{"paper_id":"9ab2d068-6978-450d-8351-ffb2c5be3cf4","body_text":"ORIGINAL ARTICLE\nEvaluation of dietary behaviours and \nphysical activity of Polish women with \nendometriosis\nOcena zachowań żywieniowych i aktywności fizycznej polskich kobiet \ncierpiących na endometriozę\nAdrianna Adamus1,A-F \n , Katarzyna Oszajca1,A,E-F  \n1 Faculty of Health Sciences, Department of Medical Biochemistry, Medical University of Lodz, Poland  \nA – Research concept and design, B – Collection and/or assembly of data, C – Data analysis and interpretation,  \nD – Writing the article, E – Critical revision of the article, F – Final approval of article\nOszajca K, Adamus A. Evaluation of dietary behaviours and physical activity of Polish women with endometriosis. Med Og Nauk Zdr.  \n2024; 30(2): 123–130. doi: 10.26444/monz/189910\nAbstract\nIntroduction and Objective. Endometriosis (EM) is a chronic \ninflammatory disease for which pharmacological treatment \ndoes not always give the desired results. The importance of \ndiet in the course of the disease is increasingly highlighted. \nThe aim of the study was to evaluate the nutritional behaviour \nand physical activity of women with EM and the influence of \nthe abovementioned factors on the specific symptoms of the \ndisease.   \nMaterials and Method.  A cross-sectional study was \nconducted using an online questionnaire-based survey. The \nquestionnaire was posted on social media groups related to \nendometriosis and diet, obtaining 230 responses. Correlations \nbetween variables were examined using Spearman›s rank \ncorrelation coefficient. The significance of differences between \nthe independent groups was tested using the Mann-Whitney \nU test.   \nResults.  According to the survey, 64.8% of women \nparticipating in the study adhered to a diet because of EM. The \nmost frequent changes in nutritional habits were reduction in \nthe consumption of sugar and sweets, and resignation from \nfast foods. There were significant differences between the \ngroup of women adhering to a diet,and the group of women \nnot adhering to a diet in the consumption of products such as \nred meat, fish, milk and dairy products, legumes, white bread, \ngluten-free bread, seeds and nuts, gluten-free groats, cereals, \nfruits, vegetables, sweetened beverages, and fruit juices. \nFollowing dietary changes, 83.9% of the women reported an \nimprovement in at least one of the endometriosis symptoms. \nConclusions. The study proves that women with EM seek relief \nthrough dietary modifications, with the majority experiencing \nimprovements in symptoms and well-being after making the \nchanges. Further research is required to establish what kind \nof a diet and what type of products are the most efficient in \nalleviating the symptoms of endometriosis. \nKey words\ndiet, endometriosis, life style, nutrition, Polish women\nStreszczenie\nWprowadzenie i cel pracy.  Endometrioza jest przewlekłą \nchorobą zapalną, której leczenie farmakologiczne nie zawsze \nprzynosi pożądane rezultaty. Coraz częściej podkreśla się \nznaczenie diety w przebiegu tej choroby. Celem badania była \nocena zachowań żywieniowych i aktywności fizycznej kobiet \ncierpiących na endometriozę oraz wpływu tych czynników na \nspecyficzne objawy choroby.   \nMateriał i metody.  Badanie przekrojowe przeprowadzo -\nno za pomocą ankiety internetowej. Kwestionariusz został \nzamieszczony w mediach społecznościowych na grupach \nzwiązanych z endometriozą i dietą. Uzyskano 230 wy  peł-\nnionych ankiet. Korelacje między zmiennymi badano za po -\nmocą współczynnika korelacji rang Spearmana, a istotność \nróżnic pomiędzy niezależnymi grupami za pomocą testu \nU Manna-Whitneya.  \nWyniki. Jak wynika z przeprowadzonego badania, 64,8% \nrespondentek stosowało dietę z powodu endometriozy. Naj-\nczęściej dokonywanymi zmianami nawyków żywieniowych \nbyło ograniczenie spożycia cukru i słodyczy oraz rezygnacja \nz żywności typu fast food. Pomiędzy grupą kobiet stosujących \ndietę a grupą kobiet niestosujących diety stwierdzono is -\ntotne różnice w spożyciu takich produktów jak: czerwone \nmięso, ryby, mleko i produkty mleczne, rośliny strączkowe, \nbiałe pieczywo, pieczywo bezglutenowe, nasiona i orzechy, \n kasze bezglutenowe, płatki zbożowe, owoce, warzywa, napoje \nsłodzone i soki owocowe. Po wprowadzeniu zmian w diecie \n83,9% kobiet zgłosiło poprawę co najmniej jednego z objawów \nendometriozy.   \nWnioski. Badanie dowodzi, że kobiety cierpiące na endo -\nmetriozę szukają ulgi w dolegliwościach za pomocą od -\npowiedniego odżywiania, a większość z nich po wprowa -\ndzeniu zmian doświadcza złagodzenia objawów i poprawy \nsamopo czucia. Konieczne są dalsze badania w celu ustalenia, \njaki rodzaj diety i które produkty są najbardziej skuteczne \nw łagodzeniu objawów endometriozy.