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Current IssueSpecial IssueEditorial BoardOnline First ArticlesArchive

Review Article

Effects of Various Diets on Anthropometric and Hormonal Changes in Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis

K
Kajal Dhama1
https://orcid.org/0009-0002-9348-7542
L
Luxita Sharma1,*
https://orcid.org/0000-0002-4700-4792
D
Dhananjay Sharma1
https://orcid.org/0000-0003-3264-4188
D
Deepika Pal1
https://orcid.org/0000-0002-3522-9310
1Department of Dietetics and Applied Nutrition, Amity Medical School, Amity University, Gurugram-122 001, Haryana, India.

ABSTRACT

Diets such as the ketogenic diet, low-carbohydrate diet, along with Mediterranean diet help to improve weight in obese patients and due to weight reduction insulin resistance improves which may be considered beneficial in PCOS. The study objective of the paper is to pool studies that are done on human subjects to analyse the effects of various diets on anthropometric measurements (weight and BMI) and reproductive hormones (LH/FSH ratio and free testosterone) and to know the evidences of changes in the body weight. Data was collected and searched from Google Scholar and PubMed for evaluating the effects of various diets on women with PCOS. In this study, to pool the data, a random-effects model was used and to assess the quality of selected studies the Cochrane Risk of Bias Tool was used. Meta-analysis pooling the studies under the random effect model has shown that there is a statistically significant relation between the diets and reduced BMI (d -0.509, 95% Cl -0.821, -0.196, P<.001). Similarly, there is also significant weight loss in the subjects of PCOS (d -0.315, 95% Cl -0.628, -0.02, P =0.049) in diet intervention. There is a statistically reduced level of LH/FSH ratio (d -0.346, 95% Cl -0.660, -0.032, P=0.031) is seen in the PCOS patients along with a reduction in free testosterone (d -0.317, 95% Cl -0.612, -0.023, P = 0.035) in the intervention with diet in the same cohort study. There is possibly an association between diets and improvement in the anthropometric measurements and the reproductive hormones in PCOS females.

INTRODUCTION

Polycystic ovary syndrome (PCOS) is the main endocrino-pathy that is affecting the females of reproductive age. However, still, it is not considered a major health problem across the globe. It is affecting 4% to 20% of reproductive age females in the world. Following the latest studies, the PCOS prevalence according to the Rotterdam criteria is 19.5% in Iran and according to NIH criteria is 6.8% (Abasian et al., 2018). The PCOS prevalence, its etiology, criteria for diagnosis, management and issues related to psychology and preventive methods are still confusing aspects of PCOS (Deswal et al., 2020).
       
PCOS was first introduced in the year 1935 by Stein and Leventhal in a more comprehensive way (Deswal et al., 2020). It is a complicated endocrine disorder that is characterized by hyperandrogenaemia, insulin resistance and anovulation (Baptiste et al., 2010). Women suffering from PCOS produce less amount of estrogen and progesterone hormones, which are crucial for maintaining normal menstruation (MacLean and Hayashi 2022). These hormonal imbalances can cause various problems with fertility, hirsutism means excessive hair growth and acne (Yau et al., 2017). The major reason of infertility is caused by a lack of ovulation in on average 75% of the cases approximately (Abasian et al., 2018).  In addition, PCOS patients often experience problems with weight management and blood sugar control (Studen and Pfeifer 2018).
       
Diet plays a very essential role in PCOS management. When the diet contains less amount of GI foods then it leads to weight gain that stimulates hunger due to insufficient carbohydrates in the body. In each meal, calories should be distributed properly to maintain a healthy weight (Farshchi et al., 2007). Some studies have shown that diet has a crucial role in improving blood glucose levels and diets that are low in saturated fats and have high amounts of fibre from foods that have low glycemic index are recommended (Marsh and Brand-Miller, 2005). A diet which is low in carbohydrates helps to reduce insulin resistance and maintain body weight in PCOS patients (Mavropoulos et al., 2005). Various kinds of diets that includes the diet like the Mediterranean diet are rich in fibre and complex carbohydrates along with high amounts of monounsaturated fatty acids. Studies have shown that diets including the ketogenic diet along with low-carbohydrate help to improve weight in obese patients and due to weight reduction insulin resistance improves which may be considered beneficial in PCOS (Mavropoulos et al., 2005). Mediterranean diet is known as the diet that helps to improve healthy dietary patterns as it has various peculiar features that result in weight reduction and shows very good activity like anti-inflammatory that is caused due to microbiota-derived production of short-chain fatty acids induced by the antioxidants, dietary fiber and more intake of polyun-saturated fatty acids omega 3 (Barrea et al., 2019). However, different studies on various diets are investigated in the meta-analysis and systematic review to analyze the usefulness of diet in PCOS and to know the effect in obese patients on their weight loss who have followed the intervention with various types of diet.
 
