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Ted Bundy Although serial killer Ted Bundy was responsible for an estimated 30-plus murders, there was little physical evidence to connect him to the crimes when he was arrested in 1975. Two years later, having been convicted only of kidnapping, Bundy was preparing to stand trial for murder in Colorado when he escaped and headed to Florida. There, he killed three more people early in 1978, and when he was finally captured in February of that year, the physical evidence in those cases led to his conviction. Most crucial was the matching of a bite mark on the buttock of victim Lisa Levy to the Bundy’s distinctive, crooked and chipped teeth. He was convicted also of the murder of 12-year-old Kimberly Leach based on fibres found in his van that matched the girl’s clothing. Bundy was put to death in 1989.

The Lindbergh Kidnapping On March 1, 1932, Charles Lindbergh Jr., the 20-month-old son of the famous aviator, was kidnapped, and although a ransom of $50,000 was paid, the child was never returned. His body was discovered in May just a few miles from his home. Tracking the circulation of the bills used in the ransom payment, authorities were led to Bruno Hauptmann, who was found with over $14,000 of the money in his garage. While Hauptmann claimed that the money belonged to a friend, key testimony from handwriting analysts matched his writing to that on the ransom notes . Additional forensic research connected the wood in Hauptmann’s attic to the wood used in the make-shift ladder that the kidnappers built to reach the child’s bedroom window. Hauptmann was convicted and executed in 1936.

The Atlanta Child Murders In a two year period between 1979 and 1981, 29 people — almost all children — were strangled by a serial killer. Police staked out a local river where other bodies had been dumped and arrested Wayne Williams as he was driving away from the sound of a splash in an area where a body was recovered a couple of days later. Police didn’t witness him drop the body, so their case was based largely on forensic evidence gathered from fibers found on the victims . In all, there were nearly 30 types of fiber linked to items from Williams’ house, his vehicles and even his dog. In 1982, he was convicted of killing two adult victims and sentenced to life in prison, although the Atlanta police announced that Williams was responsible for at least 22 of the child murders.

The Howard Hughes Hoax In 1970, authors Clifford Irving and Richard Suskind concocted a scheme to forge an autobiography of notoriously eccentric and reclusive billionaire Howard Hughes. Assuming that Hughes would never come out from hiding to denounce the book, they felt that their plan was fool-proof. Irving went to publisher McGraw-Hill claiming that Hughes had approached him to write his life story and that he was willing to correspond with only the author. As proof, Irving produced forged letters that he claimed were from Hughes. McGraw-Hill agreed, paying $765,000 for the right to publish the book. When word of the book was made public, however, Hughes contacted reporters to denounce it as false. Not wishing to appear in public, the billionaire would talk to reporters only via telephone. Thus, a “spectographic voiceprint analysis,” measuring tone, pitch and volume, was conducted to determine if the speaker was indeed Howard Hughes. Although a handwriting expert had previously been fooled by the notes that Irving had forged, the voice analyst correctly identified the speaker as Hughes. Irving was exposed and confessed before the book was published. He spent 17 months in prison, while Suskind spent five. Irving later wrote a book about the scheme, The Hoax , which became a major motion picture in 2008.

The Night Stalker Between June 1984 and August 1985, a Southern California serial killer dubbed the Night Stalker broke into victims’ houses as they slept and attacked, murdering 13 and assaulting numerous others. With citizens on high alert, an observant teenager noticed a suspicious vehicle driving through his neighborhood on the night of August 24, 1985. He wrote down the license plate and notified police. It just so happened that the Night Stalker’s latest attack took place that night in that area, so police tracked down the car. It had been abandoned, but police found a key piece of evidence inside: a fingerprint . Using new computer system, investigators quickly matched the print to 25-year-old Richard Ramirez and plastered his image in the media. Within a week, Ramirez was recognized and captured by local citizens. He was sentenced to death.

Machine Gun Kelly George “Machine Gun” Kelly was a notorious criminal during the Prohibition era, taking part in bootlegging, kidnapping and armed robbery. On July 22, 1933, he and another man kidnapped wealthy Oklahoma City oilman Charles Urschel. After a series of ransom notes and communications, a $200,000 ransom was paid — the largest amount ever paid in a kidnapping to date. Urschel was released nine days later, unharmed. The oilman had shrewdly paid close attention to every detail during his ordeal and was able to relate it all to police. Although he was blindfolded, he could tell day from night and was able to estimate the time of day that he heard airplanes fly above. He also noted the date and time of a thunderstorm and the types of animals he heard in what he presumed to be a farmhouse. Using his memories, the FBI pinpointed the likely location in which Urschel was held to a farm owned by Kelly’s father-in-law. What truly linked Kelly and his gang to the kidnapping, though, was Urschel’s fingerprints , which he made sure to place on as many items in the house as possible. Kelly was sentenced to life in prison, where he died in 1954.

The Green River Killer The Green River Killer was responsible for a rash of murders — at least 48 but possibly close to 90 — along the Green River in Washington state in the ’80s and ’90s. Most of the killings occurred in 1982-83, and the victims were almost all prostitutes. One of the suspects that police had identified as early as 1983 was Gary Ridgway , a man with a history of frequenting and abusing prostitutes. However, although they collected DNA samples from Ridgway in 1987, the technology available didn’t allow them to connect him to the killings. It wasn’t until 2001 that new DNA techniques spurred the reexamination of evidence that incriminated Ridgway . He was arrested and later confessed. Ridgway pleaded guilty to 48 murders — later confessing to even more, which remain unconfirmed — in exchange for being spared the death penalty. He was sentenced to 48 life sentences without the possibility of parole.

BTK Killer The BTK (“Bind, Torture, Kill”) Killer was a serial killer who terrorized the Wichita, Kansas area between 1974 and 1991, murdering 10 people over the span. The killer craved media attention and sent letters to local newspapers and TV stations, taunting investigators. It’s this egotism that led to his capture, however. When he resurfaced in 2004 with a series of communications, he chose to send a computer floppy disk to the Wichita Eagle . Forensic analysts traced the deleted data on the disk to a man named Dennis at the Christ Lutheran Church in Wichita . It didn’t take long for the police to arrest Dennis Rader , who confessed and was sentenced to nine life terms in prison.

Jeffrey MacDonald Early in the morning of February 17, 1970, the family of Army doctor Jeffrey MacDonald was attacked, leaving the doctor’s pregnant wife and two young daughters dead from multiple stab wounds. MacDonald himself was injured by what he claimed to be four suspects, but he survived with only minor wounds. Doubt was immediately cast on the doctor’s story, based on the physical evidence on the scene that suggested that he was the killer. However, the Army dropped the case because of the poor quality of the investigative techniques. Several years later, though, MacDonald was brought to trial in a civilian court. Key evidence was provided by a forensic scientist who testified that the doctor’s pajama top, which he claimed to have used to ward off the killers, had 48 smooth, clean holes — too smooth for such a volatile attack. Furthermore, the scientist noted that if the top was folded, the 48 holes could easily have been created by 21 thrusts — the exact number of times that MacDonald’s wife had been stabbed. The holes even matched the pattern of her wounds, suggesting that the pajama top had been laid on her before during the stabbing and not used in self-defense by the doctor. This crime scene reconstruction was crucial in MacDonald’s conviction in 1979. He was sentenced to life in prison for the three murders.

John Joubert In 1983, two murders of schoolboys rocked the Omaha, Nebraska area. The body of one of the boys was found tied with a type of rope that investigators couldn’t identify. While following up on the lead of a mysterious man scouting out a school, they traced the suspect’s license plate to John Joubert , a radar technician at the local Air Force base. In his belongings, they found a rope matching the unusual one used in the murder (which turned out to be Korean). Although DNA analysis technology was not yet an option, the extreme rarity of the rope was enough to lead to Joubert’s confession . Furthermore, hair from one of the victims was found in Joubert’s car . The child killer was even linked to a third murder, in Maine, when his teeth were found to match bite marks on a boy killed in 1982. Joubert was found guilty of all three murders and was put to death in the electric chair in 1996.

Source: Criminal Justice School

Serial Killers

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The OJ Simpson Trial: Forensic Investigation, Controversies, and Legal Impact

Explore the forensic investigation of the infamous OJ Simpson trial, including the evidence, controversies, and outcome. Learn about the incriminating evidence, the highly publicized trial, and its impact on forensic science.

Introduction

The OJ Simpson trial, which captivated the nation in the mid-1990s, remains one of American history’s most infamous criminal cases. The trial centered around the brutal murders of Nicole Brown Simpson, OJ’s ex-wife, and her friend Ronald Goldman. Orenthal James “OJ” Simpson, a renowned actor and former football star, became the prime suspect in the case. This article delves into the forensic investigation of the OJ Simpson trial, highlighting the evidence, controversies, and the ultimate outcome.

The Discovery and Initial Investigation

Late in the evening on June 12, 1994, a dogwalker stumbled upon the lifeless bodies of Nicole Brown Simpson and Ronald Goldman outside Nicole’s Beverly Hills home. Both victims had been repeatedly stabbed, with their throats cut, while Nicole’s two sons slept inside the house. The police immediately launched an investigation, and suspicion swiftly fell upon OJ Simpson, Nicole’s estranged husband, due to his history of alleged abuse.

Upon learning about his former wife’s murder, OJ was located in a Chicago hotel. He returned to Los Angeles and voluntarily went to the police station, providing fingerprints Fingerprint, impression made by the papillary ridges on the ends of the fingers and thumbs. Fingerprints afford an infallible means of personal identification, because the ridge arrangement on every finger of every human being is unique... , a blood sample, and an interview. Detectives noticed a bandage on his middle finger, which Simpson claimed was a result of breaking glass, although his explanation would later change.

Incriminating Evidence and OJ’s Arrest

Substant incriminating evidence was discovered during the search of both the crime scene and OJ’s residence. A bloodied glove found near the victims was later revealed to contain DNA DNA, or Deoxyribonucleic Acid, is the genetic material found in cells, composed of a double helix structure. It serves as the genetic blueprint for all living organisms. from OJ, Nicole, and Goldman. This glove matched another found outside OJ’s home. Bloodstains were found on the door of Simpson’s Ford Bronco, and droplets led into his house. Inside, bloodied socks were uncovered, with the blood matching Nicole’s DNA.

On June 17, 1994, an arrest warrant was issued for OJ Simpson. However, he could not be located immediately. OJ’s friend and lawyer, Robert Kardashian, publicly read a letter that Simpson had written, which was perceived as a suicide note. Shortly after, OJ was spotted driving on the highway but refused to pull over. Al Cowling, a passenger in the car, dialed 911 and informed the police that Simpson had a gun and appeared suicidal. A dramatic car chase ensued, involving multiple police vehicles and extensive media coverage. Eventually, the chase ended, and Simpson was apprehended with a firearm, a large sum of money, and a disguise.

The Trial and Controversies

On January 23, 1995, the highly publicized eight-month trial of OJ Simpson began. He faced two counts of murder, to which he pleaded not guilty. Simpson leveraged his wealth and power to assemble a defense team consisting of renowned lawyers and forensic specialists, including Robert Kardashian, Robert Shapiro, Johnnie Cochran, Barry Scheck, and Peter Neufeld.

The prosecution painted a picture of OJ as an abusive man who committed the murders in a jealous rage. They presented various pieces of seemingly incriminating DNA evidence and highlighted OJ’s lack of alibi for the night in question. However, the defense team, aided by a series of police errors, managed to cast doubt on much of the evidence presented.

The processing of the crime scene was criticized for being sloppy, with evidence mishandled and overlooked. Police photographs lacked scales for reference, and bloody shoe prints from the officers contaminated the scene. Notably, a bloodied fingerprint found on the gateway of the house was initially documented but later forgotten and lost. OJ’s blood sample, taken by investigators, was carried around in an investigator’s pocket for hours instead of being immediately submitted as evidence. Additionally, a portion of the blood sample was reported missing, leading to allegations of evidence tampering. The primary detective on the case, Mark Fuhrman, faced accusations of racism, further fueling suspicions of foul play. Furthermore, socks with Nicole’s blood were discovered in OJ’s home, but the bloodstains were not noticed during the collection process. The defense argued that the bloodstain patterns did not align with the prosecution’s narrative.

The Acquittal and Aftermath

Amidst concerns over the handling of evidence and doubts raised by the defense, OJ Simpson was found not guilty on October 3, 1995.

The acquittal was met with polarizing reactions across the country, with some celebrating the verdict as a triumph of the justice system, while others believed that Simpson had gotten away with a double murder.

Following the trial, OJ Simpson’s life took a tumultuous turn. In 1997, a civil trial found him liable for the wrongful deaths of Nicole Brown Simpson and Ronald Goldman. He was ordered to pay substantial damages to the victims’ families. In 2007, Simpson made headlines again when he was arrested and convicted of armed robbery and kidnapping in an unrelated case. He served nine years in prison before being granted parole in 2017.

The OJ Simpson trial continues to be a topic of fascination and debate. It highlighted issues of race, celebrity influence, and the complexities of the criminal justice system. The case also significantly impacted the field of forensic science, leading to a greater emphasis on DNA analysis and evidence-handling protocols.

The OJ Simpson trial remains a significant chapter in forensic investigation and criminal justice history. The case brought attention to the importance of proper evidence collection, handling, and chain of custody. The controversies surrounding the trial raised questions about racial bias and police misconduct. Despite the acquittal, the trial’s outcome continues to be debated, impacting the American legal system.

Forensic Analyst by Profession. With Simplyforensic.com striving to provide a one-stop-all-in-one platform with accessible, reliable, and media-rich content related to forensic science. Education background in B.Sc.Biotechnology and Master of Science in forensic science.

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Focus Shifts to Physical Evidence in Simpson Case

By David Margolick

April 4, 1995

The focus of the O. J. Simpson case shifted fundamentally today as prosecutors finally began to discuss the physical evidence -- blood drops, hair samples, footprints, a blue knit cap and a pair of leather gloves -- that they believe ties Mr. Simpson to the killings of Nicole Brown Simpson and Ronald L. Goldman.

With the appearance of Dennis Fung, the Los Angeles Police Department's chief criminalist in the case, testimony shifted from the stormy nature of the Simpsons' marriage and Mr. Simpson's activities last June 12 to the manner in which the department collected and preserved evidence and just what that evidence might prove.

Mr. Fung described how he and an assistant on June 13 lifted spots of blood from Mr. Simpson's white Ford Bronco, from the ground near the car, from along the driveway and from Mr. Simpson's home at 360 North Rockingham Avenue. He also described picking up a bloody right-hand glove, either scooping it up with a paper bag or placing it in that bag while wearing latex gloves.

