Lower fiber consumption in women with Polycystic Ovary Syndrome: A Meta-analysis of observational studies

Lower fiber consumption in women with Polycystic Ovary Syndrome: A Meta-analysis of observational studies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Article Lower fiber consumption in women with Polycystic Ovary Syndrome: A Meta-analysis of observational studies Wing-Ting Leung, Zhi-Jing Tang, Yuan-Yuan Feng, Hai-Yun Guan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1458595/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Polycystic ovary syndrome is a common endocrine disorder of reproductive women which is associated with metabolic abnormalities and gut microbiota dysbiosis. The deficiency of dietary fiber, a crucial nutrient in daily diet, is also associated with a wide range of metabolic and reproductive abnormalities, and an altered gut microbial ecosystem. This study is a meta-analysis to summarize the available evidence on dietary fiber intake level in PCOS patients. Databases of PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov were searched for observational studies and 13 studies were finally included. The pooled standardized mean difference (SMD) with 95% confidence interval (CI) of daily dietary fiber intake and total energy intake were calculated using random-effect model. The pooled result (12 studies) on absolute dietary fiber intake showed that while there was no significant difference in the total energy intake [− 0.17 (− 0.44, − 0.009), P = 0.208], the dietary fiber intake was significantly lower in PCOS women than those of controls [− 0.32 (− 0.50, − 0.14), P < 0.001]. However, significant heterogeneity was detected across the studies ( I 2 = 65.6%, P = 0.001). Meta-regression suggested that geographic region and dietary assessment method may confer borderline significance of influence on the heterogeneity. The pooled result (2 studies) on dietary fiber intake which adjusted for total energy intake, however, showed no significant difference [−2.11 (− 4.77, 0.56), P = 0.122]. In subgroup analyses based on absolute dietary fiber intake, a lower dietary fiber intake in PCOS was observed in the studies which conducted in Asia, or studies which adopted food diary or records or food recall as dietary assessment method, or studies which had a case-control study design, or used Rotterdam criteria for PCOS definition. The difference of SMD was still significant in adult subgroup or in studies matched or unmatched for age. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Polycystic ovary syndrome (PCOS) is a heterogeneous disorder in women of reproductive age characterized by a combination of signs and symptoms including hyperandrogenism, ovulatory dysfunction and polycystic ovary morphology 1 . Although not being part of the diagnostic criteria, metabolic abnormalities including insulin resistance, obesity and dyslipidemia often coexist in PCOS 2 – 4 . Affecting 6–20% women worldwide, PCOS is by far the most prevalent endocrinopathy of female 5 , 6 . However, the pathogenesis remains largely unknown. Recent studies have addressed the critical role of gut microbial dysbiosis in the development of PCOS. It is now acknowledged that PCOS is a polygenic disorder with strong internal (e.g., gut microbiota) and external (e.g., lifestyle factors) environmental influences 2 , 7 . Lifestyle, mainly dietary, management is recommended as the first-line therapy for PCOS 8 – 10 . However, due to the lack of reliable evidence, currently there are no specific suggestions for dietary intervention in PCOS 11 . Dietary fiber, a crucial dietary component which is found high amounts in fruit, vegetables, and whole grains, has been identified to have multiple beneficial effects in human including weight control, inflammation, insulin resistance, lipid metabolism and hormonal derangements 12 – 15 . Higher intakes of dietary fiber could confer benefits to protect against type 2 diabetes, cardiovascular diseases and even malignancies such as colorectal and breast cancer 16 – 18 . The benefits on health were not confined to specific fiber types and were apparent across the range of intakes 12 . Besides, reliable studies have also revealed the effects of dietary fiber on shaping the gut microbial compositions and modulating the microbial metabolites that are important for host health 19 – 21 . On the contrary, inadequate intake of dietary fiber is associated with a wide range of detrimental effects. For example, studies have shown that lower fiber intake is associated with a higher insulin level 22 , enhancement in inflammatory response 23 , and higher risks for diseases such as diabetes, cardiovascular diseases, and colon cancers 24 , 25 . Besides, a diet low in dietary fiber is also detrimental to the maintenance of a diverse microbiota and production of key metabolites, such as short chain fatty acids (SCFAs), resulting in adverse effects on host health 26 , 27 . Considering the identified benefits of dietary fiber on the human metabolism and gut microbial communities, which are also often found abnormal in PCOS, it is reasonable to question: Do women with PCOS consume enough dietary fiber in their daily life? Or rather, is there a difference between PCOS and non-PCOS women on daily dietary fiber intake? Studies by far have provided conflicting results. Thus, it remains controversial whether there is any potential relationship between dietary fiber intake and PCOS. Therefore, we performed a meta-analysis of observational studies which investigated the dietary fiber intake level in PCOS. The results may provide important clues for future exploration of the PCOS pathogenesis from dietary perspective, and may provide evidence to the development of evidence-based dietary interventions for the PCOS treatment. Materials And Methods The meta-analysis was conducted in accordance with the Meta-analysis Of Observational Studies in Epidemiology guideline (MOOSE) 28 . Data Sources and Searches strategy A comprehensive literature search in the PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov online database through December 2021 was conducted to identify all the available studies published. Th search terms or text terms were used as: ("polycystic ovary syndrome" OR "polycystic ovar*" OR "stein leventhal" OR "PCOS" OR "PCO") AND ("dietary fiber" OR "fiber*"OR "fibre*"). To identify any other eligible studies that were not identified by our search strategy, we also manually reviewed the reference lists of identified papers. No language or region restrictions were applied. Unpublished studies were not included in this meta-analysis. Study Selection The study selection was performed independently by two investigators (W.-T.L. and Z.-J.T.). Duplicates studies were screened and removed firstly by reference manager software (EndNote version 20.2; Thomson Reuters Corp., New York, NY, USA) and later checked by manual. Then titles and abstracts were screened for relevancy. Records that were deemed irrelevant were excluded. For studies that were uncertain of eligibility, full texts were reviewed. Studies were included if they met all of the inclusion criteria: (1) had an observational design (e.g., cohort, case–control or cross-sectional); (2) investigated the dietary fiber intake level in women with PCOS and women controls; (3) reported the means and SDs of daily dietary fiber intake data in both groups, or provided data for their calculation. Studies were excluded if they met any of the exclusion criteria: (1) duplicated publications; (2) not original articles (e.g., review, meta-analysis or conference abstract); (3) not conducted in human subjects; (4) lack a non-PCOS control group; (5) PCOS cases were self-reported without further confirmation of diagnosis; (6) dietary fiber intake not adjusted for total energy intake, or data of total energy intake not given; (7) incomplete data. When multiple studies reported data based on overlapping populations, the one with more informative data was considered. Any disagreements regarding study eligibility from the authors were discussed. If the disagreement remained, further discussion with a third author was performed until consensus was reached. Data extraction The following information were extracted from each included study onto a standardized form: first authors’ names, year of publication, study design, country where the study was conducted, period of enrolment for case–control and cross-sectional studies, or follow-up for cohort studies, criteria for PCOS definition, method of dietary fiber intake assessment, whether data was adjusted for total energy intake, sample sizes of cases and controls, means and standard deviations of daily fiber intake and total energy intake, subject age and BMI, matched or adjusted confounders. If the included studies reported dietary fiber intake data stratified by BMI classification, the above information of each weight group was also separately recorded. If only medians and IQRs of daily fiber intake were reported, formulas proposed by Wan et al. 29 was used to calculate means and SD values. If standard error of mean (SEM) of daily dietary fiber was given, the SD is calculated by the formula: \(SEM=SD/\sqrt{n}\) . The process of data extraction was also conducted by the two authors independently. Any disagreements from the two authors were discussed with referring back to the original text in case of incorrect or unclear data. Quality Assessment Two investigators (W.-T.L. and Z.