Source of information and search method
 
To identify the relevant research studies, in the preparation of this review was prepared using the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) that are followed in order to know the impact of various kinds of diets on participants of PCOS, the literature assessment was done thoroughly. From 2018 to 2023 November, an online literature review of all articles written in language English was conducted. According to this, databases of Systematic literature searches were looked up in Google Scholar and PubMed.
       
For the Google Scholar search engine, the specific keywords used were “PCOS” AND “Obesity”, “PCOS” AND “Diet”, “PCOS” AND “Overweight”, “PCOS” AND “Obese”, “PCOS” and “Nutrient” and “PCOS” and “Nutrition”.
       
For the PubMed search engine, the specific keywords used were (PCOS) AND (Obesity), (PCOS) AND (Diet), (PCOS) AND (Nutrient), (PCOS) AND (Nutrition), (PCOS) AND (Overweight), (PCOS) and (Obese). The systematic and meta-analysis research was carried out from the month of January to February 2024, at Amity University Haryana.
 
Criteria for inclusion and exclusion
 
Inclusion
 
•  The literature search was primary focusing on PCOS females along with diet in obese and overweight patients  was included.
•  Published studies that are written in the English language only were selected and included in the paper.
•  Studies were done on human participants who have participated in intervention for at least 6 weeks.
•  Levels of the Reproductive hormone along with testosterone level along with anthropometric measures such as BMI and weight were included.
•  We included studies such as cross-sectional observa-tional studies, randomised controlled trials, retrospective studies, interventional studies, cross-sectional studies, etc.
•  PCOS participants were selected according to any one of the criteria used by each article including the Rotterdam criteria and European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine (ESHRE/ASRM), National Institute of Health (NIH) and self-reported.
•  Studies that reported the mean difference along with the  SD and adequate data to calculate the anthropometric measurements and level of reproductive hormones were found suitable for inclusion in the study.
•  Participants whose BMI ≥ 25 kg/m2 and age ≥18 years according to WHO, 2000 were included.
 
Exclusion 
 
•  The studies included letters to the editors and short communications were excluded from the study.
•  The studies were written other than English.
•  Pregnancy, lactating women, Induction of labor, perinatal depression, chronic diseases and miscarriage patients were excluded from the specific systematic review and meta-analysis paper.
•  Case series along with case reports and reviews, were also excluded from this paper.
 
Quality assessment
 
Two authors K.D. and L.S. independently checked the data that is retrieved from the databases to include in the paper. Studies included in this paper were based on the title of the paper, abstract and screening of articles with full text. Two authors collected all the databases with the help of Mendeley on the HP desktop. Discrepancies were sorted by consensus and discussion with one of the senior authors (L.S.) so that a consensus could not be reached. 
Extraction of data was done by both the authors (L.S. and K.D.) using the standardized form. To evaluate the biases, The Cochrane Risk of Bias Tool was used for randomized trials using supplementary material. All the data was collected from the real articles - first author, publication year, country, number of participants, characteristics of study, follow-up length, interest outcome along with effect size measurements such as mean differences and standard error.
 
Assessment of methodological quality
 
Both the authors (K.D and D.S) independently checked the quality of methodology of each and every study included in the paper by using the Revised Cochrane Risk of Bias tool for the randomized trials. This tool consists of five main domains that were extracted based on the evidence of empirical and theoretical considerations that were further separated into seven following parts - (i) Consideration in the preliminary stage; (ii) biasness risk occurring from the process of randomization; (iii) biasness risk because of the deviations from the intended interventions (intervention assignment effect); (iv) biasness risk because of the deviations from the intended interventions  (the adhering to intervention effect); (v) missing outcome data leads to biasness risk; (vi) biasness risk because of the measurement of the outcome; and (vii) biasness risk in the reported result selection. The overall evaluation of methodological assessment was done in final results that lead to evaluation based on good, fair, or poor. Discrepancies were resolved by the consensus and discussion with the senior authors (L.S and D.P) so that a consensus could not be reached. 
 