The criminalist described how the glove had looked to him -- "somewhat dry with some shiny areas on it," he said. Then, opening envelopes within bags within packages in the fashion of a Russian nesting doll, he extracted the wrinkled, fur-lined brown leather glove, which he held up for inspection. His demonstration came weeks after the jury had seen its mate, found near the bodies of Mrs. Simpson and Mr. Goldman. Later, Mr. Fung described picking up a pair of bloody socks found in Mr. Simpson's bedroom.

Mr. Fung also recounted his arrival at Mrs. Simpson's condominium at 875 South Bundy Drive -- where, he said, the bodies of Mrs. Simpson and Mr. Goldman were "being processed" and where he obtained some of the other physical evidence in the case. Blood spots and prints there, he said, suggested that the perpetrator was an adult who walked rather than ran away from the two corpses.

Anticipating defense arguments that police officers out to frame Mr. Simpson doused exhibits with his blood, Mr. Fung testified that all blood evidence collected on June 13 was under lock and key by the time Philip Vannatter, one of the two lead detectives in the case, handed him a vial of blood taken from Mr. Simpson at police headquarters.

Guided by Hank Goldberg, an Assistant District Attorney, Mr. Fung sought to defuse what is certain to be a major issue on cross-examination: his need to return to the Bundy address on July 3 to lift blood smears from the rear gate at Mrs. Simpson's condominium. By waiting three weeks to collect that evidence, the defense said, Mr. Fung effectively made it useless.

The criminalist, who spent considerable time describing his studies in blood spatter interpretation and forensic microscopy and stressed the need to collect a selective sampling, conceded that had he known of the blood on the gate he would have collected it earlier. But he said he could not remember having been told about the smears.

Throughout his testimony, Mr. Fung tried to show that he and his associate, Andrea Mazzola, took care to protect and respect evidence. He painstakingly re-enacted the process of collecting blood samples, describing his use of tiny cloth swabs, distilled water, control samples and tweezers subjected to frequent cleanings. The jurors got to see sample swabs, inspecting them far more quickly than they did, some weeks back, Mr. Goldman's ring.

The defense has also contended that the comparatively inexperienced Ms. Mazzola wielded responsibility at the crime scene beyond her expertise. Mr. Fung countered that although his junior colleague had nominally been in charge at the outset, he had quickly supplanted her.

"When I found out that it was a high-profile case and it was going to be a complicated crime scene, I decided that she should, in a sense, take the back seat," he testified. "She did not have any opportunity to direct anybody."

Prosecutors clearly hoped that by his very appearance Mr. Fung would fortify their case. In contrast to what the defense has said was slipshod the police work, Mr. Fung had an almost military bearing. An 11-year member of the Los Angeles Police Department who said he had investigated 500 crime scenes, Mr. Fung spoke carefully and precisely. The moment he fielded a question from Mr. Goldberg, he turned to the jurors and looked at them until he finished.

Both Mr. Fung and Mr. Goldberg are youthful looking, giving the impression that veterans in the case had been supplanted by replacement players.

That the case was entering a new and critical phase, one that will lead directly into DNA testimony, was apparent from the new and enlarged cast of characters -- all of whom, at Judge Lance A. Ito's request, were introduced to the jury. Each bade the panel a chipper "good morning," which the jury promptly returned. All told, 10 defense lawyers were in court today, and that did not include F. Lee Bailey.

But the composition of the jury, which has already lost five members since opening statements, may change yet again. Judge Ito is said to be investigating whether one juror, a 38-year-old black woman, misrepresented her experiences with domestic violence in the jury selection process. Should she be replaced, six alternates will remain for what is likely to be several more months of testimony.

While Mr. Fung testified, the paper war continued. Judge Ito withheld a decision on a defense request to ask Dr. Irwin Golden, who performed the autopsies on the victims, about two sensitive topics. But an exchange indicated how prosecutorial defense lawyers plan to be with Dr. Golden, and how defensively prosecutors are approaching one of their own important witnesses.

In fact, the Deputy District Attorney, Brian Kelberg, acknowledged that the argument he invoked to limit the cross-examination of Dr. Golden was the one prosecutors scorned when Mr. Simpson's lawyers tried to keep them from questioning Dr. Kary Mullis, a defense expert on DNA, on his personal life.

Mr. Simpson's lawyers want to ask Dr. Golden about an episode that took place on July 21, 13 days after he underwent what they say was their blistering cross-examination during the preliminary hearing in the case. In the incident, the doctor brought a gun into the county coroner's office and declared, according to one witness, "You know, we ought to go out and kill 9 or 10 of these attorneys." Another witness heard something similar but considerably more obscene.

In addition, the defense lawyers want to ask Dr. Golden about two autopsies he purportedly botched in 1990. In one, they say, he misidentified entry and exit wounds; in the other, he mischaracterized the distance from which a gunshot wound was inflicted.

Repeatedly and strikingly, Mr. Kelberg acknowledged that Dr. Golden had made mistakes in his autopsies. One, he conceded, was discarding the contents of Mrs. Simpson's stomach. Although the largely intact state of the 500 cubic centi meters of rigatoni shed little light on the time of Mrs. Simpson's death, he said, it would have been wiser to save the stomach contents, if only to rebut defense complaints.

"Dr. Golden is going to admit to his mistakes," Mr. Kelberg said. "The issue is not whether mistakes were made, but the significance of any mistakes."

Mr. Kelberg insisted that the two proposed topics of inquiry were not pertinent and urged the court not to "deviate into these little tributaries of irrelevant baloney." Dr. Golden, he suggested, used a toy gun and made the anti-lawyer comment in jest. But even if the gun and the comment had been real, he said, all they would have shown was that Dr. Golden shared a widely held contempt of all lawyers, not just those defending Mr. Simpson.

Gerald Uelmen, the defense lawyer handling such evidentiary matters, belittled the idea that the coroner had been kidding.

"It's not paranoia, Your Honor, for us to believe that Dr. Golden was talking about us," he said. "If it's a joke, let the jury hear it, and let them decide what bearing that has on whether they should give weight and credibility to the opinions of this expert witness."

Mr. Simpson's lawyers also urged Judge Ito to punish the prosecution for failing to turn over until last Friday a videotape of Mr. Simpson's house taken on the afternoon of June 13. The police insist that they made the tape simply to document what was in Mr. Simpson's house, so that Mr. Simpson could not sue them afterward for breaking or stealing his Heisman trophy or other valuable mementos.

The defense contends that withholding the tape, which contains at least some footage of the blood drops the police found in the foyer, inflicted "irremedial" harm on it; the prosecution says the tape has no probative value.

Despite several hours of testimony on Friday and today -- all outside the jury's presence -- and papers filed by both sides, Judge Ito withheld a decision until lawyers could argue even further over the issue. He originally set that hearing for 4:30 today, but thought better of it.

"Four-thirty today may be a little tough, Your Honor, for obvious reasons," said Mr. Simpson's chief trial lawyer, Johnnie L. Cochran Jr.

He spoke cryptically, but Judge Ito evidently understood. "I forgot," the judge replied. "And we need to be somewhere at 5:40."

That was five minutes before the scheduled tipoff in the Arkansas-U.C.L.A. national championship basketball game. Judge Ito, along with Marcia Clark, the chief prosecutor; Mr. Goldberg; Mr. Cochran and another of Mr. Simpson's lawyers, Robert L. Shapiro, are all alumni of U.C.L.A. In a case with little unanimity on anything, the parties agreed on their priorities for the afternoon.

"All right, all right, tomorrow then we'll take it up," the judge said.

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Distinguishing case study as a research method from case reports as a publication type

The purpose of this editorial is to distinguish between case reports and case studies. In health, case reports are familiar ways of sharing events or efforts of intervening with single patients with previously unreported features. As a qualitative methodology, case study research encompasses a great deal more complexity than a typical case report and often incorporates multiple streams of data combined in creative ways. The depth and richness of case study description helps readers understand the case and whether findings might be applicable beyond that setting.

Single-institution descriptive reports of library activities are often labeled by their authors as “case studies.” By contrast, in health care, single patient retrospective descriptions are published as “case reports.” Both case reports and case studies are valuable to readers and provide a publication opportunity for authors. A previous editorial by Akers and Amos about improving case studies addresses issues that are more common to case reports; for example, not having a review of the literature or being anecdotal, not generalizable, and prone to various types of bias such as positive outcome bias [ 1 ]. However, case study research as a qualitative methodology is pursued for different purposes than generalizability. The authors’ purpose in this editorial is to clearly distinguish between case reports and case studies. We believe that this will assist authors in describing and designating the methodological approach of their publications and help readers appreciate the rigor of well-executed case study research.

Case reports often provide a first exploration of a phenomenon or an opportunity for a first publication by a trainee in the health professions. In health care, case reports are familiar ways of sharing events or efforts of intervening with single patients with previously unreported features. Another type of study categorized as a case report is an “N of 1” study or single-subject clinical trial, which considers an individual patient as the sole unit of observation in a study investigating the efficacy or side effect profiles of different interventions. Entire journals have evolved to publish case reports, which often rely on template structures with limited contextualization or discussion of previous cases. Examples that are indexed in MEDLINE include the American Journal of Case Reports , BMJ Case Reports, Journal of Medical Case Reports, and Journal of Radiology Case Reports . Similar publications appear in veterinary medicine and are indexed in CAB Abstracts, such as Case Reports in Veterinary Medicine and Veterinary Record Case Reports .

As a qualitative methodology, however, case study research encompasses a great deal more complexity than a typical case report and often incorporates multiple streams of data combined in creative ways. Distinctions include the investigator’s definitions and delimitations of the case being studied, the clarity of the role of the investigator, the rigor of gathering and combining evidence about the case, and the contextualization of the findings. Delimitation is a term from qualitative research about setting boundaries to scope the research in a useful way rather than describing the narrow scope as a limitation, as often appears in a discussion section. The depth and richness of description helps readers understand the situation and whether findings from the case are applicable to their settings.

CASE STUDY AS A RESEARCH METHODOLOGY

Case study as a qualitative methodology is an exploration of a time- and space-bound phenomenon. As qualitative research, case studies require much more from their authors who are acting as instruments within the inquiry process. In the case study methodology, a variety of methodological approaches may be employed to explain the complexity of the problem being studied [ 2 , 3 ].

Leading authors diverge in their definitions of case study, but a qualitative research text introduces case study as follows:

Case study research is defined as a qualitative approach in which the investigator explores a real-life, contemporary bounded system (a case) or multiple bound systems (cases) over time, through detailed, in-depth data collection involving multiple sources of information, and reports a case description and case themes. The unit of analysis in the case study might be multiple cases (a multisite study) or a single case (a within-site case study). [ 4 ]

Methodologists writing core texts on case study research include Yin [ 5 ], Stake [ 6 ], and Merriam [ 7 ]. The approaches of these three methodologists have been compared by Yazan, who focused on six areas of methodology: epistemology (beliefs about ways of knowing), definition of cases, design of case studies, and gathering, analysis, and validation of data [ 8 ]. For Yin, case study is a method of empirical inquiry appropriate to determining the “how and why” of phenomena and contributes to understanding phenomena in a holistic and real-life context [ 5 ]. Stake defines a case study as a “well-bounded, specific, complex, and functioning thing” [ 6 ], while Merriam views “the case as a thing, a single entity, a unit around which there are boundaries” [ 7 ].

Case studies are ways to explain, describe, or explore phenomena. Comments from a quantitative perspective about case studies lacking rigor and generalizability fail to consider the purpose of the case study and how what is learned from a case study is put into practice. Rigor in case studies comes from the research design and its components, which Yin outlines as (a) the study’s questions, (b) the study’s propositions, (c) the unit of analysis, (d) the logic linking the data to propositions, and (e) the criteria for interpreting the findings [ 5 ]. Case studies should also provide multiple sources of data, a case study database, and a clear chain of evidence among the questions asked, the data collected, and the conclusions drawn [ 5 ].

Sources of evidence for case studies include interviews, documentation, archival records, direct observations, participant-observation, and physical artifacts. One of the most important sources for data in qualitative case study research is the interview [ 2 , 3 ]. In addition to interviews, documents and archival records can be gathered to corroborate and enhance the findings of the study. To understand the phenomenon or the conditions that created it, direct observations can serve as another source of evidence and can be conducted throughout the study. These can include the use of formal and informal protocols as a participant inside the case or an external or passive observer outside of the case [ 5 ]. Lastly, physical artifacts can be observed and collected as a form of evidence. With these multiple potential sources of evidence, the study methodology includes gathering data, sense-making, and triangulating multiple streams of data. Figure 1 shows an example in which data used for the case started with a pilot study to provide additional context to guide more in-depth data collection and analysis with participants.

An external file that holds a picture, illustration, etc.
Object name is jmla-107-1-f001.jpg

Key sources of data for a sample case study

VARIATIONS ON CASE STUDY METHODOLOGY

Case study methodology is evolving and regularly reinterpreted. Comparative or multiple case studies are used as a tool for synthesizing information across time and space to research the impact of policy and practice in various fields of social research [ 9 ]. Because case study research is in-depth and intensive, there have been efforts to simplify the method or select useful components of cases for focused analysis. Micro-case study is a term that is occasionally used to describe research on micro-level cases [ 10 ]. These are cases that occur in a brief time frame, occur in a confined setting, and are simple and straightforward in nature. A micro-level case describes a clear problem of interest. Reporting is very brief and about specific points. The lack of complexity in the case description makes obvious the “lesson” that is inherent in the case; although no definitive “solution” is necessarily forthcoming, making the case useful for discussion. A micro-case write-up can be distinguished from a case report by its focus on briefly reporting specific features of a case or cases to analyze or learn from those features.

DATABASE INDEXING OF CASE REPORTS AND CASE STUDIES

Disciplines such as education, psychology, sociology, political science, and social work regularly publish rich case studies that are relevant to particular areas of health librarianship. Case reports and case studies have been defined as publication types or subject terms by several databases that are relevant to librarian authors: MEDLINE, PsycINFO, CINAHL, and ERIC. Library, Information Science & Technology Abstracts (LISTA) does not have a subject term or publication type related to cases, despite many being included in the database. Whereas “Case Reports” are the main term used by MEDLINE’s Medical Subject Headings (MeSH) and PsycINFO’s thesaurus, CINAHL and ERIC use “Case Studies.”

Case reports in MEDLINE and PsycINFO focus on clinical case documentation. In MeSH, “Case Reports” as a publication type is specific to “clinical presentations that may be followed by evaluative studies that eventually lead to a diagnosis” [ 11 ]. “Case Histories,” “Case Studies,” and “Case Study” are all entry terms mapping to “Case Reports”; however, guidance to indexers suggests that “Case Reports” should not be applied to institutional case reports and refers to the heading “Organizational Case Studies,” which is defined as “descriptions and evaluations of specific health care organizations” [ 12 ].

