Perspectives and dietary management of excess weight in polycystic ovary syndrome: A focus group study with clinicians of traditional Indian medicine

Abstract

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.

1. Introduction

Polycystic ovary syndrome (PCOS) is a chronic disorder among women of reproductive age with a global prevalence of 10 %−13 %.¹ It is associated with complex aetiology and heterogeneous clinical presentation involving reproductive, endocrine, cardiometabolic, dermatological and psychological features.² Insulin resistance (IR) plays an important role in PCOS development along with several other modifiable risk factors such as increased weight and unhealthy lifestyle.3, 4, 5 Increased weight and the presence of IR are independent risk factors for developing type 2 diabetes, impaired glucose tolerance, cardiovascular complications,^{5, 6} infertility, and poor response to infertility treatments.7, 8, 9 Lifestyle management aiming to promote a healthy lifestyle is a first-line treatment for managing symptoms of PCOS, particularly in women with overweight/obesity. However, there is currently no consensus on the most effective lifestyle approaches to this pathology.^1,10,11

The International Evidence-based Guideline for PCOS¹⁰ advocates lifelong healthy lifestyle modifications to manage reproductive, metabolic and psychological health, emphasizing dietary recommendations and person-centred care to enhance long-term effectiveness. Social and cultural factors also impact lifestyle changes, leading some women to seek advice from other non-credible sources such as on the internet.^12,13 Alternatively, women may seek treatments from traditional, complementary, and integrative medicines (TCIM) as they may have greater trust in these forms of medicine over Western medicine.¹⁴ Approximately, 70–80 % of women living with PCOS use some form of TCIM such as nutritional and herbal supplements, Ayurveda and yoga to manage symptoms of PCOS.^14,15

Traditional medicine systems are often viewed as parallel to conventional medical practices in many cultures and are often associated with changes to dietary and lifestyle practices.¹⁶ Ayurveda, originating from India, represents the traditional medicine system of the country.¹⁷ It is commonly used among Indian community members to manage their primary health needs irrespective of their global geographical location.¹⁸ Furthermore, the use of Ayurveda continues to grow as a ‘wellness modality’ with the establishment of institutes offering Ayurveda lifestyle courses, which is expanding internationally.^19,20 Given this demand and interest, there is a need to systematically explore and understand the Ayurveda lifestyle principles to enable safe and optimum benefits.

Although there might be some differences in understanding and managing a disease from the perspectives of Ayurveda and conventional medicine,²¹ food and nutrition are the central aspects of both sciences. Both advocate for a healthy lifestyle, personalised dietary changes based on an individual’s preferences, reducing sedentary lifestyle, and bringing healthy behavioural changes that can support diet and physical activity-related changes for managing PCOS.^10,22 However, there are differences in some fundamental concepts in both the sciences. For example, Ayurveda views the human body through the Panchamahabhuta (five great elements) and Tridosha (Vata, Pitta, and Kapha) concepts, representing the body and mental type of individuals and their key physio-psychological functions, biological rhythms, and metabolic processes which are essential for health and disease.²³

In Ayurveda, various therapeutic approaches including the study of food and medicine, and dietary and lifestyle suggestions are also grounded in these fundamental concepts.²⁴ Ayurveda, predating modern nutrition, emphasizes profoundly on food’s role in health and aims for an extensive understanding of classical food science.²⁵ Ayurveda sees food as prana (life force), classified by consistency, taste, properties, qualities, and compatibility, affecting body, mind, and spirit.²² Ayurveda guidelines include both general food items that promote health (Pathya) and cause diseases (Apathya) in addition to disease-specific dietary suggestions.

‘Sthoulya’ is the Ayurveda term for excess weight, is a type of ‘Medoroga’ (a disorder of adipose tissues) characterized by excessive Medodhatu (fat) accumulation.²⁶ Excess weight is generally due to Kaha dosha aggravation, often from impaired Agni (digestive/metabolic factors), leading to water retention and fat accumulation.²⁶ Therefore, the treatment of excess weight involves the prescription of a diet that is aimed at reducing excess Kapha dosha and Medodhatu in the body while improving the Agni for example inclusion of barley, green gram, garlic, and wheat bran in the diet. Ayurveda clinicians utilize these concepts to address individual health needs.^25,27 A scientific reappraisal with a multi-disciplinary approach may validate these practices. Moreover, aligning health care with the preferences, lifestyles, and cultural beliefs of diverse populations fosters a comprehensive, reasonable, and culturally competent environment that respects traditional and cultural medical knowledge.²⁸