-J.T.) conducted the quality assessment of included study using Newcastle-Ottawa Scale (NOS) 30 , 31 , as recommended by Cochrane Collaboration. The scaling used three parameters for quality assessment in case-control or cohort studies: selection (maximum score = 4), comparability (maximum score = 2) and exposure / outcome (for case-control or cohort studies respectively; maximum score = 3). A maximum of 9 points can be allocated to each study. Studies scoring ≥ 6 points were considered of high quality. Statistical Analysis All statistical analysis was performed using STATA version 15.1 (Stata Corporation, College Station, TX, USA). The standard mean difference (SMD) and 95% confidence intervals (CI) of daily dietary fiber intake and total energy intake were calculated. Statistical heterogeneity of pooled results was assessed by chi-square (χ2) test and quantified by I-square (I 2 ) statistic which represent the proportion of total variation explained by variation among studies. Heterogeneity was considered significant if P 50% 32,33 . Random-effect or fixed-effect model 32 , 34 was applied to calculate the SMD and 95% CIs according to the result of heterogeneity test. Our primary meta-analysis compared the daily dietary fiber intake between PCOS women non-PCOS. Since the dietary fiber intake in most of the studies were not adjusted for total energy intake, we also pooled and compared the overall energy intake given by these studies to yield more reliable conclusions. In order to evaluate the potential reasons for heterogeneity, subgroup analysis according to factors that may contribute to the high heterogeneity was performed. These factors include: geographic locations (continents), dietary assessment methods, study designs, criteria for PCOS definition, adjustment for BMI and age. Meta-regression was conducted to evaluate the heterogeneity brought about by the potential covariates. Influence analysis was performed by omitting one study at a time to assess the influence of each study on the overall estimate. Publication bias was indicated by visualization of funnel plots and evaluated by Begg’s test and Egger’s tests 35 , 36 . All reported probabilities (P values) were two-sided, with a P < 0.05 considered to be statistically significant. Results General characteristics of included studies Through a comprehensive search, a total of 1389 articles were identified. After the selection process, 13 articles including 10 case-control studies 37 – 46 , 1 cross-sectional studies 47 and 2 cohort studies 48 , 49 were ultimately deemed eligible and included in the meta-analysis. A flow chart of detailed steps of literature search and selection process is presented in Fig. 1 . The included articles were all published in English and published between 2006 and 2021. The studies cumulatively reported data on a total of 2469 participants including 1130 PCOS cases and 1339 controls. Among the 13 studies, five were conducted in Europe (Italy, Spain, Turkey, Poland), four from Asian (China, Iran), three from North America (USA, Canada), and one from South America (Brazil). Two studies 37 , 38 enrolled only overweight or obese women as participants, while the other studies did not limit the BMI for inclusion. Two studies 39 , 41 reported results stratified by the weight ranges of PCOS cases and controls, and we considered each weight class as a separate study. With regard to the data adjustment, one study 48 provided data adjusted and unadjusted for total energy intake at the same time, one study 40 only presented adjusted data, the rest of the studies 37–39,41−47,49 reported only unadjusted data. Table 1 summarizes the characteristics of each included studies. Table 1 Characteristics of the included studies First Author, (Reference), year, country Study Design (period of enrollment) PCOS definition Dietary assessment method Adjusted for total energy group n Mean daily fiber intake (g/d) SD (g/d) P value Total energy intake* (kcal/d) Age* (year) BMI* (kg/m 2 ) Matched/Adjusted factors Altieri P, 37 , 2013, Italy Case-control (2005–2010) Rotterdam 7-day food diary No overweight/obese PCOS 100 19.30 5.00 0.025 2220.00 ± 457.00 27.7 ± 5.2 34.7 ± 5.5 Age, BMI overweight/obese controls 100 18.20 5.30 2223.00 ± 405.00 28.4 ± 5.8 34.8 ± 5.4 Álvarez-Blasco F, 38 , 2011, Spain Case-control (2002–2005) AES FFQ/ not stated No overweight/obese PCOS 22 23.00 11.00 0.361 2374.00 ± 681.00 26.3 ± 7.6 35.2 ± 6.7 Age overweight/obese controls 59 22.00 7.00 2368.00 ± 702.00 32.2 ± 7.5 34.8 ± 6.1 Barrea L, 47 , 2019, Italy Cross-sectional (2014–2019) Rotterdam 7-day food record No PCOS 112 15.43 3.66 0.001 2245.31 ± 290.75 24.21 ± 5.47 30.95 ± 5.66 Age, BMI controls 112 17.22 4.19 2254.84 ± 272.37 24.07 ± 5.05 30.76 ± 5.60 Cunha NBD, 39 , 2019, Brazil Case-control (2015–2017) Rotterdam 7-day food report No all PCOS 39 11.50 5.38 0.580 1651.42 (1184.19-1949.22) 25.17 ± 3.86 24.43 (20.90-33.84) Age, BMI all controls 34 12.65 7.46 1487.88 (1240.79-1903.91) 25.67 ± 4.42 23.95 (21.62–31.01) lean PCOS 20 15.31 11.29 NA 1683.64 (1415.49-2156.04) (18–35) NA lean controls 19 12.48 5.96 1704.98 (1120.49-2120.01) NA overweight/obese PCOS 19 9.50 3.18 NA 1479.12 (1030.53-1922.42) NA overweight/obese controls 15 12.87 8.68 1372.38 (1258.75-1665.95) NA Cutler DA, 48 , 2019, Canada Cohort (2014–2016) Rotterdam 3-day food record No PCOS 87 19.80 6.03 ≤0.01 1783.00 (1516.00-1966.00) 30.7 ± 4.6 29.0 ± 7.1 Unmatch Yes PCOS 87 19.77 6.26 No controls 50 24.83 9.46 1815.00 (1578.00-2083.00) 35.7 ± 5.2 24.1 ± 5.1 Yes controls 50 25.03 8.40 Douglas CC, 49 , 2006, USA Cohort (not specified) NIH (1990) 4-day food record No PCOS 30 14.90 3.30 0.761 1781.50 ± 444.80 28.9 ± 6.3 29.7 ± 4.8 Age, race, BMI controls a 27 15.40 6.80 1783.90 ± 379.30 28.9 ± 6.5 29.1 ± 4.8 Eslamian G, 40 , 2017, Iran Case-control (2012–2014) Rotterdam FFQ/ stated Yes PCOS 281 12.00 5.30 ≤0.001 3215.00 ± 721.00 28.8 ± 7.6 31.2 ± 7.5 age controls 472 29.50 4.90 2489.00 ± 561.00 29.4 ± 7.5 25.9 ± 3.8 Liang Z, 41 , 2021, China Case-control (not stated) Rotterdam 24-h food recall No all PCOS 20 8.99 2.10 <0.05 1578.75 ± 334.98 26.54 ± 5.17 23.90 ± 4.41 Age,BMI all controls 20 11.43 4.28 1780.00 ± 379.44 27.60 ± 5.06 23.24 ± 3.69 lean PCOS 10 9.04 2.43 NS 1568.80 ± 351.01 24.13 ± 2.45 20.46 ± 1.58 lean controls 10 10.78 4.27 1728.50 ± 417.00 25.08 ± 3.59 20.43 ± 1.19 overweight/obese PCOS 10 8.94 1.84 <0.05 1588.70 ± 336.84 28.94 ± 6.13 27.34 ± 3.51 overweight/obese controls 10 12.08 4.42 1831.50 ± 352.37 30.12 ± 5.20 26.05 ± 3.13 Lin AW, 42 , 2019, USA Case-control (2013–2018) Rotterdam FFQ No PCOS 80 24.00 8.99 0.49 2218.00 (2017.00-2419.00) 26.8 (25.4–28.1) 31.5 (29.5–33.4) Unmatch controls 44 25.00 9.87 2180.00 (1866.00-2494.00) 29.5 (27.5–31.4) 28.0 (26.1–29.8) Melekoglu E, 43 , 2020, Turkey Case-control (2013–2013) Rotterdam 3-day food record No PCOS 65 20.70 7.70 <0.001 1732.70 ± 474.00 26.45 ± 7.42 29.7 ± 9.13 age controls 65 25.80 9.70 1854.40 ± 452.80 26.52 ± 8.90 22.6 ± 6.60 Mizgier M, 44 , 2021, Poland Case-control (not stated) Rotterdam 3-day food record No PCOS 61 15.53 6.91 0.069 1663.50 (1444.70-1788.40) 16 (15–17) NA Age controls 35 18.27 5.93 1474.01 (1189.44-1746.39) 15 (15–17) NA Pourghassem Gargari B, 45 , 2015, Iran Case-control (2009–2010) Rotterdam 3-day food recall and FFQ No PCOS 30 6.00 1.00 NS 1334.90 ± 143.40 25.83 ± 4.00 25.00 ± 3.61 BMI controls 30 6.70 0.60 1716.10 ± 142.07 26.06 ± 4.44 23.68 ± 3.07 Sharkesh EZ, 46 , 2021, Iran Case-control (2019–2020) Rotterdam FFQ No PCOS 203 38.01 18.21 <0.001 2500.07 ± 696.19 28.98 ± 5.43 25.74 ± 5.44 Unmatch controls 291 44.73 23.47 2388.03 ± 657.88 30.15 ± 6.21 23.65 ± 3.90 Abbreviations: n number of participants; SD standard deviation; FFQ Food Frequency Questionnaire; BMI body mass index, NS no significant; NA not available; *Values are presented as mean ± SD, or median (interquartile range), or (range); a Includes underweight participants and those who did not state their weight; b Data was collected from two previous weight loss interventions. According to NOS system, 9 out of 13 studies were considered as high quality, with three studies scoring 5 points and one study scoring 4 points. Table S1 presented the detailed scoring and total score for the included studies. Daily dietary fiber intake in PCOS and controls Since one included study 48 provided both types of data which adjusted or unadjusted for total energy intake, and the rest of studies provided either unadjusted (12 studies) or adjusted (one study) data, the two types of data was separately pooled in meta-analysis to compare the dietary fiber intake in PCOS women and controls. Pooling of unadjusted data given by 12 studies revealed that the daily dietary fiber intake level was significantly lower in PCOS women [SMD (95% CI): − 0.32 (− 0.50, − 0.14), P for Z < 0.001; I 2 = 65.6%, P for I 2 = 0.001] compared to the non-PCOS controls (Fig. 2 ), while there was no significant difference in total energy intake [SMD (95% CI): − 0.17 (− 0.44, 0.09), P for Z = 0.208; I 2 = 84.5%, P for I 2 < 0.001; Fig. 3 ]. The two studies 40 , 48 that provided adjusted data both reported significantly lower fiber intake level in PCOS. However, the pooled results did not show statistical significance [SMD (95% CI): − 2.11 (− 4.77, 0.56), P for Z = 0.122; I 2 = 99.4%, P for I 2 < 0.001; Fig. 4 ]. Since substantial heterogeneity was observed across the studies, random effects model was used for analyses. We also extracted and pooled the data according to BMI classification (overweight/obese or lean) from the included studies which stratified fiber intake by BMI range. As shown in Supplementary Fig. 1, the overall effect sizes showed no significant difference [SMD (95% CI): − 0.15 (− 0.60, 0.31), P for Z = 0.531; I 2 = 64.7%, P for I 2 = 0.04] in dietary fiber intake between overweight or obese PCOS women and controls. Besides, no significant difference was found between lean PCOS women and controls [SMD (95% CI): − 0.03 (− 0.82, 0.75), P for Z = 0.938; I 2 = 52.8%, P for I 2 = 0.145]. Meanwhile, no significant difference was found on total energy intake in both comparisons [SMD (95% CI): − 0.04 (− 0.26, 0.18), P for Z = 0.748; and − 0.04 (− 0.56, 0.48), P for Z = 0.872 respectively; Supplementary Fig. 2]. Subgroup analysis As there were only two studies which reported the daily dietary fiber intake data adjusted for total energy, which is too few for further subgrouping. Studies which provided the unadjusted data (a total of 12 studies) were included