\nSłowa kluczowe\ndieta, odżywianie, styl życia, endometrioza, Polki\n Address for correspondence: Katarzyna Oszajca, Medical University of Lodz, \nFaculty of Health Sciences, Department of Medical Biochemistry, Kościuszki 4, \n90-419 Łódż, Poland\nE-mail: katarzyna.oszajca@umed.lodz.pl\nReceived: 13.09.2024; accepted: 1 1.06.2024; first published: 28.06.2024\nMedycyna Ogólna i Nauki o Zdrowiu 2024, Tom 30, Nr 2, 123–130\nwww.monz.pl\n\nAdrianna Adamus, Katarzyna Oszajc a. Evaluation of dietary behaviours and physical activity of Polish women with endometriosis\nINTRODUCTION\nEndometriosis (EM) is a chronic gynaecological disease \n[1]. Occurrence in the endometrium – the uterine mucosa, \nconsisting of stromal cells and glandular cells outside the \nuterine cavity – is typical in this condition [2]. The etiology \nof the disease is controversial and not fully understood. \nGenetic, immunological, hormonal, and environmental \nfactors contribute to development of the disease [3]. The \nmost common symptoms of endometriosis is painful \nmenstruation, pelvic pain, dyspareunia and infertility. In \neach menstrual cycle, ectopic endometrial tissue triggers the \nactivation of macrophages and pro-inflammatory cytokines, \nincluding tumour necrosis factor α (TNF-α), IL-1, IL-6, \nand IL-8. Repeated tissue damage with local inflammation, \nangiogenesis and neurogenesis, may result in painful \nsymptoms, even causing chronic pain [4]. Conventional \ntreatment methods often do not give satisfactory effects and \nwomen often search for relief in the diet.\nThe role of nutrition in endometriosis became the object \nof interest of scientists due to the observations that processes \nconnected with the disease, such as inflammation, hormonal \nactivity, menstrual cycle or metabolism of prostaglandins, \nmay be modified by diet [5]. In recent years, many researchers \nhave evaluated the effect of nutrition on endometriosis, \nfocusing mainly on the risk of the disease; however, \nthere are some studies on the role of diet on the course \nof the disease [6]. Supplementation with a composition \nincluding quercetin, curcumin, parthenium, nicotinamide, \n5-methyltetrahydrofolate and omega-3/6 demonstrated \nsignificant reduction of pain symptoms in the EM \npatients in the intervention group compared to controls. \nMoreover, a significant reduction in serum concentrations \nof prostaglandin E2 and carbohydrate antigen 125 (CA-\n125) was observed [7]. Another study showed that dietary \nintervention including supplementation of vitamins (B 6, A, \nC, E), minerals salts (Ca, Mg, Se, Zn, Fe), lactic ferments and \nfish oil (omega-3/6) was equally effective in reducing non-\nmenstrual pelvic pain as hormonal suppression therapy [8]. \nA diet high in antioxidants resulted in an increase in plasma \nvitamin concentrations and antioxidant enzyme activity, \nand decrease in oxidative stress markers [9]. Adherence \nto the Mediterranean diet also led to a decrease in pain \nsymptoms [10]. Some of the studies focused on particular \ndietary components, such as fatty acids, vitamins and \npolyphenols. Research shows the potential protective \nrole of polyunsaturated fatty acids (PUFA) [11–14]. As \nreported, omega-3 can alleviate the pain associated with \nEM, reduce lesion size and prevent infertility [15]. However, \nstudies in women with EM did not show the advantage of \nsupplementing PUFA or fish oil over placebo in decreasing \nthe symptoms [15, 16]. Vitamins may affect oxidative stress, \nestrogen levels and prostaglandin metabolism. Studies report \nthat supplementation with witamins C and E decreases \nthe level of inflammatory markers [17], reduces oxidative \nstress markers and the severity of pain, dysmenorrhea and \ndyspareunia. [18, 19]. A recently published meta-analysis \nsuggests that vitamins may effectively decrease the pain \nsymptoms in EM [20].  Vitamin D mainly plays a role in \nregulating blood calcium concentration and modulates \nmetabolic reactions and immune response by decreasing \nthe production of IL-17 and IL-6, reducing expression of \nVEGF-α genes and inhibiting the NF-κB pathway, which \nmay result in a decrease in the invasion and proliferation \nof endometriosis lesions. [21]. However, studies by Nodler \nand Almassionokiani showed no statisticially important \ndifference between the vitamin D supplementation group \nand placebo group [16, 22]. To the contrary, in a trial by \nMehdizadehkashi, vitamin D supplementation resulted in \ndecreased pelvic pain, decreased CRP, and increased total \nantioxidant capacity compared to placebo [23].\nResveratrol is a very promising compound in terms of \nmitigating endometriosis symptoms – a polyphenol, it has \nanti-inflammatory, anti-neoplastic, anti-axidative and anti-\nangiogenic properties, processes that are strongly connected \nwith endometriosis pathogenesis. Studies report that \nresveratrol supplementation may decrease TNF–α, the VEGF \ngene and protein expression, as well as inhibiting aromatase \nactivity, COX-2 expression and pain symptoms [24].