Polyendocrine metabolic ovarian syndrome (PMOS), formerly known as polycystic ovary syndrome, is a chronic condition driven by genetic, epigenetic and lifestyle factors. The resulting endocrine changes, including hyperinsulinaemia and hyperandrogenism, underpin the clinical manifestations of PMOS and are amplified by overweight and obesity. Reproductive features of PMOS, including ovulatory disturbance, endometrial abnormalities, subfertility and an increased rate of pregnancy and birth complications, have long been documented in these patients, but awareness in clinical practice has only increased in the past decade. The pathophysiology of PMOS interacts with physiological changes in pregnancy, leading to pregnancy and birth complications, exacerbated by the high prevalence of pre-pregnancy overweight, obesity and increased gestational weight gain in PMOS. However, the condition is poorly recognized as an independent risk factor for pregnancy and birth complications in antenatal guidelines and clinical practice. The 2023 international evidence-based guidelines, supported by extensive meta-analyses, have advanced knowledge on PMOS and pregnancy and birth outcomes. They recommend recognition of 'higher-risk' status for individuals with PMOS in pregnancy and aim to improve antenatal prevention, awareness, screening and treatment. Here, we explore the pathophysiology of PMOS and PMOS during pregnancy as well as related pregnancy and birth complications. We also outline current guideline recommendations, implementation strategies and research priorities related to PMOS in pregnancy.

BACKGROUND:The time before conception is an important opportunity to improve maternal lifestyle, and hence improve fertility and health. However, the components of effective preconception lifestyle interventions are unclear. OBJECTIVE AND RATIONALE:This review aimed to assess the association of intervention characteristics and behaviour change techniques with the effect of lifestyle interventions on fertility, obstetric, foetal, anthropometric, and metabolic outcomes in women planning a pregnancy. Understanding the optimal components of preconception lifestyle interventions is essential to improve success of future interventions. SEARCH METHODS:We searched Ovid MEDLINE, PsycINFO, Embase, Emcare, Scopus, Cochrane Central Register of Controlled Trials, and CINAHL (6 December 2024). We included randomized controlled trials on women planning a pregnancy which assessed the effect of lifestyle intervention compared to standard minimal care or no intervention on fertility, obstetric, foetal, anthropometric, and metabolic outcomes. We performed random-effects meta-analysis with subgroup analysis based on participant characteristics, intervention characteristics (using the Template for Intervention Description and Replication (TIDieR) framework), and behaviour change techniques (using the Behaviour Change Taxonomy v1). We assessed trustworthiness (using the Trustworthiness in Randomised Controlled Trials (TRACT) checklist), risk of bias (using the Cochrane Risk of Bias 2.0 tool), and certainty of the evidence (using the GRADE approach). OUTCOMES:Following eligibility screening and trustworthiness assessments, we included 24 studies (n = 7795 women), of which the majority were conducted in high-income countries (79%) and studied women with infertility (67%). Risk of bias was low for seven studies, some concerns for 15 studies and high for two studies. Overall, there was no difference in clinical pregnancy (odds ratio [95% CI]: 1.06 [0.84, 1.35], I2 = 24.22%) or live birth (odds ratio [95% CI]: 1.17 [0.82, 1.67], I2 = 48.73%) with lifestyle intervention. Odds of clinical pregnancy were higher for interventions delivered over ≥10 sessions (2.17 [1.21, 3.86] vs 0.88 [0.72, 1.07], P = 0.004 for subgroup differences) and with the behaviour change technique Adding objects to the environment (e.g. provision of intervention-compliant food and/or exercise equipment) (3.51 [1.70, 7.23] vs 0.90 [0.75, 1.08], P < 0.001 for subgroup differences). Lifestyle interventions reduced weight (mean difference [95% CI]: -3.87 kg [-5.76, -1.97], I2 = 95.03%) and fasting blood glucose (mean difference [95% CI]: -0.15 mM [-0.25, -0.04], I2 = 0%). Greater weight loss was observed for interventions with a weight loss aim (-4.19 kg [-6.30, -1.92] vs -0.81 kg [-1.48, -0.14], P = 0.003 for subgroup differences). Greater weight loss was observed for interventions delivered solely via face-to-face (-6.02 kg [-8.96, -3.07]) compared to those delivered via a combination of face-to-face and technology (-2.21 kg [-3.62, -0.81], P = 0.02 for subgroup differences). WIDER IMPLICATIONS:Effectiveness of preconception lifestyle interventions aiming to enhance fertility may be improved by a structured, intensive approach. Preconception lifestyle interventions reduce weight, particularly face-to-face interventions with a weight loss aim. However, these findings based on subgroup analyses should be interpreted with caution and warrant further investigation due to the exploratory nature of the analysis, limited number of studies included, and potential aggregation bias of study-level subgroup effects. Selection of intervention characteristics for future preconception lifestyle interventions should consider patient preferences and practical considerations. REGISTRATION:This review was prospectively registered in the Prospective Register of Systematic Reviews (PROSPERO) (CRD42022333066).