PsycINFO’s subject term “Case Report” is “used in records discussing issues involved in the process of conducting exploratory studies of single or multiple clinical cases.” The Methodology index offers clinical and non-clinical entries. “Clinical Case Study” is defined as “case reports that include disorder, diagnosis, and clinical treatment for individuals with mental or medical illnesses,” whereas “Non-clinical Case Study” is a “document consisting of non-clinical or organizational case examples of the concepts being researched or studied. The setting is always non-clinical and does not include treatment-related environments” [ 13 ].

Both CINAHL and ERIC acknowledge the depth of analysis in case study methodology. The CINAHL scope note for the thesaurus term “Case Studies” distinguishes between the document and the methodology, though both use the same term: “a review of a particular condition, disease, or administrative problem. Also, a research method that involves an in-depth analysis of an individual, group, institution, or other social unit. For material that contains a case study, search for document type: case study.” The ERIC scope note for the thesaurus term “Case Studies” is simple: “detailed analyses, usually focusing on a particular problem of an individual, group, or organization” [ 14 ].

PUBLICATION OF CASE STUDY RESEARCH IN LIBRARIANSHIP

We call your attention to a few examples published as case studies in health sciences librarianship to consider how their characteristics fit with the preceding definitions of case reports or case study research. All present some characteristics of case study research, but their treatment of the research questions, richness of description, and analytic strategies vary in depth and, therefore, diverge at some level from the qualitative case study research approach. This divergence, particularly in richness of description and analysis, may have been constrained by the publication requirements.

As one example, a case study by Janke and Rush documented a time- and context-bound collaboration involving a librarian and a nursing faculty member [ 15 ]. Three objectives were stated: (1) describing their experience of working together on an interprofessional research team, (2) evaluating the value of the librarian role from librarian and faculty member perspectives, and (3) relating findings to existing literature. Elements that signal the qualitative nature of this case study are that the authors were the research participants and their use of the term “evaluation” is reflection on their experience. This reads like a case study that could have been enriched by including other types of data gathered from others engaging with this team to broaden the understanding of the collaboration.

As another example, the description of the academic context is one of the most salient components of the case study written by Clairoux et al., which had the objectives of (1) describing the library instruction offered and learning assessments used at a single health sciences library and (2) discussing the positive outcomes of instruction in that setting [ 16 ]. The authors focus on sharing what the institution has done more than explaining why this institution is an exemplar to explore a focused question or understand the phenomenon of library instruction. However, like a case study, the analysis brings together several streams of data including course attendance, online material page views, and some discussion of results from surveys. This paper reads somewhat in between an institutional case report and a case study.

The final example is a single author reporting on a personal experience of creating and executing the role of research informationist for a National Institutes of Health (NIH)–funded research team [ 17 ]. There is a thoughtful review of the informationist literature and detailed descriptions of the institutional context and the process of gaining access to and participating in the new role. However, the motivating question in the abstract does not seem to be fully addressed through analysis from either the reflective perspective of the author as the research participant or consideration of other streams of data from those involved in the informationist experience. The publication reads more like a case report about this informationist’s experience than a case study that explores the research informationist experience through the selection of this case.

All of these publications are well written and useful for their intended audiences, but in general, they are much shorter and much less rich in depth than case studies published in social sciences research. It may be that the authors have been constrained by word counts or page limits. For example, the submission category for Case Studies in the Journal of the Medical Library Association (JMLA) limited them to 3,000 words and defined them as “articles describing the process of developing, implementing, and evaluating a new service, program, or initiative, typically in a single institution or through a single collaborative effort” [ 18 ]. This definition’s focus on novelty and description sounds much more like the definition of case report than the in-depth, detailed investigation of a time- and space-bound problem that is often examined through case study research.

Problem-focused or question-driven case study research would benefit from the space provided for Original Investigations that employ any type of quantitative or qualitative method of analysis. One of the best examples in the JMLA of an in-depth multiple case study that was authored by a librarian who published the findings from her doctoral dissertation represented all the elements of a case study. In eight pages, she provided a theoretical basis for the research question, a pilot study, and a multiple case design, including integrated data from interviews and focus groups [ 19 ].

We have distinguished between case reports and case studies primarily to assist librarians who are new to research and critical appraisal of case study methodology to recognize the features that authors use to describe and designate the methodological approaches of their publications. For researchers who are new to case research methodology and are interested in learning more, Hancock and Algozzine provide a guide [ 20 ].

We hope that JMLA readers appreciate the rigor of well-executed case study research. We believe that distinguishing between descriptive case reports and analytic case studies in the journal’s submission categories will allow the depth of case study methodology to increase. We also hope that authors feel encouraged to pursue submitting relevant case studies or case reports for future publication.

Editor’s note: In response to this invited editorial, the Journal of the Medical Library Association will consider manuscripts employing rigorous qualitative case study methodology to be Original Investigations (fewer than 5,000 words), whereas manuscripts describing the process of developing, implementing, and assessing a new service, program, or initiative—typically in a single institution or through a single collaborative effort—will be considered to be Case Reports (formerly known as Case Studies; fewer than 3,000 words).

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Examination of Physical Evidence: A Detailed Study

Published by lipi hathishah on 16/06/2021 16/06/2021, introduction:.

Physical evidence is any tangible object that plays some character within the matter that gave rise to the litigation, introduced as evidence during litigation like an attempt to manifest a fact in a problem supported the object’s physical characteristics. It’s also called real evidence or material evidence. The aim of recognizing physical evidence is that it is often collected and examined. It’s difficult to work out the load a given piece of evidence will have during a case as within the end the load is going to be decided by judges. Evidence that’s found on the crime scene is named Physical evidence. The thing of identifying the proof is to work out its physical or chemical identity. The method of identification needs the testing processes that give characteristic results for explicit standard materials. After the results are being recognized, they could be recorded permanently and used repeatedly to prove the identity of suspect materials.

Physical evidence is often the proof of the commitment of crime and provides the situation for investigation, for instance, gasoline found at the scene of a ﬁre can prove the ignition. It can support witness testimony or prove it false sort of a forensic scientist can test a bloodstain that a suspect claim as his own and not the victim. It can link a suspect with a victim or with a criminal offence scene as a broken piece of headlight glass found within the cuff of a suspect’s pants could place him at the scene during a hit-and-run accident. Physical evidence can identify the identity or character of the people associated with a crime; for instance, DNA, ﬁngerprints, or handwriting, might prove that a particular person was there at a criminal offence scene. It can allow investigators to rebuild a criminal offence scene, or the blood splash patterns may show where the suspect and victim were located comparative to every other and should indicate what happened there and in what order.

Examination of Physical Evidence

The examination of physical evidence by a forensic scientist and therefore the officers is typically administered for identification or comparison purposes. Identification determines the physical or chemical identity of a substance. An examination of documents found at the scene or associated with the crime is usually a crucial part of forensic analysis. Such examination often helps to make not only the author but more importantly identify any variations that happened. Specialists also are ready to recover text from documents that were damaged accidentally or intentionally. A successful crime investigation is determined by the gathering and analysis of several kinds of evidence. Forensic scientists categorize evidence in several ways and have precise ways of handling it. Physical evidence refers to any item that comes from a non-living origin.

Examination of such evidence is often conducted by various methods like making impressions in plaster, lifting fingerprints from the objects encountered, or taking images of marks. The examination of such evidence is significant for forensic analysis. Identifying the alterations is one of the most purposes of such examination. Later, such evidence is often wont to identify and compare things, like method or technique employed by the defendant to harm the plaintiff, sort of manufacturing method want to manufacture the murder weapon or the opposite tool.

The role of physical evidence : The physical evidence present at a crime scene plays an essential role in rebuilding the events that happened during the crime. Even though the evidence doesn’t define everything that happened there during the crime, but it can support or oppose the statements and accounts given by witnesses and suspects. Information acquired by physical evidence can also generate leads on the cases and make sure the rebuilding of a criminal offence within the courts. The gathering and documentation of physical evidence is the groundwork of reconstruction on the crime scene.

The criminal justice system is needing increased use of physical evidence and expert testimony concerning the knowledge attained from its examination. It’s not enough for an officer to work out that a criminal offence has been committed and to easily identify and arrest a suspect. The officer must be able to form the conditions in the incident by utilizing physical evidence from the individuals involved and the crime scene to support the criminal charges. It is, therefore, obligatory upon the professional police officer to make intellectual and effective use of the crime laboratory as an investigative aid. Accordingly, with the courts placing greater emphasis on physical evidence greater than ever, the chain of custody and therefore the integrity of the evidence is being cautiously examined and sometimes challenged. The importance then of proper methods in collecting, marking, and preserving evidence cannot be overemphasized.

Laws and Acts

According to Section 3 of the Indian Evidence Act, 1872 [1] evidence means and includes oral and documentary evidence. Oral evidence talks about all or any statements which the court permits to be made before it by the witness, and such evidence should be associated with the matter of fact under inquiry. Whereas documentary or written evidence talk about all the electronic records presented in the court. This definition is reflected to be a narrow definition as it doesn’t include things like a weapon, identification proceedings, local inquiry results, statements made in court, etc. or they can be summed up as material things.

While there are common principles associated with an investigation of a crime scene, native laws, rules, and regulations administer many actions of the crime scene investigation and forensic process. They relate to issues such as how to obtain authorization or to get a search warrant, to conduct the investigation, to handle evidence e.g., the type of sealing procedure required in the crime scene, and to submit physical evidence to the forensic laboratory. They eventually determine the admissibility of the evidence collected at the crime scene. Failure to obey existing laws, rules, and regulations can result in a situation where the evidence cannot be used in court. It is therefore of importance for an officer working at the scene to look carefully and remember every little detail and ensure proper compliance with these rules. If adequate laws, rules, and regulations to enable the forensic process do not exist, their establishment may be a matter of necessity.

Punishment for False Evidence

The person who gives or present false evidence in the court could get an imprisonment sentence of up to 7 years and a fine, whereas if the person has given false evidence outside the court can receive 3 years and fine. Giving false evidence is a non-cognizable offence i.e., arresting someone who gave false evidence without an arrest warrant is not possible. It is a type of bailable offence i.e., bail can be taken from the court by the person. He can claim bail as being a matter of right. It is non-compoundable means the person who has given false evidence against it the person can’t compromise with him and the case has to stay open and Section 194 to 195A of the Indian Penal Code deals with the aggravated form of offences. Aggravate form means serious form. For example, Under Section 302 of the Indian Penal Code, if someone falsely accuses a person of murder and that victim gets wrongly punished for that, it is considered an offence. There are different forms of punishment under Section 194 as when someone is convicted and when someone is convicted and executed.

International Perspective

It is a criminal offence to damage, tamper, or hide the evidence knowing that its existence can affect the jurisdiction or it is being seen by the law enforcement officers. This is also a crime under the statutes of many U.S. states. A 2004 review found that concealment, destruction, or tampering with evidence is prohibited in any form by 32 states. Evidence tampering generally refers to physical evidence and isn’t founded on false statements or the concealment of data by false statements. It falls within the extensive set of obstacles of justice-related crimes; others include destruction of state property, bribery, perjury, and escape.

In general, the features of the offence are that the person being aware of the proceeding to be in place or is going to be instituted in the future and that person takes action to change, destroy, conceal, or misplace the evidence and that the person intents to threaten the value or obtainability of the evidence to affect the procedure or results in proceeding or investigation.

Self-incrimination: In the case of Pennsylvania v. Muniz (1990) [2] , the U.S. The Supreme Court distinguished physical and demeanour evidence from testimonial evidence, holding that evidence of the former does not threaten Fifth Amendment protection self-incrimination. The U.S. Court of Appeals for the Ninth Circuit had held that physical evidence includes one’s fingerprints, vocal characteristics, stride, gestures, stance, blood characteristics or handwriting.

Present Scenario

There are few methods used to support a probable sequence of events by the observation and evaluation of physical evidence, as well as statements made by those involved with the incident, one of them is referred to as reconstruction which is used in the present time. Crime-scene reconstruction relies on the combined efforts of doctors, criminalists, and enforcement personnel to recover physical evidence and to map out the events surrounding the occurrence of a criminal offence. Criminalistics is that profession and scientific discipline directed to the acknowledgement, identification, individualization, and evaluation of physical evidence by application of the natural sciences in law-science matters. The court includes all Judges and Magistrates, and all persons except the Arbitrators, who are legally authorized to take evidence.

Paint: Physical elements like colour and layers, or chemical elements like composition and available chemicals within the paint indicate its class or what sort of paint it’s auto, house, nail enamel, etc. All the individual characteristics, including features of paint chips, are often analyzed and connect the evidence to the suspect.

Ballistics: Rifling during a barrel causes distinctive marks on fired bullets. Features of firearms, ammunition, and gunshot remains are inspected to seek out matches between suspects and evidence found at a criminal offence scene. This sort of evidence requires the integrated ballistics identification system because of the database.

Dust & dirt: Such sort of evidence can specify the whereabouts of an individual who has travelled because it could also be hand-picked up at a criminal offence scene or left behind. Investigators inspect samples for pollen, plants, and other organic matter, chemical composition, to seek out and connect the links to a selected crime scene.

Fingerprints: AFIS stands for the automated fingerprint identification system there are 3 sorts of patterns: arches, loops, and whorls. Unique features also are used for identification. AFIS is that the database employed by investigators to seek out matches to latent fingerprints found at a criminal offence scene.

Hairs & fibres: They both are often transferred from a suspect to a victim and the other way around. Hairs are often examined to spot their origins, like humans or animals. Root intact hair is often tested for DNA. Fibres are wont to make clothing, carpeting, and furniture. They’ll be natural fibres or synthetic.

Skeletal remains: The explanation for death or life history are often determined by analyzing forensic anthropologists to spot remains. Sex is often determined by examining the femur and pelvis. Teeth, bone growth, and therefore the length of specific bones determine the age and structure of the person. By analyzing the skull for specific characteristics race is often determined.

Wounds: Wounds can specify the sort of weapon or tool marks on the weapon. The sort of wound talks about the form and size of the weapon. Wound analysis provides recommendations on a victim’s injuries, details about the suspect like is left-handed, right-handed, height, etc., and therefore the positions of the victim and suspect.

Body fluids: Blood, semen, saliva, sweat, and urea are all subjects to examination for providing information about the crime also as its victim or the suspect. Chemicals and UV light represent the presence and site of body fluids within the crime scene, which are swabbed, bagged, and picked up in vials.