in the subgroup analyses. Table 2 shows the comparisons of daily fiber intake between PCOS and controls in the pre-planned subgroup meta-analyses. Table 2 Subgroup analysis of dietary fiber intake and PCOS Subgroup N SMD (95%CI) Test of SMD = 0 Heterogeneity Articles included Z P for Z I 2 (%) P for I 2 Geographic location Asia 4 −0.53 (− 0.78, − 0.27) 4.03 <0.001 46 0.135 41 , 43 , 45 , 46 North America 3 −0.31 (− 0.71, 0.09) 1.52 0.128 65.2 0.056 42 , 48 , 49 Europe 4 −0.14 (− 0.52, 0.24) 0.72 0.470 79.1 0.002 37 , 38 , 44 , 47 South America 1 −0.18 (0.64, 0.28) 0.76 0.447 - - 39 Dietary assessment Food diary/ records 7 −0.32 (− 0.58, − 0.05) 2.35 0.019 73.1 0.001 37,39,43,44,47−49 FFQ 3 −0.18 (− 0.41, 0.05) 1.51 0.131 37.7 0.201 38 , 42 , 46 Food recall 2 −0.73 (− 1.07, − 0.39) 3.83 <0.001 0.0 0.768 41 , 45 Study design Case-control 9 −0.28 (− 0.50, − 0.06) 2.51 0.012 68.1 0.001 37–39,41−46 Cohort 2 −0.42 (− 0.98, 0.15) 1.45 0.147 69.1 0.072 48 , 49 Cross-sectional 1 −0.46 (− 0.72, − 0.19) 3.36 0.001 - - 47 Adult or Adolescent Adult 11 −0.31 (− 0.51, − 0.12) 3.17 0.002 68.5 0.000 37–39,41−43,45−49 Adolescent 1 −0.42 (− 0.84, 0.00) 1.95 0.052 - - 44 PCOS definition Rotterdam 10 −0.37 (− 0.57, − 0.18) 3.77 <0.001 68.1 0.001 37,39,41−48 AES 1 0.12 (− 0.37, 0.61) 0.48 0.628 - - 38 NIH 1 −0.10 (− 0.62, 0.43) 0.36 0.720 - - 49 Adjustment or match for confounders age Yes 7 −0.25 (− 0.50, − 0.00) 1.99 0.047 67.8 0.003 37 , 39 , 41 , 43 , 44 , 47 , 49 No 5 −0.44 (− 0.72, − 0.16) 3.10 0.002 63.7 0.041 38 , 42 , 45 , 46 , 48 BMI Yes 6 −0.31 (− 0.65, 0.03) 1.81 0.071 75.5 0.001 37 , 39 , 41 , 45 , 47 , 49 No 6 −0.35 (− 0.55, − 0.15) 3.43 0.001 51.6 0.066 38 , 42 – 44 , 46 , 48 Since the dietary pattern could vary greatly with different geographic locations, subgroup analysis stratified by geographic location (continent) was conducted. Significant results were observed in the studies conducted in the Asia [SMD (95% CI): − 0.53 (− 0.78, − 0.27), P for Z < 0.001], but not found in Europe, North America, or South America. When we stratified the study by the dietary assessment method, studies that used the food diary or records [SMD (95% CI): − 0.32 (− 0.58, − 0.05), P for Z = 0.019], and studies that used food recall [SMD (95% CI): − 0.80 (− 1.21, − 0.39), P for Z < 0.001], but not FFQ, reported significantly lower fiber intake in PCOS women. In stratified analysis by the study design, significant association was found for case-control studies [SMD (95% CI): − 0.28 (− 0.50, − 0.06), P for Z = 0.012], but not for cohort studies [SMD (95% CI): − 0.42 (− 0.98, 0.15), P for Z = 0.147]. Only one included study 47 was cross-sectional and it reported a significant lower level of dietary fiber intake in PCOS. When we pooled the results in adults other than in adolescent girls, the difference in dietary fiber intake was still significant [SMD (95% CI): − 0.31 (− 0.51, − 0.12), P for Z = 0.002]. For the analysis by criteria for PCOS definition, studies that used the Rotterdam criteria for PCOS diagnosis reported significantly lower fiber intake in PCOS women [SMD (95% CI): − 0.37 (− 0.57, − 0.18), P for Z < 0.001]. The results were also significant in studies matched or not matched by age [SMD (95% CI): − 0.25 (− 0.50, − 0.00), P for Z = 0.047; − 0.44 (− 0.72, − 0.16), P for Z = 0.002], but not for studies matched for BMI [SMD (95% CI): − 0.31 (− 0.65, 0.03), P for Z = 0.071]. No difference was found in total energy intake between PCOS and controls in each subgroup mentioned above (data not shown). Meta‑regression As shown in Fig. 2 , high between-study heterogeneity ( I 2 = 65.6%) was demonstrated. To further investigate the contribution of available covariates on the high heterogeneity demonstrated in the above studies, univariate meta-regression with the covariates of continents, age group, study design, individual age match, individual BMI match, PCOS definition, dietary assessment method, publication year and country were conducted respectively. The P values from meta-regression of the above covariates were listed in Table 3 . The results show that these covariates suggested did not confer significant influence on the between study heterogeneity. Only borderline significance of influence was noted in geographic region and dietary assessment method. Table 3 Meta-regression of covariates possible for heterogenicity Covariates for meta-regression P values Continent (Asia, North America, Europe, South America) 0.060 Age group (adult, adolescent) 0.777 Study design (case-control, cross-sectional, cohort) 0.498 Individual age match (yes, no) 0.317 Individual BMI match (yes, no) 0.817 PCOS definition (Rotterdam, AES, physician-confirmed but criteria not stated) 0.234 Dietary assessment method (FFQ, food diary/record, food recall) 0.058 Publication year (2000s, 2010s, 2020s) 0.221 Country (Italy, Spain, Brazil, Canada, USA, Iran, China, Turkey, Poland, Australia) 0.061 Influence analysis and publication bias Influence analysis showed that the pooled result of association between dietary fiber intake and PCOS was not significantly influenced by a single study (Supplementary Fig. 3). Through visual observation, the distribution of all studies on funnel plot appeared to be symmetrical, suggesting no obvious publication bias existed (Supplementary Fig. 4). Consistently, Egger’s test and Begg’s test revealed no evidence of publication bias ( P = 0.434 and P = 0.784 respectively, Supplementary Fig. 5 and Supplementary Fig. 6). Discussion To our knowledge, this is the first meta-analysis which investigated the dietary fiber intake in PCOS, and also the first meta-analysis which compare the consumption of specific dietary component in women with and without PCOS. On pooling the 12 studies which provided absolute value of fiber intake, we confirmed that, while there was no difference in the total energy intake, PCOS women consumed a significantly lower level of dietary fiber compared with the non-PCOS controls. Influence analysis further confirmed the validity and robustness of the main result. Subgroup analyses were conducted for further interpretation. In the subgroup analysis using geographic location, the difference in dietary fiber intake was found significant in Asia with acceptable between-study heterogeneity, but not found in the other continents. Lower fiber intake was also found in studies that used food diary/records or food recall as dietary assessment method. In addition, studies which had a case-control design or cross-sectional design, or studies which acquired Rotterdam criteria for PCOS definition, also showed a significant difference. When the study on adolescent PCOS was not included, the result was still significant. In the subgroup analysis by whether studies were adjusted or matched by BMI or age, we did not find a meaningful influence on the main results. On the other hand, however, no significant difference was found when pooling the two studies which adjusted fiber intake by total fiber intake, although they both reported a significantly lower fiber intake in PCOS women compared with the controls. The high heterogeneity between the study may explain the inconsistency with the main result. Also, when we pooled the data stratified by BMI and subgroup according to BMI classification, no difference was found in the dietary fiber intake or in total energy intake A few studies have corroborated an association between inadequate dietary fiber intake and metabolic disturbance in PCOS. For instance, research has reported an inverse correlation between dietary fiber intake and body fat accumulation, insulin resistance, fasting insulin and glucose tolerance in PCOS women 39 , 48 . A recent randomized controlled trial 50 which used the resistant dextrin (a soluble dietary fiber) as intervention in PCOS women, showed significant improvements of metabolic parameters and inflammatory markers including decrease in the serum level of LDL-C, triglycerides, total cholesterol and high sensitivity C-reactive protein. Besides, research has also revealed a possible beneficial effect of fiber intake on hormonal regulation in PCOS. A study 47 from Italy which investigated on 224 women with and without PCOS reported that, following adjustments for BMI and total energy intake, the testosterone level in PCOS women was significantly negative correlated with the adherence to Mediterranean diet (a dietary pattern rich in fiber), or fiber consumption. The clinical trial by Gholizadeh Shamasbi S 50 also reported an improvement in hyperandrogenism and hirsutism as well as menstrual cycle irregularity in PCOS following dietary fiber intervention. Similar results were also found in another study 48 . Since lower dietary fiber intake is indicated to be associated the metabolic and hormonal disturbances in PCOS, and our result has confirmed a significantly lower level of dietary fiber intake in PCOS women compared with controls, it brings up an interesting question on how dietary fiber intake may influence with PCOS. One of the most important physiological roles of dietary fiber in human is that through direct interaction with the gut microbes, it can beneficially shape the microbial ecosystem and enhances the production of key microbial metabolites 51 – 53 . On the contrary, low dietary fiber intake not only lead to progressive loss of microbial diversity 21 , 54 , but also shifts the microbial metabolism towards utilization of less favorable substrates 55 , 56 and degradation of protective mucin 57 , which are detrimental to the hosts. In PCOS, numerous studies have demonstrated a significant decrease in biodiversity in the gut microbiome 58 – 62 . Whether a low dietary fiber intake contribute to the variation in microbial communities remains unclear. Another mechanism which dietary fiber intake may affect PCOS is the modulation of microbial metabolites. Short-chain fatty acids (SCFAs), which are key microbial metabolites produced in colon through fermentation of dietary fiber by gut microbes 53 , 63 , are