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3. Ep 73: PCOS Nutrition with Melissa Groves Azzaro

Ep 73: PCOS Nutrition with Melissa Groves Azzaro

• Transcript of Podcast Episode

  Rena: Hi everyone. We are Rena and Dara, and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your own best advocate.
  Dara: Melissa Groves Azzaro,RDN, LD is an integrative dietician who helps busy women with hormone imbalances, PCOS and fertility issues regain regular periods and get pregnant naturally. She uses a functional approach to figure out the root causes of your symptoms and helps you develop a personalized nutrition, supplement, and lifestyle plan to balance your hormones and optimize your fertility. She works virtually with clients one-on-one and in group programs, has a self-study course on PCOS called the PCOS root cause roadmap and is the author of A Balanced Approach to PCOS, a meal planning cookbook that is focused on addressing the root causes of PCOS. Melissa, I'm so happy to have you on today.
  Melissa: Thank you so much for having me. I'm so glad we were able to connect.
  Dara: I know. I always love connecting with a fellow dietician and specifically someone who specializes in something that I am very passionate about in PCOS. So, especially this is PCOS awareness month, so perfect time to connect and kind of catch up our listeners on everything PCOS and its relation to nutrition and fertility. So before we get started into speaking about PCOS, I always like to kind of get a background of where it all started for you, how it began in terms of your practice and why you decided to specialize in PCOS.
  Melissa: Yeah, I think it's funny in chatting with you because I was also a New Yorker for many, many years. I worked in advertising in New York City. And so, you know, I'm sure you have friends in that field and know that it's like 90 plus hour weeks, and you're traveling all the time and it just got to the point where what happened was I ran the New York marathon in 2008 and I was qualified for 2009. I got about halfway through the training and just really because of my job and because of my lifestyle, I wasn't able to train as well as I should have. And I, you know, I'm not the kind of person who does something just to do something. So I was like, I don’t want to run again, just to run again. I want to run again to run better than I ran last time. And so I ended up bailing on the marathon in 2009 and then the same thing happened in 2010 where I got, and I was just, you know, two weeks out of the country and all of these things. And so it got to the point where right around that time, I was like, how much more of my life do I want to sacrifice for work? And like many women, I struggled with a lot of hormone issues myself, you know, not really understanding the connection between my stressful lifestyle and you know, my painful periods. I didn't really understand. I didn't see the connection at the time. And so I had always been interested in food and nutrition and food politics and cooking. And, you know, I just had one of those sort of existential crises moments in my living room in Brooklyn, where I was like, I have to get out, I have to do something.I have to do something else. What can I do really like staring at my four bookshelves full of books on like food politics and cookbooks and diet books. And I was like what would it take to do that for a living. And so I started at that point really 2010, 2011, that's kind of checking off the prerequisites to go back to school and become a dietician. And, you know, there were parts that I had to do in person, which I felt like I couldn't really do. I'm living in New York City without working full time to maintain that New York city apartment and lifestyle. So, that's how we ended up here in New Hampshire which is where my parents are. And I ended up completing the in-person portion of school and the internship here. And then sort of, you know, so how I made the transition into private practice and working with hormones was sort of from my own experiences with hormone imbalances, but I was working one of my first jobs was in the office of a functional medicine, dietician who specialized in gut health. And she would send me all of the clients who came in for weight loss and from the functional medicine perspective, you're, you know, you're looking at what they're eating, you're looking at how much they're exercising and you're like, something's not adding up here. Like, I don't understand, like the math is not working. And so that's where you do that deeper dig find, oh, this person has insulin resistance or this person has a low thyroid or this person that's high cortisol. And you know, there's so many conditions that can affect weight and metabolism. And that was really the first time I had encountered anyone who had PCOS. And I'm one of those people, I'm like an Enneagram eight, like I get very angry on behalf of other people. And I got so angry that like, you know, these women are really being given the short end of the stick when it came to treatment from conventional medicine. They were just being told to lose weight without, you know, any question about how much they were eating or how much they were exercising. They were just being put on the pill. They were being told, come back when you're ready to get pregnant. We'll put you on fertility meds. And yeah, the more I started digging, the more I was like, we can do a lot for you, you know, with food and supplements and lifestyle changes. And so when I started my practice, you know, you want ideally for a successful practice, you want to have a specialty and a niche and it's a pretty big niche when you're considering 10 to, you know, upwards of 20% of women struggle with PCOS and, you know, related hormone conditions and fertility. So that's kind of how I ended up here. So a long story, but I, you know, even though I don't have PCOS myself, I feel like I can empathize with those who have hormone conditions that are very strongly tied to what they're eating and how they're living.
