and errors.

Methods of collection of data
All the patients were given counseling and data was collected by using the following: 1. Data on dietary intake was collected by using the self-designed diet questionnaire form 2. Data regarding physical activity was noted on the IPAQ (International Physical Activity Questionnaire) short form.
3. BP measurements were done during the baseline and follow-up after 90 days.

Statistical Analysis
All the data of recruited subjects were entered on a Microsoft Excel spreadsheet. In order to assess the statistical signi icance of interventional parameters like BP, diet and physical activity, we used the graph pad version 8.3.0 and a statistical signi icance of pvalue (p ≤ 0.05) was observed to be signi icant.

RESULTS AND DISCUSSION
In present work total sample size was 57, out of them 7 patients were excluded as they are unwilling to give their consent form. Out of 50 patients, 5 patients were adolescents and the remaining 45 patients were young adults. Among 50 patients, 30 patients were willing to participate and the rest of 20 patients were excluded as they were not willing to continue their treatment in the present study site as shown in Figure 1. In this research study, entire 30 study participants were recruited and categorized into two groups based upon age-wise categorization i.e., Group I: adolescents (12-18 yrs) and Group II: young adults (19-24).

Graphical representation of different groups based on age
The majority of the PCOD patients in our study were young adults 27 (90%) and adolescents were 3 (10%) as represented in Table 1.

Comparing the effect of Blood pressure on PCOD patients
This was done by measuring the systolic and diastolic BP levels of the patients. Among 30 patients average systolic BP of adolescents at baseline was 106.67 mm of Hg and after followup was 113.33 mm of Hg and average diastolic at baseline and followup was same 80 mm of Hg. Young adult's average systolic BP at baseline was 109.26 mm of Hg and after followup it was 110.37 mm of Hg, the diastolic average BP at baseline was 110.3 mm of Hg and after followup 81.85 mm of Hg. There was no signi icance in blood pressure of systolic p-value = 0.186 and diastolic BP p-value = 0.735 as shown in Table 2.

Effect of Diet in PCOD patients
We categorized the 30 patients into 3 categories based upon the self designed questionnaire of diet chat as shown below Table 3 and the inal score was calculated by using formula.
Final score = Initial score × 100/40 Among 30 patients the average DIET score of adolescents at baseline was 50.55±10.42 and followup was 77.35±13.90. The average DIET score of young adults at baseline was 55.08±11.0 and followup was 75.16±13.63. A statistically signi icant value (P<0.0113) was observed among the younger adults and adolescents with PCOD as shown in Table 4.

Effect of Physical activity in PCOD patients
We used the standard IPAQ questionnaire short form to categorize the patients into 3 groups as a) Vigorous b) Moderate and c) Low. The IPAQ adolescents baseline average MET-score was 830 ± 661.81 and followup average MET-score was 2382.53 ± 287.31, IPAQ score in young adults was at baseline was 967.69 ± 595.61 and follow-up average METscore was 1960.10 ± 588.43. The physical activity (IPAQ MET-SCORE) has shown signi icance with a pvalue 0.029 as shown in Table 5.

Impact of healthy lifestyle interventions on menstrual condition
Among 30 patients the adolescent's menstrual condition who were with amenorrhea (3.33%) and oligomenorrhea (6.667%) are normalized at follow up (10%) when compared with baseline. The menstrual condition of young adults who are with amenorrhea (10%), oligomenorrhea (33.33%), Dysmenorrhoea (3.33) and irregular menses (3.33) at baseline. Most of them are identi ied normal menstrual status (73.33) and few are oligomenorrhea (16.66) at follow up as presented in Table 6. In the present study overall effect of lifestyle modi ications had an improvement in menstrual or reproductive health of   the PCOD patients. This is clearly explained by the follow-up results of menstrual conditions as represented in Table 6 where most of the menstrual where most of the menstrual irregularities in the PCOD females at baseline are normalized after the post counseling and implementation of the lifestyle modi ications. This was similar to work done by Haqq et al. which concluded that diet and exercise interventions can improve the hormonal levels in PCOD patients (Haqq et al., 2014) and also Hoeger study which concluded that weight reduction plays a signi icant role in reduction of PCOD (Hoeger, 2006).
Another study by Karimzadeh and Javedani also concluded that lifestyle modi ications can improve that hormonal status that is exactly proved by our study (Karimzadeh and Javedani, 2010). In our study most of the patients having PCOD were observed in the age group of young adults (19-24 years) is 90%. This may be due to the high burden of PCOD among young adults, especially in rural areas. Also a majority of the PCOS patients with lifestyle modi ications has shown signi icant improvement in menstrual condition among adolescents and young adults of PCOD patients to regular in post-intervention, and clinically resemble to Elmenim and Emam, shown the effective results in 56.4% of studies population were having regular menstrual cycles after a year following of healthy life style compared to baseline (Balaji et al., 2015).
This study inferred that there was a clear signi icance of intervention on IPAQ MET physical activity rate and dietary lifestyle which has shown to a greater extent on the menstrual condition from baseline to follow-up through the contribution of a clinical pharmacist, that is similar to Sedighi et al., as suitable diet is a contributing factor for restoring hormonal imbalances to normal (Elmenim and Emam, 2016;Sedighi et al., 2014). In many litera-ture is a con lict on evidence regarding the role of androgen whether they can increase hypertension in the PCOD Patients. However, our study concluded that there is no signi icant relationship between the impacts of blood pressure on PCOD patients.
This contrasts with the indings of Chen et al. that concluded that there is a signi icant association among the androgen and blood pressure in PCOD patients (Chen et al., 2007). Nowadays, amending healthy lifestyle by dietary changes and increase in physical activity focus to maintain androgen hormone limits and set ovulation is considered as the irst line therapy.

Limitations
This includes small sample size, duration of the study, and follow-up of the subjects.

CONCLUSIONS
Our study concluded that blood pressure does not show any impact on PCOD patients also lifestyle modi ications like an increase in physical activity and intake of a balanced diet had improved menstrual conditions of PCOD patients. Regardless of pharmacological therapy, all the patients need to improve the physical activity and take an appropriate diet that is less in carbohydrates to maintain good reproductive health. Special care and education is needed among PCOD patients to reduce the long term complications. Onus is on the health care professionals to educate patients regarding lifestyle modi ications and complications of PCOD to improve the health community status.