How do nutrition and lifestyle impact Polycystic Ovarian Syndrome? What can patients do to improve their symptoms and fertility? We talk with Angela Grassi, MS in Nutrition and a Registered Dietitian Nutritionist, and founder of The PCOS Nutrition Center where she provides evidence-based nutrition information and coaching to people with PCOS. She is the author of several books on PCOS including The PCOS Workbook: Your Guide to Complete Physical and Emotional Health.
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How do nutrition and lifestyle impact Polycystic Ovarian Syndrome? What can patients do to improve their symptoms and fertility? We talk with Angela Grassi, MS in Nutrition and a Registered Dietitian Nutritionist, and founder of The PCOS Nutrition Center where she provides evidence-based nutrition information and coaching to people with PCOS. She is the author of several books on PCOS including The PCOS Workbook: Your Guide to Complete Physical and Emotional Health.
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* Note that this is an automatic transcription, please forgive the errors.
Speaker 2:Welcome everyone. Today we're going to be talking about how nutrition and lifestyle impacts CCOs. We are talking with Angela Grossey. She is a registered dietician nutritionist, the founder of the PCO S nutrition center where she provides evidence based nutrition information and coaching to people with DCOS. She is the author of several books on PCLs including the PCLs workbook, your guide to complete physical and emotional health. And I'd like to say that is a great book and she also is the author of the PCO S nutrition center cookbook. In addition, she has PCO, C O S herself. And so this topic has personal as well as professional interests. Welcome Angela. Uh, and thank you so much for being here today to talk to us about all things nutrition and lifestyle as it relates to polycystic ovary syndrome.
Speaker 3:Great to be here, Don. Thanks for having me.
Speaker 2:Good. Let's start by talking about, um, what is PCOM exactly and, and what causes it.
Speaker 3:Okay, that's a great question to start with. DCOS stands for polycystic ovary syndrome and it's a very under recognized condition that affects about 10% of reproductive age women. And it has always been viewed as a reproductive disorder. So women with this condition typically will present with irregular periods. They will have, um, problems with ambulation and in trouble getting pregnant. In fact, PCLs is the most common cause of Abila Tori in fertility. So it's always been viewed as this, um, hormonal disorder. But now we know that there's reproductive, uh, consequences that extend into the endocrine aspect. So it's actually, uh, primarily viewed now as an endocrine disorder. And the reason for that is that we see higher rates of women who have this having insulin resistance and it's associated with a whole, a bunch of other metabolic conditions.[inaudible]
Speaker 2:and so when you're talking about Metapod the metabolic impacts of polycystic ovary system,
Speaker 3:exactly. So seeded with PCLs, we're going to see higher rates of thyroid disorders, fatty liver disease. We're gonna see problems with autoimmune disorders, dyslipidemia. And so what typically presents is high levels of LDL, high levels of triglycerides and low levels of HDL cholesterol.
Speaker 2:So when somebody is concerned that they may have PCLs or these are a, what type of testing should they out?
Speaker 3:Sure. Well, the first is to understand the diagnostic criteria for PCLs and and right now, and there's so much we don't know about PCLs, but right now it's an agreed upon criteria and it States that a woman has TCOs if she has to have the following three. The first is if she has a, the presence of these little immature follicles on her ovaries. So this would be through an ultrasound, usually a transvaginal ultrasound that looks at her ovaries. And part of this hormonal disorder is that women have higher levels of testosterone. These, this male hormones, um, to sass around in its precursor, DHE a sulfate which converts into testosterone. So not only do we look at the ovaries to see if they have these immature follicles, but we also look at their hormone levels. So we look at testosterone and you can do blood levels of total and free testosterone to see if levels are elevated. Typically if levels are over 40, then that's kind of consistent for a total testosterone with PC EOS. But we don't just go buy the blood work because testosterone is not a very sensitive test. It varies a lot. And doesn't pick up a lot and really just not a good test. So we also look at other signs of having high testosterone in women, which is going to be acne, um, hair loss and excessive hair growth. So some women who have PCs will get like a mustache or we'll get a beard, um, here in the central part of her body, for example, in between her breasts or inner thighs. Uh, that's probably more than a woman would normally have and it becomes problematic.
Speaker 2:And as you would imagine, male factor type pair growth is where is
Speaker 3:exactly the central part of the body. So we don't just go by a testosterone test itself, but we also look at signs on the body. So that would be the second criteria. And then the third would be as the woman has irregular cycles. So if her period is not regular or absent altogether, that is the third criteria for having PCLs.