\nDue to the limited number of studies and their \nheterogeneity, it is not possible to prepare specific nutritional \nguidelines for patients with endometriosis. However, based \non a systematic review, the authors suggest that a properly \nbalanced diet in endometriosis should focus on eliminating \nnutritional deficiencies common in patients with EM, the \nmost frequently observed deficiencies being magnesium, \niron, B vitamins, zinc, selenium and folic acid, as well as \non eliminating excess estrogen, reducing inflammation, \noxidative stress and exposure to estrogen derivatives such \nas phytoestrogens and xenoestrogens [21].\nThe aim of this study was to evaluate the nutritional \nbehaviour and physical activity of Polish women with \nendometriosis, and the influence of the above-mentioned \nfactors on the specific symptoms of the disease.\nMATERIALS AND METHOD\nA cross-sectional study targeting Polish women with \nendometriosis was conducted by an online questionnaire-\nbased survey. All interested women over 18 years of age \ndiagnosed with EM had an opportunity to complete the \nquestionnaire. Based on dietary behaviour, the study \nparticipants were divided into two groups: women who \nmodified their diet because of EM and women who did \nnot change their diet due to the disease. The study was \nobservational in nature and participation was voluntary \nand anonymous. Therefore, it did not require the approval \nof the Bioethics Committee. The questionnaire was designed \nby the study authors based on a review of the related literature, \nand was pre-tested by 6 respondents to ensure comprehension \nand feasibility. Necessary adjustments were made, and the \nquestionnaire was administered using the Google Forms \ntool. A link to the survey was placed in the Facebook groups \nassociated with endometriosis and diet. The form accepted \nresponses from 11–15 January 2021.\nThe questionnaire consisted of 47 questions divided into \n3 sections. The first section focused on socio-demographic \ninformation, such as age, education level, place of residence, \nand history of the disease: time from diagnosis, stage of \ndisease, predominant symptoms and number of symptoms. \nThe second section was addressed to women who modified \ntheir diet because of endometriosis, and investigated changes \nin dietary patterns and their impact on the disease symptoms. \nRespondents were questioned about the following dietary \nmodifications: reduction or elimination of consumption \nMedycyna Ogólna i Nauki o Zdrowiu 2024, Tom 30, Nr 2124\n\nAdrianna Adamus, Katarzyna Oszajc a. Evaluation of dietary behaviours and physical activity of Polish women with endometriosis\nof meat, animal products, milk and dairy, dairy products \nwith lactose, eggs, products containing gluten, sugar and \nsweets, fast foods, soy and soy products, legumes, vegetables, \nfruits; increased consumption of legumes, vegetables, fruits, \nwholemeal products, fish and vegetable oils, as well as about \nimplementation of fasting. The questionnaire also included \nan open ‘other (please specify)’ option with space for \nrespondents to provide their own answer. Participants were \nthen asked about the implications of dietary modification \non the EM symptoms and other health effects.\nThe last section of the survey evaluated the frequency \nof consumption of particular products by all women \nparticipating in the study. Respondents were queried about \ntheir intake of the following products: read meat, white meat, \nfish, milk and dairy products, eggs, soy and soy products, \nlegumes, white bread, wholegrain bread, gluten free bread, \nseeds and nuts, groats containing gluten, gluten free groats, \ncereals, white rice, brown rice, potatoes, fruits, vegetables, \nfruit juices, sweetened beverages, coffee, tea, alcohol and \nwater.\nFor the analysis of intake frequency, eight categories were \ndefined to which scores were assigned:\n– several times a day – score 1;\n– once a day – score 2;\n– 2–3 times a week – score 3;\n– once a week – score 4;\n– 2–3 times a month – score 5;\n– once a month – score 6;\n– less than once a month – score 7;\n– never – score 8.\nFor the amount of water consumed, the categories were \nas follows:\n– up to 0.5 L – score 1;\n– from 0.5 L- 1 L – score 2;\n– from 1 L-2 L – score 3;\n– more than 2 L – score 4;\n– does not drink water (prefers other beverages) – score 5.