Background/Objectives: Risk perception of future disease may play a role in supporting lifestyle change to prevent diabetes mellitus (DM) and cardiovascular disease (CVD). It is unknown how women in the postpartum period with different cardiometabolic conditions perceive their future risk of DM and CVD, and whether this perception influences engagement in a healthy lifestyle. Methods: Cross-sectional study of women who delivered in the past five years (n = 497) living in Australia. Logistic regression analyses examined associations between history of pregnancy (gestational diabetes mellitus (GDM), gestational hypertension (GHP), pre-eclampsia, spontaneous preterm birth (PTB), small-for-gestational-age (SGA) infants), and non-pregnancy (polycystic ovary syndrome (PCOS), infertility) conditions with perceived risk of DM or CVD, and with lifestyle behaviours (physical activity, sedentary behaviour, and diet). Results: Overall, most participants had a low perceived risk of developing future DM (73.4%) and CVD (75.2%), which varied by condition type. History of GDM and GHP were associated with higher DM risk perception (OR 1.83, 95% CI 1.06, 3.15; OR 2.73, 95% CI 1.28, 5.84), whereas history of pre-eclampsia and DM were associated with higher CVD risk perception (OR 4.48, 95% CI 1.88, 10.62; OR 3.78, 95% CI 1.20, 11.88). History of PTB, SGA infant, PCOS, infertility, and lifestyle behaviours were not consistently associated with perceived risk of DM and CVD. Conclusions: Postpartum risk perception of developing future DM and CVD was low, even in the presence of female-specific cardiometabolic conditions. This highlights the need for greater postpartum support to enhance risk awareness and support a healthy lifestyle.

Background Sleep disturbances are common in women with polycystic ovary syndrome (PCOS), but no prospective studies have explored whether childhood-adolescence sleep disturbances are associated with later PCOS risk. Understanding behavioral markers may support early identification and intervention.Objective To examine whether poor sleep behaviors from childhood to adolescence are prospectively associated with a diagnosis of PCOS at age 14 years.Materials and methods Sleep behavior data (Child Behavior Checklist) from a longitudinal study of 226 female participants of the Raine Study cohort (37 with PCOS), assessed at ages 5, -8, -10, and -14 years, with PCOS diagnosis at age 14 years were analyzed. PCOS diagnosis was based on both hyperandrogenism and ovulatory dysfunction according to the 2023 PCOS Guideline adolescent diagnostic criteria. Generalized estimating equations examined longitudinal sleep behavior differences by PCOS status at age 14; logistic regression explored specific sleep behavior associations with PCOS risk at age 14.Results After adjustment for covariates, results showed higher sleep behavior problem scores from childhood to adolescence, with differences becoming more pronounced over time among girls with PCOS at age 14 (adjusted mean difference = 0.49; 95% CI = 0.10-0.87; P = .013). Analysis of individual items showed significant associations between PCOS at age 14 and "trouble sleeping" at age 10 (odds ratio [OR] = 2.95; 95% CI = 1.30-6.69) and "sleeping less than most kids" at age 10 (OR = 2.48; 95% CI = 1.18-5.22).Conclusion Sleep difficulties may serve as early, modifiable behavioral markers of PCOS risk. Poor sleep may worsen hormonal and metabolic dysfunction, promoting insulin resistance, obesity, and sleep disturbances.