Research exploring the role of Ayurveda interventions in PCOS continues to grow. In a recent scoping review, Rao et al. identified 57 studies including 13 randomized controlled trials (RCTs), that examined the efficacy of various Ayurveda treatments for PCOS management. However, the research on Ayurveda diet and lifestyle practices in PCOS is limited.²¹ Moreover, there is no evidence on the perspectives of Ayurveda doctors regarding PCOS and its management through diet and lifestyle. Thoroughly examining Ayurveda concepts will enhance understanding of the application of these to lifestyle research and PCOS care. Therefore, we conducted this qualitative study aimed to investigate the experiences of Ayurveda clinicians and explore the characteristics of Ayurveda dietary and lifestyle suggestions for weight management in women with PCOS.

2. Methods

2.1. Study design

A qualitative focus group approach was employed to capture in-depth information and provide a comprehensive and perceptive view from a group of Ayurveda clinicians on this particular topic.²⁹ This study was conducted and reported according to the Consolidated criteria for reporting qualitative studies (COREQ) guidelines³⁰ to ensure sound and logical conduct of the research process (Supplement 1).

2.2. Ethics

This study was approved by the Western Sydney Human Research Ethics Committee (approval number H 15,187). All clinicians provided written informed consent before participating in the focus group discussion. Oral consent was obtained at the beginning of the focus group discussion for a recording of the session and publication of the findings.

2.3. Participants

We purposively attempted to include experienced Ayurveda clinicians to provide credible information. Ayurveda clinicians who fulfilled the following eligibility criteria were included: were able to provide consent; held a Bachelor of Ayurvedic Medicine and Surgery from India – a rigorous five-and-a-half-year professional medical program, including developing a sound knowledge of Ayurveda food and dietary guidelines; were able to speak English fluently; residing/practising anywhere in the world and; with at least five years of clinical experience in managing women with PCOS. Clinicians who did not fulfil the above criteria were excluded.

2.4. Sampling and recruitment

The study aimed to analyse at least 8–10 clinicians, which represents the ideal size of a focus group.²⁹ Hence, 20 clinicians were identified and invited to participate using purposive and snowball sampling methods; through peer referrals and social media calls.³¹ An invitation letter containing information related to the study, and a Qualtrics survey link was emailed to the prospective participants. The survey link contained the participant information sheet, informed consent form, and questions related to eligibility and options for a suitable date and time for the focus group discussion. Clinicians were asked to forward the study details to their colleagues who might be eligible and interested in participating in the study. A reminder email was sent after two weeks to the potential clinicians if the survey had not been completed. The eligible clinicians completed the basic demographic survey which included questions related to gender, country of residence, clinical experience, and education. A suitable date and time for the virtual focus group was decided based on the consensus. A subsequent email containing a Zoom link for the online meeting and interview schedule was emailed to the clinicians in advance of the focus group meeting.

2.5. Reflexivity and trustworthiness

Six authors were females and two were males (MA and BSC). The first author (VSR) is a qualified and experienced researcher in Ayurveda, public health, and qualitative methods. Six authors (SG, MA, BSC, CAS, LM and CE) helped develop the focus group guide and have extensive experience in researching women’s health. CE is a GP and LM is a conventional dietitian. Both have extensive experience conducting lifestyle research involving women with PCOS and supervised the study contents to ensure its relevance to international PCOS guidelines. VB is an Ayurveda gynaecologist with several years of experience in providing Ayurveda treatments to women with PCOS.

Participants were recruited through purposive and snowball sampling techniques to ensure effective data saturation and to enable rich exploration of the experiences of the clinicians who treat women with PCOS.³² To enhance transferability, efforts were made to include clinicians unrelated to one another and coming from different parts of the world and institutions.³² The clinicians had no relationship with the authors; however, the participants became aware that VSR is a PhD student with an interest in PCOS and Ayurveda. No external individual was present during the focus group meeting. Although the focus of the study was to explore Ayurveda dietary suggestions for weight management in women with PCOS, the clinicians were encouraged to openly share all perspectives of their clinical experiences except pharmacological suggestions. VSR performed the data collection and analysis, but the development of categories was continuously discussed between VSR, SG and CE to challenge assumptions that might impact the process. Clinicians were asked if they would like to receive the transcript of the focus group discussion for further comments, however, none of the clinicians requested the same.