  Dara: I love that. I love that, you know, your compassion shines through from really feeling for the patients that you are working with who are struggling and, you know, doing what they thought was great in terms of the medical aspect. But I love that you, I think working, it sounds like working with a functional dietician really helped you find the root cause of perhaps those hormonal imbalances and looking at the nutrition and the lifestyles changes that could help support them.
  Melissa: Yeah. I think people get so caught up in the idea that diet is everything and that, you know, you can eat a perfect diet and that's going to…
  Dara: Perfect.
  Melissa: Exactly. Quote unquote, perfect. And it's going to heal any condition, but it may not be perfect for you. And you know, if I had a dollar for every time someone on a discovery call tells me they eat a healthy diet, I would have a private island by now. You know, it's really, it's like, well, healthy by whose definition? And are you doing the things that are supportive of the root causes of PCOS, you know, so restriction is not it.
  Dara: I love that you say that. I think that's a big thing with the patients that I work with with PCOS. And that's one of the first things that I always like to reassure them, because I do think that, you know, many people who have that PCOS diagnosis right off the bat think, oh great, I can never eat carbs anymore. Or, you know, I have to have something very restrictive in order to feel good. So it's nice that you have a similar philosophy to me. And let's kind of like before we get into more of the crux in terms of, you know, foods that could be supportive for PCOS, let's talk about more, you know, baseline of PCOS and kind of what you see with your patients are like the typical symptoms that kind of define PCOS.
  Melissa: Yeah. So PCOS is polycystic ovary syndrome for those who don't know what that is. Typically it's diagnosed using the Rotterdam criteria, which means you have to have two of the following three conditions: number one is irregular periods or ovulation or no ovulation or periods. Number two is high androgens, which are diagnosed, you know, either by symptoms like high androgen symptoms or things like acne and oily skin, excess facial hair, male pattern, hair loss. And then the third criteria is polycystic ovaries, which is actually kind of a misnomer. It's not really an accurate name because it's not the same as ovarian cyst. It's multiple small immature follicles that start to build up because you're not ovulating them when you should. You could have a combination of any two of those three, you could have all three, but because it's a syndrome, it presents differently in everybody. So everyone who comes to me has a, a different combination of symptoms and I approach it from a root cause approach. I think the causes that are driving most of these PCOS symptoms are insulin resistance, which, you know, isn't present in every person with PCOS, but you know, 75% of women with lean PCOS, which is, you know, a BMI under 25, you know, and they, they also have insulin resistance. Up to 95% of women with a BMI that categorizes them as overweight or obese have insulin resistance. Inflammation is really common in PCOS as well. Gut imbalances and we know, you know, from the research that there are some specific changes that happen in the gut microbiome with PCOS. There's a lot of commonality between people with PCOS and IBS or celiac. So there's a lot of crossover in those populations. And then finally those hormone imbalances and those are really different for everybody. For most, I’d say it's probably, probably breaks down to about a third, a third, a third, where about a third of the folks that I see have high testosterone as their high androgen, which is coming from the ovaries primarily and it's being driven mostly by that insulin resistance which makes our ovaries make more testosterone. Another third tends to have the high adrenal androgens, which is DGADGAS. And then the other third are lucky enough to have both, you know, where it's really about balancing the blood sugar, lowering the insulin, but also addressing those lifestyle factors like stress and skipping meals and not getting enough sleep. So really, you know, it's very diverse the way that people present with PCOS and what they need to work on, which is why, you know, I always am emphasizing that there's no one size fits all diet plan for PCOS. There's no one size fits all exercise or supplement plan for PCOS because every person is different. And not only that, they have different needs and goals and lifestyles and cultural backgrounds. And so it's really gotta be customized for the person.