Statistical analysis
 
Data was analyzed by using the SPSS statistics for Windows version 29.0. The mean difference and SD were done based on the intervention of diets and the results that are pooled in this study were reported as mean differences that are presented by 95% Cl with double-sided P value. In this study, meta-analysis was conducted for the studies that are available for specific outcomes. In the studies covered in the meta-analysis, the statistical heterogeneity and homogeneity between the available studies were performed. Results were analyzed and the probability value of <.05 was statically considered to be significant.
 
Selection of articles
 
The search of the original database turned out to be 5564 articles in total which includes 3976 in PubMed, 1136 in Google Scholar and 452 from the unidentified sources. After the removal of all the articles that are duplicated, a total of 3627 studies were searched (In total there were 1937 duplicate articles identified), that was then lowered further to 625 articles that were full text following analysis of the study titles along with the abstracts. However, as per the full-text analysis of the studies, it resulted in the inclusion of 13 articles that are full text and after the articles removal with appropriate reason. The assessment done further led to 13 articles selected for systemic assessment which were divided in the way the included articles were characterized based on the review (n=13) and selected for the meta-analysis (n=5) out of 13 articles.
       
To select the included studies follows the guidelines using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were used which are shown in Fig 1. Articles are searched in the very first step of selecting the various studies that are included in this paper to search from the Google Scholar database using the similar search strategy to get 1136 articles and 3976 were obtained from PubMed and 452 records were identified by the additional sources that were analysed further to include AND (“clinical trial” OR “clinical studies”) NOT (animal OR rats) to get the final 625 reviews by removing duplicates and articles without a clinical trial. After the screening process of title along with the abstract, only 13 review papers were used in the quantitative analysis out of 625 articles by excluding with appropriate reason.

Fig 1: Flow chart of PRISMA model.


 
Characteristics of included studies
 
The characteristics are shown in Table 1 of the available studies that are given and are used in this paper that is showing the country, design of the study, age of participants along with their BMI, study duration, criteria used for diagnosis and their result in the given table. The score of methodological quality was fair in all the studies included in the paper.

Table 1: Characteristics included in the systematic review and meta-analysis evaluating the effect of diets.


 
Formulations of various diets included in the study
 
In Table 2 Composition of various diets that are included in this paper is given showing the composition of carbohydrates, proteins and fats.

Table 2: Composition of various diets included in the meta-analysis across the studies.


 
Anthropometric measurements
 
Meta-analysis pooling the studies under the random effect model has shown that there is a statistically significant relation or association between the diets and reduced BMI (d -0.509, 95% Cl -0.821, -0.196, P< .001) in Fig 2 Similarly, there is also significant weight loss in the subjects of PCOS (d -0.315, 95% Cl -0.628, -0.02, P =0.049) in diet intervention Fig 3.

Fig 2: Forest plot showing the association between BMI and diets.



Fig 3: Forest plot showing the association between Weight loss and diets.


 
Reproductive hormones
 
There is a statistically reduced level of LH/FSH ratio (d -0.346, 95% Cl -0.660, -0.032, P=0.031) is seen in the PCOS patient’s Fig 4 along with a reduction in free testosterone (d -0.317, 95% Cl -0.612, -0.023, P = 0.035) in the intervention with diet in the same cohort study Fig 5. 

Fig 4: Forest plot showing the association between LH/FSH ratio and diets.



Fig 5: Forest plot showing the association between free testosterone and diets.


 
Publication bias
 
Assessed the Publication bias by using the funnel plot for anthropometric measurements (BMI and Diets) in Fig 6, (Weight loss and Diets) in Fig 7 and reproductive hormones (LH/FSH ratio and Diets) in Fig 8 and (Free Testosterone and Diets) in Fig 9 in the study showing the absence of potential biases.

Fig 6: The funnel plot showing a symmetrical distribution of all the included study distributions (BMI and Diets), suggesting the absence of potential publication biases.



Fig 7: The funnel plot showing a symmetrical distribution of all the included study distributions (Weight loss and Diets), suggesting the absence of potential publication biases.



Fig 8: The funnel plot showing a symmetrical distribution of all the included study distributions (LH/FSH ratio and Diets), suggesting the absence of potential publication biases.



Fig 9: The funnel plot showing a symmetrical distribution of all the included study distributions (Free Testosterone and Diets), suggesting the absence of potential publication biases.