2.6. Data collection

Data were collected through a focus group discussion. A virtual focus group meeting was conducted with an eligible team of clinicians using online videoconferencing technology (Zoom™ Video Communications, Inc.) in March 2023 until data saturation/up to 90 min. Discussions were conducted in English and were video-recorded. The discussions were moderated by VSR. The ground rules were established at the beginning of the discussion to highlight the focus group approach and the aim and objective of the study. Informed consent was obtained at the start of the discussion. We developed a guide containing questions to promote discussion among the clinicians on methods they use during their consultation and the lifestyle advice they provide to manage weight in women with PCOS (Table 1). All Clinicians were provided with a $AUD 50 Amazon gift card as a token for their participation.

Table 1.

Focus group guide.

Categories	Questions
Framework	What is the role of the Ayurveda diet and lifestyle in your clinical practice when you care for women with PCOS?
Assessment	What assessment tools do you use to assess the individual and presenting complaints? Do you use modern diagnostic tools? What Ayurveda patterns are found in women with PCOS and excess weight?
Ayurvedic diet: approach and contents	What are the goals of your Ayurveda dietary treatment? What should be the dietary approach and guidelines? What should be the components of the Ayurveda diet therapy? What kinds of foods to suggest? What kinds of foods to avoid? Duration to follow?
Clinical outcomes	In what areas would you expect to find improvement other than weight management? In what areas would you expect to see no change?
Additional comments and recommendations

2.7. Data analysis

The demographic data was transferred from Qualtrics to Microsoft Excel 2016 Version 15.40 for further analysis. The recording was transcribed verbatim by an independent transcribing service named Happyscribe, cross-checked by VSR and amended as needed for accuracy. Qualitative content analysis was undertaken to analyse and code the data.³³ VSR read the transcript multiple times and initial meaning units were condensed into codes using colour themes in Microsoft Word. Codes with similar patterns were grouped into categories and subcategories through mind mapping.³⁴ This process and the subsequent categorisation were discussed with another author (SG) who independently coded a subset (20 %) of the transcript to ensure reflexive practice and greater inter-rater reliability. After consensus was reached regarding the classification of codes and subsequent categorisation, quotations in each domain were summarised and presented in a qualitative descriptive manner. To maintain confidentiality, clinicians were assigned a code number from 1–10.

3. Results

3.1. Participant’s characteristics

Of 20 clinicians invited, 11 consented to participate. Finally, 10 attended the focus group and were included in the analysis (Fig. 1). The demographic details of the clinicians are presented in Table 2. All 10 clinicians were women and resided in India (n = 7), the United States of America (n = 1), the United Kingdom (n = 1), and the United Arab Emirates (n = 1). Six clinicians were practising in urban areas, two in rural areas and the remaining two were working in suburban areas. The clinical experience among the clinicians varied from 5 years to 30 years. All clinicians held qualifications in Ayurveda medicine including two with a PhD, six with postgraduate qualifications and two with a bachelor’s degree. Those who lived outside of India worked in private clinics (n = 3) while those who lived in India worked in a mixed setting; private independent clinics or hospital / private college and associated hospital (n = 7) or a government teaching hospital (n = 1).

Fig. 1.

Study flow chart.

Table 2.

Demographic characteristics of the clinicians (n = 10).

Characteristics	Number of clinicians
Sex
Female	10
Male	0
Current Country of Residence
United States of America	1
United Kingdom of Great Britain and Northern Ireland	1
United Arab Emirates	1
India	7
Work setting
Working in a Suburban Area (semiurban)	2
Working in an Urban Area	6
Working in a Rural Area	2
Clinical Experience
5–10 years	2
11–20 years	4
21–30 years	2
More than 30 years	2
Highest Qualification
Bachelor of Ayurveda Medicine and Surgery (BAMS)	1
Postgraduate in Ayurveda	7
PhD and above	2
Practice set up
Private independent clinic/hospital	9
Private college and associated hospital	5
Government Ayurveda College and Hospital	1

3.2. Content analysis

Fig. 2 presents the mind-mapping technique utilized for the analysis. The data was categorized into five categories, each having sub-categories with participants’ quotes. Extra quotes are given in Supplement 2. Ayurveda terminologies used in this paper are mentioned in Supplement 3 along with their meaning.

Fig. 2.

Data organization using a mind-mapping technique.