Background: Sex hormone alterations, such as estrogen deficiency or testosterone excess, substantially increase cardiovascular disease (CVD) risk in females. Dietary fibre and its microbial by-products, short-chain fatty acids (SCFAs), have cardioprotective effects, but it remains unclear whether these benefits extend to females with an altered sex hormone profile. In this study, we aim to investigate whether dietary fibre intake, measured via plasma acetate-the most abundant SCFA-is associated with improved cardiovascular outcomes in females with altered sex hormone profiles. Methods: This cohort study included 116,235 female participants from the UK Biobank and Biobank Japan with up to 10 years of follow-up. We analysed early menopause (as a surrogate for estrogen insufficiency) and plasma free testosterone (in a subset). The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes were blood pressure. Proteomics analyses explored potential mechanisms. Results: Acetate levels were associated with lower 10-year MACE incidence (-0.618/1000 woman-year, HR=0.900, p=0.002) and systolic blood pressure (-0.231 mmHg per 1 SD, p<0.001) in the UK Biobank. High acetate levels attenuated the increased MACE risk associated with early menopause (HR=1.158, p=0.057) compared with low acetate (HR=1.425, p<0.001), with similar patterns replicated in Biobank Japan (high: HR=1.322, p=0.090; low: HR=1.385, p=0.042). Proteomics analyses suggested a mechanism involving pro-inflammatory proteins. Moreover, high acetate levels attenuated the increased MACE associated with elevated free testosterone in the UK Biobank (high: HR=1.238, p=0.024; low: HR=1.056, p=0.666). A significant interaction between acetate and free testosterone on systolic blood pressure indicated that the effect of rising testosterone on blunting acetate's effect (0.167, 95% CI: [5.212x10-2-2.818x10-1], p=0.004) was partially mediated by central obesity (waist-to-hip ratio). Conclusions: Higher plasma acetate levels were associated with lower cardiovascular risk, particularly in females with early menopause or elevated free testosterone, potentially via inflammatory pathways. These findings underscore the importance of hormonal context in shaping cardiometabolic resilience and support personalised CVD prevention strategies for females with altered sex hormone profiles, including increasing dietary fibre intake. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement F.Z.M. is supported by a Senior Medical Research Fellowship from the Sylvia and Charles Viertel Charitable Foundation, a National Heart Foundation Future Leader Fellowship (105663), and National Health & Medical Research Council (NHMRC) Emerging Leader Fellowship (GNT2017382). S.N. was supported by AMED (JP24tm0424228, JP24tm0524009, JP25kk0305032, and JP256f0137004), Takeda Science Foundation, and Japan Foundation for Applied Enzymology. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This research has been conducted using the UK Biobank Resource under Application Number 86879. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Deidentified clinical data of UK Biobank and Biobank Japan is available upon request. The R codes for free testosterone conversion and plotting are available at https://github.com/ChrYang/SexHormone.

Polycystic ovary syndrome (PCOS) is the most common reproductive endocrine disorder impacting the health of young female populations. Using harmonized estimates from 953 locations, we assessed temporal trends, geographic inequalities, and forecasts of PCOS among individuals aged 10-24 years from 1990 to 2040. Between 1990 and 2021, global prevalence and disability burden increased by more than 30%, with the highest burden observed among those aged 20-24 years. Substantial geographic heterogeneity was identified, with particularly high prevalence in Europe and East Asia. While high-income regions carried the greatest absolute burden, low-and middle-income regions showed the fastest growth, accompanied by widening socio-economic inequalities. Forecasting analyses suggest that PCOS burden in young populations will continue to rise through 2040. These findings characterize the evolving global landscape of PCOS, providing evidence to support targeted public health surveillance and prevention strategies for adolescent and young adult populations.

Polyendocrine metabolic ovarian syndrome [PMOS; previously known as polycystic ovary syndrome (PCOS)] is an endocrine condition affecting 10%-13% of women of reproductive age, with cardiometabolic, reproductive and psychological features. The PMOS guidelines have established recommendations for its management, which can include pharmacological, lifestyle and/or traditional medicines. The aim of this narrative review is to explore the pathophysiology, treatment recommendations and current evidence for lifestyle management for those with PMOS. Using the consolidated framework for implementation research (CFIR) and capability, opportunity, motivation and behaviour (COM-B) frameworks, this review identifies barriers and facilitators to implement lifestyle recommendations for PMOS, followed by strategies to support improvement in lifestyle management. There is limited high-quality evidence to support specific physical activity and dietary recommendations for those with PMOS. Underlying physiological mechanisms driving PMOS can impact energy expenditure, metabolism, appetite and satiety hormones, acting as barriers for weight and lifestyle-management strategies. Qualitative research suggests that implementation of lifestyle-management strategies from the PMOS guidelines has not been adopted. From a psychosocial perspective, those with PMOS often report that their health needs are not being met by health professionals. This might be related to a disproportionate focus on weight-focused care, inadequate lifestyle-management education for health professionals and inadequate support for people with PMOS to achieve lifestyle management. Working in partnership with those who have lived experience is crucial to translate the PMOS guidelines to improve health professional education, resources and adaption of lifestyle-management programmes to meet the needs of those with PMOS better.