Speaker 2:Okay. And, um, do we, what do we know about what causes a PCO S
Speaker 3:there is still so much to learn about PCs. We're not exactly sure of the exact cause of it. There's a whole bunch of theories and a whole bunch of, um, kind of ideas of what could cause it. For example, maybe babies being exposed to high testosterone levels in utero,
Speaker 2:how would a baby be exposed to a higher than normal levels of testosterone in utero?
Speaker 3:Sure. So let's say the mother had PCLs and her testosterone was high and she was pregnant. Cause it, there's definitely genetic link to P cos we're definitely seeing families that have, the mother has it. Um, it's a good chance that her daughter's gonna have at it. It tends to run in families with like sisters. If one sister has it, chances are the other sister's going to have it too. So there has been a gene identified. Um, but then we look at environmental impact to, you know, from pollution and environmental contamination. And then we look at the gut bacteria. And does that play a role into this whole pathophysiology of CCOs?
Speaker 2:That's fascinating. What is the microbiome and how that might, the gut microbiome is what you're talking about.
Speaker 3:Exactly. And we do have some research that correlates poor gut bacteria to higher levels of testosterone in PCLs.
Speaker 2:Fascinating. But that's not part of the diagnostic criteria. No, it's just as far as trying to understand cause and things such as that. Exactly. Where does inflammation fit in as far as inflammation we know is harmful on so many different levels including cardio, health, physical health, you name it. Is inflammation a culprit are a cause are a result of polycystic ovarian syndrome?
Speaker 3:Definitely. I think inflammation only adds fuel to the fire. And what we see is when somebody has higher levels of inflammation, it makes that insulin resistance worse and vice versa. High insulin levels then makes the inflammation worse. So a lot of the treatment for PCLs is aimed at reducing both the inflammation and the insulin resistance.
Speaker 2:Okay. And that's a segue into now obviously the actual treatment it needs to be done by an and preferably by a reproductive endocrinologist, but you need to see a medical professional to diagnose your own specific. But what are some of the treatment options available for women who present with polycystic ovarian syndrome?
Speaker 3:Well, the good news is that we do know, know a little bit more about PCs than we have in the past decade or so. And there are many more treatment approaches available. The primary treatment approach is through nutrition. So how you feed your body and what you give your body can really help to reduce that inflammation and that insulin resistance. And another thing to consider is that PCLs because there is a, an insulin resistance component in the majority of patients who have it that that can turn into type two diabetes down the road. So it's really important to be preventative whenever possible and try to know your numbers, know your A1C, get an oral glucose tolerance test done and monitor for that and uh, make lifestyle factors like changing up your nutrition. Exercise is so important. Uh, sleep, stress management, all of that plays into decreasing insulin and inflammation. And then we always have other lifestyle options like supplements and medications that can help with PCLs.
Speaker 2:Okay. And briefly, what are the predominant medications, again, depending on the case and the patient, but what are some of the, uh, the more common medications?
Speaker 3:Sure. The most common medications used for PCLs right now is going to be Metformin, which is a common diabetes medication, which helps to reduce insulin and glucose. And taking Metformin can also help to regulate cycles, helping to get periods more regular. It can also bring down cholesterol. And we're also seeing that birth control pills are, are often use. I, I usually am not a great fan of them because there are significant side effects of taking them. And it's kinda like just a bandaid for PCs because it will regulate a cycle, but it does increase insulin, increases inflammatory markers like CRP and can increase cholesterol as well.
Speaker 2:Excellent. And you mentioned supplements. What supplements would a medical professionals consider for a woman with TCOs?
Speaker 3:Yeah, I'm a big fan of supplements as they provide a good option to help treating PCs without side effects usually. So they're usually very well tolerated. Some of the most studied of supplements for PCs include in all talls like myo and[inaudible] and D, Cairo and ASA tol. Uh, we're seeing that fish oil can play a role in helping to decrease triglycerides and help with inflammation. Um, we're also seeing that vitamin D is really important for ambulation and for equality and possibly helping with insulin. And then we see some herbal like berberine or the antioxidants and acetol cystine also known as NAC being a good option to help bring down insulin and now cause also been shown to improve a quality and ambulation as well.