3.2.1. Characteristics of women visiting Ayurveda clinicians

Most clinicians agreed that there have been increasing numbers of individuals, including adolescents, visiting their clinics either with previously diagnosed PCOS and carrying their medical reports or with symptoms of irregular menstrual cycles.

"There are two sets of people who come to us; most come with pre-diagnosed conditions of PCOS and a few come with the symptoms (such as) they come with missed cycles for two or three months or with weight gain..” (Clinician 2)

Most clinicians highlighted that individuals present with several symptoms and concerns that vary according to life stage. For example, adolescents and young unmarried women usually present with concerns about irregular menstrual cycles, weight gain, acne and excessive unwanted facial hair and married women are usually concerned with difficulty in conceiving. Married women with children visit them only when there is a complaint of a heavy or prolonged menstrual period.

“…especially the young girls between 15 and 20 or 30 age will be coming to us with menstrual irregularity…have not got their periods for the last two, or three months or for the first time they noticed an abnormal menstruation. Usually, married women who already had two or three kids, are not at all worried about PCOS and they will come to us only when they are having an issue like heavy bleeding.” (Clinician 8)

A few clinicians highlighted that these women visit us with a sense of frustration with the symptoms of PCOS and primarily because they were unsatisfied with their current PCOS management and wanted more natural and holistic care options to manage their PCOS.

“They (patients) will come with their reports and say that I have PCOS and my gynecologist is suggesting a hormonal approach or some medication, but I am looking for a holistic approach like ayurveda or how food can help me.” (Clinician 4)

3.2.2. Ayurveda clinical toolkit for understanding PCOS features

When asked about their diagnostic approach, there were two different opinions. Some clinicians emphasized that PCOS is not an Ayurveda diagnosis and that there is no single disease mentioned in the Ayurveda textbooks that can be directly attributed to PCOS. Hence, depending on the presenting complaints an Ayurveda diagnosis can be made. Several Ayurveda diagnostic names were suggested, such as Pushpaghni Jaataharani, Granthi, Sthoulyata, Arthavakashya, Nashtarvata and Rasakshaya.

In Ayurveda, we do not have a specific name (for PCOS) but we can translate (symptoms) into a specific Ayurveda term. It could be Granthi (presence of polycystic ovaries), different Yonivyapads (diseases of the female reproductive system) and you must correlate the symptoms.” (Clinician 10)

Irrespective of the modern diagnosis, most clinicians highlighted that although they see the medical reports of the patients to understand their medical history, making an Ayurveda diagnosis is important for them, while others reported using the Rotterdam criteria to diagnose such as prescribing ultrasound and blood tests if the individual presents with an irregular menstrual cycle.

“…So I'll just focus on that (Ayurveda assessment) to diagnose irrespective of the USG report. Of course, the USG report will help me to say whether it is PCO or not, but from my point of view for treatment I will always rely upon my understanding of the case and that mainly comes from the symptomatology.” (Clinician 11)

When asked about their clinical assessment techniques, most of the clinicians emphasized that having experiential clinical knowledge and observational skills along with a thorough understanding of Ayurveda principles mentioned in the Ayurveda textbooks is essential to formulating a customized treatment plan.

“For treatment, I will always rely upon my understanding of the case and presenting symptomatology such as menstrual disorders, acne, weight gain, and inability to conceive. I would also like to say that (it is important to explore) mental framework (mindset), lifestyle factors and how a person can cope with stress is also important to evaluate.” (Clinician 8)

Clinicians revealed diverse clinical tools such as history taking, Astavidha pareeksha (examining 8 items), Dashavidha pareeksha (examining 10 items) and Artava pareeksha (examining the menstrual cycle) that they utilize in their practice to understand the pathogenesis of the presenting complaints. However, most agree that a thorough clinical assessment of the individual and the presenting complaints is crucial. Some clinicians agreed that ‘depending on Prakriti they are trying to assess the condition.

“It is the Dashavida Pareeksha (10-item diagnosis tool) the Ashtavida Pareeksha (8-item diagnosis tool) and Artava Pareeksha (examination of menstrual fluid) that help me to make the final diagnosis.” (Clinician 7)

When asked about their observational findings related to a common assessment in their clinics, most clinicians highlighted that in women with PCOS and excess weight, they have observed a slow metabolism (Agni) resulting in the formation of Ama (toxin waste) and thus, choosing food items that can ‘help to correct Agni’ (digestion/metabolic state) and reduce excess Ama and Kapha dosha is of high importance.