famous for possessing functional roles in regulating host metabolism 52,64−66 , immune system 65 , 67 , 68 , and cell proliferation 69 , 70 . Decrease in fiber intake could possibly affected with the production of metabolites especially SCFAs, and finally influence with the overall health and well-being. Consider that PCOS women consume less dietary fiber, whether there is a reduction in SCFA production remain unclear. Furthermore, by increasing the SCFA level through modulation of dietary fiber intake, or through dietary supplements, whether there might be beneficial effects on the disorder warrants further investigation. Several limitations of the present meta-analysis should be considered. First, the significant heterogeneity detected could not be sufficiently explained by further meta-regression or subgroup analyses. We attributed the heterogeneity to a number of factors which include: the severity or subtypes of PCOS, inconsistent exclusion criteria, inconsistent nutrient analysis method, measurement or reporting inaccuracy of diet. Second, there were limited number of studies included in the certain subgroups, such as the cohort study or adolescent subgroup, making the results lack certain representation. Third, most of the controls in studies were enrolled from outpatient visitors and may result in a lack of representativeness. Fourth, energy adjustment is advantageous in analyses of diet-disease associations since it mitigates the influence of body size, metabolic efficiency, physical activity etc, and also diminish the measurement errors 71 , 72 . However, only two included studies 40 , 48 conducted energy adjustment. Thus, it was difficult to yield stronger evidence appreciably for result interpretations. In order to diminish the influence of total energy intake and give a more comprehensive interpretations for the results, we also pooled and compared the overall energy intake. Fifth, as only four studies 37 – 39 , 41 presented information based on BMI classification, it was difficult to confirm the dietary fiber intake level in overweight or obese PCOS women, who are the focus group for dietary or lifestyle interventions. How dietary fiber intake differs in this group remain to be evaluated in future investigations. Conclusions The present meta-analysis showed that dietary fiber intake level may be significantly lower in women with PCOS, albeit there was a high heterogeneity of included studies. Decreased dietary fiber intake might play a role in the development of PCOS and warrant attention when considering the dietary intervention strategy for this clinical population. In the future, more studies are needed to further confirm our observations, and to investigate whether and how an increase in dietary fiber intake can be beneficial as a dietary approach to improve PCOS health outcomes. Declarations Data availability The data sets analyzed in this study are available from the corresponding author on reasonable request. Acknowledgement This study was funded by the National Natural Science Foundation of China (81771587). Author contributions W.-T.L. and W.Z. conceived this work. W.-T.L. and Z.-J.T. organized and performed the analysis. W.-T.L., Z.-J.T. and W.Z. interpreted the data. Y.-Y.F., H.-Y.G. and Z.-S.H. prepared the figures and tables. W.-T.L. and Z.-J.T. draft the manuscript and W.Z. made the revision. All authors reviewed and approved the final submitted version. 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18:53:41","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":10280218,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfiguresandtable.docx","url":"https://assets-eu.researchsquare.com/files/rs-1458595/v1/0d01a72f4ea820f7953c25fd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lower fiber consumption in women with Polycystic Ovary Syndrome: A Meta-analysis of observational studies","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePolycystic ovary syndrome (PCOS) is a heterogeneous disorder in women of reproductive age characterized by a combination of signs and symptoms including hyperandrogenism, ovulatory dysfunction and polycystic ovary morphology \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Although not being part of the diagnostic criteria, metabolic abnormalities including insulin resistance, obesity and dyslipidemia often coexist in PCOS \u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Affecting 6\u0026ndash;20% women worldwide, PCOS is by far the most prevalent endocrinopathy of female \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However, the pathogenesis remains largely unknown. Recent studies have addressed the critical role of gut microbial dysbiosis in the development of PCOS. It is now acknowledged that PCOS is a polygenic disorder with strong internal (e.g., gut microbiota) and external (e.g., lifestyle factors) environmental influences \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Lifestyle, mainly dietary, management is recommended as the first-line therapy for PCOS \u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. However, due to the lack of reliable evidence, currently there are no specific suggestions for dietary intervention in PCOS \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDietary fiber, a crucial dietary component which is found high amounts in fruit, vegetables, and whole grains, has been identified to have multiple beneficial effects in human including weight control, inflammation, insulin resistance, lipid metabolism and hormonal derangements \u003csup\u003e\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Higher intakes of dietary fiber could confer benefits to protect against type 2 diabetes, cardiovascular diseases and even malignancies such as colorectal and breast cancer \u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The benefits on health were not confined to specific fiber types and were apparent across the range of intakes \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Besides, reliable studies have also revealed the effects of dietary fiber on shaping the gut microbial compositions and modulating the microbial metabolites that are important for host health \u003csup\u003e\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. On the contrary, inadequate intake of dietary fiber is associated with a wide range of detrimental effects. For example, studies have shown that lower fiber intake is associated with a higher insulin level \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, enhancement in inflammatory response \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, and higher risks for diseases such as diabetes, cardiovascular diseases, and colon cancers \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Besides, a diet low in dietary fiber is also detrimental to the maintenance of a diverse microbiota and production of key metabolites, such as short chain fatty acids (SCFAs), resulting in adverse effects on host health \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eConsidering the identified benefits of dietary fiber on the human metabolism and gut microbial communities, which are also often found abnormal in PCOS, it is reasonable to question: Do women with PCOS consume enough dietary fiber in their daily life? Or rather, is there a difference between PCOS and non-PCOS women on daily dietary fiber intake? Studies by far have provided conflicting results. Thus, it remains controversial whether there is any potential relationship between dietary fiber intake and PCOS. Therefore, we performed a meta-analysis of observational studies which investigated the dietary fiber intake level in PCOS. The results may provide important clues for future exploration of the PCOS pathogenesis from dietary perspective, and may provide evidence to the development of evidence-based dietary interventions for the PCOS treatment.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eThe meta-analysis was conducted in accordance with the Meta-analysis Of Observational Studies in Epidemiology guideline (MOOSE) \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Sources and Searches strategy\u003c/h2\u003e \u003cp\u003eA comprehensive literature search in the PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov online database through December 2021 was conducted to identify all the available studies published. Th search terms or text terms were used as: (\"polycystic ovary syndrome\" OR \"polycystic ovar*\" OR \"stein leventhal\" OR \"PCOS\" OR \"PCO\") AND (\"dietary fiber\" OR \"fiber*\"OR \"fibre*\"). To identify any other eligible studies that were not identified by our search strategy, we also manually reviewed the reference lists of identified papers. No language or region restrictions were applied. Unpublished studies were not included in this meta-analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Selection\u003c/h2\u003e \u003cp\u003eThe study selection was performed independently by two investigators (W.-T.L. and Z.-J.T.). Duplicates studies were screened and removed firstly by reference manager software (EndNote version 20.2; Thomson Reuters Corp., New York, NY, USA) and later checked by manual. Then titles and abstracts were screened for relevancy. Records that were deemed irrelevant were excluded. For studies that were uncertain of eligibility, full texts were reviewed. Studies were included if they met all of the inclusion criteria: (1) had an observational design (e.g., cohort, case\u0026ndash;control or cross-sectional); (2) investigated the dietary fiber intake level in women with PCOS and women controls; (3) reported the means and SDs of daily dietary fiber intake data in both groups, or provided data for their calculation. Studies were excluded if they met any of the exclusion criteria: (1) duplicated publications; (2) not original articles (e.g., review, meta-analysis or conference abstract); (3) not conducted in human subjects; (4) lack a non-PCOS control group; (5) PCOS cases were self-reported without further confirmation of diagnosis; (6) dietary fiber intake not adjusted for total energy intake, or data of total energy intake not given; (7) incomplete data. When multiple studies reported data based on overlapping populations, the one with more informative data was considered. Any disagreements regarding study eligibility from the authors were discussed. If the disagreement remained, further discussion with a third author was performed until consensus was reached.