Lifestyle-related non-communicable diseases (NCDs) are emerging as the leading causes of morbidity and mortality across the globe, particularly in developing nations. These conditions share common modifiable risk factors including poor dietary habits, physical inactivity, stress, and exposure to harmful substances like tobacco and alcohol. Importantly, evidence underscores that multi-component lifestyle interventions targeting these modifiable risks can effectively delay or prevent the onset of NCDs such as diabetes, cardiovascular disease, and metabolic syndrome. Interventions rooted in dietary improvement, physical activity, stress management, and behavioural counselling have shown sustainable, low-cost benefits with the potential for long-term health impact[1]. One such condition with strong ties to lifestyle patterns is Polycystic Ovary Syndrome (PCOS), a complex endocrine disorder affecting approximately 4.21% - 35.3% of Indian women[2] of reproductive age. PCOS manifests with a variety of clinical symptoms, including irregular menstrual cycles, hirsutism, acne, and anovulation. Central to its pathophysiology are insulin resistance, hyperandrogenism, and metabolic dysfunction—all of which are highly influenced by body composition and adiposity[3]. Obesity, particularly central obesity, has been identified as a key exacerbating factor in PCOS, worsening both the metabolic and reproductive manifestations of the syndrome. Anthropometric markers such as weight, body mass index (BMI), waist circumference, hip circumference, and waist-to-hip ratio serve as important indicators of metabolic status and cardiovascular risk. In women with PCOS, these parameters are frequently elevated, reflecting underlying insulin resistance and a predisposition to further metabolic derangements. Although international guidelines recommend lifestyle modification as the first-line therapy for PCOS[4], its implementation in clinical practice, particularly in India, remains suboptimal. Research examining the effects of structured lifestyle interventions on anthropometric outcomes in women with PCOS remains limited, with most existing studies focusing predominantly on fertility outcomes. Most data have been derived from Western populations, limiting applicability in Indian women due to cultural, dietary, and socioeconomic differences. Moreover, adherence to diet and exercise regimens has been notably poor among Indian women, compounded by limited awareness, accessibility, and social support. Pharmacological interventions, while effective, are often cost-prohibitive and not sustainable in the long term for the average Indian woman. The current study aims to bridge this gap by evaluating the impact of a 10-week structured lifestyle intervention on anthropometric measures in women with PCOS at a tertiary care hospital in India. This intervention is designed to be realistic, culturally sensitive, and economically feasible—incorporating not only physical activity and dietary modifications but also behavioural strategies to promote adherence. By quantifying changes in anthropometric parameters, this research seeks to highlight the tangible benefits of non-pharmacological management in PCOS, offering a scalable and sustainable model.