  Dara: I love how you're saying that. It's true. I mean, it also depends on where people are living, but in terms of the lifestyle, I think that's a huge one. You know, some people who are living in a big city who are working very long hours, ordering in, you know, compared to someone who's living in a rural town who actually might have limited access to certain grocery stores, I mean, you really, I think it really should be a customized approach. And I just, it's interesting because I feel like I've been an, an RD now at RMA for 11 years. And just even like the idea of integrative functional approach, that customized or, well, so I guess more integrative functional. We, I haven't even heard that term as it relates to a dietician. And I think it's brilliant. I think it's so clever. And I hope that in school, this is something that people are educated more about is finding the root cause and then also customizing someone's goals and needs based upon what each person needs based on their current hormones and their goals of what they want to kind of get at the end of the day.
  Melissa: Yeah and if you're not aware of it, there's the dieticians and integrative and functional medicine practice group of the academy. I’ve actually done, I'm on the board with them, so I've, I've actually done quite a few educational activities around PCOS for other dieticians there.. So yeah. You know, there are some schools they think, and I think there are some internship programs that are starting to be more integrative and functional focused, but I found for the most part, for most of us, we've done that learning above and beyond, you know, once we're past school.
  Dara: I know it'd be great to have, I feel like the next generation of dieticians will probably be more informed and hopefully be more involved in this, but it's great to see this, yeah, this new area, I feel like, really blossom and grow. And, you know, I do think the key here is customization. Of course, there may be some common threads. And as you mentioned, there's three specific PCOS type cases, depending upon hormone profiles. And of course, based on that, certain recommendations would vary a little bit, but let's talk about maybe the general idea or some of the key highlights in terms of how we can support ourselves nutritionally and then also lifestyle wise, aside from nutrition, which you kind of touched upon, you know, hormones related to sleep and stress and what we can do to kind of help balance everything out while
  Melissa: Yeah you know, it is interesting, you know, first of all, developing a self study course that people would be able to go through and figure out well, which of these recommendations would apply to me and my lifestyle and also doing the book, you know, because it's like there's very little scientific background or education in the book since it's a cookbook. That being said, like the principles that the recipes were developed using are pretty applicable to most people. And I think even for people who don't have PCOS, there's some basic sound nutrition principles that can help us a lot. You know, especially for women, I find that the biggest one is eating doesn't help balance your blood sugar. You know, how many women do you know? And I mean, this is me in New York City where I’d grab a bagel like a plain bagel on the way to the office. Couple of hours later, I'd be starving. I’d grab a banana. Couple of hours later, I'd be starving. I’d go grab my salad. And then by like three o'clock when the cookies were in the break room, I'd be like, grabbing five or six cookies and a coffee just to keep going. So I think it's really, really common for women to not really understand how to balance their blood sugar and to think they're doing a good thing by like, grabbing a piece of fruit for breakfast. It's like, what's wrong with eating a piece of fruit? The problem is when you're eating carbs by themselves, all you're doing is spiking your blood sugar up and down all day and so you're riding that blood sugar roller coaster all day. Whereas if you do some simple things, like make sure you're getting protein and some healthy fat and some fiber together with those carbs, then it helps keep you steady longer. So, you know, that's really integral for PCOS, you know, from a foundational diet perspective is a blood sugar balancing diet. But, honestly, I've really not met anyone who can't benefit from balancing their blood sugar
  Dara: I'm with you. I think it's interesting. And I tell this to my PCOS patients all the time is that what I typically recommend for a PCOS patient would be very similar with a non PCOS patient because blood sugar stability is important for hormone balance overall. And even for someone who may not have those hormone imbalances, it really does keep you feeling satiated. It doesn't give you those extreme highs and lows, but it's so interesting that typical breakfast foods are ones that are higher in quicker acting carbohydrates. You know, you don't see many people eating bagels or pancakes or things like that, middle of the day or in the afternoon, but it is something that we often see in the morning. And if breakfast means breaking the fast and you haven't had anything in your, you know, any food in your system for quite some time, your body is that much more sensitive. And, you know, unless most people aren't having, you know, spreading some peanut butter over their pancakes, or, you know, I guess sometimes eggs are included in a breakfast, but it's so interesting that, you know, most people with their bagels, as you even said, eating bagels by themselves or adding some jam or even cream cheese, which is still going to give you a minimal amounts of protein.