“Agni dushti is the main problem that is leading to this condition. Because all these patients are having some sort of disturbance in their Agni so first, we need to correct the Agni levels first.” (Clinician 8)

Although there were different opinions regarding individuals with which dosha Prakriti/Vikriti (constitution/imbalance state) commonly present with increased weight and associated PCOS issues, an individual with Kapha dominant constitution/imbalance state was mentioned to be at the most risk of facing weight gain and associated symptoms of PCOS such as having fewer periods or scanty periods.

“Whenever there is Kapha Pradhan prakriti (Kapha dominant constitution), though all the three doshas are seen in PCOS, wherever there is Kapha, it is the major dosha (bio-energies of the body) in the manifestation of PCOS. We see that type of individuals will be Sthula (overweight/obesity) and they will have Anartava (absence of menstrual cycle).” (Clinician 2)

3.2.3. Ayurveda dietary approach to manage excess weight

When discussing the management of PCOS, most clinicians agreed they provide various Ayurveda lifestyle suggestions alongside Ayurveda medicines. A few clinicians reported that during the initial few consultations, they aim to correct the patient’s lifestyle and dietary habits before suggesting Ayurveda medicines. All the clinicians agreed that the focus of the Ayurveda dietary approach is not only on weight reduction but on cultivating healthy habits that ‘(patients) can follow sustainably’. A few clinicians suggested the use of ‘healthy’ food items in their diet that help in maintaining health, irrespective of their weight. Some clinicians indicated that they do not overload the individuals with several dietary suggestions, instead, they suggest one dietary change at a time, explore barriers to a healthy lifestyle and help facilitate ‘easy to follow’ dietary adjustments.

“The main aim of the (treatment) is not to lose weight temporarily. So, I want them to adopt these lifestyle and diet changes for the long term.” (Clinicians 5)

“We can tell them what small changes they can bring. And once they achieve it regularly… they can do it slowly.. we can suggest the next one.” (Clinician 3)

Most clinicians agree that individuals respond to the same medicine/food/lifestyle differently, hence it is important to consider the pathogenesis of the disorder in an individual and then provide tailored suggestions. However, some differences in approach were evident. Clinicians living in India mentioned Ayurveda-specific considerations such as Agni (digestive fire), Prakriti (Body constitution), Satva (mental capability), Satmyata (what is accustomed), season, and time of the day to better personalise holistic recommendations.

“It is not a generalised approach but we can classify it as Pathya and Apathya and, having a balanced diet is important. So, I always guide people to have a variety of food.” (Clinicians 4)

Clinicians living outside of India highlighted that it is important to consider ethnicity, culture, country and place of residence, dietary habits and preferences, and the availability of specific food items in addition to the general considerations.

“What's their diet? They might be Indian by ethnicity they might not be eating anything Indian that you must manage but you must look into what is heavy in their diet. Is it Indian-heavy or Mediterranean-heavy? Or is the fast food heavy? So, then you must take off the fast food. You can advise the spices from the Mediterranean set also, or this French and English set of spices also.” (Clinicians 7)

When asked about a clinical scenario in which the Ayurveda dietary approach can provide optimum results, most clinicians suggested that the results depend upon the adherence and compliance of the patients.

“We (clinicians) can get better results in those cases which are diagnosed as Artavakshaya (infrequent menstrual cycles/less menstrual flow). Actually, it is possible for those persons who are completely following the diet, who are ready to do the exercise to achieve two to three-kilogram reduction in weight in four weeks.” (Clinician 8).

Most clinicians emphasized that identifying the Nidana (causative factors) through questioning is a critical step in the treatment of a patient to help advocate prevention and health promotion. Those clinicians agreed that various causative factors are involved in the pathophysiology of weight gain which can be modified. Factors such as Dusta bhojana (unhealthy food), stress, unhealthy lifestyle, improper quantity and quality of food, improper way of eating, and eating Virudhha Ahara (incompatible foods), cause the manifestation of symptoms of PCOS.

“Dusta Bojana (unhealthy food) is one of the Nidana (cause) in case of Yonivyapat (diseases of the female reproductive system). Maybe it is the processed food or junk food also. So, I elicit that.” (Clinicians 2)

3.2.4. Advice related to dietary adjustments

Although Ayurveda diet counselling is a personalised approach specific to the individual and presenting symptoms, some clinicians agree that some common suggestions can be given to most individuals with PCOS irrespective of their weight. For example, suggesting taking fresh, locally grown, cooked whole foods as per the season and in proper quantity with the addition of vegetables, grains, and spices. Additionally, eating late at night, eating outside the home, fast and processed food, and raw foods were suggested to be restricted.