     
In this present study association between various diets with anthropometric measurements and reproductive hormones is evaluated in PCOS females. This study is done by pooling and analyzing the clinical trial studies that have shown improvements in the various anthropometric measure- ments such as BMI and weight along with reproductive hormones such as LH/FSH ratio and serum-free testosterone analysed carefully and results are relevant. The effect of various types of diet is evaluated in PCOS female subjects showing improvements in weight and reproductive hormones are reduced in the diet intervention.
       
PCOS is a hormonal disorder and very complex trait in reproductive women that leads to various disorders such as obesity, insulin sensitivity, hirsutism, defects in insulin secretion, sleep disorders, depression and excessive weight gain that shows the complex pathogenesis of the PCOS that serve as a syndrome’s multifactorial nature along with its manifestation that are heterogeneous (Rosenfield and Ehrmann 2016). In PCOS the LH to FSH ratio increases and it is as high as 2 or 3 while in healthy women this ratio is between 1 to 2. However, an increase in the LH directly stimulates the production of ovarian androgen while a decrease in FSH results in impairing the follicular development in women and due to this increase in LH/FSH ratio, it cannot lead to ovulation in females with PCOS. Hyperandrogenism also leads to increased free testosterone levels in females who have PCOS due to the release of more steroidogenesis from the proliferation process of the ovarian theca cells that shows disturbance from LH/FSH imbalance. It leads to the cause of different complicated disorders like type 2 diabetes mellitus, atherosclerosis, hypertension, kidney diseases, etc. In this study it is shown that there is a significant reduction in the reproductive hormones due to the consumption of diet along with a reduction in the level of testosterone in PCOS women (Khalid et al., 2023).
       
In the anthropometric measurements, it is found that diet has shown good results on various parameters in females and effective results in the reduction BMI along with weight loss in the female participants that were following the diet and were part of the study. In this study, all the reviews that are included in this paper showed that weight is reduced by diet intervention following a ketogenic diet, along with low carbohydrate diet and Mediterranean diet and the significant changes are seen in PCOS women. A diet has a significant role in reducing weight and improving hormones however, despite weight loss ketogenic diet (Paoli et al., 2013), the Medi terranean diet (Barrea et al., 2019) and the diet like low carbohydrate have also been shown to improve effects in insulin resistance, body composition, metabolic health and improved sex hormone imbalance in PCOS women (Paoli et al., 2013). It is crucial to check the characteristics of the baseline in the  participants included in the study to analyze the applicability and transferability of the result’s impact. So, considering the characteristics such as BMI, weight, participant’s age, gender and their health status that will help to understand the negative effects and benefits of the diet as the accurate impact of diets such as the keto diet is still not clearly found and their implications in long term is still not accurately understood and adequately studied (Barrea et al., 2019). In evaluating the biases, The Cochrane Risk of Bias Tool was used for randomized trials using supplementary material (Cochrane Collaboration 2023).
               
In this recent study was done to know the results of various diets on anthropometric measurements including BMI and weight and reproductive hormones along with the levels of testosterone in the females having PCOS. All the clinical studies available for diet in PCOS are included in this paper to know the effect of diet on PCOS women. The studies pooled in this review have shown a positive impact in reducing weight and BMI and improving reproductive hormones in the females. As a smaller number of studies with a small population size were analysed in this paper, the requirement of more studies is also needed to clearly understand the concept of PCOS along with its effects on hormones and reproductive hormones and in weight loss that can be proven to improve the situation of PCOS women effectively by including a large number of studies that includes huge groups for research. From this study, useful hypotheses can be formulated that can be proven effective in treating PCOS symptoms in women with PCOS (Dhama and Sharma, 2025; Sharma et al., 2025; Yadav et al., 2021; Li et al., 2021; Ebenezer et al., 2020).

CONCLUSION

In Conclusion, this systematic review and meta-analysis have shown that there is possibly an association between diets and improvement in the anthropometric measurements and the reproductive hormones in PCOS females according to the studies included in this paper. We have reported the various kinds of diets and their positive impact on PCOS patients along with the anthropometric and reproductive hormone level improvement in the available and usable studies. In conclusion, the included papers still have various limitations that necessitate careful analysis of the review, lowering the applicability and transferability of these results to the general PCOS population. We conclude that the study would be important for the clinical purpose and their implication, especially for endocrinologists and dietitians so that they can plan an effective management along with the dietary recommendation for the PCOS patients and help them achieve desirable healthy weight by improving their lifestyle choices.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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    Review Article

    Effects of Various Diets on Anthropometric and Hormonal Changes in Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis

    K
    Kajal Dhama1
    https://orcid.org/0009-0002-9348-7542
    L
    Luxita Sharma1,*
    https://orcid.org/0000-0002-4700-4792
    D
    Dhananjay Sharma1
    https://orcid.org/0000-0003-3264-4188
    D
    Deepika Pal1
    https://orcid.org/0000-0002-3522-9310
    1Department of Dietetics and Applied Nutrition, Amity Medical School, Amity University, Gurugram-122 001, Haryana, India.