  Melissa: Yeah. Or even an egg. You know, people will tell me how I eat an egg with breakfast. And it's like, okay, great. That's six grams. Where are you getting the rest of your protein from? You know, I think if there's one thing that people take away from this and try, it's like try having a high protein breakfast and see how that feels for you. You know? It's really kind of life-changing. It sets the tone for the whole day, just in terms of cravings. I don't know about you, but like if we go out and have pancakes at a diner for breakfast on a weekend, you know, all I want is more carbs the rest of the day. It's like, I just want nachos for lunch and pizza for, like I just want to keep eating carbs. But if I start out on that higher protein foot, then I'm in a better place for the rest of the day. So yes, blood sugar balancing is really like the main thing that we focus on and it fits the one thing that you do, that's the thing I want you to do. And then we start to layer on recommendations based on what they need, you know, an anti-inflammatory approach. And what I mean by anti-inflammatory is we'll have people think what anti-inflammatory means, which is cut out, gluten cut out, dairy, cut out sugar, cut out, you know, fun entirely. I mean, adding cut fruits and veggies, colorful fruits and vegetables and adding omega threes in on a regular basis, you know? Sure. We, we know that eating Reeses cups all day is not like a solid nutritional approach, but like you can have your little bit of dark chocolate with lunch and it's not going to ruin anything for you. You know, we want to minimize the amounts of processed carbohydrates that we're eating, but there's no need to eliminate anything entirely in this case.
  One of the reasons why I'm so passionate about this approach in PCOS is because PCOS is a lifelong condition. I think, you know, a lot of folks kind of approach it with the, okay, we just need to get you pregnant and you get that baby and then you're fine, but it's like, all the long-term effects of PCOS, don't even start showing up until your forties, you know, the diabetes and heart disease and the endometrial cancer. And so, you know, really have to consider that if PCOS is a lifelong condition, any changes you make, you have to be able to sustain for a lifetime. And so if sprinkling an ounce of cheese on your taco is what's going to make you happy and make you able to live with the diet, like great. That's what we're going for is what you can live with.
  Dara: Yeah. And I liked the approach of also focusing on or educating people about the foods that they should be eating. And I think that's, you know, a lot of times when people meet with the dietician, the first thing they think about is to depravity, is it being deprived of the things that they enjoy. Granted you could still enjoy healthy food, you know, food that may be more nutritious for you, but no matter what I think the idea of focusing on what are the things kind of what the, the basis, the baseline of your day to day, you know, making sure you add in your vegetables and your fruit and your protein and including some healthy fats and complex carbs with fiber, you know, high fiber foods, you know? And I agree with you that I think once you tell people not to have something, which is like a, you know, a typical diet, I'm not sure about you, but don't people usually want those foods much more so when they know they can't have it?
  Melissa: Yeah, absolutely. And, you know, I think it's definitely a fear when working with a dietician that I'm going to take away all your favorite foods, but, you know, I track my clients' diets. They share what they’re eating with me and it's super simple. It's not triggering, they just take a picture and upload it. And then I tell them, I'm like, I fully expect every Friday to just scroll down and everyone's eating pizza for dinner on Friday. But I'm going to see that salad next to the pizza. I’m going to see that you've got enough protein with the pizza and to see that instead of eating four pieces of pizza, and that's it, you have one or two pieces of pizza and a salad and some meatballs, you know, it's more about the balance. Like you can still have those foods that you love just in a more balanced way.
  Dara: Yeah. And I think also which kind of goes back to the functional integrative approach, which, you know, we both trained much more Western philosophy, but there's something to be said about Eastern philosophy and the notion of mindful eating and intuitive eating, which, you know, I think a lot of us, when we feel deprived is often when we want to have larger portions of things and, you know, eating four slices of pizza for the most part, we're not actually enjoying that because we're feeling deprived and we want to have volume but we can actually slow down and pay attention to the food without the shame, without the guilt, with pure enjoyment because pizza really does taste good. Salads tastes great too, but a pizza tastes really good. And, you know, when you can actually slow down and appreciate and be grateful and mindful, that slice is so much more satisfying.