\nStatistical analysis of the results was performed in \nthe Microsoft Excel 2010 and Statistica 13.3 (Statsoft) \nprogrammes. In descriptive statistics, categorical data were \npresented as the number of cases (n) and percentages (%). \nFrequencies of food intake were expressed as median of \nscores categorising frequency (with interquartile range). \nCorrelations between variables were examined using \nSpearman’s rank correlation coefficient. The significance \nof differences between the independent groups was tested \nusing the Mann-Whitney U test or Pearson’s chi-squared \ntest, as appropriate. The level of statistical significance was \nset at p < 0.05.\nRESULTS\nThe study involved a total of 230 women with endometriosis. \nThe socio-demographic characteristics of the study group \nare presented in Table 1. The largest group were women aged \n30–39 years; average body mass of women participating in \nthe study was 62.6 kg (± 12.3 kg). Most of the respondents \nhad normal BMI (18.5–24.99  kg/m 2), higher education, \nand lived in the cities. Information regarding the course of \nendometriosis among surveyed women is shown in Table 2.\nWhen asked about the role of nutrition in the treatment of \nendometriosis, 57.4% of the women indicated that diet can \nsupport treatment and 26.5% answered that diet is the basis \nTable 1. Socio-demographic characteristics of the study group\nVariable No. \n(n=230)\nPercent  \n(%)\nWomen adhering to a diet\n(n=149)\nPercent\n(%)\nWomen not adhering to a diet\n(n=81)\nPercent\n(%)\nAge (years) 18–24 23 10.0 13 8.7 10 12.3\n25–29 66 28.7 40 26.8 26 32.1\n30–39 121 52.6 84 56.4 37 45.1\n40–49 20 8.7 12 8.1 8 9.9\nBMI (kg/m2) <16 1 0.4 1 0.7 0 0.0\n16.0–16.99 9 3.9 6 4.0 3 3.7\n17.0–18.49 19 8.3 15 10.1 4 4.9\n18.5–24,99 146 63.5 99 66.4 47 58.0\n25–29.9 42 18.3 22 14.8 20 24.7\n30–34.99 10 4.3 5 3.4 5 6.2\n35–39.99 2 0.9 0 0.0 2 2.5\n≥40 1 0.4 1 0.7 0 0.0\nEducation Primary 1 0.4 1 0.7 0 0.0\nVocational 3 1.3 3 2.0 0 0.0\nSecondary 47 20.4 20 13.4 27 33.3\nHigher 179 77.8 125 83.9 54 66.7\nPlace of \nresidence\nVillage 54 23.5 30 20.1 24 29.6\nCity up to 50,000 inhabitants 25 10.9 15 10.1 10 12.3\nCity up to 100,000 inhabitants 26 11.3 15 10.1 11 13.6\nCity up to 250,000 inhabitants 24 10.4 16 10.7 8 9.9\nCity of more than 250,000 inhabitants 101 43.9 73 49.0 28 34.6\nMedycyna Ogólna i Nauki o Zdrowiu 2024, Tom 30, Nr 2 125\n\nAdrianna Adamus, Katarzyna Oszajc a. Evaluation of dietary behaviours and physical activity of Polish women with endometriosis\nof therapy. However, 13.5% did not know the role of diet \nin EM. Of all the study participants, 149 (64.8%) declared \nthat they were using nutritional modifications because of \nendometriosis (Tab. 3). Among other changes not listed in the \nsurvey, elimination of alcohol (2.7%) and coffee or caffeine \n(2.7%) were mentioned. The correlation between selected \nvariables characterizing the study participants and dietary \nadherence are presented in Table 4.\nIn the group of respondents who modified their diet, 31.5% \nmade changes in dietary habits not earlier than 6 months \nbefore the research, 24.8% adhered to a diet from 6 months \nup to 1 year, 20.8% followed the diet from 1 up to 2 years, \nand 22.8% for more than 2 years (data not shown).\nRespondents were looking for information regarding the \ndiet in EM in different sources (Tab. 5). Among other responses \nnot listed in the survey, ‘my knowledge’, ‘naturopath’, ‘trial \nand error’ and ‘self-observation’ were mentioned. For 17.4% \nof the women who modified their nutritional behaviours, \nwebsites and/or Facebook groups or Internet forums were \nthe only sources of information about diet in EM.\nThe alleviation of endometriosis symptoms after dietary \nmodifications was observed by 83.9% of the surveyed women \n(Tab. 6). After changing their nutritional habits, 40.3% of \nrespondents observed the mitigation of one symptom and \n25.5% of 2 symptoms of the disease Moreover, 18.1% of \nthe surveyed women reduced their drug doses while 8.7% \ncompletely discontinued them.\nThe study showed significant differences in nutritional \nhabits between the group of women following a diet due \nto EM and those not engaged in dietary modifications \n(Tab. 7). Women adhering to a diet more often consumed \nTable 2. Characteristics of the subjects in terms of the course of endometriosis\nVariable No. \n(n=230)\nPercent \n(%)\nWomen adhering to a diet\n(n=149)\nPercent\n(%)\nWomen not adhering to a diet\n(n=81)\nPercent\n(%)\nTime from \ndiagnosis\nLess than 1 year 55 23.9 30 20.1 25 30.9\n1–3 years 84 36.5 54 36.2 30 37.0\n4–7 years 46 20.0 30 20.1 16 19.8\n7–10 years 21 9.1 17 11.4 4 4.9\n10 and more years 24 10.4 18 12.1 6 7.4\nStage of disease I 7 3.0 5 3.4 2 2.5\nII 8 3.5 7 4.7 1 1.2\nIII 35 15.2 23 15.4 12 14.8\nIV 67 29.1 51 34.2 16 19.8\nNon-specified 113 49.1 63 42.3 50 61.7\nPredominant \nsymptoms\nPainful periods 198 86.1 132 88.6 66 81.5\nHeavy periods 125 54.3 83 55.7 42 51.9\nAbdominal pain not related to menstruation 157 68.3 104 69.8 53 65.4\nDyspareunia 131 57.0 92 