Speaker 2:Excellent. Thank you. Let me remind everyone that this show is underwritten by our corporate sponsor faring pharmaceutical for women who have been struggling with infertility and infertility treatment and need some emotional support in and who doesn't. Let's be honest, there is an app available called fair to call. It was designed by reproductive psychologist and it was designed specifically to, uh, help women address the many challenging emotional life situations that arise while struggling to conceive. You could get more information at[inaudible] column f.com. Angela. All right, let's talk about nutrition and PCLs. One of the first things that most people assume is that if you have PCO S you are overweight and the assumption is that you are overweight because you eat too much or exercise too little. And this part we're going to focus more on nutrition. Let's talk about that belief that a lot of people, including medical professionals have a that suffers of PCO S or women with PCLs are overweight due to eating too much.
Speaker 3:Okay. So the most frustrating and most common advice given to patients with DCOS by their healthcare providers is to lose weight. And if they lose weight, then they're told that their cycles will improve, their symptoms will improve and PCs can go away. And that's just not true. Uh, I know that patients with PCs are so dedicated to wanting to lose weight because here they are with having this insulin resistance, they tend to gain weight rapidly out of the blue, a significant amount of weight, almost like they just blew up overnight. The only thing I can equate it to is like having a thyroid disorder and gaining a rapid amount of weight in a relatively short amount of time. And a lot of time that weight occurs in the midsection of the body. So some patients will even refer to it as like a spare tire around their waist. And that's the role of fat around their belly button area. And patients want to get control over it. Here they are with this symptom that's been out of control and they do want to control it. And chances are patients with PCs have gone on diet after diet maybe to lose a little bit of weight but only to quickly regain it. And that's because of the powerful influence of insulin. Insulin is a growth hormone. Its job in the body is to promote fat storage, which is weight gain. And when we compare women with BCS to women without it, we do see that women with PCs have higher levels of insulin. So they are gonna, um, struggle with their weight. It doesn't mean that it's due to eating too much because, um, I work with patients all the time that are eating sometimes a low calorie diet training for marathons and have still experienced this rapid weight gain. So it's more due to the influence of insulin and that sometimes we put this pressure on our patients to lose weight. We are taking away the emphasis of lifestyle in helping to improve their condition.
Speaker 2:And it should also mention it as possible to have PCLs and not be overweight. Although I think the majority of patients do present with increased weights. Do you happen to know the percentages?
Speaker 3:I think around 70% of women with PCs are of a heavier weights.
Speaker 2:You have an entire workbook on this subject question. What, uh, what should women with PCLs be eating?
Speaker 3:Sure. So the first thing is to it based on the patient's needs. So when I meet with a patient, I do a full detailed PCLs nutrition assessment. So we're discussing, um, what they eat on a regular basis. The foods that they prefer, the foods that they don't prefer, and their lifestyle. If they work a very demanding job, if they're doing a lot of travel, what's the home situation? Do they have children? All those factors play into a nutrition plan for P cos. But in general, it's important for patients to have the education about how food affects insulin levels. So what we know is that very high sugary foods or refined foods that tend not to have enough fiber protein, they tend to enter your bloodstream very quickly. And that's going to cause a big surge in insulin and that's eating those foods on a regular basis if it's becomes problematic, that can only worsen insulin resistance. So instead I try to help patients to emphasize the low GI foods, the low glycemic index foods that don't spike up insulin and including plenty of fruits and vegetables that contain antioxidants. And that's going to help to fight the inflammation as well as getting in a balanced meal plans. So to balance the insulin, you want to have the protein and fat at each meal and snack to balance those insulin and glucose levels.
Speaker 2:So how does food impact insulin levels and one would assume high sugar. And you're saying non-complex uh, carbohydrates, simple carbohydrates. What are some of those foods that would directly help, uh, allow insulin despite high glycemic foods?
Speaker 3:Right? So if you think of foods that are already almost processed, so like juice would enter your bloodstream right away, that would cause a big surge in your insulin versus like let's say an Apple, which has that whole fibrous skin around it, that your body has to break down the fiber to get the nutrients. So that gets digested a lot slower. So just in general, like foods that don't have fiber or protein, white rice, a lot of processed foods that tend to really quickly enter the bloodstream because they're already processed and that causes a big surge in insulin levels,
Speaker 2:higher complex carbohydrates, whole grains, whole, whole fruits and vegetables are okay, but eaten whole, not as a, a juice or a, a liquid format. What about, uh, things like, uh, potatoes and uh, different types of starchy that shuttles,
Speaker 3:right. So those are carbohydrates, but they have a lot of fiber. So what I usually educate my patients about is kind of looking at the PCLs plate. Half your plate should be vegetables, a quarter should be protein, and then a quarter should be the starchy carbs or the whole grain carbs. And then in the middle should be some good healthy fats to balance everything out.