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData extraction\u003c/h2\u003e \u003cp\u003eThe following information were extracted from each included study onto a standardized form: first authors\u0026rsquo; names, year of publication, study design, country where the study was conducted, period of enrolment for case\u0026ndash;control and cross-sectional studies, or follow-up for cohort studies, criteria for PCOS definition, method of dietary fiber intake assessment, whether data was adjusted for total energy intake, sample sizes of cases and controls, means and standard deviations of daily fiber intake and total energy intake, subject age and BMI, matched or adjusted confounders. If the included studies reported dietary fiber intake data stratified by BMI classification, the above information of each weight group was also separately recorded. If only medians and IQRs of daily fiber intake were reported, formulas proposed by Wan et al.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e was used to calculate means and SD values. If standard error of mean (SEM) of daily dietary fiber was given, the SD is calculated by the formula: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(SEM=SD/\\sqrt{n}\\)\u003c/span\u003e\u003c/span\u003e. The process of data extraction was also conducted by the two authors independently. Any disagreements from the two authors were discussed with referring back to the original text in case of incorrect or unclear data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQuality Assessment\u003c/h2\u003e \u003cp\u003eTwo investigators (W.-T.L. and Z.-J.T.) conducted the quality assessment of included study using Newcastle-Ottawa Scale (NOS) \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e, as recommended by Cochrane Collaboration. The scaling used three parameters for quality assessment in case-control or cohort studies: selection (maximum score\u0026thinsp;=\u0026thinsp;4), comparability (maximum score\u0026thinsp;=\u0026thinsp;2) and exposure / outcome (for case-control or cohort studies respectively; maximum score\u0026thinsp;=\u0026thinsp;3). A maximum of 9 points can be allocated to each study. Studies scoring\u0026thinsp;\u0026ge;\u0026thinsp;6 points were considered of high quality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analysis was performed using STATA version 15.1 (Stata Corporation, College Station, TX, USA). The standard mean difference (SMD) and 95% confidence intervals (CI) of daily dietary fiber intake and total energy intake were calculated. Statistical heterogeneity of pooled results was assessed by chi-square (χ2) test and quantified by I-square (I\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e) statistic which represent the proportion of total variation explained by variation among studies. Heterogeneity was considered significant if P\u0026thinsp;\u0026lt;\u0026thinsp;0.1 or \u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;\u0026gt;\u0026thinsp;50% \u003csup\u003e32,33\u003c/sup\u003e. Random-effect or fixed-effect model \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e was applied to calculate the SMD and 95% CIs according to the result of heterogeneity test.\u003c/p\u003e \u003cp\u003eOur primary meta-analysis compared the daily dietary fiber intake between PCOS women non-PCOS. Since the dietary fiber intake in most of the studies were not adjusted for total energy intake, we also pooled and compared the overall energy intake given by these studies to yield more reliable conclusions. In order to evaluate the potential reasons for heterogeneity, subgroup analysis according to factors that may contribute to the high heterogeneity was performed. These factors include: geographic locations (continents), dietary assessment methods, study designs, criteria for PCOS definition, adjustment for BMI and age. Meta-regression was conducted to evaluate the heterogeneity brought about by the potential covariates. Influence analysis was performed by omitting one study at a time to assess the influence of each study on the overall estimate. Publication bias was indicated by visualization of funnel plots and evaluated by Begg\u0026rsquo;s test and Egger\u0026rsquo;s tests \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. All reported probabilities (P values) were two-sided, with a P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered to be statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003eGeneral characteristics of included studies\u003c/h2\u003e\n \u003cp\u003eThrough a comprehensive search, a total of 1389 articles were identified. After the selection process, 13 articles including 10 case-control studies\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e, 1 cross-sectional studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e and 2 cohort studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e were ultimately deemed eligible and included in the meta-analysis. A flow chart of detailed steps of literature search and selection process is presented in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eThe included articles were all published in English and published between 2006 and 2021. The studies cumulatively reported data on a total of 2469 participants including 1130 PCOS cases and 1339 controls. Among the 13 studies, five were conducted in Europe (Italy, Spain, Turkey, Poland), four from Asian (China, Iran), three from North America (USA, Canada), and one from South America (Brazil). Two studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e enrolled only overweight or obese women as participants, while the other studies did not limit the BMI for inclusion. Two studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e reported results stratified by the weight ranges of PCOS cases and controls, and we considered each weight class as a separate study. With regard to the data adjustment, one study \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e provided data adjusted and unadjusted for total energy intake at the same time, one study \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e only presented adjusted data, the rest of the studies \u003csup\u003e37\u0026ndash;39,41\u0026minus;47,49\u003c/sup\u003e reported only unadjusted data. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the characteristics of each included studies.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of the included studies\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr style=\"height: 87px;\"\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eFirst Author, (Reference), year, country\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eStudy Design (period of enrollment)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003ePCOS definition\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eDietary assessment method\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eAdjusted for total energy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eMean daily fiber intake (g/d)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eSD (g/d)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eTotal energy intake* (kcal/d)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eAge* (year)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eBMI* (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"height: 87px;\"\u003e\n \u003cp\u003eMatched/Adjusted factors\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eAltieri P, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e, 2013, Italy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(2005\u0026ndash;2010)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e7-day food diary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003eoverweight/obese PCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e19.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2220.00\u0026thinsp;\u0026plusmn;\u0026thinsp;457.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e27.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e34.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eAge, BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003eoverweight/obese controls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e18.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e5.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2223.00\u0026thinsp;\u0026plusmn;\u0026thinsp;405.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e\u0026Aacute;lvarez-Blasco F, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e, 2011, Spain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(2002\u0026ndash;2005)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eAES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eFFQ/ not stated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003eoverweight/obese PCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e23.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e11.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e0.361\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2374.00\u0026thinsp;\u0026plusmn;\u0026thinsp;681.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e26.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e35.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003eoverweight/obese controls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e22.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2368.00\u0026thinsp;\u0026plusmn;\u0026thinsp;702.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e32.