A Capital murder Case study [3]

In 1990, the Henrico County Police Forensic Unit was sent to investigate a murder involving the sexual abuse and stabbing of a 22-year-old female. After a lengthy investigation, little or no significant evidence was discovered; the most promising evidence was a pillowcase discovered near the victim’s body, which had many bloodstains on it. One stain had some ridge detail, but it had faded to the point that even the expert’s eye could not see it. They took the pillowcase to the Henrico County Forensic Unit, where the bloodstain pattern was studied. This analyzed report found that numerous blood strains were according to a contact of a blade and fingerprint detail on it looked to possess some potential for identification. This evidence was taken to the Virginia Division of Forensic Science and processed with a comparatively new chemical almost like Ninhydrin 1, 8-Diazaflouren-9-one (DFO). The finest DFO photograph was taken to Hunter Graphic Information Systems in Charlotte, North Carolina. Handing out with image enhancement equipment was a success, and a print was obtained satisfactory for identification. In the post-mortem examination, semen was recovered from the victim’s leg. The original serological study was based on the initial perpetrator, who happened to be the victim’s next-door neighbour, and as a result of his unusual blood type, he was only found in 5% of the population. The warrant was given solely based on the serological findings. Defence lawyers successfully prosecuted the defendant for capital murder, a 22-year-old female, in April 1991, based on overwhelming forensic proof of image-enhanced fingerprint recognition inside the victim’s blood, DNA matching of liquid body substance contained on the victim’s body, and hence the knife found inside the suspect’s apartment.

Bone-in Tree – A Case Study [4]

A government employee was living in some residential quarters in the elevated land area. The region was densely forested, with some trees, and was frequently inaccessible. Someone may have noticed some human remains on the ground under a tree and reported them to the authorities. The police and forensic team went to the scene after receiving the details. According to the informer, a skull and some bones were discovered lying under the tree at one point on the ground, almost undisturbed. A long bone, a torn pant (wearing apparel), and a section of rope tied with one of its ends in a tree branch was also discovered during the search. All the objects were brought down to be examined further to extract the details they contained. During the investigation, a mobile phone was discovered in the pocket of the damaged pant. In this case, all physical evidence was obtained for further study.

The following physical evidence was detected at the crime scene for forensic examination: The skull with the long/short bones seems to be from the same individual. All of the skeletal remains were gathered together on the ground underneath the oak. One torn black pant with a tailor’s mark of ’28’ was discovered in a tree branch. One mobile phone was found in one of the black pants pockets (Make: Callbar; Model: C66; SIM-1: Standard Airtel; SIM-2: Micro Airtel) One shaving blade was found in a different pocket of the same pant. One long bone (femur, length 44.5cm) dangling from a tree branch, safe from falling. a few hairs/fibre fragments. A length of rope tied in a branch with one end tied in a noose that appears to be old and ripped (suspected to be a part of hanging material) A pair of sky-blue slippers was discovered near the tree’s base. For testing, soil from just below the skeletal remains was collected, along with control soil. The sequence of events was recorded in chronological order, with the photograph used to prove the crime theory.

The victim’s ruined pant pocket held the mobile phone, which was retrieved. Since it had been exposed to unusual conditions for such a long time, it was almost rusted and appeared destroyed. However, with proper cleaning, the SIM card was found and through software, the mobile phone number was retrieved to be provided by the Airtel service provider. To aid the investigation, the service provider (Airtel) provided a copy of the customer’s enrolment form, which included the person’s photograph and other contact information. The fact that the form included a photograph and an address aided in leading the inquiry in the right direction. The parents were contacted and visited the house based on the address. Along with the other information provided in the enrolment form, the photograph available in the form was also identified as their son. Allelic profiling was performed earlier because the unknown skeletal remains were visible, and to validate the identification, allelic profiling of the alleged parents was compared and matched beyond a reasonable doubt, establishing the identity of the deceased as their biological offspring.

Based on a trail of incidents found at an undisturbed crime scene, the crime was reconstructed. In this scenario, the victim could have climbed the tree while holding hanging stuff, leaving his slipper at the base of the tree (rope). He (victim) even took care to hide within branches to escape public attention before hanging himself. For a long time, the hanging corpse went unnoticed, eventually decomposing, resulting in the detachment of various body parts and its eventual collapse to the ground. A long bone (femur) and the victim’s pant (wearing apparel) were unable to fall due to the tree’s roots protecting them, but other bones were discovered lying under the tree. Furthermore, the disconnected portion of the rope (hanging material) found bound one end with the branch without noose was also present, implying that the body had detached from the noose over time. This is due to the rope’s gradual weakening in its ability to withstand the weight of the decomposed body, resulting in body parts detaching and lying under the tree.

Physical evidence is a peremptory portion of every case, as it confirms the fact whether it is in a criminal case or a civil case. The facts are used in evidence for determining and proving the disputed facts. Physical evidence attaches importance to the facts cited as evidence. Thus, different kinds of evidence are used for proving and disproving facts. Moreover, it helps in saving the time dedicated to a particular case. Thus, it can be concluded that the physical evidence acts for judicial behaviour like the reasoning acts for logic.

References:

[1] https://devgan.in/iea/section/3/

[2] 496 U.S. 582 (more)110 S.Ct. 2638

[3] N Tiller; T Tiller. Power of Physical Evidence: A Capital Murder Case Study, 135793, Journal of Forensic Identification Vol: 42 Issue: 2 Dated: (March/April 1992) Pg: 79-83, 1992.

[4] Sabyasachi Nath, Ajitesh Pal, Juthika Debbarma, H.K. Pratihari (2019) Bone in Tree – A Case Study. J Forensic Sci Criminol 7(2): 203

Evidence Law

Forensic report writing.

Some facts, not otherwise relevant, are relevant if they are inconsistent with the opinions of experts when such opinions are relevant.

Forensic Scientist and Duties of Forensic Scientist

A forensic expert is required to acquire data, look for evidence, gather, document & preserve evidence to reconstruct the timeline of events.

Introduction to Forensic Science

Forensic science, sometimes referred to as criminalistics, applies the knowledge of science to the definition and enforcement of laws.

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Prosecutor: Physical evidence just recently sent to lab following October murder of Hialeah mother

Amanda Batchelor , Digital Executive Producer

HIALEAH, Fla. – A status hearing was held Wednesday for Derek Rosa , 13, who is accused of fatally stabbing his mother last year.

According to police, Rosa murdered his mother, Irina Garcia , 39, as she slept next to his 14-day-old half-sister on Oct. 12 at the Amelia Oaks apartment complex, located at 211 W. 79th Place in Hialeah.

About the Author

Amanda batchelor.

Amanda Batchelor is the Digital Executive Producer for Local10.com.

Exclusive: Queen Creek police chief goes over timeline of arrests in Preston Lord case

QUEEN CREEK, AZ (AZFamily) — In an exclusive interview, Queen Creek Police Chief Randy Brice weighs in on the timeline leading up to the arrests in the beating death of Preston Lord and addresses criticisms it took too long.

It’s his first interview with Arizona’s Family since his department released a 1,162-page police report and more than 40 minutes of 911 calls.

Brice also posted a new video online on Tuesday, with a new timeline trying to clarify the events surrounding the death of Lord, who was attacked outside a Halloween house party on Oct. 28 and died two days later.

Special coverage: East Valley Teen Violence

Brice said his department only got one 911 call relayed to their officers before Preston was ambushed.

The other calls that came in saying kids were drunk and someone was going to get hurt or die came from another party breaking up at the same time about a mile away.

Brice said his officers did the best with the information they had at the time. Those officers got called to an escalating domestic violence call, and all other officers were accounted for.

Brice said the report is important because it showed they have a lot of circumstantial and physical evidence, corroborating witness testimony, DNA, and suspect confessions. Police also had digital evidence like photos, videos, text messages, social media posts, and surveillance videos.

While he wouldn’t say how many suspects his detectives tied to the physical attack on Lord, his team put together a timeline and suspect lineup extremely fast, getting names of the primary suspects and search warrants within that first week, which helped secure more physical evidence like that stolen necklace.

The report had evidence the teens talked about deleting videos and pictures, started up a private group chat and bought burner phones just days after the attack.

They went from threatening others to turning against each other, including one saying they wanted in on the $10,000 reward.

“Oftentimes, people turn on each other. They revert to saving themselves,” said Brice.

“There are reports and video surveillance alleging 10-15 in that group of primary suspects. Have your detectives been able to ID the number of suspects who attacked Preston?” asked Nicole Crites.

“Other people, we’re still looking at, the ability to be able to prove these facts. We said from the very beginning the arrests aren’t enough. It’s the conviction that we’re really looking for,” Brice said.

He said it wasn’t just about stealing a gold chain or getting someone to delete something off their phone. The attack was one of the most brutal he’s seen in his decades in law enforcement.

Brice added there are two new charges for adult suspects police have recommended to prosecutors. However, he wouldn’t say if these are for suspects who attacked Lord or others, perhaps for obstruction.

Brice is getting pushback from some of the witnesses who helped them build their case who feel outed since they are named in the report and some of the suspects implicated in the attack have yet to be arrested.

We asked him about why some witness names weren’t redacted in the report.

“The state of Arizona has a very specific set of laws about redaction,” Brice said. “If they provide their names as part of the submission, we have to include those in our report, and they can’t be redacted per state law. Now, I don’t think that’s great not only for the ability for us to get information but just the general idea of public safety. So we are looking at what we can do as a town and elected officials to help influence maybe the state legislature to update that law.”

The chief wants to encourage upstanders to keep coming forward. There’s strength in numbers, and you can now give tips anonymously.

“It’s not just a QCPD problem. It’s statewide, and something needs to change,” Brice said.

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Open access
Published: 16 January 2023

Lifestyle management in polycystic ovary syndrome – beyond diet and physical activity

Stephanie Cowan ORCID: orcid.org/0000-0001-6731-4221 1 ,
Siew Lim 2 ,
Chelsea Alycia 1 ,
Stephanie Pirotta 3 ,
Rebecca Thomson 4 ,
Melanie Gibson-Helm 1 , 5 ,
Rebecca Blackmore 6 ,
Negar Naderpoor 1 ,
Christie Bennett 7 ,
Carolyn Ee 8 ,
Vibhuti Rao 8 ,
Aya Mousa 1 ,
Simon Alesi 1 &
Lisa Moran 1

BMC Endocrine Disorders volume 23 , Article number: 14 ( 2023 ) Cite this article

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Polycystic ovary syndrome (PCOS) is a common condition affecting reproductive-aged women with reproductive, metabolic and psychological consequences. Weight and lifestyle (diet, physical activity and behavioural) management are first-line therapy in international evidence-based guidelines for PCOS. While these recommend following population-level diet and physical activity guidelines, there is ongoing interest and research in the potential benefit of including psychological and sleep interventions, as well as a range of traditional, complimentary and integrative medicine (TCIM) approaches, for optimal management of PCOS. There is limited evidence to recommend a specific diet composition for PCOS with approaches including modifying protein, carbohydrate or fat quality or quantity generally having similar effects on the presentations of PCOS. With regards to physical activity, promising evidence supports the provision of vigorous aerobic exercise, which has been shown to improve body composition, cardiorespiratory fitness and insulin resistance. Psychological and sleep interventions are also important considerations, with women displaying poor emotional wellbeing and higher rates of clinical and subclinical sleep disturbance, potentially limiting their ability to make positive lifestyle change. While optimising sleep and emotional wellbeing may aid symptom management in PCOS, research exploring the efficacy of clinical interventions is lacking. Uptake of TCIM approaches, in particular supplement and herbal medicine use, by women with PCOS is growing. However, there is currently insufficient evidence to support integration into routine clinical practice. Research investigating inositol supplementation have produced the most promising findings, showing improved metabolic profiles and reduced hyperandrogenism. Findings for other supplements, herbal medicines, acupuncture and yoga is so far inconsistent, and to reduce heterogeneity more research in specific PCOS populations, (e.g. defined age and BMI ranges) and consistent approaches to intervention delivery, duration and comparators are needed. While there are a range of lifestyle components in addition to population-recommendations for diet and physical activity of potential benefit in PCOS, robust clinical trials are warranted to expand the relatively limited evidence-base regarding holistic lifestyle management. With consumer interest in holistic healthcare rising, healthcare providers will be required to broaden their knowledge pertaining to how these therapies can be safely and appropriately utilised as adjuncts to conventional medical management.

Peer Review reports

Introduction

Polycystic ovary syndrome (PCOS) is a common condition affecting up to 13% of reproductive-aged women [ 1 ]. It is diagnosed through the European Society for Human Reproduction and Embryology/American Society for Reproductive Medicine (ESRHE/ASRM) criteria, requiring two of the following features: polycystic ovaries on ultrasound, oligoovulatory or anovulatory cycles and biochemical or clinical hyperandrogenism [ 2 ]. Women with PCOS experience a combination of reproductive (infertility, pregnancy complications) [ 3 ], metabolic (risk factors for and conditions of type 2 diabetes (T2DM) and cardiovascular disease (CVD)) [ 4 , 5 ] and psychological (conditions including anxiety, depression, poor quality of life (QoL), disordered eating) comorbidities [ 6 , 7 ].

Insulin resistance (IR) is defined as a key pathophysiological feature in PCOS, contributing to hyperandrogenism and worsening the clinical presentation of PCOS. While lean women present with IR in a form that is mechanistically different from IR caused by excess weight, overweight and obesity further exacerbate IR and consequent hyperinsulinaemia [ 8 ]. Women with PCOS also display a higher rate of weight gain over time [ 9 ] and a greater prevalence of overweight and obesity [ 10 ], which can further contribute to this worsening of IR and hence worsening of the presentation of PCOS [ 11 ]. The reason for this is unclear, but may be related to differences in intrinsic psychological and biological mechanisms [ 12 , 13 , 14 , 15 ], or extrinsic lifestyle factors such as diet and physical activity [ 16 , 17 ]. Improving IR and excess adiposity are therefore key targets in PCOS management.

The International Evidence-Based Guideline for the Assessment and Management of PCOS [ 18 ], highlights lifestyle intervention as the primary early management strategy. Lifestyle interventions are traditionally defined as those designed to improve dietary intake or physical activity through appropriate behavioural support. In the 2018 PCOS guideline, lifestyle management is recommended for general health benefits [ 18 ]. Given that excess weight is associated with increased IR in PCOS [ 8 ], the guideline additionally promotes weight management, defined as: 1) weight gain prevention in all women with PCOS, and 2) achieving and maintaining modest weight loss in women with excess weight [ 18 ].