Abstract Women who develop cardiometabolic pregnancy complications including gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), fetal growth restriction (FGR) and preterm birth (PTB) are at increased risk of type 2 diabetes and cardiovascular disease. This scoping review explores the extent, range and nature of qualitative research investigating experiences of women at-risk of or diagnosed with cardiometabolic pregnancy complications. Original research (n = 623) and review (n = 66) articles with qualitative data from women, partners, healthcare professionals and community and professional stakeholders were included. Studies involving women with GDM (n = 342, 49.6%), HDP (n = 163, 23.7%) and FGR (n = 17, 2.5%) primarily explored lifestyle, medical or pharmacotherapy interventions during pregnancy, whereas studies regarding PTB (n = 198, 28.7%) primarily explored psychosocial health postpartum. Risk of future diabetes or cardiovascular disease were prevalent concepts in GDM and HDP literature. Extensive qualitative research exists relating to maternal cardiometabolic health. Understanding women’s experiences may guide cardiovascular disease prevention and screening initiatives.

OBJECTIVES:To explore key stakeholder's perspectives and co-design the design, content and delivery of a lifestyle intervention to optimise cardiometabolic health during and after pregnancy for women at risk or diagnosed with gestational diabetes mellitus (GDM) and/or hypertensive disorders of pregnancy (HDP). METHODS:Pre-implementation qualitative study using co-design workshops (n = 2) and semi-structured interviews (n = 6). Workshop discussions and interviews were audio recorded, transcribed and thematically analysed using template analysis. RESULTS:Women with prior cardiometabolic pregnancy complications (n = 11) and research partners (n = 13) participated. Participants reported liking that the intervention fills a healthcare gap and highlighted the importance of a holistic, user-friendly, patient-centred, culturally diverse approach to intervention design, content and delivery. Delivery by female healthcare professionals who utilise good risk communication skills, display empathy and understanding was recommended to empower and support women with the knowledge, resources and skills to take ownership of their health and reduce cardiometabolic risks. CONCLUSION:This research supported the co-design of a lifestyle intervention to reduce cardiometabolic risks in women at risk or diagnosed with GDM and/or HDP. PRACTICE IMPLICATIONS:The findings demonstrate the importance of stakeholder engagement in intervention design and the need for a patient-centred approach when developing lifestyle interventions for pregnant and postpartum women at risk of cardiometabolic conditions.

OBJECTIVE:Sleep problems like obstructive sleep apnea (OSA) are common in polycystic ovary syndrome (PCOS), although the underlying mechanisms are not well understood. We aimed to determine the prevalence of sleep problems, synthesise and appraise studies analysing the associations between serum sex hormones, sex hormone-binding globulin (SHBG) and sleep problems in females with PCOS. DESIGN:Systematic review and meta-analysis. METHODS:A systematic search using MEDLINE, Embase, PsycInfo, CINAHL, Scopus, and Google Scholar was performed till 3 August 2024. Studies that examined serum sex hormones, SHBG or hyperandrogenism with sleep disorders and/or sleep disturbances in PCOS were eligible. Random effects meta-analyses of sex hormones and SHBG among females with PCOS with compared to without OSA were conducted. RESULTS:From 4487 screened studies, 24 were included, with nine suitable for meta-analyses. Among females with PCOS, 46.0% had OSA and 56.0% had other sleep disturbances. SHBG levels were significantly lower in women with PCOS and OSA compared to those without OSA (standardised mean difference = -0.62; 95% CI = -0.82 to -0.42; I2 = 0%; 179 participants; p < 0.00001), but no differences were seen in total and free testosterone, dehydroepiandrosterone sulfate, androstenedione, and oestradiol. No significant associations between serum sex hormones, SHBG or hyperandrogenism with sleep disturbances in PCOS were observed. CONCLUSION:SHBG, rather than hyperandrogenism, may play a more important mechanistic role for OSA in PCOS, while other sleep disturbances exhibit a less severe SHBG profile. These findings enhance comprehension of underlying pathophysiology of sleep problems in PCOS. Further validation across PCOS populations is warranted.