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eBarrea L, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e, 2019, Italy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eCross-sectional\u003c/p\u003e\n \u003cp\u003e(2014\u0026ndash;2019)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e7-day food record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e15.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e3.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2245.31\u0026thinsp;\u0026plusmn;\u0026thinsp;290.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e24.21\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e30.95\u0026thinsp;\u0026plusmn;\u0026thinsp;5.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eAge, BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e17.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e4.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2254.84\u0026thinsp;\u0026plusmn;\u0026thinsp;272.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e24.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e30.76\u0026thinsp;\u0026plusmn;\u0026thinsp;5.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 366px;\"\u003e\n \u003cp\u003eCunha NBD, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e, 2019, Brazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 366px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(2015\u0026ndash;2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 366px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 366px;\"\u003e\n \u003cp\u003e7-day food report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 366px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eall PCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e11.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e5.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003e0.580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e1651.42 (1184.19-1949.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e25.17\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e24.43 (20.90-33.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 366px;\"\u003e\n \u003cp\u003eAge, BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eall controls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e12.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e7.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e1487.88 (1240.79-1903.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e25.67\u0026thinsp;\u0026plusmn;\u0026thinsp;4.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e23.95 (21.62\u0026ndash;31.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003elean PCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e15.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e11.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e1683.64 (1415.49-2156.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\" style=\"height: 244px;\"\u003e\n \u003cp\u003e(18\u0026ndash;35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003elean controls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e12.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e5.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e1704.98 (1120.49-2120.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eoverweight/obese PCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e9.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e3.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e1479.12 (1030.53-1922.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eoverweight/obese controls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e12.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e8.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e1372.38 (1258.75-1665.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 35px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"4\" style=\"height: 140px;\"\u003e\n \u003cp\u003eCutler DA, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e, 2019,\u003c/p\u003e\n \u003cp\u003eCanada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\" style=\"height: 140px;\"\u003e\n \u003cp\u003eCohort\u003c/p\u003e\n \u003cp\u003e(2014\u0026ndash;2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\" style=\"height: 140px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\" style=\"height: 140px;\"\u003e\n \u003cp\u003e3-day food record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 35px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 35px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e19.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e6.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\" style=\"height: 140px;\"\u003e\n \u003cp\u003e\u0026le;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 70px;\"\u003e\n \u003cp\u003e1783.00 (1516.00-1966.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 70px;\"\u003e\n \u003cp\u003e30.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 70px;\"\u003e\n \u003cp\u003e29.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\" style=\"height: 140px;\"\u003e\n \u003cp\u003eUnmatch\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 35px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 35px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 35px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e19.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e6.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 35px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 35px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 35px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e24.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e9.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 70px;\"\u003e\n \u003cp\u003e1815.00 (1578.00-2083.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 70px;\"\u003e\n \u003cp\u003e35.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 70px;\"\u003e\n \u003cp\u003e24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 35px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 35px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 35px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e25.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 35px;\"\u003e\n \u003cp\u003e8.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eDouglas CC, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e, 2006, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eCohort\u003c/p\u003e\n \u003cp\u003e(not specified)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNIH (1990)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e4-day food record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e14.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e3.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e0.761\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1781.50\u0026thinsp;\u0026plusmn;\u0026thinsp;444.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eAge, race, BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003econtrols\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e15.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e6.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1783.90\u0026thinsp;\u0026plusmn;\u0026thinsp;379.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e29.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eEslamian G, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e, 2017, Iran\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(2012\u0026ndash;2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eFFQ/ stated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e281\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e12.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e5.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e\u0026le;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e3215.00\u0026thinsp;\u0026plusmn;\u0026thinsp;721.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e28.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e31.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e29.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e4.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2489.00\u0026thinsp;\u0026plusmn;\u0026thinsp;561.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e25.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 288.375px;\"\u003e\n \u003cp\u003eLiang Z, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e, 2021, China\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 288.375px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(not stated)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 288.375px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 288.375px;\"\u003e\n \u003cp\u003e24-h food recall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 288.375px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003eall PCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e8.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1578.75\u0026thinsp;\u0026plusmn;\u0026thinsp;334.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e26.54\u0026thinsp;\u0026plusmn;\u0026thinsp;5.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e23.90\u0026thinsp;\u0026plusmn;\u0026thinsp;4.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\" style=\"height: 288.375px;\"\u003e\n \u003cp\u003eAge,BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003eall controls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e11.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e4.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1780.00\u0026thinsp;\u0026plusmn;\u0026thinsp;379.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e27.60\u0026thinsp;\u0026plusmn;\u0026thinsp;5.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e23.24\u0026thinsp;\u0026plusmn;\u0026thinsp;3.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003elean PCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e9.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1568.80\u0026thinsp;\u0026plusmn;\u0026thinsp;351.