Lifestyle interventions in PCOS management can also be viewed as a broader construct beyond physical health. Since the emergence of the biopsychosocial model of healthcare in 1977, health disciplines have seen a gradual shift away from the classical biomedical model (where health is defined as the ‘absence of disease’) towards whole person or holistic care [ 19 ]. This is an approach that reflects many facets of the patient context, via integrating care that addresses biological, psychological, social, spiritual and ecological aspects [ 20 ]. It therefore requires a range of different treatment strategies to improve health. Provision of whole person or holistic care has been identified as a core objective of healthcare reforms internationally [ 21 , 22 , 23 ]. In line with these reforms the PCOS guideline recognises the importance of emotional wellbeing to overall health and QoL in women living with PCOS [ 18 ]. It also highlights evidence which suggests that the psychological impact associated with PCOS is under-appreciated in clinical care [ 4 , 5 ], and that few women are satisfied with the mental health support they receive [ 6 , 7 ]. Recommendations for appropriate screening, assessment and treatment strategies for anxiety, depression, psychosexual dysfunction, eating disorders and poor body image are provided [ 18 ]. These specific areas of emotional wellbeing are of particular concern, with research showing a higher prevalence and severity of depression and anxiety [ 24 , 25 ], lower scores for satisfaction with sex life and feeling sexually attractive [ 26 ] and a higher prevalence of disordered eating and eating disorders [ 7 ] in women with PCOS. Features of PCOS, in particular hirsutism and increased weight, have also been shown to negatively affect body image [ 27 , 28 ], with poor body image being strongly related to depression in women with PCOS [ 29 , 30 ].

While the current PCOS guideline is comprehensive, considering all available evidence at the time of development and providing best-practice recommendations for necessary screening, risk assessment and management, it could not possibly cover all aspects of PCOS care. An International Delphi process was used to prioritise clinical questions, with consensus reached through extensive consultation with both consumers and multidisciplinary clinicians with expertise in PCOS care. Therapies, such as traditional, complementary and integrative medicine (TCIM), supplement use, sleep and meditation interventions are either briefly considered or not at all included in the 2018 PCOS guideline. Many of these therapies are novel and there is a paucity of evidence to support intervention efficacy on PCOS outcomes. However, as patient interest in these types of non-pharmacological interventions are growing [ 31 , 32 , 33 , 34 , 35 ], it is prudent to provide more guidance to healthcare providers in this area on their potential efficacy in PCOS. Whole person or holistic care recognises that the doctor-patient relationship should be one of open dialogue, where healthcare providers involve the patient in negotiating their care and recognises patient’s autonomy to guide treatment (Figure 1 ) [ 36 ].

Viewing lifestyle modifications through a whole person or holistic care lens. The key features of whole person or holistic care listed in the centre of the figure have been adapted from Thomas et al. [ 20 ]. ‘Recognises individual personhood’ relates to focusing on the unique needs of the person rather than the disease. ‘Importance of therapeutic relationship’ emphasises patient autonomy and responsibility. ‘Acknowledges humanity of the doctor’ considers the doctors’ ability to self-reflect on how they engage in the care of the patient. ‘Health as more than absence of disease’ incorporates the mental, emotional, physical, environmental and social needs of the patient. ‘Employs a range of treatment modalities’ promotes continuity of care across health disciplines, and while it may include traditional, complementary and integrative medicine (TCIM), TCIM is not holistic if used in isolation and without adequate integration into conventional healthcare

This review provides an extensive overview of evidence to date on lifestyle strategies used to optimise management of PCOS. Using a holistic definition of patient care, this review considers the traditional components of lifestyle change (diet, physical activity and behavioural change), psychological and sleep interventions, as well as TCIM approaches (supplements, herbal medicine, acupuncture and yoga). To improve translation of findings, evidence summaries are accompanied by an overview of relevant recommendations from the existing PCOS guideline. This highlights where emerging evidence supports current recommendations or provides new insights for research. As this is a narrative review, while evidence summaries include peer-reviewed journal articles identified from databases including Medline OVID, this is supplemented by expert opinion of the authors.

Traditional lifestyle and weight management

The PCOS guideline recommends the promotion of healthy lifestyle behaviours in all women with PCOS, to achieve and/or maintain a healthy weight and to optimise general health [ 18 ]. In women with excess weight, a weight loss of 5-10% is advised, aiming for an energy deficit of 30% or 500-750 kcal/day (1200-1500 kcal/day). While weight management is seen as a core component of lifestyle interventions, the guideline recognises that a healthy lifestyle provides benefits that occur independent of weight change.

A recent Cochrane review of 15 randomised controlled trials (RCT) and 498 participants, reported that lifestyle interventions compared with minimal intervention or usual care, significantly reduces weight (kg) and body mass index (BMI) and improves secondary reproductive outcomes such as free androgen index (FAI), testosterone (T), sex hormone-binding globulin (SHBG) and hirsutism (Ferriman-Gallwey score) [ 37 ]. In terms of metabolic outcomes, lifestyle intervention resulted in significant reductions in total cholesterol (TC), low density lipoprotein cholesterol (LDL-C) and fasting insulin (FINS). These findings are largely similar to that of other systematic reviews [ 38 , 40 , 41 , 41 ]. While no studies in the Cochrane review assessed clinical reproductive outcomes [ 37 ], individual trials that were not included in the review have reported that lifestyle interventions resulting in modest weight loss (2-5% total body weight) improve ovulation and menstrual regularity [ 42 , 44 , 45 , 45 ]. Losing >5% of weight is additionally associated with being able to conceive, having live births, reduction of ovarian volume and reduction in the number of follicles [ 46 , 48 , 49 , 50 , 51 , 52 , 52 ].

Although weight loss has shown clear benefits to PCOS outcomes, including not only on reproductive function, but also glucoregulatory status, androgen status and lipid profiles [ 42 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 52 ], there are varying degrees of responsiveness to weight loss in terms of improvement of PCOS symptoms. One study by Pasquali et al. [ 53 ] found that when women achieved similar levels of weight loss (>5% weight) only one-third displayed a full recovery from PCOS, with the remainder showing only partial or no recovery. Higher waist circumference (WC), waist-hip-ratio (WHR) and androstenedione at baseline were associated with a poorer chance of successful outcomes [ 53 ], suggesting that central adiposity and more severe hyperandrogenism may predict responsiveness to weight loss interventions in PCOS. Huber-Bucholz et al. [ 45 ] also reported women who achieve greater reductions in central fat and insulin sensitivity show greater symptom improvement with weight loss. This suggests that lifestyle interventions which simultaneously reduce IR and improve body composition (namely fat distribution), may help to optimise outcomes in PCOS management independent of changes in weight status.

The 2018 PCOS guideline recognises there is insufficient evidence to suggest that any specific dietary approaches provide greater benefits on health outcomes [ 18 ]. Dietary recommendations may take on a variety of balanced dietary strategies according to the individual’s lifestyle needs and preferences, as per general population recommendations [ 18 ]. This advice is based on a systematic review comparing different dietary compositions (e.g. low carbohydrate, low glycaemic index (GI) and glycaemic load (GL), high protein, monounsaturated fatty acid (MUFA) enriched and fat counting diets) to best manage PCOS, identifying minimal differences between diets on anthropometric outcomes, concluding weight loss improves the presentation of PCOS regardless of dietary composition [ 16 , 54 ]. There is now an emerging body of evidence that suggests a range of dietary strategies may produce favourable effects on PCOS features that occur independent of weight loss. It is important that the emerging findings from these studies are thoroughly considered to support consumer and health professional interests. To summarise current evidence this review has grouped diets in terms of those that modify carbohydrates, protein and fat, as well as specific dietary patterns.

Carbohydrates

The use of altered carbohydrate composition remains the most researched dietary approach for PCOS management. Two systematic reviews published after guideline inception support altered carbohydrate intake to improve intermediate markers of PCOS [ 55 , 56 ], finding that altering carbohydrate type, as opposed to content, is preferable to better manage PCOS [ 55 ]. RCTs [ 57 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 72 ] and pre-post intervention studies [ 73 , 75 , 76 , 77 , 78 , 79 , 80 , 80 ] demonstrate that following a low GI/GL diet for at least eight weeks significantly reduces WC [ 55 , 73 , 74 ] and BMI when compared to high GI/GL [ 56 ] or a regular diet [ 73 , 75 , 76 , 76 ], although levels of weight loss are generally comparable to other dietary compositions [ 59 , 60 , 72 , 74 ]. These reductions are proposed to be a result of decreased hunger, which may reduce energy intake and make it easier to follow dietary recommendations in the long-term [ 78 , 81 , 83 , 84 , 84 ]. Low GI/GL diets also improve insulin sensitivity and reproductive hormones (T, SHBG, FAI) compared to high carbohydrate [ 16 , 55 , 57 , 79 , 85 ] or control diets [ 56 , 59 , 73 , 75 , 76 , 76 ], contributing to improvements in reproductive function, specifically menstrual regularly [ 60 , 79 ]. Lastly, low GI/GL diets can improve risk factors for T2DM and CVD, including glucose [ 86 , 87 ], TC [ 55 , 56 , 59 , 75 , 77 ], LDL-C [ 55 , 59 , 75 , 85 ], TAG [ 55 , 59 , 73 ] and HDL-C [ 75 ], when compared to a regular or high GI/GL diet. It must be noted that beneficial effects of low GI/GL diets may also be attributed to proportional increases in protein and/or fat loads.

In women with PCOS higher protein intakes may be superior at supressing androgen levels when compared to high carbohydrate diets. Postprandial research has shown that high protein meals can reduce insulin and dehydroepidiandrosteone stimulation compared to meals rich in glucose [ 88 ]. Research in the general population has also shown that reduced appetite and energy intakes from low GI/GL diets are related to increased protein intakes [ 89 , 90 ]. RCTs and pre-post intervention studies found that high protein diets (defined here as protein constituting ≥25% energy [ 91 ]) consumed for at least four weeks reduce weight [ 12 , 73 , 74 , 92 , 94 , 95 , 96 , 96 ], BMI [ 73 , 74 , 92 , 95 ], WC [ 73 , 74 , 92 , 97 ], WHR [ 73 ] and fat mass [ 74 , 92 , 97 ]. These reductions in anthropometric measures are accompanied by improved FINS [ 12 , 74 , 95 , 98 ] and HOMA-IR [ 12 , 73 , 95 , 98 ], blood lipids [ 12 , 96 ], T [ 73 , 92 , 94 ] and hirsutism (Ferriman-Gallwey score) [ 73 ]. However, only three of these studies were able to show significant improvements in anthropometric measures [ 97 ], insulin sensitivity [ 98 ] and blood lipids [ 12 ] when compared to low/standard protein [ 12 , 97 ] or control diets [ 98 ]. Only one study investigated effects on mental health outcomes and found that a high protein diet reduced depression and improved self-esteem [ 99 ].

Fatty acid composition is also an important consideration as metabolic disorders associated with PCOS can benefit from increased MUFA and polyunsaturated fatty acid (PUFA) intakes [ 63 , 65 , 65 ]. Postprandial research in PCOS reported prolonged reductions in T for high fat compared to low fat meals, which likely results from delayed nutrient absorption [ 86 ]. Two acute meal studies in lean and obese women with and without PCOS reported that proatherogenic inflammatory markers [ 100 ] and oxidative stress [ 101 ] were elevated, independent of but augmented by obesity, following saturated fat ingestion with this associated with worsened IR and androgens. Two experimental studies in PCOS investigated the effects of habitual walnut (PUFA rich diet) [ 102 , 103 ] and almond (MUFA rich diet) [ 102 ] intake for at least six weeks and reported no differences in glucoregulatory status, lipids or androgens with the exception of HbA1c significantly decreasing in the walnut relative to the almond group. Kasim-Karakas et al. [ 103 ] reported increased fasting and postprandial glucose (oral glucose tolerance test (OGTT)) for increased walnut intake compared to habitual (control), which they postulated may be related to the control diet being rich in oleic acid. Together these findings suggest minimal benefit for improving dietary PUFA compared to MUFA content. Two RCTs in women with PCOS investigated the effects of diets rich in olive [ 104 , 105 ], canola [ 105 ] and sunflower [ 105 ] oil. Yahay et al. [ 105 ] reported 25g/day canola oil caused reductions in TAG, TC/HDL-C, LDL-C/HDL-C, TAG/HDL-C and HOMA, but not androgens, compared to 25 g/day olive and sunflower oils [ 105 ]. This may be related to the more favourable fatty acid composition of canola oil, with comparable MUFA content to olive oil, higher alpha-linolenic acid, lower omega-6/omega-3 ratio and saturated fat than both olive and sunflower oils. Douglas et al. [ 104 ] reported weight and the acute insulin response (OGTT) were lower following a eucaloric low carbohydrate compared to a eucaloric MUFA-enriched olive oil diet, suggesting that reduced carbohydrate intake may have grater glucoregulatory benefits than increased MUFA intake [ 104 ]. Lastly, two RCTs compared hypocaloric low-fat diets to a low carbohydrate [ 106 ] or low GI [ 107 ] diets, with reductions in weight [ 106 ], WC [ 106 ], body fat [ 106 , 107 ], FINS [ 106 ] and FAI [ 106 ] in both groups but no difference between groups.

Dietary and eating patterns

In addition to diets that focus on specific macronutrient manipulations, there are a range of dietary patterns which have been explored in PCOS management. A systematic review (including 19 studies and 1,193 participants) published after guideline development (2020) found that the Dietary Approaches to Stop Hypertension (DASH) diet (rich in fruit, vegetables, wholegrains, nuts, legumes and low-fat dairy and with a predominantly low-GI carbohydrate profile) was the optimal choice for reducing IR [ 85 ]. RCTs in PCOS also report beneficial effects on weight [ 63 , 64 ], BMI [ 62 , 63 ], IR [ 62 ] and hormonal profile, including SHBG [ 64 ], androstenedione [ 64 ] and FAI [ 62 ] for a DASH compared to a control diet after 8-12 weeks. A vegetarian diet also reduced inflammatory markers (CRP, resistin and adiponectin) compared to a meat inclusive diet [ 80 ]. A vegan diet improved weight loss at three, but not six months [ 68 ], and a pulse-based diet led to similar reductions in weight, insulin sensitivity and reproductive hormones compared to a healthy control diet [ 72 ]. All of these dietary patterns are high in fibre and plant proteins, producing favourable effects on microbial diversity and encouraging production of short-chain fatty acids that possess potential anti-inflammatory actions [ 108 , 109 ]. With mechanistic animal studies suggesting a possible pathophysiological role of gut microbiota in IR and ovarian dysfunction, it is possible that metabolic and hormonal benefits associated with plant-based dietary patterns in PCOS are related to increased intakes of dietary prebiotics [ 110 ]. However, further mechanistic studies exploring the role of gut microbiota in PCOS and RCTs investigating effects of dietary prebiotics on PCOS outcomes are required.