Speaker 2:And is there a preference as to the type of fats? Um, I know right now a lot of people are talking about coconut oil. Does it matter? The type of fat
Speaker 3:fat is going to be good at every meal. It's, it's important to have fat at every meal. But we do see that some fats provide antioxidants like avocados of olive oil, olives, not seeds, fatty fish. All these types of fats actually can help to decrease inflammation.
Speaker 2:What about dairy? Is dairy a is, is it forbidden or is it encouraged? And, and if dairy, what type of dairy? Well, we put that low fat,
Speaker 3:right? So dairy is actually kind of controversial in PCLs. We have just a very few studies that have shown that fat-free dairy that having two servings or more have fat-free dairy can increase insulin and testosterone levels and that can contribute to higher testosterone and even more acne production.
Speaker 2:And that's, that's skim milk. Your low fat or skim products, you're low fat yogurts are fat free yogurts. So that's kind of contradictory in what we have been hearing in the past, which is if you've got a weight problem, you are focusing on, you know, the skim milk products,
Speaker 3:right? So what we're finding with these fat free or skim products is that they remove the fat and it changes the whole hormone composition of the, of the dairy. And so women are taking it in and it's actually left with higher androgens, which then increase their androgen levels. Oh, that's fascinating. Yeah. So I really individualize it with patients they're in, you know, there are some studies that show that a couple servings, just one or two servings a full fat dairy is beneficial for fertility and it's a great source of vitamin D. so it's important to individualize it, um, for the patient. Some patients just can't tolerate dairy much is causing more inflammation for them if they can't digest it. So if, uh, if anything, if you do have dairy, I do recommend going for just one or two servings, a full fat each day.
Speaker 2:All right, so dairy is, if you can tolerate it is fine. Aim for the full fat versus the low-fat. That's fascinating. You talked about the PCO S plate being half fruits and vegetables, a quarter complex carbohydrates in a quarter protein. Is that, is that correct?
Speaker 3:Half vegetables, fruit would go into that quarter apart with the the carbs.
Speaker 2:Alright. What type of protein is this? A, uh, a diet that the type of matters or as long as its protein is protein,
Speaker 3:right. Any kind of protein is going to be beneficial. It's almost gonna act as like a buffer with those carbohydrates to keep blood sugar levels even throughout the day.
Speaker 2:Okay. So it can be chicken, it can be soy. What about vegetable based protein? Is that preferable or not? Beans.
Speaker 3:I think beans and legumes are great to include there. I'm really high in fiber. They've got a lot of antioxidants and they have protein, so I think they're fine to have and to really important to get a variety and also not to even look at this as like a diet. This is just a lifestyle. This is how you eat for PCLs.
Speaker 2:Yeah, I do hear that. Is that what you're, this is not intended to be a diet for losing weight. It is intended to be a, a healthy eating regime is, is, is what I am hearing. Right. All right. So what about now you've mentioned you would not encourage juices, eat the fruit itself. Avoid the juice. What about alcohol? Glass of wine? A beer, a mixed drink. Uh, on occasion is a, is that allowed?
Speaker 3:On occasion those drinks are fine to have. In fact, a red wine might be the best choice of all because it's got a lot of antioxidants in it. We do see that several having several drinks a week though can affect fertility. So if someone does have PCLs and is trying to get pregnant, they might want to cut back on their alcohol as well as coffee and take.
Speaker 2:Well, you just got to next, uh, one of my favorite beverages. Coffee. Um, what is the evidence, what does the science say about coffee and a polycystic ovarian syndrome?
Speaker 3:We don't have any evidence per se in PCLs with coffee, but if someone is trying to get pregnant, I would just limit their coffee intake to no more than two cups a day. And that's two eight ounce cups.
Speaker 2:You know, I'm uh, because I am a tea drinker I think in terms of a lot of times I love the research. It says green tea is good for you since I love green tea and drink it. Um, is there any research that would uh, that support that uh, teas, green tea or our other, our black days are beneficial.
Speaker 3:There is Dawn, you'll be happy to know green tea, um, is loaded with antioxidants and has been shown to help to decrease testosterone levels in patients with PCLs.