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e24.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e20.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003elean controls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e10.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e4.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1728.50\u0026thinsp;\u0026plusmn;\u0026thinsp;417.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e25.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e20.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48.375px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48.375px;\"\u003e\n \u003cp\u003eoverweight/obese PCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48.375px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48.375px;\"\u003e\n \u003cp\u003e8.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48.375px;\"\u003e\n \u003cp\u003e1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96.375px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48.375px;\"\u003e\n \u003cp\u003e1588.70\u0026thinsp;\u0026plusmn;\u0026thinsp;336.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48.375px;\"\u003e\n \u003cp\u003e28.94\u0026thinsp;\u0026plusmn;\u0026thinsp;6.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48.375px;\"\u003e\n \u003cp\u003e27.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003eoverweight/obese controls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e12.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e4.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1831.50\u0026thinsp;\u0026plusmn;\u0026thinsp;352.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e30.12\u0026thinsp;\u0026plusmn;\u0026thinsp;5.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e26.05\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eLin AW, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e, 2019, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(2013\u0026ndash;2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eFFQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e24.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e8.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e2218.00 (2017.00-2419.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e26.8 (25.4\u0026ndash;28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e31.5 (29.5\u0026ndash;33.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eUnmatch\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e9.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e2180.00 (1866.00-2494.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e29.5 (27.5\u0026ndash;31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e28.0 (26.1\u0026ndash;29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eMelekoglu E, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e, 2020, Turkey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(2013\u0026ndash;2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e3-day food record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e20.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e7.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1732.70\u0026thinsp;\u0026plusmn;\u0026thinsp;474.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e26.45\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e25.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e9.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1854.40\u0026thinsp;\u0026plusmn;\u0026thinsp;452.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e26.52\u0026thinsp;\u0026plusmn;\u0026thinsp;8.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e22.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eMizgier M, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e, 2021, Poland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(not stated)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003e3-day food record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e15.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e6.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e1663.50 (1444.70-1788.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e16 (15\u0026ndash;17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 122px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 61px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e18.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 61px;\"\u003e\n \u003cp\u003e5.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e1474.01 (1189.44-1746.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003e15 (15\u0026ndash;17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 61px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003ePourghassem Gargari B, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e, 2015, Iran\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(2009\u0026ndash;2010)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e3-day food recall and FFQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e6.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1334.90\u0026thinsp;\u0026plusmn;\u0026thinsp;143.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e25.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e25.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e6.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e1716.10\u0026thinsp;\u0026plusmn;\u0026thinsp;142.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e26.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e23.68\u0026thinsp;\u0026plusmn;\u0026thinsp;3.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eSharkesh EZ, \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e, 2021, Iran\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003cp\u003e(2019\u0026ndash;2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eFFQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003ePCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e38.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e18.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2500.07\u0026thinsp;\u0026plusmn;\u0026thinsp;696.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e28.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e25.74\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"height: 96px;\"\u003e\n \u003cp\u003eUnmatch\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003econtrols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e44.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"height: 48px;\"\u003e\n \u003cp\u003e23.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e2388.03\u0026thinsp;\u0026plusmn;\u0026thinsp;657.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e30.15\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"height: 48px;\"\u003e\n \u003cp\u003e23.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr style=\"height: 41px;\"\u003e\n \u003ctd colspan=\"14\" style=\"height: 41px;\"\u003eAbbreviations: n number of participants; SD standard deviation; FFQ Food Frequency Questionnaire; BMI body mass index, NS no significant; NA not available; *Values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, or median (interquartile range), or (range); \u003csup\u003ea\u003c/sup\u003e Includes underweight participants and those who did not state their weight; \u003csup\u003eb\u003c/sup\u003e Data was collected from two previous weight loss interventions.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eAccording to NOS system, 9 out of 13 studies were considered as high quality, with three studies scoring 5 points and one study scoring 4 points. Table S1 presented the detailed scoring and total score for the included studies.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003eDaily dietary fiber intake in PCOS and controls\u003c/h2\u003e\n \u003cp\u003eSince one included study \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e provided both types of data which adjusted or unadjusted for total energy intake, and the rest of studies provided either unadjusted (12 studies) or adjusted (one study) data, the two types of data was separately pooled in meta-analysis to compare the dietary fiber intake in PCOS women and controls. Pooling of unadjusted data given by 12 studies revealed that the daily dietary fiber intake level was significantly lower in PCOS women [SMD (95% CI): \u0026minus; 0.32 (\u0026minus;\u0026thinsp;0.50, \u0026minus; 0.14), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;65.6%, \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.001] compared to the non-PCOS controls (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), while there was no significant difference in total energy intake [SMD (95% CI): \u0026minus; 0.17 (\u0026minus;\u0026thinsp;0.44, 0.09), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.208; \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;84.5%, \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e]. The two studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e that provided adjusted data both reported significantly lower fiber intake level in PCOS. However, the pooled results did not show statistical significance [SMD (95% CI): \u0026minus; 2.11 (\u0026minus;\u0026thinsp;4.77, 0.56), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.122; \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;99.4%, \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e]. Since substantial heterogeneity was observed across the studies, random effects model was used for analyses.\u003c/p\u003e\n \u003cp\u003eWe also extracted and pooled the data according to BMI classification (overweight/obese or lean) from the included studies which stratified fiber intake by BMI range. As shown in Supplementary Fig.