Objectives This study aimed to follow best practice by temporally evaluating existing gestational diabetes mellitus (GDM) prediction models, updating them where needed, and comparing the temporal evaluation performance of the machine learning (ML)-based models with that of regression-based models. Study Design and Setting We utilized new data for the temporal validation dataset with 12,722 singleton pregnancies at the Monash Health Network from 2021 to 2022. The Monash GDM Logistic Regression (LR) model with six categorical variables (version 2) and the Monash GDM ML model (version 3), along with an extended LR GDM model (version 3), each with eight categorical and continuous variables, were evaluated. Model performance was assessed using discrimination and calibration. Decision curve analyses (DCA) were performed to determine the net benefit of models. Recalibration was considered to improve model performance. Results The development datasets for model versions 2, 3, and the new temporal validation dataset included 21.2%, 22.5%, and 33.5% of pregnant women aged ≥35 years, respectively; 22%, 23.7%, and 24.0% with a body mass index ≥30 kg/m2; and GDM prevalence rates of 18%, 21.3%, and 28.6%, respectively. There was similar discrimination performance across the models, with area under the receiver operating characteristic curve (AUC) of 0.72 [95% CI: 0.71, 0.73], 0.73 [95% CI: 0.72, 0.74], and 0.73 [95% CI: 0.73, 0.74] for version 2 and version 3 ML and LR models, respectively. All models exhibited overestimation with calibration slopes of 0.87, 0.99, and 0.87, respectively, which improved with recalibration. DCA showed that all models had better net benefits as compared to treat all and treat none. For all models, some variability has been observed in prediction performance across ethnic groups and parity. Conclusion Despite significant changes in the background characteristics of the population, we have demonstrated that all models remained robust, especially after recalibration. However, the performance of the original ML model decreased significantly during validation. Dynamic models are better suited to adapt to the temporal changes in baseline characteristics of pregnant women and the resulting calibration drift, as they can incorporate new data without requiring manual evaluation.

OBJECTIVES:To examine trends in preconception and pregnancy cardiometabolic risk factors and conditions, pregnancy and birth complications, obstetric interventions, and the impact of COVID-19, and to forecast future disease burden. DESIGN:A multi-centre retrospective cohort study. SETTING:A large hospital network with three maternity hospitals serving ethnically diverse populations in Melbourne, Australia. PARTICIPANTS:Pregnant women who gave birth between 2016 and 2022. OUTCOME MEASURES:Trends in cardiometabolic conditions, birth complications and obstetric interventions. RESULTS:Over 7 years, 63 232 women were included, of whom 40% were nulliparous, and 60.9% were born overseas from 167 countries. From 2016-2022, maternal age (30.2-31.3 years), obesity (21.0%-26.2%), gestational diabetes mellitus (GDM) (15.9%-28.1%) and caesarean delivery (28.5%-37.6%) increased, while average gestational weight gain, premature births and special care admissions declined from 12.6-11.6 kg, 6.3%-4.9% and 24.2%-14.1%, respectively; and was statistically significant (p<0.05). Hypertensive disorders of pregnancy remained stable, fluctuating slightly (6.5% in 2016, 7.6% in 2020, 6.9% in 2022). During the COVID-19 lockdown period, the odds of GDM and induced birth increased by 8.0%, whereas the odds of caesarean section decreased by 5.0%. GDM is forecast to reach 43.0% by 2028. CONCLUSIONS:Prepregnancy and pregnancy cardiometabolic risk factors and conditions, pregnancy and birth complications, and obstetric interventions increased markedly over 7 years. Despite this, offspring complications, including special care admissions, stillbirths and prematurity, decreased, while pregnancy complications peaked during COVID-19. GDM is forecasted to increase to 43.0% by 2028, posing an unsustainable health and economic burden that necessitates urgent public health initiatives.

BACKGROUND:Experiencing gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), intrauterine growth restriction (IUGR) and preterm birth (PTB) increases women's risk of future type 2 diabetes and cardiovascular disease. Pregnancy and postpartum present ideal opportunities to intervene through lifestyle management and risk awareness to prevent or delay the onset of cardiometabolic pregnancy complications and future cardiometabolic disease. Designing interventions aligning with the needs and priorities of stakeholders is a critical first step in developing acceptable interventions. AIMS:To explore stakeholder perspectives and prioritise the optimal timing and setting to deliver a lifestyle intervention to improve cardiometabolic health amongst women high-risk for or diagnosed with a cardiometabolic pregnancy complication. METHODS:A pre-implementation study using an embedded mixed-methods research design. Facilitator-led workshops were used to prioritise the preferred timing (pregnancy or postpartum) and setting (hospital, primary healthcare, community health program, maternal and child health nurse appointments or online) for an intervention. FINDINGS:Women with prior GDM, HDP, IUGR and/or PTB (n = 9), and research partners (n = 15) (obstetricians, endocrinologists, community health representatives, researchers, a midwife, general practitioner and dietitian) participated. The findings suggest developing a lifestyle intervention for women commencing during pregnancy (in the hospital) and continuing into postpartum (online) should be considered. CONCLUSION:Stakeholders prioritised a pregnancy and postpartum intervention delivered via hospital antenatal care and online. Commencing interventions during pregnancy and continuing into postpartum will likely support continuity of care and improve health outcomes across both life stages. Early stakeholder engagement supports the development of acceptable, tailored interventions, for translation into real-world healthcare settings.