Speaker 2:Excellent. So green tea over other tea, a black tea then it sounds like,
Speaker 3:absolutely. I think black tea has a lot of antioxidants too, but the, what we know from the literature is that it's more the green tea and even spearmint tea has been shown to decrease testosterone.
Speaker 2:So we want this to be not viewed as a punitive diet. We want this to be viewed as a lifestyle change. So, uh, what is an effective way to start implementing R? R should you just bite the bullet and do it all at once?
Speaker 3:Well, I would definitely recommend getting some help with this cause chances are if you have dieted in the past, you have a lot of myths maybe surrounding food and are very confused about what to eat. And if you search the internet, there's a lot of myths about PCLs and nutrition. So working with a registered dietician such as myself that's experienced in PCLs would be helpful. I would also recommend my book, the PC Wes workbook, which does include nutrition is part of it to helping you get started. But I would just start with one meal and after you get the education about how food affects insulin and knowing what even insulin is, then I would start with say breakfast, make that a good balanced breakfast, get a lot of whole grains in there, get a good amount of protein, some fat, and once you have breakfast down, maybe work on the next meal.
Speaker 2:Excellent. Let me pause and let people know that this show is brought to you with the support of our partners and our partners are organizations that believe in our mission of providing unbiased, accurate, uh, medically accurate information to the patient community. One such partner is Fairfax Cryobank. They are the U a U S based leading donor sperm bank and the trusted and uh, one of the largest selections of donors and donor information products available and they have six sites across the U S and they can provide a large and diverse selection of donuts. We also have CooperSurgical Cooper surgical fertility and genomic solutions. Our global leaders in IVF and reproductive genetics. They offer a, an assortment of different type of chest, a, G, T, a, P, G, T, the M, P, G, T, S, R as well as some endometrial receptivity testing for individuals as well as for couples. And really most important or not most important but very important at least to me, is that they provide comprehensive genetic counseling to their patients. And it is a huge part of their belief system that that genetic counseling is crucial to help people understand the impact of the genetic testing and not leave them stranded. And so we ranked them all right. In addition to food, we also know that there are other things we need to focus on that that affect not only your general health but particularly a health with the health of a woman with polycystic ovarian syndrome. Let's talk about sleep. You know, I always like to say sleep is, is the easiest thing to change in some ways, but it really isn't for a lot of people. I appreciate that. What does the research show about how sleep impacts women with TCOs? Sleep
Speaker 3:plays a significant role in PCLs and we do see in patients with PCs that they have more sleep disorders, um, than perhaps other populations. So we're finding that a lot of women would be, cos maybe they have anxiety and that's affecting their sleep. Maybe they can't fall asleep or they wake up in the middle of the night and have trouble going back to sleep or wake up really early. And then we have some women that have sleep apnea. In fact, sleep apnea is twice as common in PCLs patients. And there is a link with high testosterone levels that high testosterone levels affect the sleep receptors in the brain and that can contribute to apnea. And when you have sleep apnea, it makes insulin resistance worse. And certainly if you're struggling with sleep, um, it can make insulin worse just getting lack of sleep. We know that cortisol levels, there's a whole circadian rhythm and that, um, when that's affected, it can affect cortisol levels and that can affect cortisol as a stress hormone that can also affect insulin levels. So we devoted a whole chapter in the[inaudible] workbook to sleep and helping patients develop good sleep hygiene and give us the, uh, the high points of what you mean by good sleep hygiene, good sleep hygiene may means making sleep a priority, going to bed at the same time each night and trying to wake up around the same time trying not to do other things in the bed other than sleep, maybe sex too. But I'm not doing any work, not watching TV, even in your bed, not even reading. So just keep the beds asleep and, and uh, sex and even just other things to help like room darkening shades, doing some mindfulness meditation before bed. Things like that can really help. And if you are struggling with insomnia, it's very treatable. And I would recommend working with a mental health professional to help you get to the underlying issues of what's contributing to your insomnia. And if you do have sleep apnea, there's good treatment for that. Typically it is with a C CPAP machine to help you, um, get enough oxygen in. And they're much better than they used to be. They're much quieter and more comfortable and people who wear them see a big difference in how they feel during the day. They're not as tired, their blood pressure comes down and then it can also bring down their insulin levels as well. So how much sleep does an adult woman have? Everybody is different. And if you go on vacation and you go to bed and sleep until you just wake up and need to do that for a couple of days, you'll get a good sense of how many hours a night that you typically need. I for one need nine hours. I need a lot of sleep, but I think the average is seven to eight.