Lastly, particular eating patterns, such as eating smaller more frequent meals across the day [ 111 ] and eating a larger breakfast and smaller dinner [ 66 ], have also been found to be beneficial for insulin sensitivity [ 66 , 111 ] and androgen reductions [ 66 ]. This is an important finding, as women with PCOS are more likely to either skip breakfast or consume their breakfast and lunch later in the day [ 112 ].

Studies examining specific food items in relation to PCOS outcomes, including raw onions [ 65 ], concentrated pomegranate juice [ 69 , 113 , 115 , 115 ] and flaxseed powder [ 70 , 116 ] have yielded largely inconsistent results. A core limitation of these single food studies is that foods are never consumed alone within the diet, omitting the influence of the dietary matrix and the interactions that occur amongst dietary constituents within meals. These studies provide limited applicability in the context of formulating practical dietary recommendations [ 117 ]. Please see Table 1 for a summary of available evidence from reviews and experimental studies investigating the effects of different types of diets on PCOS outcomes.

Physical activity

The 2018 PCOS guideline recommends ≥150 minutes per week of moderate or ≥75 minutes per week of vigorous intensity exercise for weight gain prevention, and ≥250 minutes per week of moderate or ≥150 minutes per week of vigorous intensity exercise for weight loss and weight regain prevention [ 18 ]. Minimising sedentary time and the inclusion of strength training exercise for two days per week is also recommended [ 18 ].

To date the most comprehensive review in PCOS (including 27 papers from 18 trials up until June 2017) reported that exercise improved FINS, HOMA-IR, TC, LDL-C, TAG, body composition (body fat percentage and WC) and aerobic fitness (VO 2max ) [ 119 ] compared with usual care or control groups. In regards to exercise type, subgroup analysis reported aerobic exercise improved BMI, WC, body fat percentage, FINS, HOMA-IR, TC, TAG and VO 2max . In contrast, while resistance training produced unfavourable effects on HDL-C (decrease) and BMI (increase), it improved other measures of anthropometry, including WC. Combined interventions (using both aerobic and resistance training) had no effect on any of the measured markers. Subgroup analysis also found that more outcomes improved when interventions were supervised, of a shorter duration (≤ 12 weeks) and were conducted in women who were above a healthy weight [ 119 ].

Three more recent systematic reviews have looked at the effects of specific types of exercise on PCOS outcomes [ 120 , 122 , 122 ]. These reviews found that vigorous aerobic exercise can improve measures of insulin responsiveness and resistance, including HOMA-IR [ 121 ] and the insulin sensitivity index [ 120 ]; body composition, including WC [ 121 ] and BMI [ 122 ]; and cardiorespiratory fitness (VO 2max ) [ 121 ]. High intensity interval training (HIIT) alone may be effective for improving IR and BMI [ 123 ], however this has not been consistently shown [ 124 ]. Interventions involving a combination of aerobic and resistance exercise [ 122 ] or resistance training only [ 120 ] did not result in improvements in BMI [ 122 ] or weight status [ 120 ]. Exercise involving resistance training did result in other beneficial improvements to body composition (reduced body fat, WC and increased lean mass) and strength. This is important, as the degree of central adiposity predicts responsiveness to weight loss interventions in PCOS [ 53 ], and women who achieve greater reductions in central fat show greater symptom improvement with weight loss [ 45 ]. Resistance training may also improve androgen levels, though findings are inconsistent and more research is needed to draw definite conclusions [ 120 ]. There was insufficient evidence from available data to assess the effects of exercise type on reproductive function [ 122 ]. Please see Table 2 for a summary of available evidence from meta-analyses investigating the effects of different types of exercise on PCOS outcomes.

When comparing the effects of exercise and diet combined with diet alone, a systematic review and meta-analysis (three studies) found no differences for any measured outcomes (glucose, insulin HOMA-IR, weight, BMI, WC, body fat, fat free mass, T, SHBG and FAI) [ 119 ]. In regards to exercise and diet combined compared to exercise alone, subgroup analysis (including 17 studies) from a large systematic review found that the addition of diet to exercise, particularly vigorous intensity aerobic exercise, resulted in greater reduction to BMI, WC, FAI and HOMA-IR than exercise only [ 121 ]. In regards to exercise (aerobic) alone versus diet alone, one intervention study found that exercise induced weight loss produced greater improvements in menstrual frequency and ovulation rates [ 125 ], with no differences in pregnancy rates [ 125 ]. However, this study was not randomised and treatments were self-selected, which may have biased the results and precludes firm conclusions [ 125 ].

Behavioural

The 2018 PCOS guideline promotes the use of behavioural interventions that foster self-efficacy [ 18 ]. These include the use of SMART (specific, measurement, achievable, realistic and timely) goals, self-monitoring, stimulus control, problem solving and relapse prevention [ 18 ].

Behavioural and cognitive interventions are required to improve sustainability of lifestyle changes, through considering not only the specific behaviour, but also their antecedents, consequences and cognition [ 126 , 127 ]. Given that women with PCOS show higher rates of weight gain over time [ 9 ] and high attrition rates in clinical weight management research [ 37 ], there is a clear need to improve adherence to diet and physical activity interventions. However, the majority of research investigating lifestyle change in PCOS involve short-term dietary interventions with/without an exercise element, and there is a paucity of research on behavioural change strategies. As such, guideline development relied heavily on evidence taken from the general population. Only three RCTs in women with PCOS included a ‘behavioural intervention’ [ 128 , 130 , 130 ]. While these studies showed enhanced weight loss [ 128 , 130 ] and improved androgen and lipid profiles [ 129 ] when compared with placebo, the interventions were not well defined, with negligible context provided regarding the theoretic framework or behavioural strategies utilised.

More recently, a cross-sectional study in 501 women with PCOS [ 131 ] and two RCTs [ 44 , 132 ] explored the use of self-management strategies [ 131 ] and behavioural modification interventions [ 44 , 132 ] in PCOS. In the cross-sectional study, implementation of physical activity self-management strategies improved the likelihood of meeting physical activity recommendations, but had no association with BMI. Dietary self-management strategies were associated with reductions in BMI, though were not related to weight or nutritional intake [ 131 ]. In the RCTs, only the behavioural modification programme and not the control (general healthy lifestyle recommendations) produced significant weight loss after four months. A significantly greater proportion of women in the intervention group also improved menstrual regularity [ 44 ] and psychological well-being (lower anxiety and depressive symptoms) [ 132 ] when compared to the control group. The women who achieved greater weight loss reported higher social desirability and lower embitterment scores on a personality trait assessment measure [ 132 ]. These findings are particularly novel, as they provide insight into the influence of personality traits and their contribution to success in following behavioural modifications [ 132 ].

Alcohol and smoking

In the clinical setting, smoking and alcohol consumption are often addressed alongside dietary and physical activity changes, employing the same behavioural and cognitive interventions to promote adherence. Hence, alcohol and cigarette use are considered here under traditional lifestyle strategies. The PCOS international guideline highlights the importance of assessing alcohol consumption and cigarette smoking when improving fertility and reproductive outcomes in women with PCOS [ 18 ]. Assessment of cigarette use is also recommended when evaluating CVD risk factors and thromboembolism risk associated with oral contraceptive pills [ 18 ]. These recommendations are based on existing practice guidelines used for the general population.

There is a paucity of observational research characterising alcohol consumption in women with PCOS. One Swedish study comparing women with PCOS ( n =72) to healthy controls ( n =30), demonstrated a lower alcohol intake in the PCOS group [ 133 ]. A larger study in Australia comparing women with ( n =409) and without ( n =7,057) PCOS, reported no significant difference in alcohol intake [ 134 ]. Similarly, a Spanish study ( n =22 PCOS and n =59 controls) and a Chinese study ( n =2,217 PCOS and n =279 controls), found no significant difference in alcohol intake between PCOS and non-PCOS groups [ 135 , 136 ].

Current evidence on the impact of alcohol intake on anovulatory infertility (a common feature of PCOS) is controversial, with some studies showing adverse effects and others reporting no significant correlation [ 136 , 137 ]. One prospective study including 18,555 married women from The Nurses’ Health Study II, who had no history of infertility, found no clinically significant impact of alcohol intake on anovulatory infertility, after adjusting for parity and other factors [ 138 ]. Similarly, a Danish study ( n =6,120 women aged 21 to 45 years) found no fertility effect with alcohol consumption of less than 14 standard drinks per week [ 137 ]. In contrast, a study on 3,833 women who recently gave birth and 1,050 women with infertility, reported an increased risk of anovulatory infertility and endometriosis with increasing alcohol intake [ 139 ].

Current observational evidence does not reveal any significant difference in smoking between women with and without PCOS [ 135 , 136 , 140 ], with the exception of one study in pregnant women which showed a lower smoking rate in women with PCOS ( n =354) compared to women without PCOS at 15 weeks gestation [ 3 ]. However, a significantly higher rate of smoking (including passive and active) is reported in women with PCOS and oligo-anovulation and/or reduced fertility compared to women with PCOS and normal menstruations or healthy controls [ 141 , 142 ]. Smoking is also associated with PCOS risk independent of BMI and age [ 142 ]. A Mendelian randomisation study supports these findings, demonstrating a 38% higher risk of PCOS development in genetically predicted smokers (based on single-nucleotide polymorphisms associated with smoking initiation) compared with those who never smoked [ 143 ]. In PCOS, smoking is associated with increased levels of T, DHEAS, TC, LDL-C and FINS [ 141 , 144 , 145 ]. However, the underlying mechanisms are not fully understood and there are inconsistencies in findings from different studies. Furthermore, smoking is associated with lower conception and live birth rates and less favourable ART outcomes in women with PCOS [ 141 , 146 ].

Psychological

The current guideline highlights the need for awareness, and appropriate assessment (such as stepwise screening) and management, of QoL, depression and anxiety, psychosexual dysfunction, negative body image and disordered eating [ 18 ]. The guideline emphasises the importance of clinicians and women working in partnership to address women’s individual priorities; understanding that the impact of PCOS on an individual’s QoL is key to delivering meaningful outcomes [ 147 , 148 ]. To assist women to communicate with clinicians about what is important to them, the PCOS Question Prompt List [ 149 ] was developed and is consistent with the 2018 guideline. The 2018 guideline recommends screening for risk factors and symptoms of depression and anxiety at time of diagnosis. Women with positive screening results should be supported with further assessment and treatment by appropriately qualified clinicians. To screen for psychosexual dysfunction tools such as the Female Sexual Function Index [ 150 ] should be utilised. If negative body image, disordered eating or eating disorders are suspected, the PCOS guideline outlines a stepped approach for screening, and where appropriate promotes the use of psychological therapy offered by trained health professionals, which should be guided by regional clinical practice guidelines [ 18 ].

While the PCOS guideline provides justification and summarises evidence for mental health screening and diagnostic assessment, there is also a need for consideration of additional aspects, such as the efficacy of different types of psychological interventions and how psychological interventions influence engagement with lifestyle change. This is important, as poorer mental health outcomes at baseline are positively associated with higher rates of attrition in lifestyle interventions [ 13 ]. Cognitive behavioural interventions could be considered to improve engagement and adherence to healthy lifestyle in women with PCOS. Research has shown support for a range of different psychological interventions, such as counselling [ 151 ], cognitive behavioural therapy (CBT) [ 152 , 154 , 154 ] and mindfulness meditation [ 155 , 156 ], helping to change the way clinicians’ approach and deliver optimal PCOS management.

CBT is one of the most widely-researched psychological interventions, and is well-recognised as the most effective psychological treatment for depression and anxiety [ 157 ]. One RCT showed that eight weekly group CBT sessions were effective in improving QoL ratings and reducing psychological fatigue in women with PCOS [ 152 ]. Another more recent RCT investigated the outcome of a 1 year three-component intervention focusing on CBT, diet and exercise [ 154 ] and reported improvements in self-esteem and depressive symptoms as compared to usual care [ 154 ]. Similarly, an RCT by Cooney et al. [ 153 ], comparing the effects of CBT and lifestyle modification versus lifestyle modification alone, reported the CBT/lifestyle modification group lost more than twice as much weight per week and had greater improvements in QoL compared to lifestyle only. Depression scores decreased in the overall group and there was no difference between the two groups [ 153 ]. Lastly, a pilot intervention study of adolescents with PCOS has shown promising results for the use of CBT in the reduction of weight and improvement in depressive symptoms [ 158 ].

Mindfulness meditation programs have gained increasing popularity over the past few decades, and are being included as part of clinical trials to reduce stress and improve psychological wellbeing across a range of medical conditions [ 159 ]. Mindfulness meditation can be used to reduce the production of adrenal androgens, activated via the adrenal glands as a direct result of psychological distress [ 156 ]. Despite the proposed benefits, there are very few studies investigating the use of mindfulness meditation as a treatment for psychological symptoms associated with PCOS. One RCT ( n =86) compared the provision of an eight week mindfulness-based stress reduction (MBSR) program, and found that when compared to the control group (health education), the MBSR group produced greater reductions in perceived stress, depressive symptoms and fasting blood glucose [ 160 ]. Similarly, another RCT investigating the impact of mindfulness meditation for eight weeks in PCOS showed reduced stress, depression and anxiety symptoms, and increased life satisfaction and QoL in the intervention group compared to no treatment [ 156 ]. In adolescents with PCOS ( n =37), a pilot RCT reported higher levels of nutrition and physical activity self-efficacy following a mindfulness and self-management program [ 161 ]. Mindfulness-based cognitive therapy (MBCT) combines both elements of MBSR and CBT, but as yet there are no trials investigating this intervention in PCOS.

In addition to CBT and mindfulness meditation, there is some evidence to support group counselling sessions as beneficial in conjunction with exercise programs to increase and support weight loss [ 151 ]. In one RCT ( n =17) participants followed a high-intensity aerobic exercise program for eight weeks, followed by eight weeks of group counselling [ 151 ]. Qualitative analysis of data taken from the group counselling and physical exercise sessions revealed that development of supportive relationships was important for successful behavioural change. By fostering the exchange of narratives relating to their illness (e.g. effects of PCOS on aspects of everyday life), and generating feedback between group members, counselling sessions helped to reduce social isolation and improve adherence to the exercise intervention [ 151 ]. Please see Table 3 for a summary of experimental studies investigating effects of psychological interventions on PCOS outcomes.

