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What is Lean PCOS? An Expert's Best Tips From Diet to Fitness

One out of three people with PCOS don't struggle with their weight, but still have the condition. What does lean PCOS mean for their health and lifestyle?

July 12th, 2024 | 9 min. read

By Monica Moore, MSN, APRN

While the majority of people with PCOS have excess weight, it is possible to have the condition and still have a BMI within normal range. This is known as "lean PCOS," and it can make it even harder to get a proper diagnosis. Let's explore why.

In this article:

Lean PCOS vs PCOS: What’s the difference?

As a woman with so-called "lean PCOS," I am one of the 1 out of 3 people with PCOS who do not qualify as overweight. But just because I don't struggle with my weight doesn't mean I can ignore maintaining an active lifestyle and healthy diet.

Those of us with lean PCOS have simply gotten a little help from our genetics. We must acknowledge that the reasons for having excess weight with PCOS are deep-rooted, complex, and multifactorial, with a strong genetic component. 

Not everyone fits the stereotypical image we have of PCOS: Someone who is overweight, struggling with acne and excess facial hair. Some PCOS patients may actually have few outward symptoms, but still struggle internally with related issues. 

That said, it does help to try and achieve a healthy BMI. Why? Weight has a dose-dependent relationship with metabolic changes - meaning the more weight you gain, the greater the chance of metabolic disturbances.

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Weight Management & PCOS 

One significant challenge the majority of people with PCOS encounter is insulin resistance. This means that the cells are not responsive to the level of insulin being produced, so the pancreas produces more and more insulin in order to achieve the desired effect. 

Insulin resistance is usually linked with obesity, but women of normal weight with PCOS also have an increased risk of developing insulin resistance even though they're not overweight.

Did you know? Researchers report that 20% to 25% of people with lean PCOS (defined as having a body mass index under 25) are insulin resistant.


Why is insulin resistance bad?

Insulin is a hormone whose job is to store fat, an evolutionary adaptation that was helpful for people in prehistoric times, when food was scarce. However, in our current environment, where food is plentiful and highly processed, this adaptation becomes a problem, because our body works hard to store fat, particularly in the abdomen.

Abdominal fat contributes to insulin resistance by producing substances that decrease your body’s sensitivity to insulin - one of the vicious cycles of PCOS. It’s like insulin resistance and abdominal fat are always on a car ride together, one might be the driver, but the other is always along for the ride.

If that weren't difficult enough, insulin resistance distorts your satiety and hunger hormones, causing mixed signals, so that you feel that you can’t eat intuitively because you are always hungry.

Therefore, the secret to managing PCOS is to make the body more sensitive to insulin. Seems simple, right? Unfortunately, finding ways to make your body sensitive to insulin is anything but simple. It requires hard work - and a lot of trial and error.

Did you know? Medications like Metformin (and newer drugs such as Ozempic) can help to reduce insulin resistance in those with PCOS, alongside diet and exercise.

My Personal PCOS Story

Most people have a moment in life that serves as a wake-up call. Mine was in college. In high school, I took the birth control pill and played team sports every season, which helped me maintain a normal weight and decreased my symptoms of PCOS.

Once I got to college, I was unable to participate in sports due to my part-time job. That, plus the addition of the "college student diet" caused me to be gain a significant amount of weight for the first time in my life.

It's important to reiterate how big of a role genetics plays in your weight 'set point.' My entire family is on the lean side, so I simply have genetics working in my favor. For that, I am eternally grateful, as many people with PCOS who are overweight are also genetically inclined to have a higher weight set point. 

I was able to find a way to control the things I can: what I eat, how much I move, and what I do to relieve stress. Speaking of stress, did you know that chronic stress not only increases inflammation in the body, but contributes to diseases like diabetes and high cholesterol?

How Life Changes with PCOS

When I was first diagnosed with PCOS, I couldn’t process the enormity of the condition, so I just ignored it. But I soon realized that by eating mindlessly without paying attention to my body's response wasn't worth it.