61.7 39 48.1\nIntestinal symptoms 170 73.9 119 79.9 51 63.0\nInfertility 93 40.4 66 44.3 27 33.3\nOthers 41 17.8 31 20.8 10 12.3\nNo. of symptoms 1 16 7.0 10 6.7 6 7.4\n2 31 13.5 16 10.7 15 18.5\n3 40 17.4 20 13.4 20 24.7\n4 43 18.7 26 17.4 17 21.0\n5 56 24.3 42 28.2 14 17.3\n6 and more 44 19.1 35 23.5 9 11.1\nTable 3. Dietary modifications made by women with endometriosis to \nalleviate symptoms of the disease\nType of dietary modification No. \n(n=149)\nPercent \n(%)\nReduction of meat consumption 90 60.4\nTotal resignation from meat consumption 20 13.4\nTotal resignation from animal products consumption 3 2.0\nResignation from dairy products with lactose 62 41.6\nTotal resignation from milk and dairy 35 23.5\nReduction of products containing gluten 67 45.5\nTotal resignation from products containing gluten 29 19.5\nReduction of sugar and sweets consumptions 121 81.2\nResignation from fast foods 120 80.5\nElimination of eggs 11 7.4\nReduction of soy and soy products consumption 65 43.6\nReduction of legumes consumption (except soy) 21 14.1\nIncrease of legumes consumption 26 17.4\nReduction of vegetables consumption 3 2.0\nIncrease of vegetables consumption 106 71.1\nReduction of fruit consumption 10 6.7\nIncrease of fruit consumption 74 49.7\nIncrease of consumption of wholemeal products 61 40.9\nIncrease of fish consumption 80 53.7\nIncrease of vegetable oils consumption 92 61.7\nImplementation of fasting 20 13.4\nOthers 20 13.4\nMedycyna Ogólna i Nauki o Zdrowiu 2024, Tom 30, Nr 2126\n\nAdrianna Adamus, Katarzyna Oszajc a. Evaluation of dietary behaviours and physical activity of Polish women with endometriosis\nfish, legumes, gluten-free bread, seeds and nuts, gluten-free \ngroats, cereals, fruits, vegetables, and fruit juices. On the \nother hand, they less frequently consumed red meat, milk \nand dairy products, white bread, and sweetened beverages.\nA statistically significant correlation was shown between \nadhering to the diet and the thermal processing method of \nfood (p=0.003, according to a Pearson’s chi-squared test). \nAmong the women who changed their dietary patterns \nbecause of EM, the most popular methods were, respectively, \nboiling in water (24.2%), stewing (21.5%), frying (16.8%), and \nbaking in the dish or oven bag (15.4%). Women not adhering \nto a diet the most frequently chose frying (32.1%), traditional \nbaking (23.5%), and boiling in water (21%) (Tab. 8).\nPhysical activity was practiced regularly by 38.7% of \nrespondents, the most popular disciplines stated being yoga \n(27%), fitness (25.8%), walks (23.6%), gym (16.9%), cycling \n(14.6%), and jogging (11.2%). Women adhering to a diet were \nmore frequently engaged in regular physical activity; in this \ngroup, 44.3% of women exercised regularly, contrary to only \n28.4% of the women not adhering to a diet (Tab. 9). The \ncorrelation between adhering to a diet and regular physical \nactivity was statistically significant (p=0.018, according to \nthe Pearson’s chi-squared test).\nDISCUSSION\nThis cross-sectional study shows that women with EM often \nmodify their diet in order to improve their well-being. Among \nthe study participants, 64.8% were following a diet while \ntaking part in the survey. Changes in the nutritional habits \nTable 4. Spearman›s rank correlation analysis for the relationship \nbetween selected variables characterizing the study participants and \ndietary adherence\nVariable Correlation coefficient (R) p\nBMI -0.17 0.010*\nAge 0.07 0.304\nTime from diagnosis 0.15 0.025*\nNumber of symptoms 0.20 0.001*\nStage of endometriosis -0.04 0.630\np < 0.05 was considered to be statistically significant (*)\nTable 5. Sources of knowledge of surveyed women about the role of \ndiet in endometriosis\nSource of knowledge No. (n=149) Percent (%)\nDoctor’s recommendation 45 30.2\nDietician 56 37.6\nFacebook groups or Internet forums 98 65.8\nFamily or friends 11 7.4\nWebsites 105 70.5\nScientific articles 55 36.9\nBooks 42 28.2\nOthers 6 4.0\nTable 6. Changes in endometriosis symptoms and other effects observed \nafter dietary modifications\nEffects of the diet Type of change No. (n=149) Percent (%)\nChanges linked \nto endometriosis\nLess painful menstruation 73 49.0\nLess heavy menstruation 32 21.5\nAlleviation of abdominal pain not \nrelated to menstruation 73 49.0\nAlleviation of dyspareunia 19 12.8\nWorsening of symptoms 1 0.7\nNo changes observed 23 15.4\nOthers 22 14.8\nOther effects \nof diet\nIncrease in frequency of excretions 54 36.2\nDecrease in frequency of \nexcretions 10 6.7\nImprovement of hair, skin and nails \ncondition 50 33.6\nWorsening condition of hair, skin \nand nails 5 3.4\nImprovement of well-being 107 71.8\nDeterioration of well-being 1 0.7\nLoss of body mass 74 49.7\nGain in body mass 7 4.7\nNo changes observed 12 8.1\nOthers 11 7.4\nTable 7. Differences in