“I asked them to go for locally produced, farm-fresh food. On absolute contraindications, what I tell all my PCOS clients is not to indulge in trans fats, ultra-processed foods, food from industrial sources, artificial sweetener, any type of extra indulgence in Madhur rasa (sweet taste), Abhishyandi foods, anything straight from the refrigerator, excessive salt, salt with sneha (fat)- something like cheese, So, I make it a point to ask them to stay away from these kinds of combination.” (Clinician 8)

All clinicians provided specific dietary suggestions to manage symptoms of PCOS. For example, if a patient complaint of infrequent menstrual cycles or less menstrual flow, a decoction of black sesame seeds or soup of horse gram or Aliv seeds laddu are suggested and individuals who feel water retention in their body just before the onset of periods can add ginger and long pepper in their diet.

“If the endometrial thickness is around seven (mm) we will be giving Tilakwata (sesame seeds decoction) or else with Kulata Yusha (horse gram soup) to help increase the endometrial thickening. In such cases what I usually do is along with Avarnahara chikitsa I see that, I give something for nourishment, that is Prithvi-dravya prayoga, where we increase the thickening of the endometrium so that it becomes easy for the patient to get the cycles.” (Clinician 2)

Most clinicians mentioned that they give personalised pathya (to be followed) and apathya (to reduce/avoid) charts to their patients which include various dietary and lifestyle suggestions to manage and reduce weight in women living with PCOS. A detailed food list as suggested by the clinicians, to follow and avoid is provided in Box 1.

“So, helping them understand the concepts is also important. And giving a clear guideline about pathya (to be followed more often) and apathya (not to be followed or minimise).” (Clinician 4)

Box 1.

Dietary suggestions that were recommended to follow/avoid to manage weight in women with PCOS.

Follow more often:

Source: grown on a farm, locally produced, organic in nature, freshly procured, seasonally appropriate.

Properties: wholesome, decreases excess Kapha dosha and Medo dhatu in the body, improves Agni, removes Ama from the body and has low Glycaemic Index.

Food items that are freshly cooked, light to digest and hot in potency.

Grains and lentils: Multigrain, wheat, barley, millets such as kutu, multigrain, mung beans, horse gram.

Add more vegetables to the diet, in particular, green leafy vegetables, ash gourd, bottle gourd, asparagus, fenugreek leaves, mint leaves, ginger, garlic, lemon, Indian

gooseberry and aloe vera.

Add more spices to the diet such as cumin seeds, asafoetida, turmeric, cinnamon, fenugreek, pepper, long pepper, ginger powder, fennel seeds, black sesame seeds, aliv

seeds, flax seeds, carom seeds, buttermilk, warm milk, and ghee.

Follow Aharavidhi (guidelines to eat food) elaborated in Ayurveda textbooks.

Avoid/limit:

Source: Food from industrial sources,

Properties: Trans-fat, processed, packaged /leftovers, with preservatives and artificial flavours, fast food, excessively salty and oily, refrigerator and reheated several times,

raw/uncooked, deep fried, incompatible foods such as milk and fruit smoothies, Abhishyandi foods such as curd, excessive intake of black gram, desserts in dinner, and

food that is heavy to digest and cold in potency.

3.2.5. Advice related to eating and lifestyle behaviours

Certain eating patterns and behaviours were suggested to avoid such as overeating, eating before a previous meal is digested, eating heavy food items in dinner, not eating at appropriate times (e.g. not eating when hungry or eating when there is no hunger), disturbed sleep and a sedentary lifestyle. Most clinicians suggested that it is important to eat mindfully, eat at regular intervals, never miss a meal, and have an early dinner (by 7 pm-8 pm). One clinician explained the importance of certain activities that should be followed or not to be followed to help digest the meal. For example, it was advised to sip water during the meal and walk 100 steps after a meal. It was suggested to avoid drinking large quantities of water before or after the meal, sitting, doing heavy exercises, or sleeping immediately after a meal.