    ABSTRACT

    Diets such as the ketogenic diet, low-carbohydrate diet, along with Mediterranean diet help to improve weight in obese patients and due to weight reduction insulin resistance improves which may be considered beneficial in PCOS. The study objective of the paper is to pool studies that are done on human subjects to analyse the effects of various diets on anthropometric measurements (weight and BMI) and reproductive hormones (LH/FSH ratio and free testosterone) and to know the evidences of changes in the body weight. Data was collected and searched from Google Scholar and PubMed for evaluating the effects of various diets on women with PCOS. In this study, to pool the data, a random-effects model was used and to assess the quality of selected studies the Cochrane Risk of Bias Tool was used. Meta-analysis pooling the studies under the random effect model has shown that there is a statistically significant relation between the diets and reduced BMI (d -0.509, 95% Cl -0.821, -0.196, P<.001). Similarly, there is also significant weight loss in the subjects of PCOS (d -0.315, 95% Cl -0.628, -0.02, P =0.049) in diet intervention. There is a statistically reduced level of LH/FSH ratio (d -0.346, 95% Cl -0.660, -0.032, P=0.031) is seen in the PCOS patients along with a reduction in free testosterone (d -0.317, 95% Cl -0.612, -0.023, P = 0.035) in the intervention with diet in the same cohort study. There is possibly an association between diets and improvement in the anthropometric measurements and the reproductive hormones in PCOS females.

    INTRODUCTION

    Polycystic ovary syndrome (PCOS) is the main endocrino-pathy that is affecting the females of reproductive age. However, still, it is not considered a major health problem across the globe. It is affecting 4% to 20% of reproductive age females in the world. Following the latest studies, the PCOS prevalence according to the Rotterdam criteria is 19.5% in Iran and according to NIH criteria is 6.8% (Abasian et al., 2018). The PCOS prevalence, its etiology, criteria for diagnosis, management and issues related to psychology and preventive methods are still confusing aspects of PCOS (Deswal et al., 2020).
           
    PCOS was first introduced in the year 1935 by Stein and Leventhal in a more comprehensive way (Deswal et al., 2020). It is a complicated endocrine disorder that is characterized by hyperandrogenaemia, insulin resistance and anovulation (Baptiste et al., 2010). Women suffering from PCOS produce less amount of estrogen and progesterone hormones, which are crucial for maintaining normal menstruation (MacLean and Hayashi 2022). These hormonal imbalances can cause various problems with fertility, hirsutism means excessive hair growth and acne (Yau et al., 2017). The major reason of infertility is caused by a lack of ovulation in on average 75% of the cases approximately (Abasian et al., 2018).  In addition, PCOS patients often experience problems with weight management and blood sugar control (Studen and Pfeifer 2018).
           
    Diet plays a very essential role in PCOS management. When the diet contains less amount of GI foods then it leads to weight gain that stimulates hunger due to insufficient carbohydrates in the body. In each meal, calories should be distributed properly to maintain a healthy weight (Farshchi et al., 2007). Some studies have shown that diet has a crucial role in improving blood glucose levels and diets that are low in saturated fats and have high amounts of fibre from foods that have low glycemic index are recommended (Marsh and Brand-Miller, 2005). A diet which is low in carbohydrates helps to reduce insulin resistance and maintain body weight in PCOS patients (Mavropoulos et al., 2005). Various kinds of diets that includes the diet like the Mediterranean diet are rich in fibre and complex carbohydrates along with high amounts of monounsaturated fatty acids. Studies have shown that diets including the ketogenic diet along with low-carbohydrate help to improve weight in obese patients and due to weight reduction insulin resistance improves which may be considered beneficial in PCOS (Mavropoulos et al., 2005). Mediterranean diet is known as the diet that helps to improve healthy dietary patterns as it has various peculiar features that result in weight reduction and shows very good activity like anti-inflammatory that is caused due to microbiota-derived production of short-chain fatty acids induced by the antioxidants, dietary fiber and more intake of polyun-saturated fatty acids omega 3 (Barrea et al., 2019). However, different studies on various diets are investigated in the meta-analysis and systematic review to analyze the usefulness of diet in PCOS and to know the effect in obese patients on their weight loss who have followed the intervention with various types of diet.
     