the consumption of individual products between \nthe group of women adhering to a diet and those not adhering to a diet. \nData expressed as median of scores categorising frequency of food \nconsumption (with interquartile range)\nProduct Women adhering \nto a diet (n= 149)\nWomen not adhering \nto a diet (n=89)\np value\nRead meat 7 (5–8) 4 (3 – 6) <0.001*\nWhite meat 3 (3 – 5) 3 (3 – 4) 0.191\nFish 4 (3 – 5) 5 (4 – 6) <0.001*\nMilk and dairy products 4 (3 – 7) 3 (1 – 4) <0.001*\nEggs 3 (3 – 4) 3 (3 – 4) 0.304\nSoy and soy products 8 (6 – 8) 8 (7 – 8) 0.064\nLegumes (except soy) 4 (3 – 6) 6 (4 – 7) <0.001*\nWhite bread 7 (3 – 8) 3 (2 – 5) <0.001*\nWholegrain bread 3 (2 – 6) 3 (2 – 5) 0.650\nGluten free bread 8 (4 – 8) 8 (8 – 8) <0.001*\nSeeds and nuts 3 (2 – 4) 4 (3 – 6) <0.001*\nGroats containing gluten 5 (4 – 8) 6 (4 – 7) 0.555\nGluten free groats 4 (3 – 6) 7 (5 – 8) <0.001*\nCereals 4 (3 – 7) 5 (4 – 7) 0.010*\nWhite rice 5 (4 – 7) 5 (4 – 6) 0.951\nBrown rice 6 (5 – 8) 7 (5 – 8) 0.271\nPotatoes 4 (3 – 5) 3 (3 – 5) 0.184\nFruits 2 (1 – 3) 3 (2 – 3) <0.001*\nVegetables 1 (1 – 2) 2 (1 – 3) <0.001*\nFruit juices 4 (3 – 7) 5 (3 – 7) 0.034*\nSweetened beverages 8 (6 – 8) 6 (4 – 8) <0.001*\nCoffee 2 (2 – 6) 2 (1 – 5) 0.149\nTea 1 (1 – 3) 1 (1 – 2) 0.288\nAlcohol 6 (5 – 7) 6 (4 – 7) 0.085\nWater 3 (2 – 3) 3 (2 – 3) 0.567\np-values based on Mann-Whitney U test. p < 0.05 – statistically significant (*)\nMedycyna Ogólna i Nauki o Zdrowiu 2024, Tom 30, Nr 2 127\n\nAdrianna Adamus, Katarzyna Oszajc a. Evaluation of dietary behaviours and physical activity of Polish women with endometriosis\nwere most often made by women inhabiting big cities with \nmore than 250,000 inhabitants, less often by village residents. \nThis result can be connected with the availability of medical \ncare or specialists such as dietitians. Women adhering to \na diet were mostly diagnosed 7–10 years and 10 and more years \nbefore the study. Presumably, conventional treatment had not \nbrought satisfactory results and consequently decided to try \nsupplementary methods. Also, the number of symptoms were \nlinked to the dietary changes – probably women for whom \nsymptoms of the disease were more annoying, are they were \nmore eager to try unconventional methods.\nThe percentage of women who modified their diet due to \nEM reported in this study is slightly lower than in the study by \nBogusz and Górnicka [25], in which 77.3% of Polish women \ndeclared a change in dietary habits after being diagnosed \nwith EM. In turn, comparable results to those obtained in \nthe current study were reported among Italian women with \nEM (66.4%) [26].However, lower percentages of women with \nEM undertaking dietary modifications due to the disease, \nwere observed among Australian and Dutch women – 44% \nand 43%, respectively [27,28].\nThe most often implemented dietary modifications noted \nin the group of women adhering to a diet were reduction of \nsugar and sweets consumption (81,2%), resignation from fast \nfoods (80,5%), and an increase in vegetables consumption \n(71.1%). After introducing changes to the diet, some relief \nfrom EM symptom was observed by 83.9% of women. Others \nwomen experienced positive changes not directly connected \nwith endometriosis symptoms after adhering to a diet, such \nas increase in the frequency of excretion, and improvement \nin the condition of skin, hair and nails. Presumably, this \noccurred because of the better quality of the diet after \nmodifications. Respondents also indicated improvement in \nwell-being as a result of diet.\nAssessment of the consumption of individual products by \nwomen with EM showed significant differences among the \ngroup who adhered to a diet, and those who did not adhere to \na diet. Women in the first group were more likely to fulfil the \nrecommendations of the Polish National Institute of Public \nHealth – National Institute of Hygiene (NIZP-PZH) regarding \nthe reduction of red meat consumption up to 500 g per week, \nand implementing one vegetarian day during the week [29]. \nThe fish consumption advised by NIZP-PZH is 2 portions per \nweek to cover the EPA and DHA needs of the organism [30]. \nThis recommendation was met by 34.3% of women adhering \nto a diet, and by only 7.4% of those not adhering to a diet \n(data not shown). Dairy consumption was significantly higher \namong women in the second group. The median frequency of \ndairy intake among these women was 2–3 times a week, while \nfor women adhering to a diet it was once a week. NIZP-PZH \nrecommends consumption of 2 glasses of milk per day, which \nmay be substituted by yoghurt, buttermilk or white cheese \n[29]. It can be assumed that women consuming dairy several \ntimes a day meet these recommendations – according to this \nstudy it was only 5.4% in the group following a diet, contrary \nto 28.4% of women not following a diet (data not shown). \nCompared to the women not following the diet, 3 times \nas many women adhering to a diet never consumed white \nbread – 41% versus 13.6% (data not shown). They also more \nfrequently chose gluten-free bread and groats, probably due \nto a reduction or resignation from gluten. Cereals were more \noften consumed by women adhering to a diet. According to \nNIZP-PZH, 3 servings of wholegrain products (90 g) should \nbe consumed every day [29]. Seeds and nuts, a rich source \nof vegetable oils, were often consumed by women following \na diet, and increasing the consumption of seeds and nuts was \nincluded in the 2020 guidelines of NIZP-PZH [29]. Women \npracticing dietary modification often met this criterion. The \nstudy also found significant differences between the groups in \nthe consumption of fruits and vegetables, which was higher \nin the group adhering to a diet, and were more likely to meet \nthe recommendations regarding consumption of a minimum \n400 g of these products per day [29]. Women following a diet \nmore often drank fruit juices. One glass of juice may replace \none portion of fruits a day, but higher consumption is not \nrecommended [31]. Women in this group less often drank \nsweetened drinks, probably to reduce sweets and sugar in \ntheir diet.\nThe most popular methods of thermal processing of \nfood among women on a diet were boiling in the water and \nTable 9. Engagement in regular physical activity in the group of women adhering to a diet, and those not adhering to a diet\nRegular physical activity No.  (n=230) Percent (%) Women adhering to a diet (n=149) Percent (%) Women not adhering to a diet (n=81) Percent (%) p Value\nYes 89 38.7 66 44.3 23 28.4\n0.018\nNo 141 61.3 83 55.7 58 71.6\np-value based on Pearson’s chi-squared test\nTable 8. Most popular thermal processing methods among women adhering to a diet and women not adhering to a diet.\nThermal processing method No.  \n(n=230)\nPercent  \n(%)\nWomen adhering to a diet\n(n=149)\nPercent\n(%)\nWomen not adhering to a diet\n(n=81)\nPercent\n(%)\np value\nFrying 51 22.2 25 16.8 26 32.1\n0.003\nBaking in dish/oven bag 32 13.9 23 15.4 9 11.1\nTraditional baking 36 15.7 17 11.4 19 23.5\nGrilling 2 0.9 2 1.3 0 0.0\nBoiling 53 23.9 36 24.2 17 21.0\nSteam cooking 17 7.4 14 9.4 3 3.7\nStewing 39 17.0 32 21.5 7 8.6\np-value based on Pearson’s chi-squared test\nMedycyna Ogólna i Nauki o Zdrowiu 2024, Tom 30, Nr 2128\n\nAdrianna Adamus, Katarzyna Oszajc a. Evaluation of dietary behaviours and physical activity of Polish women with endometriosis\nsteaming, methods which are more health beneficial than \nfrying or traditional cooking, which were conversely more \nfrequently chosen by women not undertaking any dietary \nmodifications. According to the current study, the women \nwho made changes in their nutritional habits cared not only \nabout the ingredients, but also about the way of preparing \nfood and chose the healthier options.\nChanges in dietary habits, such as reduction of meat \nconsumption, limitation of sugar and sweets, elimination \nof fast foods, increase in legumes, fruits, vegetables, vegetable \noils, and fish consumption, are beneficial for health and \nin accordance with NIZP-PZH recommendations [29,31]. \nModifications such as complete resignation from meat, dairy, \ngluten, soy, limitation of fruits and vegetables, or fasting, \nare not scientifically justified and may lead to nutritional \ndeficiencies, considering long-term use of the diet and the \nlow percentage of women consulting with a dietitian.\nThe main source of knowledge about nutrition for the \nsurveyed women were websites, Internet forums and/or \nFacebook groups. Similar results were presented in another \nstudy on Polish women conducted by Szymańska and \nDąbrowska-Galas [32]; O’Hara et al. also indicated the Internet \nas the main source of knowledge [33]. According to the authors \nof the above-mentioned study, looking for information about \nthe disease on their own gives the women a sense of control and \nthe decision about their health. On the other hand, the process \nof research is connected with a feelings of being overwhelmed, \nfear, and difficulties with implementing mutually exclusive \nrecommendations [33]. Arena et. al. investigated the risk of \nfake news in the Internet and according to the study 76% \nof patients with endometriosis read fake news about the \ndisease, including 39% of patients who found information \nthat endometriosis can be treated exclusively by diet [34].