When I decided to learn how to eat to fuel my body, I noticed an immediate shift in how I felt.

Be Aware of Your Risk Factors

If you have PCOS (lean or not), is important to have regular check-ups with your doctor, because you are still at risk for high cholesterol (an accumulation of bad lipids in the bloodstream), even if you feel you're maintaining a healthy weight.

You are also still at risk for impaired glucose tolerance and type 2 diabetes mellitus.  In addition, you (like me) may not be ovulating regularly and end up needing help conceiving.

The good news? With a little assistance, I was able to conceive four healthy children. 

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What is the best lean PCOS diet?

After much experimentation, I began to learn which foods make my body feel good and which ones don't. Learning to pay attention to this is a big (but necessary) shift that you need to make when you have PCOS.

I've found that the foods I eat directly impact how I feel that day - and often the next day as well. I prioritize 'slow' carbs (i.e. brown rice, quinoa, sweet potato), healthy proteins, and fats.

You have to experiment with which particular foods in each category work for you and be proactive about meal planning, packing snacks, and making conscious choices.

If I don't prepare ahead of time and instead just eat whatever is available, I find myself dozing off around 2-3pm, having trouble focusing and being irritable the rest of the day. Remembering to go out fully prepared with my own food has become second-nature for me, and it can for you too! 

Do I resent having PCOS?

Do I wish that I could eat what everyone else is eating and not gain weight or contribute to the likelihood that I will get diabetes? Of course!

When my college roommates were scarfing down pizza without a care, I really struggled. But this was the deck of cards I was dealt. And I’m proud of how I handled my life-altering diagnosis of PCOS.

I have learned to pick up cues from my body that tell me whether what I am doing is good for me. I'm now in my forties, but many people tell me I look much younger - which I attribute to my many years mindful eating and exercise. 

What exercise is best for lean PCOS?

The first thing to know is that physical activity, regardless of what form it takes, is the greatest insulin-sensitizing agent - even if it doesn’t result in weight loss. I choose to run because it makes me feel physically empowered and increases my confidence. If running isn’t your thing, try swimming, join a group class, or just take a walk.

Moving your body consistently is really what makes the difference.

Why is stress reduction essential with PCOS?

In addition to being physically beneficial, exercise also reduces stress, which is so important. Everyone has different ways of managing stress, but here’s what I do:

Whenever I have a really good moment, memory, or sensation, I 'bottle it up' so I can revisit it later. Some examples? Snuggling with my cats, having a great conversation with a friend, how I feel after accomplishing something big, the sensation of jumping into a pool and feeling the cool water.

Then, when I'm feeling frustrated, resentful, angry, or just stressed, I tap into it. I use visualization and breath to recreate that peaceful, calm, or empowering moment. This, like any new habit, takes practice, but it works for me. For you, stress reduction might take the form of journaling, being outdoors, gardening, reading a good book, or listening to music. 

Just find what works for you!

Learning to Live with PCOS

While my current habits mean that my PCOS is "under control," it does still affect me. It will always be a part of my life. But I choose to live with it, not be weighted down because of it. 

Maybe today you chose to eat mindfully, move your body, and fight insulin resistance. Or maybe you chose to eat the fries, binge-watch some Netflix, and take the day off. Only you know what you need in the moment. But if you're feeling discouraged, remember that tomorrow is a fresh start. 

None of us are perfectly disciplined 24/7. We are all human.

As writer Elizabeth Gilbert says, "Embrace the glorious mess that you are."

Monica Moore, MSN, APRN

Monica Moore is a board-certified Advanced Practice Nurse Practitioner, nurse educator and health coach who has been caring for patients at Illume Fertility for over 20 years. She is also the founder and lead educator at Fertile Health, LLC. Monica is passionate about taking care of the whole patient, believing in the importance of integrating comprehensive care. She has a special interest in PCOS and combating weight bias with education and advocacy.

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