“So, eating habits are very important. Eating mindfully helps them not overeat, feel satisfied, and avoid snacking. (Clinician 4)

“…and sleep pattern by 10:00 pm. again, sleep is one of the factors which I focus on.” (Clinician 5)

Along with dietary suggestions, there were suggestions on including physical activity in their lifestyle such as yoga, walking, and walking in nature. Some clinicians felt it was essential to consider a physical activity that would be enjoyable and easily added to their current lifestyle without disrupting their current routine. Therefore, a tailored approach to exercise was also recommended. Practitioners felt that achieving a small weight change could help and motivate an individual living with PCOS.

“And if those people are interested in yoga practices, we will tell them to do some correct yoga postures like in the sitting position, in the lying, in the prone and supine we tell them to do that also.” (Clinician 8)

4. Discussion

This qualitative study investigated the experiences of Ayurveda clinicians and explored dietary approaches to manage weight in women with PCOS. In this novel study, Ayurveda clinicians reported an increase in women diagnosed with PCOS, presenting with irregular menstrual cycles, increased weight, and infertility issues. They emphasized the importance of tailored Ayurveda lifestyle counselling for optimizing PCOS management. This includes specific recommendations on foods to decrease excess Kapha dosha and Meda dhatu, correct Agni, remove Ama from the body, and help induce healthy eating habits. Additionally, yoga was the most prescribed form of physical activity.

The majority of the clinicians were living and practising in India, where Ayurveda remains prevalent due to its alignment with local health beliefs and socio-cultural practices.³⁵ Ayurveda is used to manage chronic disorders such as type 2 diabetes, obesity, arthritis, menstrual irregularities and PCOS.^18,21 Studies among South Asians both in India and overseas indicate a longstanding acceptance and reliance on traditional medicines,³⁶ including self-help strategies using Ayurveda foods for managing chronic diseases.¹⁶ In countries where large numbers of South Asian migrants have settled, there is greater availability of traditional foods and remedies making them more readily accessible.³⁷ Despite this greater availability, little is known about non-South Asian populations usage and uptake of Ayurvedic practices, another area for future direction.³⁷ Furthermore, given this trust placed in Ayurveda by the global South Asian diaspora, it emphasizes the need for clinic-based evidence to help improve the quality of care and make informed and safe healthcare choices.^38,39 This study will contribute to one such need to translate Ayurveda lifestyle principles into practice for researchers exploring these approaches in women living with PCOS. However, future work is needed to bridge cultural preferences and medical expertise not only in the Indian context but also in non-Indian healthcare settings among non-Indian population groups.

Aligned with the international PCOS guidelines, the clinicians emphasized that most women with PCOS expect detailed dietary recommendations to manage their symptoms. Ayurveda clinicians attempt to meet this need by providing tailored lifestyle counselling for both diet and physical activity, rather than a “one-size fits all” approach. It is expected that this tailored approach would enhance adherence to suggested lifestyle changes as it fits with the individual’s social and cultural parameters.⁴⁰ Previous research shows that this approach can lead to weight reduction,⁴¹ and promote healthy eating behaviors.⁴² Previous RCTs indicate that Ayurveda lifestyle counselling offers more patient-centred and resource-oriented solutions compared to conventional dietary and lifestyle counselling.^27,43 However, evidence on the exclusive use of the Ayurveda dietary approaches for women with PCOS and excess weight is limited. Future studies are needed to explore the feasibility and benefits of Ayurveda dietary counselling in women with PCOS.

Several modifying causative factors for excess weight have been illustrated in Ayurveda textbooks- such as intake of food that possesses qualities like heavy, sweet, cold and oily, Atisampoorana (overeating), Avyayama (no physical activity), and Divaswapana (sleeping in the day time).⁴⁴ Similar to the recommendations by the study clinicians, previous studies conducted among non-PCOS individuals have found a strong association between these factors with the presence of obesity including psychological distress.45, 46, 47, 48 Future large observational and in-depth qualitative studies would benefit from expanding the understanding of these lifestyle factors and developing guidelines to help modify them in women with PCOS and excess weight.