\nMost of the women adhering to a diet reported some \nrelief from pain symptoms, and improvement in well-being. \nSimilar results were also obtained by other researchers [25, \n27, 35–37]. In the study by Armour et al., the effectiveness \nof diet in reducing endometriosis symptoms was rated at \n6.4 (± 2,4) on a 0–10 scale [27]. According to O’Hara et al. \n[34] and Vennberg Karlsson et al. [37], adhering to a diet \ngave the patients a sense of control over the disease and the \ntreatment process, leading to improvement in well-being. The \ncurrent study indicated that 18.1% of women limited their \ndoses of medicaments, and 8.7% completely resigned from \npharmacological treatment. A similar effect of the diet was \nobserved by Armour et al. in which 18% of women limited \ntheir doses of drugs by at least 50% [27].\nAccording to the current study, only 38.7% of the surveyed \nwomen exercised regularly, preferring such activities as yoga, \nfitness and walking. In the study by Armour et al., 42% \nof surveyed women used physical activity as a method of \nalleviating the symptoms of endometriosis [27]. Sachs et. \nal. indicate that women who have the disease engage in less \nphysical activity weekly than women without the disease, \nwhich may be because of the pain symptoms accompanying \nendomitriosis [38]. However, studies indicate that systematic \nphysical activity may regulate the immunologic system and \npro-inflammatory markers, reduce menstrual bleeding, and \ntherefore decrease the risk of EM [39]. High physical activity \nincreases sex hormone-binding globulin (SHBG) and reduces \nserum estrogen concentration. It also decreases insulin \nresistance and hyperinsulinaemia, which may be associated \nwith the disease risk. Another study suggested that physical \nactivity can help in reducing the risk of endometriosis, but \nthe results did not reach statistical significance [40]. The \nstudy of O’Hara et al. showed that yoga may be beneficial in \nreducing pain and improving the quality of life of women \nwith EM [33] by allowing the women to control the pain \nthrough breathing and relaxation techniques. In the current \nstudy, the women who adhered to a diet significantly more \noften exercised regularly than women not adhering to a diet, \nand shows that they not only concentrated on nutrition, but \nalso their general lifestyle. \nStudies focusing on the impact of nutrition on the risk and \ntreatment of endometriosis, however, are equivocal, due to \nthe lack of well-designed, randomized studies on large groups \nof women. Based on the published research it is not possible \nto establish precise guidelines regarding the diet in EM. \nHowever, the studies allow the assumption that diet can alter \nthe symptoms of the disease, and that the anti-oxidants and \nanti-inflammatory ingredients play the most important role. \nThe results of the current study show that women with EM \noften decide to implement changes in their nutritional habits, \nand that the diet can be an important element supporting \nthe treatment of the disease. This requires further research \nto investigate which nutritional interventions may bring the \ngreatest benefits.\nA limitation of this study is the method of recruiting \nstudy participants by making the survey available to a wide \naudience through the social media. There is a small risk \nthat the questionnaire may have been completed by women \nwho do not in fact have EM, or that the answers given were \nnot truthful. Another limitation is the lack of validation for \nthe questionnaire.\nCONCLUSIONS\nThe results of the study show that women with EM search for \nrelief in dietary modifications, and most women experience \nimprovement of the symptoms and well-being after \nimplementing changes. Statistically significant differences \nbetween the dietary habits of women adhering to a diet, and \nwomen not adhering to a diet, were observed with regard to \nthe consumption of red meat, fish, milk and dairy products, \nlegumes, white bread, gluten free bread, seeds and nuts, \ngluten free groats, cereals, fruits, vegetables, fruit juices \nand sweetened beverages. However, not all modifications \nimplemented by the women were desirable and beneficial for \nhealth. 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BMJ \nOpen. 2020;10:e032321. doi:10.1136/bmjopen-2019-032321\n38. Sachs MK, Dedes I, El-Hadad S, et al. Physical Activity in Women \nwith Endometriosis: Less or More Compared with a Healthy Control? \nInt J Environ Res Public Health. 2023;20(17):6659. doi:10.3390/\nijerph20176659\n39. Harris HR, Chavarro JE, Malspeis S, et al. Dairy-Food, Calcium, \nMagnesium, and Vitamin D Intake and Endometriosis: A Prospective \nCohort Study. AJE. 2013;177(5):420–30. doi:10.1093/aje/kws247\n40. Youseflu S, Sadatmahalleh SJ, Mottaghi A, et al. Effects of endometriosis \non sleep quality of women: does life style factor make a difference? \nBMC Women’s Health. 2020;20(1):168. doi:10.1186/s12905-020-01036-z\nMedycyna Ogólna i Nauki o Zdrowiu 2024, Tom 30, Nr 2130","source_license":"CC0","license_restricted":false}