    Source of information and search method
     
    To identify the relevant research studies, in the preparation of this review was prepared using the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) that are followed in order to know the impact of various kinds of diets on participants of PCOS, the literature assessment was done thoroughly. From 2018 to 2023 November, an online literature review of all articles written in language English was conducted. According to this, databases of Systematic literature searches were looked up in Google Scholar and PubMed.
           
    For the Google Scholar search engine, the specific keywords used were “PCOS” AND “Obesity”, “PCOS” AND “Diet”, “PCOS” AND “Overweight”, “PCOS” AND “Obese”, “PCOS” and “Nutrient” and “PCOS” and “Nutrition”.
           
    For the PubMed search engine, the specific keywords used were (PCOS) AND (Obesity), (PCOS) AND (Diet), (PCOS) AND (Nutrient), (PCOS) AND (Nutrition), (PCOS) AND (Overweight), (PCOS) and (Obese). The systematic and meta-analysis research was carried out from the month of January to February 2024, at Amity University Haryana.
     
    Criteria for inclusion and exclusion
     
    Inclusion
     
    •  The literature search was primary focusing on PCOS females along with diet in obese and overweight patients  was included.
    •  Published studies that are written in the English language only were selected and included in the paper.
    •  Studies were done on human participants who have participated in intervention for at least 6 weeks.
    •  Levels of the Reproductive hormone along with testosterone level along with anthropometric measures such as BMI and weight were included.
    •  We included studies such as cross-sectional observa-tional studies, randomised controlled trials, retrospective studies, interventional studies, cross-sectional studies, etc.
    •  PCOS participants were selected according to any one of the criteria used by each article including the Rotterdam criteria and European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine (ESHRE/ASRM), National Institute of Health (NIH) and self-reported.
    •  Studies that reported the mean difference along with the  SD and adequate data to calculate the anthropometric measurements and level of reproductive hormones were found suitable for inclusion in the study.
    •  Participants whose BMI ≥ 25 kg/m2 and age ≥18 years according to WHO, 2000 were included.
     
    Exclusion 
     
    •  The studies included letters to the editors and short communications were excluded from the study.
    •  The studies were written other than English.
    •  Pregnancy, lactating women, Induction of labor, perinatal depression, chronic diseases and miscarriage patients were excluded from the specific systematic review and meta-analysis paper.
    •  Case series along with case reports and reviews, were also excluded from this paper.
     
    Quality assessment
     
    Two authors K.D. and L.S. independently checked the data that is retrieved from the databases to include in the paper. Studies included in this paper were based on the title of the paper, abstract and screening of articles with full text. Two authors collected all the databases with the help of Mendeley on the HP desktop. Discrepancies were sorted by consensus and discussion with one of the senior authors (L.S.) so that a consensus could not be reached. 
    Extraction of data was done by both the authors (L.S. and K.D.) using the standardized form. To evaluate the biases, The Cochrane Risk of Bias Tool was used for randomized trials using supplementary material. All the data was collected from the real articles - first author, publication year, country, number of participants, characteristics of study, follow-up length, interest outcome along with effect size measurements such as mean differences and standard error.
     
    Assessment of methodological quality
     
    Both the authors (K.D and D.S) independently checked the quality of methodology of each and every study included in the paper by using the Revised Cochrane Risk of Bias tool for the randomized trials. This tool consists of five main domains that were extracted based on the evidence of empirical and theoretical considerations that were further separated into seven following parts - (i) Consideration in the preliminary stage; (ii) biasness risk occurring from the process of randomization; (iii) biasness risk because of the deviations from the intended interventions (intervention assignment effect); (iv) biasness risk because of the deviations from the intended interventions  (the adhering to intervention effect); (v) missing outcome data leads to biasness risk; (vi) biasness risk because of the measurement of the outcome; and (vii) biasness risk in the reported result selection. The overall evaluation of methodological assessment was done in final results that lead to evaluation based on good, fair, or poor. Discrepancies were resolved by the consensus and discussion with the senior authors (L.S and D.P) so that a consensus could not be reached. 
     