  Melissa: And I have someone who has really strong gut issues. You know they are struggling with IBS, constipation and diarrhea, heartburn. All of these things are very common with PCOS and you know, one of the sort of more, I guess, publicly promoted approaches to gut health is to cut, cut, cut, cut foods, and eliminate this food and eliminate that food. And then finally the person is just eating like plain chicken and a sweet potato. And it's like, there's no joy. There's no, you know, and it's, they're always kind of coming to me questioning, well, should I cut out grains? Should I cut out dairy? Should, it's like, well, how about we try sitting down and chewing thoroughly for a little while and see if that helps reduce the bloating? And it's kind of amazing how much it does, but I think as a culture we've become so accustomed to eating on the go or eating in front of our work or the TV and not really focusing on our food, you know, and when you do learn how to tune into those hunger and fullness cues, then you start to realize that it really doesn't take as much of the food to satisfy you. You know, I'm, I've mentioned my dark chocolate peanut butter cups which I keep in the freezer, typically, you know, I'll have something like a salad with tuna for lunch. And I almost always grab like one dark chocolate peanut butter cup after just to have that little like bite of sweetness. And it's like most days that's plenty, you know, maybe the day before my period, that's the day I'll go back and like grab a second peanut butter cup. But like, you know, I'm going to think really hard before I go back for a third or a fourth.
  Dara: And you're going to enjoy it and you're going to enjoy it, not feel the guilt and move on. And I think, you know, a lot of times, and this is something that I speak to a lot of my patients about and I think it's a tough one is, I see a lot of the all or nothing mentality and it breaks my heart. You know, if I did one thing that I didn't feel was great, the rest of my day is ruined and it's, you know, self-sabotage and you know, it's kind of the analogy - if you like, trip, are you necessarily gonna fall flat on your face and break everything? No, you had a trip. Get back up.
  Melissa: I love the analogy. I always use the analogy of, if you're driving across the country from New York to California, get lost around Ohio, you don't go all the way back to New York to start over again. And you like, look around, pull out the map, see where you're at, and then figure out how to get where you were going from where you are right now. You don't lose all of that progress you made by having a slip up. I think another really important thing to mention is how doctors are not trained in nutrition. And they're often the ones who are recommending, you know, their patients go keto or low carb. And as a hormone dietician, I hear a lot, people in the sort of honeymoon phase of keto are like losing weight consistently a lot at first, cause it's mostly water. They're feeling great. They're like, you know, converted, they're preaching to everyone how great it is. About a year later, 18 months later or so, you know, you've completely jacked your adrenal hormones, which for most people with PCOS is just going to make the situation worse. That's where the weight loss starts to plateau. They start putting on belly fat, which was like, you know, not their intention when they first went on keto. I think it's important to remember that highly restrictive diets are stressful on the body and the body interprets that as stress which is not going to help when it comes to making your body feel safe to ovulate or to lose weight which is what most of the people with PCOS are coming to me for.
  Dara: It’s great that you brought, you mentioned both keto and paleo, cause that's something that I also see quite often with my patients. The other thing that I see and would love to hear your perspective is on intermittent fasting. I see that all the time and you know, I can let you know my philosophy. I have a feeling it's probably quite aligned with yours, but do you have any insight into that?
  Melissa: Yeah, so, you know, I think the way I talk about it, it's like, okay, well there's some studies that show that intermittent fasting can improve insulin resistance. So kind of seems like a no-brainer like, oh, well, if you have insulin resistance with PCOS, then you should try intermittent fasting because that's going to improve the insulin resistance. But I find, you know, most women are not in a stable enough place hormone-wise in order to endure the added stress of skipping meals and intermittent fasting. You know, when your blood sugar goes low, your cortisol goes high. It's just like a seesaw. So you're putting added stress on your body by skipping breakfast. And in particular, I think the people who are intermittent fasting are doing it backwards. I think if anything, we want to start eating when the sun comes up and stop eating, when the sun goes down and get our bodies aligned with the sun and aligned with nature. And I think, you know, we're doing kind of the opposite when we're starving ourselves till 12 and then eating until eight or the whatever the window is. I'm not, you know, I think intermittent fasting can be a beneficial tool for some, I think, I think possibly more post-menopause. You know, once reproductive cycles are out of the picture then possibly, but only if you are living a low stress lifestyle, you're getting enough sleep, you're not over-exercising, you've got no thyroid issues and no adrenal hormone issues, which pretty much rules of out like every single woman I've ever met. So I dunno, yeah. I move to a cabin in the woods and like never talked to anyone again and do intermittent fasting, great, like good for you. But I find it way too stressful on most women's bodies. We're very, our hormones are so sensitive to changes and especially so sensitive to scarcity. And it's like, when your body thinks you're about to go into a war or a famine, which it may think you are if you're not getting enough calories or you're not eating regularly enough, you know, your body's going to do everything it can to survive and it's going to shut down reproduction and it's just going to prioritize survival, which for most people means hanging onto fat. So yeah, it's kind of like backfiring, I think for most women.