Background: Understanding ethnic differences in factors influencing healthy lifestyles postpartum is vital for informing effective lifestyle engagement strategies for women from specific ethnic groups. We aimed to explore ethnic differences in facilitators and barriers to lifestyle management among women after childbirth. Methods: In this multi-methods study, women within 5 years of childbirth in Australia were recruited in a cross-sectional survey (n = 478) and semi-structured interviews (n = 17). Ethnicity was categorised as Oceanian, Asian and Other, according to the Australian Bureau of Statistics. Chi-square tests were used to compare the survey responses between groups. Qualitative data were thematically analysed, with identified themes mapped to the Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation and Behaviour (COM-B) model. Results: Both Oceanian and Asian women had a range of facilitators and barriers to lifestyle management relating to capability (e.g., knowledge of a healthy lifestyle), opportunity (e.g., time availability) and motivation (e.g., enjoyment in exercise). However, Asian women were more likely to report knowing the importance of a healthy lifestyle (p = 0.026), having better practical skills (p = 0.004), having a flexible work arrangement (p = 0.008) and being able to access a conducive environment (p = 0.040) as important factors to maintain a healthy lifestyle, compared with Oceanian women. In addition, Asian women suggested a need to address cultural barriers around parenting and postpartum practices. Conclusions: Asian women encountered additional barriers to lifestyle management after childbirth compared with Oceanian women. Future interventions should integrate strategies corresponding to these challenges to improve lifestyle engagement in Asian women.

Background:Polycystic ovary syndrome (PCOS) has diverse features. However, the name reflects only ovarian aspects, overlooking broader features. This study aimed to investigate international stakeholder perspectives on PCOS. Methods:We conducted international longitudinal anonymous online surveys and face-to-face workshops with individuals with PCOS and health professionals between 2015 and 2023, across six continents, seeking perspectives on clinical features of PCOS, the current name, the potential for renaming, the advantages and disadvantages of a name change, and possible alternative names. Findings:Results from 7708 survey respondents in 2015 and post publication of international guidelines in 2023, significantly improved recognition of the reproductive, cardiometabolic, hormonal, and psychological features of PCOS (p < 0·001). However, gaps remain, with ≥20% of patients and/or health professionals not recognising associations between PCOS and non-alcoholic fatty liver disease, pregnancy complications, cardiovascular risk factors, and endometrial cancer. Aligned to the breadth of PCOS, in the 2023 survey, a potential name change was explored with 85·6% of patients and 76·1% of health professionals agreeing that the name should be changed. Both groups agreed that a name change presents advantages with 59-90% agreeing with advantages and fewer than 27% agreeing with disadvantages. Terms such as 'endocrine' and 'metabolic' received the highest support in 2015 and 2023 for inclusion in a new name among both patients (78·5 and 86·2%) and health professionals (84·6 and 79·6%). Overall, 84% committed to a consensus-driven name change process on voting at a 2023 workshop. Interpretation:Widespread international engagement in 2015 showed major knowledge gaps on broad PCOS features, with follow-up in 2023 showing significant improvement after two international guidelines, widespread dissemination and advocacy group outreach. Stakeholders highlighted that the current name does not adequately reflect broad PCOS features and is confusing. They endorsed a name change, with perceived advantages outweighing potential disadvantages. This culminated in a commitment to a global consensus process to determine and implement a new name, alongside extensive education efforts, both of which are now underway. Funding:The Australian National Health and Medical Research Council (NHMRC) funded Centre for Research Excellence in Women's Health in Reproductive Life (CRE-WHiRL) [APP#1171592].

Background: Women with polycystic ovary syndrome (PCOS) use traditional medicines such as Ayurveda (traditional Indian medicine) to manage their symptoms. Dietary and lifestyle advice is one of the major components of Ayurveda treatment, however, it remains unexplored. This study aimed to understand the perspectives of Ayurveda clinicians regarding PCOS and excess weight, and its management through diet and lifestyle. Methods: A qualitative methodology was implemented using online focus group discussion. The data were transcribed verbatim and analysed using content analysis. Ayurveda clinicians who fulfilled the predefined eligibility criteria were included. Results: Ten eligible Ayurveda clinicians participated in the focus group. Five categories with relevant sub-categories were identified: characteristics of women visiting Ayurveda clinicians; Ayurveda clinical toolkit for understanding clinical presentations; Ayurveda dietary approach to managing excess weight; advice related to dietary adjustments; and advice related to eating and lifestyle behaviours. Overall, most clinicians agree that an Ayurveda dietary approach is personalized, and tailored to the health needs, primarily based on Ayurveda assessment and the clinical presentation of an individual with PCOS and excess weight. Conclusion: Consistent with ‘Recommendations from the 2023 international evidence-based guideline for the assessment and management of PCOS’ Ayurveda clinicians advocate for a cultural-specific, lifelong healthy lifestyle for optimum management of PCOS beyond weight reduction. Ayurveda lifestyle counselling provides extensive insights into holistic food and lifestyle practices that individuals may adapt to their day-to-day lives. Further research may utilize consensus methods to explore potential dietary interventions and assess their effectiveness and adaptability in women with PCOS.