    Statistical analysis
     
    Data was analyzed by using the SPSS statistics for Windows version 29.0. The mean difference and SD were done based on the intervention of diets and the results that are pooled in this study were reported as mean differences that are presented by 95% Cl with double-sided P value. In this study, meta-analysis was conducted for the studies that are available for specific outcomes. In the studies covered in the meta-analysis, the statistical heterogeneity and homogeneity between the available studies were performed. Results were analyzed and the probability value of <.05 was statically considered to be significant.
     
    Selection of articles
     
    The search of the original database turned out to be 5564 articles in total which includes 3976 in PubMed, 1136 in Google Scholar and 452 from the unidentified sources. After the removal of all the articles that are duplicated, a total of 3627 studies were searched (In total there were 1937 duplicate articles identified), that was then lowered further to 625 articles that were full text following analysis of the study titles along with the abstracts. However, as per the full-text analysis of the studies, it resulted in the inclusion of 13 articles that are full text and after the articles removal with appropriate reason. The assessment done further led to 13 articles selected for systemic assessment which were divided in the way the included articles were characterized based on the review (n=13) and selected for the meta-analysis (n=5) out of 13 articles.
           
    To select the included studies follows the guidelines using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were used which are shown in Fig 1. Articles are searched in the very first step of selecting the various studies that are included in this paper to search from the Google Scholar database using the similar search strategy to get 1136 articles and 3976 were obtained from PubMed and 452 records were identified by the additional sources that were analysed further to include AND (“clinical trial” OR “clinical studies”) NOT (animal OR rats) to get the final 625 reviews by removing duplicates and articles without a clinical trial. After the screening process of title along with the abstract, only 13 review papers were used in the quantitative analysis out of 625 articles by excluding with appropriate reason.

    Fig 1: Flow chart of PRISMA model.


     
    Characteristics of included studies
     
    The characteristics are shown in Table 1 of the available studies that are given and are used in this paper that is showing the country, design of the study, age of participants along with their BMI, study duration, criteria used for diagnosis and their result in the given table. The score of methodological quality was fair in all the studies included in the paper.

    Table 1: Characteristics included in the systematic review and meta-analysis evaluating the effect of diets.


     
    Formulations of various diets included in the study
     
    In Table 2 Composition of various diets that are included in this paper is given showing the composition of carbohydrates, proteins and fats.

    Table 2: Composition of various diets included in the meta-analysis across the studies.


     
    Anthropometric measurements
     
    Meta-analysis pooling the studies under the random effect model has shown that there is a statistically significant relation or association between the diets and reduced BMI (d -0.509, 95% Cl -0.821, -0.196, P< .001) in Fig 2 Similarly, there is also significant weight loss in the subjects of PCOS (d -0.315, 95% Cl -0.628, -0.02, P =0.049) in diet intervention Fig 3.

    Fig 2: Forest plot showing the association between BMI and diets.



    Fig 3: Forest plot showing the association between Weight loss and diets.


     
    Reproductive hormones
     
    There is a statistically reduced level of LH/FSH ratio (d -0.346, 95% Cl -0.660, -0.032, P=0.031) is seen in the PCOS patient’s Fig 4 along with a reduction in free testosterone (d -0.317, 95% Cl -0.612, -0.023, P = 0.035) in the intervention with diet in the same cohort study Fig 5. 

    Fig 4: Forest plot showing the association between LH/FSH ratio and diets.



    Fig 5: Forest plot showing the association between free testosterone and diets.


     
    Publication bias
     
    Assessed the Publication bias by using the funnel plot for anthropometric measurements (BMI and Diets) in Fig 6, (Weight loss and Diets) in Fig 7 and reproductive hormones (LH/FSH ratio and Diets) in Fig 8 and (Free Testosterone and Diets) in Fig 9 in the study showing the absence of potential biases.

    Fig 6: The funnel plot showing a symmetrical distribution of all the included study distributions (BMI and Diets), suggesting the absence of potential publication biases.



    Fig 7: The funnel plot showing a symmetrical distribution of all the included study distributions (Weight loss and Diets), suggesting the absence of potential publication biases.



    Fig 8: The funnel plot showing a symmetrical distribution of all the included study distributions (LH/FSH ratio and Diets), suggesting the absence of potential publication biases.



    Fig 9: The funnel plot showing a symmetrical distribution of all the included study distributions (Free Testosterone and Diets), suggesting the absence of potential publication biases.