Study Design and Setting This interventional study was conducted over a period of 18 months in the Gynaecology Outpatient Department (OPD) of a tertiary care hospital after getting approval from the Institutional Ethics Committee (IEC). The primary aim was to assess the impact of a structured 10-week lifestyle intervention compared to no intervention on anthropometric parameters in women with Polycystic Ovary Syndrome (PCOS). Sampling and Study Population Using a convenience sampling method, 60 women aged 18–40 years diagnosed with PCOS according to the Rotterdam Criteria[5] were enrolled. The criteria includes the presence of any two of the following three features: oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasonography (≥12 follicles measuring 2–9 mm and/or an ovarian volume >10 mL). The diagnosis was made by consulting gynaecologists in the OPD. Exclusion criteria comprised pregnancy, lactation, regular exercise or dieting in the preceding six months, and recent use of medications such as oral contraceptives, anti-androgens, insulin sensitizers, or hormonal agents. Participants with orthopaedic or other physical limitations preventing exercise were also excluded. Group Allocation After obtaining informed written consent, participants were alternately allocated into two groups using an odd-even numbering system: • Modification group (n=30): received a structured lifestyle intervention • Observation group (n=30): received no intervention and continued usual care Both groups were followed for a duration of 10 weeks. Baseline Anthropometric Assessment Anthropometric parameters which were assessed following WHO protocols[6], included: • Weight: measured using a calibrated portable weighing scale • Height: measured using a stadiometer with participants barefoot and upright • Waist Circumference: measured at the midpoint between the lower margin of the last palpable rib and the iliac crest using a constant tension tape, following WHO guidelines • Hip Circumference: measured at the widest part of the buttocks From these measurements: • Body Mass Index (BMI) was calculated as weight (kg) divided by height squared (m²) • Waist-to-Hip Ratio (WHR) was derived by dividing waist circumference by hip circumference Measurements were recorded at baseline and at the end of the 10-week period. Intervention Protocol for Modification Group Nutritional status was assessed through a 24-hour dietary recall and a subjective lifestyle questionnaire, validated by institutional experts, which helped the examiner assess the participant’s regular food habits, eating patterns, regular activity involved in their lifestyle, working patterns, barriers (e.g.: religious, financial, time constraints, social or emotional) that would limit adherence to certain dietary practices or physical activities. Dietary Intervention Based on the data recorded for each participant, individual caloric requirements were calculated using the ICMR-NIN Calorie Counter Software. A tailored diet plan was created for each participant, according to Diet and nutrition in polycystic ovary syndrome (PCOS): Pointers for nutritional management[7], to achieve a caloric deficit gradually increasing from 200kcal/day deficit to a deficit of 500 kcal/day depending on baseline intake, structured over a period of 10 week. Macronutrient composition was targeted as: • ≥20% protein • ≤30% fat • Remainder from complex carbohydrates Dietary adjustments focused on increasing fiber, reducing saturated fats, swapping calorie-dense snacks with lower calorie snacks which were easily available in local stores and encouraging fresh fruit and vegetable intake. Participants were given food portion size references and visual meal plans derived from ICMR dietary guidelines[7]. Physical Activity Intervention According to National Health Portal, Government of India guidelines for PCOS and WHO guidelines[8], participants were advised to engage in a gradually intensifying exercise regimen: • Weeks 1–2: 20 minutes of moderate-intensity activity (e.g., brisk walking) 6 days/week • Weeks 3–5: Addition of 10 minutes of high-intensity activity (e.g., jogging) 2 days/week • Weeks 6–10: Intensified to 30 minutes moderate + 10 minutes vigorous activity 3 days/week Exercise options were culturally appropriate, including walking, yoga, cycling, and household physical tasks. Desk-based workers were guided using seated workout strategies from NASA’s DeskFit program[9]. Behavioural Modification According to Journal Of Women’s Health-Lifestyle and Behavioural Management of Polycystic Ovary Syndrome[10], recommendations were made which aimed at bringing behavioural and psychological changes like: • Self-monitoring: weekly weight tracking, food journaling • Stimulus control: limiting junk food purchases • Time management: reducing screen time to increase activity • Social support: involving family members in activities • Motivational interviewing: two personal telephonic sessions during the 10 weeks for goal reinforcement Sleep hygiene (7–9 hours, no screens before bed, consistent timing) was also emphasized. Observation Group Protocol Participants in the observation group received no dietary or physical activity recommendations. They were instructed to return after 10 weeks for reassessment using the same anthropometric protocol. Follow-Up Assessment At the end of 10 weeks, both groups underwent repeat measurement of: • Weight • Waist and hip circumference • BMI • Waist-Hip Ratio (WHR) All procedures were conducted using identical instruments and techniques as baseline, to ensure reliability. Statistical Analysis Data were recorded in Microsoft Excel and analysed using SPSS. Paired t-tests were used for intra-group comparison of parametric data (weight, BMI, waist and hip circumference). Two-way ANOVA was used to assess inter-group differences. WHR, being non-parametric, was analysed using the Wilcoxon signed-rank test. Results were presented using descriptive statistics, tables, and graphs.

Participant Flow [ Figure: I] Key Anthropometric Results • The baseline characteristics showed that the mean BMI of the study participants fell in the overweight category with majority of participants in the pre-obese range. • Baseline mean WHR showed presence of abdominal obesity (i.e. >0.85) • Weight: [Table: I] o Intervention: Mean weight significantly decreased from 64.10 kg → 60.03 kg (p < 0.001, paired t-test). o Observation: Increased from 63.80 kg → 65.03 kg (p < 0.001). o Intergroup comparison using Generalised Estimating Equations (GEE): p < 0.001 → Highly significant difference in weight trends. • BMI: [ Figure: II; Table: I] o Intervention: Significantly decreased from 26.24 → 24.58 kg/m² (p < 0.001, paired t-test). o Observation: Increased from 25.88 → 26.38 kg/m² (p < 0.001). o GEE analysis: BMI reduction trend was significantly better in the intervention group (p < 0.001). • Waist Circumference: [Table: I] o Intervention: Decreased from 83.75 cm → 80.75 cm o Observation: Slight increase • Hip Circumference: [Table: I] o Intervention: Slight decrease from 97.28 cm → 96.28 cm, not statistically significant. o Observation: Remained unchanged • Waist-to-Hip Ratio (WHR): [Figure: III; Table: I] o Intervention: Significantly reduced from 0.86 → 0.84 (p < 0.001, Wilcoxon signed-rank test) o Observation: Remained constant (p = 0.673) Table- I: Comparison of the two Groups in Terms of change in Anthropometric Parameters over time Anthropometric Parameters Group P value for comparison of the two groups at each of the timepoints (t-Test) Intervention Observation Mean (SD) Mean (SD) WEIGHT (kg) Baseline 64.10 (5.49) 63.80 (6.16) 0.843 Follow-Up 60.03 (5.29) 65.03 (6.16) 0.001 WAIST CIRCUMFERENCE (cm) Baseline 83.75 (1.87) 83.86 (2.12) 0.837 Follow-Up 80.75 (1.87) 83.88 (2.27) <0.001 HIP CIRCUMFERENCE (cm) Baseline 97.28 (2.09) 97.12 (2.17) 0.763 Follow-Up 96.28 (2.09) 97.12 (2.17) 0.136 BMI (Kg/m²) Baseline 26.24 (1.80) 25.88 (1.94) 0.450 Follow-Up 24.58 (1.75) 26.38 (1.95) <0.001 WHR Baseline 0.86 (0.01) 0.86 (0.01) 0.433 Follow-Up 0.84 (0.01) 0.86 (0.02) <0.001