Objective To synthesise evidence from contemporary populations (2009-24) across diverse world regions and income settings on associations between gestational weight gain (GWG) and broad clinical outcomes, to inform updated, globally relevant GWG standards. Design Systematic review and meta-analysis. Setting Observational studies in all languages, with >300 participants, reporting pregnancy outcomes stratified by body mass index (BMI) and GWG. Participants Women aged >18 years with singleton pregnancies. Main outcome measures Birth weight and rates of caesarean delivery, hypertensive disorders of pregnancy, preterm birth, small/large for gestational age infant, low birth weight, macrosomia, neonatal intensive care unit (NICU) admission, respiratory distress, hyperbilirubinaemia, and gestational diabetes. Results Of 16 030 studies, 40 met inclusion criteria (n=1 608 711); 6% (n=65 114) of women had underweight, 53% (n=607 258) had normal weight, 19% (n=215 183) had overweight, and 22% (n=252 970) had obesity. GWG was below or above Institute of Medicine (IOM) or study specific recommendations in 23% and 45%, respectively. Using World Health Organization BMI criteria, GWG below IOM recommendations was associated with lower birth weight (mean difference -184.54, 95% confidence interval -278.03 to -91.06); lower risk of caesarean delivery (odds ratio 0.90, 0.84 to 0.97), large for gestational age infant (0.67, 0.61 to 0.74), and macrosomia (0.68, 0.58 to 0.80); and higher risk of preterm birth (1.63, 1.33 to 1.90), small for gestational age infant (1.49, 1.37 to 1.61), low birth weight (1.78, 1.48 to 2.13), and respiratory distress (1.29, 1.01 to 1.63). GWG above IOM recommendations was associated with higher birth weight (mean difference 118.33, 53.80 to 182.85); higher risk of caesarean delivery (odds ratio 1.37, 1.30 to 1.44), hypertensive disorders of pregnancy (1.37, 1.28 to 1.48), large for gestational age infant (1.77, 1.62 to 1.94), macrosomia (1.78, 1.60 to 1.99), and NICU admission (1.26, 1.09 to 1.45); and lower risk of preterm birth (0.71, 0.64 to 0.79) and small for gestational age infant (0.69, 0.64 to 0.75). For Asian BMI criteria, GWG below recommendations was associated with higher risk of hypertensive disorders of pregnancy (3.58, 1.37 to 9.39) and preterm birth (1.69, 1.25 to 2.30) and lower risk of large for gestational age infant (0.80, 0.72 to 0.89). GWG above recommendations was associated with higher risk of caesarean delivery (1.37, 1.29 to 1.46) and large for gestational age infant (1.76, 1.42 to 2.18) and lower risk of small for gestational age infant (0.62, 0.53 to 0.74) and low birth weight (0.44, 0.31 to 0.6). Conclusions This systematic review captured trends of rising maternal age and BMI from diverse world regions and income settings, with broad outcomes across all BMI groups. GWG outside IOM recommendations was associated with increased risk of adverse outcomes. These findings will help to inform the process of the WHO initiative to optimise globally relevant GWG standards for improved perinatal outcomes across world regions. Study registration PROSPERO CRD42023483168.