  Dara: Yeah. I think it's, I mean, it's funny that you said, you know, as long as you're not stressed. I'm like, find me a woman who's not stressed, especially in this day and age. in this era that we're living in. But yeah, it's true that I think in sometimes it can do more harm in terms of yes, putting people's body into survival mode and holding onto the fat ovulation-wise perhaps, you know, not making people ovulatein terms of, you know, that survival mode, but I think you said it perfectly in that what I typically see is that people are eating so much at the end of the day and not enough earlier on. And you know, and you know this too, in terms of hormone balance, especially if we don't want to overwhelm our system before going to bed, we want to kind of find that time to digest the food. So when we go to bed, our body really can relax and get that deep quality sleep. But the other thing is also if you're only having two meals a day, that's a lot of calories at one time in your body and that could be in itself taxing to your system. And it, it's hard to get in all your protein needs, all your vegetable needs. If you're just pulling it into two meals.
  Melissa: There’s actually a really interesting study on meal timing with PCOS that it was not a weight loss study. It was women with lean PCOS, and it was like an equal caloric day and what they had, what they did, they had the women at first, they eat a really big breakfast, like almost a thousand calories, a moderate lunch, and then like a 200 calorie dinner. And the other group they eat, you know, more or less what I would say most of us typically eat which is like a 200 calorie breakfast and normal lunch and then like almost a thousand calorie dinner. And it found at the end of the study that testosterone was much, much lower with the big breakfast group and, you know, several markers in PCOS were much lower with the big breakfast group. And it's like just by shifting the time that you're eating can make a huge difference.
  Dara: I would love more research to be done in terms of intermittent fasting for women because at least, you know, the majority of the research that I've looked at focuses on men and we all know that we're very different, our hormones are different. And I think it would be interesting to do, you know, to look into PCOS patients. And I wouldn't be surprised to see, you know, people who do include breakfast and a larger breakfast that's really high in proteins and healthy fats and perhaps even some fiber can really be beneficial. Interesting to see. Let's hope we can find more research in the future. Let's kind of shift now and discuss a little bit about supplements, if there's anything that you generally like to recommend, or if, of course, it's, I'm sure it's somewhat customized, but if there's any settlements that you typically like to suggest to PCOS patients.
  Melissa: Yeah. I would say that the biggest one is inositol, myoinositolspecifically, you know, because insulin resistance is so prevalent in PCOS, I tend to treat them as if they are insulin resistant until proven otherwise. So it's like until we get those labs back, just confirming yay or nay, we're just gonna like get you on a blood sugar balancing diet, start on inositol which is very safe. There are very few contra--indications for that. What inositol does is it helps sensitize yourself to the insulin so that your body uses the glucose better. And like I said, it's very safe. It generally gives you a little mood boost, you know, helps balance your blood sugar. Most people do great on that. You know, probably the two most common ones after inositol that I use are vitamin D again, because most people are deficient in vitamin D.
  Dara: Especially this past year, by the way, the past year and a half we've been in, cooped up indoors, not a lot of sunshine.