Speaker 2:Yeah. I've, I've read that the average would be seven, eight. But you're right. I mean it is individual and, and you may be a person that needs that needs more. Um, I think a lot of us kid ourselves by saying that we're, we're, we're person who needs less, but that I think that sometimes is, um, it helped me to be told that in fact, very few people need less. It's just what you're telling yourself to justify and in, in fact, that was the case for me.
Speaker 3:Yeah. It's hard to be disciplined with the sleep, you know, cause you want to watch your shows and it's easy to get sucked in and that flex. But to know that's always going to be there and your sleep is a priority.
Speaker 2:Yeah. Um, I liked what you said about one of the first steps is prioritizing sleep. Uh, that takes care of a lot of the, a lot of the issues. All right, so we're talking about lifestyle, another lifestyle. Um, that particularly we hear about with anytime there is somebody overweight, we usually here reduce the, uh, reduce your food and increase your exercise. So what is the relationship in exercise to women with DCOS?
Speaker 3:So exercise is an important part of treating PCLs. And a exercise helps to lower insulin levels. It can help lower inflammation and it can help with, um, emotional health to mental health. It's a great way to practice some mindfulness or to help with stress. But when patients ask me, well, what kind of exercise should I do and how much should I exercise? I mean, it's this, it's the same as the government guidelines really, um, that we should be lifting weights at least twice a week and we should get cardio vascular exercise, um, at least 30 minutes, 30 to 60 minutes of moderate to vigorous activity, um, on the other days.
Speaker 2:And so is there anything different than a woman with PCLs would do then, then what it's typically recommended? Cause what you're just saying is what we're all supposed to do.
Speaker 3:Right. I think doing activities that you enjoy, sometimes what I see patients do is they're trying so hard to lose weight. They're at the gym for hours on end trying to do all this exercise. And if anything that can make cortisol levels worse and insulin levels worse, it backfires on you. So you don't need to spend hours at the gym and you should be doing activities that you like.
Speaker 2:Yeah. Which yeah, it can be, you know, games. Uh, yeah. Um, walking, uh, it can be any number of things that, that, uh, that, that work with whatever you enjoy doing.
Speaker 3:Exactly. And we also see that exercise can help with fertility. So if someone is trying to get pregnant, even just taking a walk most days a week and the 15 minutes can help with their oscillation.
Speaker 2:So any other lifestyle factors that you would, uh, you'd want women to know about that they should consider if they have polycystic ovarian syndrome?
Speaker 3:Other things to keep in mind is stress management. So stress forever, you know, it's, it's in everyone's lives, it's never gonna go away.
Speaker 2:And you know, particularly I think, I think women with DCOS sometimes have more stress, number one, they may be trying to get pregnant. Number two, the misunderstanding and the impact of weight, it just seems like it's a vicious cycle because I think that stress, is there evidence to say that women with DCOS have a greater issues with stress than women without
Speaker 3:possibly, we definitely see higher rates of anxiety and depression in patients with PCLs and really, um, like you mentioned, dealing with the frustrations of getting pregnant and dealing with the frustrations of all the unwanted side effects and um, you know, dermatological aspects of PCLs, like the hair loss and acne and the weight gain. So all that, uh, does, uh, impacts someone's emotional health and puts a lot of stress on them. And I think one of the best ways to deal with stress because it isn't gonna go away and it's, so we have to learn how we manage it is remind fullness, mindfulness practice can really help. To bring down cortisol and insulin levels and really help you to deal with stress more effective.
Speaker 2:Definitely. And there there's some, there are some really strong research that shows that connection.
Speaker 3:Absolutely. So even something that I encourage my patients to do is just 10 minutes a day, get one of those apps and just listen to the app and give yourself that 10 minutes to practice the mindfulness.
Speaker 2:Yeah, those are mindfulness apps and I would mention there's the a, the further calm app, uh, that is specific to, and it includes mindfulness techniques specific to women who are struggling with infertility as well. But there are, as you point out, general apps for meditation and mindfulness and things such as that as well. And most of them are free. Absolutely. Thank you so much. Angela Grazi, registered dietician, nutritionist and founder of the PCOM nutrition center and author of the PCO S workbook, your guide to complete physical and emotional health. Let me remind everyone that, uh, the views expressed are those of the guests and do not necessarily reflect creating a family. Our underwriters are, our partners. Also keep in mind that the information given in this interview is general advice to understand how it applies to your specific situation. You need to work with your infertility professional. Thank you so much for joining us today.