Background/Objectives: A healthy diet is essential for managing Polycystic Ovary Syndrome (PCOS), yet optimal recommendations remain unclear, highlighting the need to explore alternative lifestyle interventions. The Mediterranean diet (MedDiet) supports cardiometabolic health; however, challenges with adherence within this population are unknown. This study examines the acceptability and experiences of an ad libitum MedDiet in women with PCOS, offering recommendations for implementation. Methods: A 12-week MedDiet intervention was conducted with women aged 18-45 years, diagnosed with PCOS and a BMI ≥ 25 kg/m2 (n = 12). Adherence was assessed using the Mediterranean Diet Adherence Screener. Surveys and semi-structured interviews, guided by the Capability, Opportunity, Motivation-Behaviour (COM-B) model, explored participants' experiences. Thematic analysis identified barriers and facilitators, which were mapped to the COM-B and Theoretical Domains Framework (TDF), with all findings subsequently aligned with the Behaviour Change Wheel to inform implementation strategies. Results: MedDiet adherence significantly improved from baseline to week 12 (Baseline: 4.1 ± 1.8; week 12: 8.3 ± 2.3; p = 0.001), alongside increases in knowledge (p = 0.004), cooking confidence (p = 0.01), and time management (p = 0.01). Adherence factors were mapped to 12 of the 14 TDF domains. Key facilitators included health benefits, reduced weight pressure, educational resources, and simple guidelines. Barriers involved organisation, food availability, and external influences. Effective implementation should integrate MedDiet education, behaviour change support, practical resources, and professional training for nutrition professionals and healthcare providers to support referrals and weight-neutral dietary management. Conclusions: A short-term ad libitum MedDiet is acceptable for women with PCOS. Strategies for patients and healthcare providers, aligned with the intervention functions of education, training, and enablement, are key to supporting adherence.

Introduction:Diet may impact female fertility via inflammatory pathways, but the value of specific anti-inflammatory dietary indices compared with general healthy eating guidelines is unclear. We examined associations between different measures of dietary inflammation and diet quality with female infertility in a large population-based study. Methods:Data for 5,489 participants from the Australian Longitudinal Study on Women's Health were analysed (1973-1978 cohort assessed in 2009, at 31-36 years old; n = 1,289 fertility problems, n = 4,200 no fertility problems). Dietary inflammatory potential was assessed using the energy-adjusted dietary inflammatory index (E-DII™). Diet quality was examined using the dietary guideline index (DGI) and principal component analysis (PCA) for a posteriori patterns. Cross-sectional associations between these indices and self-reported fertility problems were assessed using logistic regression, adjusted for relevant covariates. Results:A diet with greater inflammatory potential was associated with higher odds of self-reported fertility problems (adjusted odds ratio (aOR) per 1-unit increase in E-DII: 1.13, 95% confidence interval (CI): 1.06, 1.19), with significant differences between the highest and lowest E-DII quartiles (aOR: 1.53, 95%CI: 1.23, 1.90). Higher dietary quality was associated with lower odds of self-reported fertility problems (aOR per 1-unit increase in DGI: 0.99, 95% CI: 0.99, 0.99), including when comparing highest and lowest DGI quartiles (aOR: 0.76, 95% CI: 0.61, 0.95). In PCA, consumption of a Mediterranean-style dietary pattern was associated with lower odds of self-reported fertility problems (aOR: 0.92, 95% CI: 0.88, 0.97), including when comparing highest and lowest quartiles (aOR: 0.70, 95% CI: 0.57, 0.85). Discussion:Our data suggest that following a generally healthy diet is associated with improved female fertility, whether by adherence to low inflammatory potential diets, Mediterranean-style dietary patterns or national dietary guidelines. These findings suggest that general, guideline-based healthy eating can support female fertility and may offer a flexible alternative to more prescriptive dietary approaches.

While there is a recognised role of lifestyle (diet and physical activity) in management of infertility, there is limited research exploring the perspectives of people with infertility in relation to lifestyle management. The aim of this study was to understand the barriers and enablers affecting uptake of lifestyle intervention in people with infertility who were using or seeking fertility treatment. A qualitative descriptive study was performed. Online interviews were conducted with people with infertility who were using or seeking fertility treatment. Interviews explored barriers and enablers to a healthy lifestyle while attempting conception. Interview questions were informed by the Capability, Opportunity, Motivation and Behaviour (COM-B) model and theoretical domains framework (TDF). Interview transcripts were analysed using template analysis. Themes were mapped to the COM-B and TDF, and suggested interventions were developed using the behaviour change wheel method. Nine women and two men completed the interviews. The median age was 38 years (interquartile range 33 to 42 years). Barriers and enablers related to capability (e.g. managing whole-body health and disease), opportunity (e.g. unmet needs from the healthcare system) and motivation (e.g. interplay between lifestyle and emotional state). Suggested intervention components included delivering inclusive programs which accommodate individual needs and providing engaging information which debunks myths and explains the mechanism by which lifestyle promotes fertility. Our study provides novel and rich insights into the unique needs of people with infertility, and has identified several interacting factors which influence their lifestyle behaviours. Our findings highlight that changes at the organisational and policy level are essential to overcome major barriers to lifestyle management by improving access to trustworthy resources with actionable advice, and by improving service provision to deliver multidisciplinary patient-centred care. Future studies should use these findings to co-design interventions and resources to support lifestyle management of infertility. Not applicable.