         
    In this present study association between various diets with anthropometric measurements and reproductive hormones is evaluated in PCOS females. This study is done by pooling and analyzing the clinical trial studies that have shown improvements in the various anthropometric measure- ments such as BMI and weight along with reproductive hormones such as LH/FSH ratio and serum-free testosterone analysed carefully and results are relevant. The effect of various types of diet is evaluated in PCOS female subjects showing improvements in weight and reproductive hormones are reduced in the diet intervention.
           
    PCOS is a hormonal disorder and very complex trait in reproductive women that leads to various disorders such as obesity, insulin sensitivity, hirsutism, defects in insulin secretion, sleep disorders, depression and excessive weight gain that shows the complex pathogenesis of the PCOS that serve as a syndrome’s multifactorial nature along with its manifestation that are heterogeneous (Rosenfield and Ehrmann 2016). In PCOS the LH to FSH ratio increases and it is as high as 2 or 3 while in healthy women this ratio is between 1 to 2. However, an increase in the LH directly stimulates the production of ovarian androgen while a decrease in FSH results in impairing the follicular development in women and due to this increase in LH/FSH ratio, it cannot lead to ovulation in females with PCOS. Hyperandrogenism also leads to increased free testosterone levels in females who have PCOS due to the release of more steroidogenesis from the proliferation process of the ovarian theca cells that shows disturbance from LH/FSH imbalance. It leads to the cause of different complicated disorders like type 2 diabetes mellitus, atherosclerosis, hypertension, kidney diseases, etc. In this study it is shown that there is a significant reduction in the reproductive hormones due to the consumption of diet along with a reduction in the level of testosterone in PCOS women (Khalid et al., 2023).
           
    In the anthropometric measurements, it is found that diet has shown good results on various parameters in females and effective results in the reduction BMI along with weight loss in the female participants that were following the diet and were part of the study. In this study, all the reviews that are included in this paper showed that weight is reduced by diet intervention following a ketogenic diet, along with low carbohydrate diet and Mediterranean diet and the significant changes are seen in PCOS women. A diet has a significant role in reducing weight and improving hormones however, despite weight loss ketogenic diet (Paoli et al., 2013), the Medi terranean diet (Barrea et al., 2019) and the diet like low carbohydrate have also been shown to improve effects in insulin resistance, body composition, metabolic health and improved sex hormone imbalance in PCOS women (Paoli et al., 2013). It is crucial to check the characteristics of the baseline in the  participants included in the study to analyze the applicability and transferability of the result’s impact. So, considering the characteristics such as BMI, weight, participant’s age, gender and their health status that will help to understand the negative effects and benefits of the diet as the accurate impact of diets such as the keto diet is still not clearly found and their implications in long term is still not accurately understood and adequately studied (Barrea et al., 2019). In evaluating the biases, The Cochrane Risk of Bias Tool was used for randomized trials using supplementary material (Cochrane Collaboration 2023).
                   
    In this recent study was done to know the results of various diets on anthropometric measurements including BMI and weight and reproductive hormones along with the levels of testosterone in the females having PCOS. All the clinical studies available for diet in PCOS are included in this paper to know the effect of diet on PCOS women. The studies pooled in this review have shown a positive impact in reducing weight and BMI and improving reproductive hormones in the females. As a smaller number of studies with a small population size were analysed in this paper, the requirement of more studies is also needed to clearly understand the concept of PCOS along with its effects on hormones and reproductive hormones and in weight loss that can be proven to improve the situation of PCOS women effectively by including a large number of studies that includes huge groups for research. From this study, useful hypotheses can be formulated that can be proven effective in treating PCOS symptoms in women with PCOS (Dhama and Sharma, 2025; Sharma et al., 2025; Yadav et al., 2021; Li et al., 2021; Ebenezer et al., 2020).

    CONCLUSION

    In Conclusion, this systematic review and meta-analysis have shown that there is possibly an association between diets and improvement in the anthropometric measurements and the reproductive hormones in PCOS females according to the studies included in this paper. We have reported the various kinds of diets and their positive impact on PCOS patients along with the anthropometric and reproductive hormone level improvement in the available and usable studies. In conclusion, the included papers still have various limitations that necessitate careful analysis of the review, lowering the applicability and transferability of these results to the general PCOS population. We conclude that the study would be important for the clinical purpose and their implication, especially for endocrinologists and dietitians so that they can plan an effective management along with the dietary recommendation for the PCOS patients and help them achieve desirable healthy weight by improving their lifestyle choices.

    CONFLICT OF INTEREST

    The authors declare no conflict of interest.

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