Our results support the dietary suggestions advocated in the International PCOS Guidelines¹⁰ such as the inclusion of general healthy dietary composition and behaviours. Additionally, some suggestions were unique from the perspectives of Ayurveda. For example, Ayurveda emphasizes on consideration of ‘eight dietary principles’ before recommending any dietary changes to an individual. For example, it is suggested to prescribe a diet that is opposite in properties to the aggravated Kapha dosha and Medas dhatu. Similarly, all clinicians in our study advocated for a dosha-appropriate Ayurveda dietary strategy to manage weight in women with PCOS, focusing on enhancing Agni (digestive fire) and adhering to Ahara vidhi (methods of food intake). Santra et al.,⁴⁹ in their study among individuals with body mass index (BMI) more than 25 kg/m² (n = 50) found a significant weight reduction within eight days by following a Kapha-Medodhatu pacifying Ayurveda diet like horse gram, green gram, barely, and kokum fruit.⁴⁹ Similarly, other studies have demonstrated moderate weight reduction in individuals with obesity by following a similar approach.^41,50,51 Notably, these foods possess a low glycaemic index and high dietary fibre, contributing to their effectiveness in weight management.⁴⁹ Future studies will benefit from exploring the physiological mechanism of Ayurveda dietary interventions in PCOS and excess weight. While these suggestions align with general healthy eating and PCOS guidelines, we also recognise and support emerging concerns that could advance the transdisciplinary discussion between dieticians and Ayurveda practitioners regarding integrating culturally-specific Ayurveda dietary and lifestyle practices into conventional PCOS management.

4.1. Strengths and limitations

The main strength of this study is the description of Ayurveda dietary suggestions for weight management in women with PCOS by qualified and experienced Ayurveda clinicians. To our knowledge, this is the first study exploring this in an in-depth manner, with the only other qualitative study in traditional diets exploring the experiences of Ayurveda practitioners in assessing and caring for women with PCOS who want to manage weight. Data source triangulation and independent coding by another reviewer enhanced the credibility of the findings. Clinicians' characteristics were provided to assist readers in deciding on the transferability of the findings to other populations and direct quotes were provided to illustrate the themes. Focus group facilitator’s characteristics were described to address reflexivity.

This study has several limitations. We conducted only one focus group for this study because the aim was to brainstorm ideas to inform our future Delphi study. Although we tried to include clinicians from various backgrounds and experiences, our study does not include absolute information related to Ayurveda dietary practices from different regions. Ayurveda food guidelines are elaborated in detail in Ayurveda textbooks. Collecting all the evidence related to the Ayurveda lifestyle to manage PCOS was beyond the scope of our study. We aimed to recruit clinicians from different countries, however, the majority of Ayurveda clinicians are based in India with many providing online support as well.⁵² Future qualitative studies among a diverse and large group of Ayurveda practitioners living outside India could provide valuable insights into the barriers and facilitators in implementing Ayurveda diet and lifestyle practices in non-Indian populations, and the feasibility of tailoring dietary recommendations to local cuisines and preferences. Finally, as the study relied solely on participants’ accounts and narratives, recall and social desirability biases are inevitable. To this end, a larger study would be required.

4.2. Conclusion

Overall, both forms of medicine (conventional and Ayurveda) consider lifestyle modifications for the management of PCOS. However, while their strategies may differ, they also share some similarities. Ayurveda clinicians often engage with patients to help them improve their lifestyle during the entire treatment journey. The Ayurveda dietary approach is distinctive, in-depth, encompassing personalised dietary choices based on an individual’s health status while also outlining healthy eating habits and methods. These approaches should be further studied and evaluated for their benefits. The findings of the study, therefore, provide the baseline information and a platform for the discussion towards the Ayurveda dietary approach for weight management in women with PCOS. Further, an exploration of non-South Asian communities’ usage and uptake of Ayurvedic practices should be considered in future research.

Author contributions

Conceptualization: VSR, CE. Methodology: VSR, CE, MA. Validation: LM, VB. Formal analysis: VSR, SG, CE. Investigation: VSR, CE, BSC, CAS, LM, VB. Data curation: VSR. Writing – Original Draft: VSR, SG, CE. Writing – Review & Editing: VSR, SG, MA, BSC, CAS, LM, VB, CE. Supervision: CE, MA, BSC, CAS. Project administration: VSR, CE.

Declaration of competing interest

As a medical research institute, NICM Health Research Institute receives research grants and donations from foundations, universities, government agencies, and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute. The project that is the subject of this article was not undertaken as part of a contractual relationship with any donor or sponsor. CE, MA, and CAS are editorial board members of this journal but editorial board member status had no bearing on editorial consideration. Other authors have no other conflict of interest to declare.

Funding

None.

Ethics statement

This research was reviewed and approved by the institutional review board of the Western Sydney Human Research Ethics Committee (H 15,187). Informed consent was obtained from all participants.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.