  Melissa: Yeah. I see, you know, very rarely see someone with an adequate vitamin D level, even more so in patients with darker skin which blocks vitamin D absorption from the sun. So I see a lot of D deficiency. Vitamin D plays such an integral role in insulin resistance and blood sugar balance and ovulation and egg quality, and all of the things that are helpful for fertility. So, you know, that's one, I, I generally feel comfy with like a small dose of that again, until we confirm what their number is and see what we need to do to customize it a little bit more. I also like to dose vitamin D seasonally. I'll like a higher dose in the winter when we're not, you know, up where I live, we don't get enough sun to make enough D over the course of the year. So I'll take more during the winter. And then I do during the summer. And then the third one I would say that's pretty much across the board and again, because it's such a common deficiency is omega-3s. So, you know, and it helps with a lot of the different aspects of PCOS that can help with the insulin resistance that can help with the inflammation. It can help with the dyslipidemia, which is the abnormal cholesterol levels that are typically seen with PCOS, which is a low HDL in comparison to total cholesterol. So those are the three that I really are kind of, you know, not that anything's across the board, but those are the three that are like almost across the board. You know, beyond that, like, I'm sure you have a similar practice with probiotics. I don't recommend a probiotic across the board for everybody. I recommend specific strains for specific reasons. You know, other things that I feel like are sort of widely promoted in PCOS are things like zinc. I don't recommend zinc across the board because it can throw off your copper and your iron balance. And so I don't recommend high dosing across the board. I see that in a lot of PCOS supplement lens. I see Vtex thrown around a lot as something that can help balance hormones and help with ovulation. And it can.,It's very potent. Vitex is a very potent supplement. It's also called chasteberry. But again, they use it in very specific circumstances, short term, only in a few different circumstances I would use that in would be try to jumpstart ovulation, or if they have high prolactin as well, or if they are ovulating, but have lower progesterone, like someone in the sort of perimenopausal years. And, you know, I really kind of dose it based on where they are in their cycle. I really, I'm not a fan of those, you know, quote unquote hormone balancing supplements that are out there because, you know, first of all, which hormones are you trying to balance with the supplement? Looking at the ingredients for most of them, most of them seem tailored to like my peri menopausal range, so, or PMS. A lot of them are sort of PMS focused, but they're, you know, oftentimes in sub therapeutic doses or it's taking ingredients that may not necessarily be beneficial or helpful for you and your situation. And I just feel those kinds of supplements have the potential to do harm when it comes to hormone balance. I never would recommend anything like that without a full hormone panel to see what's actually going on for you and where you need support.
  Dara: I think that's great. I think it's wonderful that you are cautious to over-supplement and vitamin D, I'm with you. That vitamin D is something that can be challenging to get from food sources and especially living in the north east or anywhere where it's cold in the winter time, you know, that could be beneficial. And then someone like omega threes. And the one thing with omega threes is you can get it from food sources, but I'm not sure about you. I don't see that many of my patients getting good quality DHA from things like sardines and anchovies. Salmon can be great but again, I don't see too many people getting, you know, salmon on a weekly basis. And it's nice to see that some prenatal vitamins do contain DHA, but oftentimes not enough.
  Melissa: Yeah. Usually with a prenatal, you need an additional DHA supplement because there's not enough. And then it’s funny, I'm actually the only person I've ever tested who had adequate omega threes. And I think it was because I was pescatarian for so long. So, like, fish really was my primary protein source. And I definitely did eat salmon like two times a week. You know, I'm a dietician. I know I should be eating my sardines. I can manage to get them down like once a month if I mashed them with like avocado and, you know, I have to really disguise the sardines, but most people have trouble with fish. And again, that's like, where you live and what you have access to. I'm very lucky to live on the sea coast and have access to fresh fish, but it's a lot harder in the middle of the country,
  Dara: You know, supplements aside, I think, you know, I think as dieticians, we are all about food first. And I think it's great that with your cookbook, you can help inspire people to use ingredients and use food to help nurse themselves and give them ideas because that's something that I know I get a lot of questions about is, you know, do you have any recipes? You have any great resources and it's wonderful that you've created this.
  Melissa: Yeah one of my favorite parts about the book actually is that it's organized by season. I'm a huge fan of eating seasonally and locally when possible. And, you know, it sort of like freshens it up instead of just eating broccoli every week, you know, day in and day out. It's like, you know, right now we're in the middle of tomato season. And like the peaches right now are incredible, but it's like in a couple of weeks, we'll be, you know, sweet potatoes. It's like saying hello to your old friends again, like, oh, brussel sprouts, again, forgot, forgot how much I liked these. Say, I really liked that the book is organized along those lines to make it easier to, you know, pick a recipe that, that aligns with where we are in the year.