Women with PCOS have an increased risk of both clinical sleep disorders and non-clinical sleep disturbance, which is mediated by hormone derangement, in particular reduced oestrogen, progesterone and melatonin levels [ 164 ]. Oestrogen is required for the metabolism of neurotransmitters (norepinephrine and serotonin) involved in regulating sleep patterns, and plays an important role in maintaining a low body temperature at night [ 165 ]. Progesterone has sedative and anxiolytic actions that can support sleep quality, and acts as a respiratory stimulant that lessens airway resistance in obstructive sleep apnoea (OSA) [ 166 ]. Melatonin is a neuroendocrine hormone that is widely recognised as crucial in maintaining circadian rhythm regulation. However, melatonin is also involved in ovarian function, with actions including delaying ovarian senescence, promoting follicle formation and improving oocyte quality [ 167 , 169 , 170 , 171 , 172 , 173 , 173 ].

The current PCOS guideline recognises that OSA is 6.5-8.3 times more likely in women with PCOS [ 164 , 174 , 176 , 177 , 177 ], and promotes routine screening to identify and treat associated symptoms, such as snoring, excessive sleepiness and the potential for fatigue to worsen mood disorders [ 18 ]. Screening should include a simple questionnaire, such as the Berlin tool [ 178 ], and where appropriate women should be referred onto a specialist for further assessment and treatment [ 18 ]. The guidelines also highlight that treatment of OSA in PCOS should not be used to improve metabolic features. Since guideline inception evidence has emerged reporting weight, PCOS and sleep are interrelated factors that can each contribute to the worsening presentation of one another, whereby sleep disorders and disturbance may worsen the presentation of PCOS related metabolic outcomes and vice versa [ 179 ].

Hypersomnia and insomnia are also common clinical sleep disorders in PCOS [ 164 , 177 , 180 ], with prevalence estimated at 11% versus 1% in women with versus those without PCOS [ 180 ]. Even in the absence of clinically diagnosed sleep disorders, women with PCOS have a higher prevalence of sleep disturbances, including poor sleep quality [ 181 ], issues with sleep initiation [ 182 ], severe fatigue [ 140 ], restless sleep [ 140 ] and difficulty sleeping overnight [ 140 ]. The prevalence of sleep disturbances may be up to 20% higher in women with PCOS compared to women without PCOS [ 183 ]. Emerging research also suggests that social restrictions arising from the COVID-19 pandemic have worsened sleep disturbances in women with PCOS [ 177 ]. Findings from key studies of non-clinical sleep disturbance can be found in Table 4 .

In the general population short and disturbed sleep is consistently associated with excess weight [ 184 ], IR [ 185 ], T2DM [ 185 ] and CVD [ 186 ]. Similar relationships are observed in PCOS, where OSA and sleep disordered breathing exacerbates risk of IR and metabolic consequences of abnormal glucose tolerance [ 187 , 188 ]. A cross-sectional study in adolescents with PCOS ( n =103) reported those with sleep disordered breathing had significantly higher BMI Z-scores, and a higher prevalence of metabolic syndrome (METS) [ 188 ]. Similar metabolic consequences are seen in women with PCOS who suffer from non-clinical sleep disturbance [ 164 ]. Underlying mechanisms linking sleep disorders and disturbance with worsened metabolic outcomes include amplified sympathetic tone and oxidative stress [ 164 ], reduced adipose tissue lipolysis, and an increase in energy intake stemming from heightened hedonic and endocrine appetite signals [ 189 ].

Unfavourable effects on energy metabolism and appetite regulation, may explain why women with PCOS who display sleep disturbance have a reduced capacity to maintain dietary interventions [ 183 ]. Moreover, depression and anxiety share a bidirectional relationship with disrupted and reduced sleep [ 190 ], and as stated previously, interventions that improve mental health can help to increase engagement with dietary and physical activity recommendations [ 131 ]. Optimising sleep may therefore be an important consideration when promoting healthy lifestyle change in women with PCOS [ 183 ].

Traditional, complementary and integrative medicine

The 2018 PCOS guideline includes recommendations on inositol supplementation, though do not include evidence regarding the use of other supplements, herbal medicine or other TCIM approaches, including acupuncture and yoga [ 18 ].

Vitamins, vitamin-like supplements, minerals and other supplements

The 2018 guideline highlights that inositol (including myo-inositol (MI) and di-chiro inositol) is a nutritional supplement that may be involved in insulin signalling transduction [ 191 ]. MI in particular is a key endocrine regulator that displays impaired metabolism in PCOS [ 191 ]. MI supplementation has been explored in a meta-analysis of nine RCTs ( n =496), which showed improved metabolic profiles and reduced hyperandrogenism [ 191 ]. These findings are supported by two earlier meta-analyses, reporting improved ovulation, menstrual cyclicity, and hormonal profiles following MI supplementation [ 192 , 193 ]. The 2018 PCOS guideline recommends that inositol (in any form) should be considered as an experimental therapy in PCOS management. The guideline also recognises that women participating in any form of TCIM should be encouraged to advise their health professional. However, it does not consider emerging evidence for the use of other types of TCIM in PCOS treatment as this was outside of the scope of the 2018 guideline.

B-group vitamins (B 1 , B 6 and B 12 ), folic acid (B 9 ) and vitamins D, E, and K are critical for several biological processes that can affect metabolic and reproductive features of PCOS. B-group vitamins work alongside folic acid (the synthetic form of folate) to regulate homocysteine (Hcy) via re-methylation of Hcy to methionine [ 194 ]. Hcy is an amino acid that confers an increased risk of CVD at high levels, and which is often deranged in women with PCOS [ 195 ], likely related to a higher prevalence of folate deficiency [ 196 , 197 , 198 ]. One RCT explored the use of B-group vitamins combined with folic acid in 60 women with PCOS, and reported a reduction in the Hcy increasing effect of metformin [ 198 ]. Folic acid alone has also been examined in two RCTs of women with PCOS ( n =69 [ 199 ] and n =81 [ 200 ]), improving FINS, HOMA-IR, C-reactive protein, total antioxidant capacity (TAC) and glutathione with doses ≥ 5 mg/day when compared with placebo [ 199 , 200 ]. Regarding vitamin D supplementation, three large-scale meta-analyses reported improvements in measures of IR (HOMA-IR [ 201 , 202 ], FINS [ 201 ]), fasting glucose [ 201 ]), lipid profiles (LDL-C [ 201 , 202 , 203 ], TC [ 203 ] and TAG [ 203 ]) and androgens (T) [ 202 ], when compared with placebo. While vitamin E (or tocopherol) has various reported benefits on fertility outcomes in other populations [ 204 ], and has improved androgen profiles when co-supplemented with coenzyme Q10 (CoQ10) in women with PCOS [ 205 ], to date no RCTs have examined the use of vitamin E supplements alone in PCOS. Vitamin K also has limited available literature in PCOS, with only one RCT ( n =84) demonstrating improvements in anthropometry, insulin and androgen profiles following supplementation (90 μg/day Menaquinone-7 for eight weeks), compared with placebo [ 206 ].

Vitamin-like supplements

Vitamin-like supplements including bioflavonoids, carnitine and alpha-lipoic acid (α-LA) have well-recognised antioxidant properties and play a role in fatty acid and glucose metabolism, providing possible metabolic benefits in PCOS [ 207 ]. Bioflavonoids consist of plant-derived polyphenolic compounds, some of which have been inversely associated with METS in women with PCOS [ 207 ]. In a pilot prospective study of 12 women with PCOS, 36 mg/day of the soy isoflavone genistein for six months improved lipid profiles but not anthropometry, IR, hormonal profiles or menstrual cyclicity [ 208 ]. Carnitine, particularly the active form L-carnitine, is reported to be lower in women with PCOS and linked with hyperandrogenism, hyperinsulinaemia and reduced oocyte quality [ 209 , 210 ]. One RCT explored L-carnitine use in PCOS and found beneficial effects on mental health parameters and markers of oxidative stress [ 211 ], although the integrity of these have come under scrutiny and hence should be interpreted with caution [ 122 212 ]. Regarding α-LA, a small pre-post study ( n =6) administered 1200 mg/day for 16 weeks, and reported improved IR, LDL-C and TAG, though no effects on TAC or plasma oxidation metabolites [ 213 ]. Another RCT reported improved anthropometric (BMI), metabolic (FINS and HDL-C) and reproductive (menstrual cyclicity) features in 46 women with PCOS receiving α-LA supplementation (600 mg/day for 180 days) compared with controls [ 214 ]. However, as these women were co-supplemented with 1000 mg/day D-chiro-inostiol, findings are not isolated to the effects of α-LA alone [ 214 ].

Minerals such as calcium, zinc, selenium, magnesium and chromium picolinate (CrP) have been explored in PCOS due to their reported insulin sensitising, antioxidant and anti-inflammatory properties [ 215 , 216 , 217 ]. A small number of studies have also reported women with PCOS are at higher risk of being deficient in calcium [ 218 ], zinc [ 215 , 217 ] and selenium [ 195 ]. A recent systematic review (six RCTs) reported that vitamin D and calcium co-supplementation in women with PCOS improved lipid and androgen profiles, follicular health and menstrual cyclicity [ 219 ]. While these findings are promising, it is difficult to attribute benefits to calcium alone, given calcium is often co-supplemented with vitamin D due to their complementary mechanisms of action. One systematic review (five RCTs) in PCOS reported zinc (often co-supplemented with other nutrients such as calcium, vitamin D and magnesium), improved HOMA-IR, lipids, T, FSH and DHEAS [ 220 ] compared to placebo. Another systematic review (five RCTs) examining selenium supplementation reported reduced IR, oxidative stress and inflammation, while results for anthropometry, lipids, androgens and hirsutism were inconsistent [ 221 ]. Regarding magnesium (an intracellular cation involved in insulin metabolism), while supplementation in PCOS has been associated with reduced IR in observational research [ 222 ], these findings are not supported by data from RCTs, with considerable inconsistencies between studies [ 222 ]. Two meta-analyses examined CrP in women with PCOS [ 223 , 224 ]. While one reported that CrP supplementation reduced BMI, FINS and free testosterone [ 223 ], the other reported decreased IR, but not BMI, and increased levels of T [ 224 ].

Other supplements

Other supplements purported to provide a range of antioxidant and anti-inflammatory benefits, including omega-3 fatty acids, N-acetyl-cysteine (NAC), CoQ10, probiotics, quercetin, resveratrol and melatonin have been explored in PCOS. A meta-analysis (nine RCTs) of women with PCOS ( n =591) receiving omega-3 supplementation reported reductions in HOMA-IR, TC, TAG and LDL-C, though showed no effect on other metabolic parameters or T [ 225 ]. In a meta-analysis of eight RCTs ( n =910) examining NAC supplementation (the acylated form of L-cysteine), researchers reported improved glucose regulation and a greater likelihood of conception and livebirths in women with PCOS compared with placebo [ 226 ]. In a single RCT ( n =60) CoQ10 supplementation (100 mg/day for 12 weeks) improved fasting glucose and insulin, HOMA-IR, insulin sensitivity index and TC, compared with the placebo group [ 227 ]. Two meta-analyses reported probiotics improved FAI, SHBG, IR and blood lipids, with no differences in weight or hirsutism between intervention and placebo groups [ 228 , 229 ]. These findings may be linked to lower microbial diversity and increased intestinal permeability in women with PCOS [ 230 , 231 ]. In regards to quercetin and resveratrol, which are both food derived polyphenols with a strong antioxidant capacity, one systematic review (three experimental studies, n =246 women with PCOS) reported quercetin supplementation improved measures of IR and testosterone levels, but not anthropometry compared with placebo [ 232 ]. Similarly, one RCT in women with PCOS ( n =61) reported resveratrol (800-1500 mg/day for four days) improved androgen and metabolic profiles and oocyte and embryo quality compared with placebo [ 233 ]. Finally, a systematic review (two RCTs and one cell-culture study) investigating the effects of melatonin supplementation in women with PCOS using assisted reproductive technologies reported melatonin significantly increased clinical pregnancy rates but not live birth rates [ 172 ]. A more recent RCT ( n =56) reported improved levels of T, hirsutism, inflammatory and oxidative stress profiles in women receiving 10 g melatonin/day for 12 weeks, compared with placebo [ 234 ].

Herbal medicine

To date the most recent and comprehensive review (Cochrane review including five RCTs and n =414 women with PCOS) investigating the effects of herbal medicine on reproductive outcomes, reported no difference between the use of Chinese herbal medicine (CHM) and clomiphene for pregnancy rates, and limited evidence of increased pregnancy rate for CHM with clomiphene compared with clomiphene alone [ 235 ]. This review concluded that there was inadequate evidence to promote the use of CHM for the treatment of subfertility in women with PCOS [ 235 ]. Similarly, a smaller systematic review (five studies) investigating the effects of four herbal medicines (green tea, cinnamon, spearmint and black cohosh) on menstrual regularity in PCOS, found limited high-quality evidence from RCTs to support their clinical use and concluded that evidence for safety was lacking [ 236 ].

More recently, a number of small RCTs investigating metabolic and reproductive effects of a range of herbal medicines have been published. Curcumin, an active compound in turmeric ( Curcuma longa), may exert hypoglycemic effects via a number of mechanisms, including attenuation of circulating levels of tumor necrosis factor-α [ 237 ]. One RCT ( n =67) reported decreased levels of fasting glucose following supplementation compared with placebo [ 238 ], while another ( n =51) which used a lower dose (1000 mg/day versus 1500 mg/day) and shorter duration (six weeks versus 12 weeks), reported no between group differences for fasting glucose, HOMA-IR or lipids [ 239 ]. Salvia officinalis or sage contains multiple active compounds that display antioxidant effects and therefore effects on glucose metabolism and insulin sensitivity [ 240 ]. One RCT ( n =72) reported consuming sage extract for eight weeks improved IR and reduced BMI, with no effects on WHR or blood pressure [ 241 ] Foeniculum vulgare or fennel may provide protective effects on hormonal abnormalities in PCOS via its actions as a phytoestrogen [ 242 ]. One RCT ( n =55) reported that six months of fennel tea and dry cupping was as effective as metformin for reducing BMI and menstrual cycle length [ 243 ]. Glycyrrhiza glabra or licorice contains active phytochemicals including isoflavane and glabridin, which have been shown to have antiandrogenic effects [ 244 ]. Two experimental studies in healthy women ( n =9) [ 245 ] and women with PCOS ( n =32) [ 246 ] reported that 3.5 g/day of licorice extract decreased T [ 245 ] and reduced side effects of spironolactone [ 246 ]. Mentha spicata (spearmint), Zingiber offinale Roscoe (ginger), Cinnamomum cassia (cinnamon) and Citrus sinensis (citrus) have been shown to exert anti-inflammatory and hypoglycemic effects [ 247 , 248 , 249 , 250 ]. One RCT in infertile women with PCOS ( n =60) comparing the effects of a herbal mixture (citrus, ginger, cinnamon and spearmint) with clomiphene citrate (CC), herbal mixture alone, or CC alone reported that the herbal mixture, with or without CC, improved circulating antioxidant levels, IR and fasting blood glucose, but not menstrual regularity when compared to CC alone [ 251 ]. While observations from emerging research are promising, to support the safe translation of findings into the clinical setting there is a clear need for larger clinical trials investigating the efficacy and safety of herbal medicine use in PCOS.