This interventional study demonstrated that a structured 10-week lifestyle modification program significantly improved anthropometric parameters in women with PCOS. Compared to the observation group, participants in the intervention group showed: • A significant reduction in Weight, BMI and WHR • A notable decrease in waist circumference • And a mild, non-significant reduction in hip circumference. Comparison with Previous Studies The results align closely with existing literature: • Weight Loss: A significant decrease from 64.10 kg to 60.03 kg mirrors findings by Guzick et al.[11] and Hoeger et al.[12], both of whom showed substantial weight loss following lifestyle intervention. • Waist Circumference: Although not statistically significant, the downward trend we observed is consistent with Haqq et al.[13] and Vigorito et al.[14], who reported significant waist circumference reductions over longer interventions (≥3 months). • BMI: The baseline mean BMI of 26.06 corresponds with Thathapudi et al.[15], who also found most South Indian women with PCOS were overweight or pre-obese. The intervention-induced BMI reduction is also echoed in studies by Moran et al.[16] and Shang et al.[17], where diet alone outperformed metformin in BMI reduction. • Waist-Hip Ratio: Our statistically significant improvement in WHR (from 0.86 to 0.84) is in line with Thomson et al.[18], where combined diet and exercise intervention yielded optimal WHR reductions. WHR is a superior predictor of metabolic syndrome compared to BMI alone, as reinforced by WHO. Pathophysiological Considerations • The observed anthropometric improvements can be attributed to underlying pathophysiological mechanisms. PCOS is characterized by insulin resistance, particularly in skeletal muscle, liver, and adipose tissue. This leads to compensatory hyperinsulinemia, which in turn promotes fat storage and weight gain. The metabolic insulin resistance coexists with preserved insulin sensitivity in steroidogenic tissues like the ovaries and adrenals[19], leading to increased androgen production. • Insulin, via the MAP kinase pathway, enhances ovarian theca cell steroidogenesis while reducing Sex Hormone Binding Globulin (SHBG) synthesis in the liver, thereby increasing free testosterone levels[20]. Additionally, insulin resistance impairs glucose uptake and enhances gluconeogenesis and lipogenesis, contributing to visceral adiposity. Ferre et al.[21] highlighted the role of insulin in stimulating SREBP-1c, a transcription factor that promotes lipid synthesis, thereby exacerbating abdominal obesity. • By implementing a calorie-restricted, balanced diet and structured physical activity, our intervention likely improved insulin sensitivity, reduced compensatory hyperinsulinemia, and thereby attenuated the downstream effects on adipose tissue accumulation and androgen excess[22]. Strengths and Advantages • Holistic Intervention: Combined dietary modification, exercise, and behavioural strategies such as motivational interviewing and self-monitoring. • Individualized Plans: Calorie needs were calculated for each participant using ICMR-NIN tools, making it realistic and accessible. • Culturally Relevant: Interventions were based on local foods, affordable routines, and realistic exercise regimens (e.g., walking, home yoga). • High Retention: Despite a modest drop-out rate (13.33%), 86.67% adhered to the protocol, significantly higher than global PCOS trials where attrition often exceeds 30–50%. Limitations • A 10-week timeline may not be sufficient to observe the full impact on hip circumference or long-term metabolic outcomes. • The sample size, though adequate for preliminary analysis, limits generalizability. • Self-reported adherence and physical activity introduce possible bias. Recommendations Based on the findings, we advocate for the following clinical and public health strategies: 1. Healthcare providers should incorporate lifestyle assessment and counselling into routine PCOS care. 2. Training in lifestyle medicine, leveraging allied health support, and utilizing mobile-based tools can enhance adherence. 3. Public awareness programs are essential to educate women on the modifiable nature of PCOS symptoms. 4. Encourage peer and family support, particularly in Indian joint family setups. 5. Promote sleep hygiene and stress reduction as adjunct strategies. Future Scope This study lays the groundwork for larger, multicentric trials across India, which should: • Include biochemical markers (insulin, SHBG, androgen levels), • Extend the intervention period to 6–12 months, • Compare lifestyle intervention head-to-head with pharmacological agents, • Test mobile-health and telemedicine-based adaptations for scalability.

In conclusion, our study demonstrated that a short-term, personalized lifestyle intervention significantly improved key anthropometric parameters in women with PCOS. By targeting the root metabolic derangements—insulin resistance and adiposity—the intervention helped reduce central obesity and BMI, both of which are central to the pathophysiology and clinical burden of PCOS. These changes affirm the effectiveness of personalized, multi-component lifestyle interventions targeting diet, exercise, and behaviour in reversing key features of metabolic dysfunction in PCOS. Our study aimed at practical achievability of Lifestyle Modification, which often takes a back seat in modern medicine, as a primary line of management of PCOS. It succeeded in doing the same by addressing personal preferences, cultural and socio-economic barriers and forming customised lifestyle modifications. These findings reinforce that lifestyle modification is not merely supportive but should be central to PCOS management, especially in countries like India where pharmacological access is limited, and culturally aligned care is essential.

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