  Dara: And it also encourages people to include more variety in their diet, which in turn can help with your gut biodiversity and help with your GI tract to make it happier.
  Melissa: Absolutely. It's one of the biggest factors. Going back to why I don't recommend probiotics to people across the board, it's because eating a variety of plant foods is actually a more efficient way to diversify your microbiome than taking a probiotic that's a single strain or a couple of strains, making sure you're getting fermented foods. And, you know, I can't, I'm allergic to casein, so I can't eat yogurt, unfortunately, which makes me very sad, but we have some great local farms. I'm able to get some, you know, great local fermented sauerkraut. I'll do that with my eggs. And you know, most people, again, along with the seafood, most people are not eating fermented foods in their diet and it's not so important.
  Dara: Yeah. And you know, there is a quite diverse array of foods that can be helpful for your gut, whether it's something like kimchi or the sauerkraut or miso soup, or, you know, a little bit of kombucha a little bit can go a long way. It doesn't have to just come from what we typically think about, you know, which is coming from your yogurt, which is nice.
  Melissa: There's actually some like non-dairy kefirs on the market now, like cashew based kefirs and a little bit goes a long way. Like I'll put like an ounce or two into my smoothie for just like a little bit of tartness, extra probiotics.
  Dara: I love it at these, a lot of these companies are getting creative, especially with, yeah, plant-based, dairy free alternatives that still do incorporate some probiotics, which is nice. I am thrilled. I think we've given our listeners so much information, educated them, you know, of the importance of protein, especially in the morning, not skipping breakfast, you know, remembering to eat lots of veggies and having, you know, eating seasonally, having a resource now for a fabulous cookbook, being open to, you know, some supplementation, especially in the winter months. And also going back to the idea of balance and not living such a restrictive life and, you know, including that pizza or the peanut butter cups every now and then for your mental health, for sure. What is the best way that our listeners can find you and hopefully learn more about you?
  Melissa: Yeah. Instagram for sure. I'm @the.hormone.dietitian and my website, as well is just www.thehormonedietitian.com .
  Dara: Your Instagram is fabulous. I think you have a perfect combination of, you know, personal pictures of the food you eat and then great visuals to educate patients on, you know, certain things that are related to hormones and PCOS that really make it easy and approachable.
  Melissa: Thank you. That’s funny. I just, I, some of the behind the scenes, like casual, like not staged stuff in my stories, but you'd be surprised how many people reach out to me and tell me how helpful that is to see how I add more vegetables to my breakfast or my dinner, and just, you know, how I live that balanced approach. It reassures them when they see that I eat pizza too, you know, that kind of thing. Thank you.
  Dara: Oh, you're so welcome. So how we end our podcast is we discuss what we're grateful for today. So Melissa, where are you grateful for?
  Melissa: I'm actually very grateful that it is finally almost fall which is my favorite season, you know, in terms of temperature and the foods. And as we were discussing before we went live, my husband has recently gone back to normal work hours. So I just feel like, like, it's that fresh back to school, new start feeling right now. And I, I love that. I can't wait to put on a hoodie and fuzzy slippers and crunch some leaves in the yard.
  Dara: You actually took the exact words out of my mouth. I was going to say along similar lines, the changes of the seasons, I'm really grateful. And I, you know, in the past I would always like, really look forward to summer. And there's something about this year. Yeah. I'm looking forward to fall and wearing a fall jacket and bundling up. And even the fall foods, the fall harvest, the pumpkins and the sweet potatoes and the pears and the Brussels sprouts, a lot of exciting things to look forward to in the horizon.
  Melissa: Yeah. I think we're all craving a little bit more structure, right? It's been such an unusual year and a half where, you know, any little taste of like back to normal is welcome right now. Bring on the pumpkin spice lattes but watch it.
  Dara: But if it brings you pleasure by all means here and there add it nto your routine. Thank you Melissa, for being on our podcast and enlightening all of our listeners to so much of your knowledge and your expertise.
  Melissa: Thank you for having me.
  Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself, and remember you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.