Other traditional, complimentary and integrative medicine approaches

Acupuncture may provide beneficial impacts on sympathetic function [ 252 ] and ovarian blood flow [ 253 ] in women with PCOS. A recent meta-analysis of 22 RCTs ( n =2315 women with PCOS) reported recovery of the menstrual period in the acupuncture group when compared with placebo, but no evidence for differences between groups in terms of live birth, pregnancy and ovulation [ 254 ]. While an earlier meta-analysis reported a significant reduction in BMI following acupuncture use, this was mainly due to one RCT ( n =80) which compared acupuncture and the oral contraceptive pill to the oral contraceptive pill alone [ 255 ]. When this study was removed, the pooled analysis was no longer significant [ 255 ].

Yoga gymnastics have been recommended as an example of moderate physical activity in the 2018 evidence-based PCOS guideline [ 18 ]. However, as yoga is considered a mind-body therapy that incorporates aspects of meditation, it may provide additional benefits beyond those gained through other forms of exercise [ 256 ]. While one systematic review (16 observational and experimental studies, n =365 women with PCOS) reported yoga may provide a range of psychological, reproductive and metabolic benefits, no meta-analysis was performed and a limited summary of included studies made it difficult to confirm findings [ 257 ]. A more recent systematic review (11 experimental studies) included a meta-analysis of two RCTs and found that yoga significantly decreased clinical hyperandrogenism, menstrual irregularity and fasting glucose and insulin [ 258 ]. Lastly, findings from a recent RCT ( n =67 women with PCOS) suggests that 90 minutes of yoga per day for six weeks can significantly reduce hirsutism, waist and hip circumference when compared to controls [ 259 ]. Please see Table 5 for a summary of available evidence from meta-analyses and experimental studies investigating the effects of TCIM on PCOS outcomes.

Summary of findings and research gaps

The 2018 International Evidence-Based Guideline for the Assessment and Management of PCOS highlights lifestyle (diet, physical activity and/or behavioural) management as the primary initial treatment strategy [ 18 ]. It is important to consider that the definition of lifestyle management may warrant expansion consistent with the whole person model of healthcare provision, which may include care addressing psychological and sleep interventions, as well as a range of TCIM approaches [ 20 ]. In line with patient interest [ 31 , 32 , 33 , 34 , 35 ], and to assist women and healthcare providers in understanding the evidence to aid safe implementation of adjunct therapies, rigorous assessment of the evidence for these alternative lifestyle strategies in PCOS management in warranted. Using a holistic definition of patient care, this review has summarised evidence to date on the traditional components of lifestyle change (diet, physical activity and behavioural change), psychological interventions and non-pharmacological strategies (sleep, supplements, herbal medicine and other TCIM approaches). Table 6 provides a overview of current guideline recommendations alongside the key findings from this review, summarising the identified research gaps that need to be addressed before evidence-based recommendations for clinical practice can be updated.

With regards to traditional lifestyle treatment, the majority of studies focussed on weight loss as a primary treatment goal. This indicates more research is warranted to understand the role of diet and exercise in lean women and/or in weight gain prevention. RCTs using lifestyle interventions under isocaloric conditions that investigate effects on IR, body composition and androgens independent of weight loss are needed. Given the high risk of failure with long-term weight management [ 9 , 37 , 40 , 261 ] and high attrition in weight loss trials in PCOS [ 13 ], exploring interventions that focus on weight neural messaging around dietary quality and physical activity may also aid in optimising engagement, adherence and sustainability of lifestyle interventions. Future research should also identify subgroups who respond more favourably to weight loss [ 45 , 53 ], to aid provision of a more targeted and personalised treatment approach.

With regards to diet strategies, there is a need for more research understanding the impact of low GI/GL diets on androgen status, as well as the biological mechanisms by which low GI/GL diets may impact reproductive and cardiometabolic outcomes associated with PCOS. With regards to physical activity, additional longer-term studies are required to guide exercise prescription in PCOS, although promising evidence supports the provision of vigorous aerobic exercise performed under supervised conditions (i.e. through referral to an exercise physiologist). While behavioural interventions are essential for long term sustainability of dietary and physical activity change, research in PCOS is scarce and interventions are not well defined. Future research should incorporate appropriate theoretical frameworks and clearly outline behavioural components utilised. This will aid intervention duplication and tailoring of active elements to ensure relevance in women with PCOS.

There is currently a lack of research investigating whether women with PCOS are at a higher risk of alcohol and smoking-related complications. This is particularly relevant given the well-established relationship between higher alcohol and cigarette use and rates of depression and anxiety in the general population [ 262 , 263 , 264 , 265 ]. There is also a need to better understand the relationship between alcohol intake and reproductive outcomes (particularly anovulatory infertility) [ 139 ], as safe alcohol limits in PCOS is currently unknown [ 139 ].

With regards to psychological interventions, the current evidence base for prevalence of mental health concerns in PCOS relies heavily on symptom prevalence. More adequately powered, gold standard prevalence studies using structured diagnostic interviews administered by appropriately qualified professionals are needed. While QoL has recently been highlighted as a core outcome in PCOS research [ 266 ], the application of QoL tools in clinical care is still unclear, with research yet to validate QoL tools longitudinally or identify clinically meaningful differences in QoL scores. The emerging evidence showing support for the use of CBT in PCOS [ 152 , 154 , 154 ] highlights an opportunity for tailoring of this psychological intervention to meet the specific mental health needs of women with PCOS, with a focus on how management of mental health symptoms affect lifestyle modifications. CBT that incorporates elements of mindfulness-based stress reduction also warrants further investigation.

Future research in PCOS and sleep disorders should include more high-quality research in subclinical disorders using objective sleep measures (polysomnography and actigraphy). Future work should also consider emerging evidence showing that disturbed sleep can detrimentally effect energy expenditure, which may increase adipose tissue deposition and exacerbate IR [ 164 , 184 , 186 , 267 , 268 , 269 , 270 , 271 ], thereby worsening the presentation of PCOS. Further, a consideration of how sleep disturbance can reduce engagement with positive lifestyle changes, for example through the disruption of appetite regulation [ 272 , 273 ] or via contributing to poor mental health outcomes [ 190 , 274 ], is warranted. CBT interventions including elements of stimulus control and psychoeducation are effective non-pharmacological treatments for both clinical sleep disorders and sleep disturbances in the general population [ 275 , 276 , 277 ]. RCTs in women with PCOS that investigate effects of CBT on dietary intake, energy metabolism, appetite regulation, anthropometry, adherence to lifestyle changes and PCOS features are required.

With regards to TCIM, there is a vast array of literature suggesting some beneficial effects of vitamins (B-group vitamins, folate, vitamins D, E and K), vitamin-like nutrients (bioflavonoids, carnitine and α-LA), minerals (calcium, zinc, selenium, and CrP) and other formulations (such as melatonin, omega-3 fatty acids, probiotics, NAC and cinnamon) in PCOS [ 278 ]. However, the quality of evidence across studies ranges from meta-analyses of RCTs (vitamin D, omega-3 fatty acids and NAC) to single retrospective observational studies (vitamin K and carnitine). In addition, heterogeneity in results related to factors including variable PCOS presentation and study methodology make it difficult to draw definite conclusions. Future research should focus on specific populations within PCOS, for example age, BMI or phenotype (factors which substantially affect nutrient sufficiency), and outline more consistent approaches to supplement formulation, dosage, intervention duration and type of comparator used. Mechanistic studies are also needed to investigate herb- or nutrient-drug interactions (with common pharmacological treatments used in PCOS) and other possible interactions with the biological processes underpinning PCOS. In regards to acupuncture and yoga, more sufficiently powered RCTs are needed to determine clinical relevance and integration into PCOS management is not yet warranted.

While current research is not sufficiently robust to support integration of TCIM into routine clinical practice, healthcare providers should broaden their knowledge pertaining to how these therapies can be safely and appropriately utilised as adjuncts to conventional medical management [ 279 , 280 , 281 ]. TCIM is frequently used by women, with uptake of TCIM approaches increasing steadily over the past 10 years [ 31 , 32 , 33 , 34 , 35 ]. In women with PCOS, one cross-sectional study ( n =493) found that 70% reported use of TCIM, namely nutritional and herbal supplements [ 282 ]. The most common reasons for use were to treat PCOS symptoms, improve general wellbeing and reduce depression. Of the women using TCIM, 77% had consulted with a complementary practitioner (acupuncturists, chiropractors, naturopaths and massage therapists) [ 282 ]. While the study did not report participants engagement with medical physicians, research in the general population has shown that patients are resistant to discuss TCIM use with their consulting physician [ 283 , 284 , 285 , 286 , 287 , 288 ]. Qualified healthcare providers should be involved in TCIM discussions to help ensure appropriate use, maximise possible benefits and minimize potential harm [ 289 ]. For example, to sustain patient engagement in women who express the desire to experiment with supplementation, healthcare providers could consider inositol supplementation, using a nuanced and case-specific approach that encapsulates the variety of pathologies in PCOS.

When considering all of the research summarised here, across traditional lifestyle, psychological, sleep and TCIM interventions, there is a clear need for more real-world PCOS research. This involves the translation of findings from clinical trials (where highly selected populations, intensive treatment protocols and expert multidisciplinary teams provide an ideal research setting), into the heterogenous situations that face clinicians [ 290 , 291 , 292 ]. Health professionals provide care to women from diverse social contexts, are often restrained by finite resources and are required to juggle many competing demands for their time [ 290 , 291 , 292 ]. While some barriers to implementation, including time, resource and access issues are considered in the current PCOS guideline, they were generated by the guideline development groups and research is needed to validate and clarify their proposed concerns. Real-world research is required to: a) fully understand whether lifestyle recommendations can be practically integrated into current healthcare settings; b) tailor interventions to meet the unique needs of women with PCOS; and c) generate evidence on clinical outcomes that are of great relevance to patients and clinicians, such as live birth, miscarriage and menstrual regularity, which can be collected through routine care.

It is also important to highlight that while lifestyle management is a first-line treatment for PCOS, the addition of pharmacological therapies to further improve clinical features of hyperandrogenism, menstrual irregularity and infertility are often indicated [ 293 ]. In these instances, prescribing physicians should consider how medical management and lifestyle change can be used in adjunct to optimise treatment. For example, the use of combined oral contraceptive pills may have detrimental effects on weight gain [ 294 ] and mental health [ 295 ], which can be mitigated by appropriate lifestyle intervention. Further, the combination of lifestyle modification and metformin has been shown to lower BMI, subcutaneous adipose tissue and improve menstruation compared with lifestyle modification alone, and hence may have an additive effect on improving cardio-metabolic outcomes in high risk groups [ 296 ].

Using the whole person or holistic definition of health, this review has highlighted emerging areas of research that could be considered for integration into future classifications of lifestyle management in PCOS. When developing lifestyle recommendations for PCOS management, interpreting and communicating evidence not only for diet, physical activity and behavioural interventions, but also psychological, sleep and TCIM approaches, will aid clinicians to deliver patient-centred care by affording women more choice and therefore autonomy over their treatment options. This sentiment aligns with the core objectives underpinning the 2018 PCOS guideline, which sought to understand the unmet needs of women with PCOS through continuing to engage consumers in co-design of guideline development, implementation, translation and dissemination.

Availability of data and materials

Not applicable.

Abbreviations

Alpha-lipoic acid

Body mass index

Cardiovascular disease

Chinese herbal medicine

Chromium picolinate

Coenzyme Q10

Cognitive behavioural therapy

Dietary Approaches to Stop Hypertension

Fasting insulin level

Follicle stimulating hormone

Free androgen index

Glycaemic index

Glycaemic load

High density lipoprotein cholesterol

Homocysteine

Insulin resistance

Low density lipoprotein cholesterol

Luteinizing hormone

Maximal rate of oxygen

Metabolic syndrome

Monounsaturated fatty acid

Myo-inositol

N-acetyl-cysteine

Oral glucose tolerance test

Polycystic ovary syndrome

Polyunsaturated fatty acid

Randomised controlled trial

Sex hormone-binding globulin

Total antioxidant capacity

Total cholesterol

Testosterone

Triglycerides

Type 2 diabetes

Waist circumference

Waist-hip-ratio

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Acknowledgements

CE is supported by an endowment from the Jacka Foundation of Natural Therapies. SL and AM are supported by National Health and Medical Research Council of Australia fellowships. LM is supported by a National Heart Foundation Future Leader Fellowship.

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SC, SL, CA, SP, RT, MG, RB, NN, CB, CE, VR, AM, SA and LM reviewed the literature and wrote the first draft of the manuscript. SC, SL, CA, SP, RT, MG, RB, NN, CB, CE, VR, AM, SA and LM revised and edited the manuscript. SC and LM conceptualised and determined the scope of the manuscript and had primary responsibility for the final content. LM supervised the review process. All authors meet ICMJE criteria for authorship and approved the final version for publication.

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Cowan, S., Lim, S., Alycia, C. et al. Lifestyle management in polycystic ovary syndrome – beyond diet and physical activity. BMC Endocr Disord 23 , 14 (2023). https://doi.org/10.1186/s12902-022-01208-y

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Physical Therapy Case Study

PICO: Patient/problem/population: 15-year-old male Intervention: Exercise therapy Comparison: Manual therapy Outcome: Reduction in low back pain

Clinical Question: In a 15-year-old male, is exercise therapy or manual therapy more effective in reducing low back pain?

For accessible versions of these activities, please refer to our document Step 2: Acquire – Accessible Case Studies .

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Lifestyle management in polycystic ovary syndrome – beyond diet and physical activity

Introduction

Traditional lifestyle and weight management

Carbohydrates

Dietary and eating patterns

Physical activity

Behavioural

Alcohol and smoking

Psychological

Vitamins, vitamin-like supplements, minerals and other supplements

Vitamin-like supplements

Other supplements

Herbal medicine

Other traditional, complimentary and integrative medicine approaches

Summary of findings and research gaps

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Additional information

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About this article

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BMC Endocrine Disorders

Physical Therapy Case Study

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