\u0026nbsp;1, the overall effect sizes showed no significant difference [SMD (95% CI): \u0026minus; 0.15 (\u0026minus;\u0026thinsp;0.60, 0.31), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.531; \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;64.7%, \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.04] in dietary fiber intake between overweight or obese PCOS women and controls. Besides, no significant difference was found between lean PCOS women and controls [SMD (95% CI): \u0026minus; 0.03 (\u0026minus;\u0026thinsp;0.82, 0.75), P for Z\u0026thinsp;=\u0026thinsp;0.938; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;52.8%, P for I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.145]. Meanwhile, no significant difference was found on total energy intake in both comparisons [SMD (95% CI): \u0026minus; 0.04 (\u0026minus;\u0026thinsp;0.26, 0.18), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.748; and \u0026minus;\u0026thinsp;0.04 (\u0026minus;\u0026thinsp;0.56, 0.48), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.872 respectively; Supplementary Fig.\u0026nbsp;2].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec11\"\u003e\n \u003ch2\u003eSubgroup analysis\u003c/h2\u003e\n \u003cp\u003eAs there were only two studies which reported the daily dietary fiber intake data adjusted for total energy, which is too few for further subgrouping. Studies which provided the unadjusted data (a total of 12 studies) were included in the subgroup analyses. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the comparisons of daily fiber intake between PCOS and controls in the pre-planned subgroup meta-analyses.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSubgroup analysis of dietary fiber intake and PCOS\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSubgroup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSMD (95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTest of SMD\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHeterogeneity\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eArticles included\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eZ\u003c/span\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eP\u003c/span\u003e \u003cstrong\u003efor\u003c/strong\u003e \u003cspan class=\"BoldItalic\"\u003eZ\u003c/span\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eI\u003c/span\u003e\u003csup\u003e\u003cspan class=\"BoldItalic\"\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e \u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eP\u003c/span\u003e \u003cstrong\u003efor\u003c/strong\u003e \u003cspan class=\"BoldItalic\"\u003eI\u003c/span\u003e\u003csup\u003e\u003cspan class=\"BoldItalic\"\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeographic location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.53 (\u0026minus;\u0026thinsp;0.78, \u0026minus;\u0026thinsp;0.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.31 (\u0026minus;\u0026thinsp;0.71, 0.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.14 (\u0026minus;\u0026thinsp;0.52, 0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.470\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.18 (0.64, 0.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.447\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eDietary assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFood diary/ records\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.32 (\u0026minus;\u0026thinsp;0.58, \u0026minus;\u0026thinsp;0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e37,39,43,44,47\u0026minus;49\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFFQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.18 (\u0026minus;\u0026thinsp;0.41, 0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFood recall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.73 (\u0026minus;\u0026thinsp;1.07, \u0026minus;\u0026thinsp;0.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.768\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase-control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.28 (\u0026minus;\u0026thinsp;0.50, \u0026minus;\u0026thinsp;0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e37\u0026ndash;39,41\u0026minus;46\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.42 (\u0026minus;\u0026thinsp;0.98, 0.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCross-sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.46 (\u0026minus;\u0026thinsp;0.72, \u0026minus;\u0026thinsp;0.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdult or Adolescent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.31 (\u0026minus;\u0026thinsp;0.51, \u0026minus;\u0026thinsp;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e37\u0026ndash;39,41\u0026minus;43,45\u0026minus;49\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdolescent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.42 (\u0026minus;\u0026thinsp;0.84, 0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePCOS definition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRotterdam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.37 (\u0026minus;\u0026thinsp;0.57, \u0026minus;\u0026thinsp;0.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e37,39,41\u0026minus;48\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12 (\u0026minus;\u0026thinsp;0.37, 0.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.628\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNIH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.10 (\u0026minus;\u0026thinsp;0.62, 0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjustment or match for confounders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.25 (\u0026minus;\u0026thinsp;0.50, \u0026minus;\u0026thinsp;0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.047\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.44 (\u0026minus;\u0026thinsp;0.72, \u0026minus;\u0026thinsp;0.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.31 (\u0026minus;\u0026thinsp;0.65, 0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.35 (\u0026minus;\u0026thinsp;0.55, \u0026minus;\u0026thinsp;0.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eSince the dietary pattern could vary greatly with different geographic locations, subgroup analysis stratified by geographic location (continent) was conducted. Significant results were observed in the studies conducted in the Asia [SMD (95% CI): \u0026minus; 0.53 (\u0026minus;\u0026thinsp;0.78, \u0026minus; 0.27), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001], but not found in Europe, North America, or South America. When we stratified the study by the dietary assessment method, studies that used the food diary or records [SMD (95% CI): \u0026minus; 0.32 (\u0026minus;\u0026thinsp;0.58, \u0026minus; 0.05), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019], and studies that used food recall [SMD (95% CI): \u0026minus; 0.80 (\u0026minus;\u0026thinsp;1.21, \u0026minus; 0.39), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001], but not FFQ, reported significantly lower fiber intake in PCOS women. In stratified analysis by the study design, significant association was found for case-control studies [SMD (95% CI): \u0026minus; 0.28 (\u0026minus;\u0026thinsp;0.50, \u0026minus; 0.06), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012], but not for cohort studies [SMD (95% CI): \u0026minus; 0.42 (\u0026minus;\u0026thinsp;0.98, 0.15), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.147]. Only one included study \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e was cross-sectional and it reported a significant lower level of dietary fiber intake in PCOS. When we pooled the results in adults other than in adolescent girls, the difference in dietary fiber intake was still significant [SMD (95% CI): \u0026minus; 0.31 (\u0026minus;\u0026thinsp;0.51, \u0026minus; 0.12), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002]. For the analysis by criteria for PCOS definition, studies that used the Rotterdam criteria for PCOS diagnosis reported significantly lower fiber intake in PCOS women [SMD (95% CI): \u0026minus; 0.37 (\u0026minus;\u0026thinsp;0.57, \u0026minus; 0.18), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. The results were also significant in studies matched or not matched by age [SMD (95% CI): \u0026minus; 0.25 (\u0026minus;\u0026thinsp;0.50, \u0026minus; 0.00), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047; \u0026minus; 0.44 (\u0026minus;\u0026thinsp;0.72, \u0026minus; 0.16), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002], but not for studies matched for BMI [SMD (95% CI): \u0026minus; 0.31 (\u0026minus;\u0026thinsp;0.65, 0.03), \u003cem\u003eP\u003c/em\u003e for \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.071]. No difference was found in total energy intake between PCOS and controls in each subgroup mentioned above (data not shown).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec12\"\u003e\n \u003ch2\u003eMeta‑regression\u003c/h2\u003e\n \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, high between-study heterogeneity (\u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;65.6%) was demonstrated. To further investigate the contribution of available covariates on the high heterogeneity demonstrated in the above studies, univariate meta-regression with the covariates of continents, age group, study design, individual age match, individual BMI match, PCOS definition, dietary assessment method, publication year and country were conducted respectively. The \u003cem\u003eP\u003c/em\u003e values from meta-regression of the above covariates were listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. The results show that these covariates suggested did not confer significant influence on the between study heterogeneity. Only borderline significance of influence was noted in geographic region and dietary assessment method.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMeta-regression of covariates possible for heterogenicity\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCovariates for meta-regression\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP values\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContinent (Asia, North America, Europe, South America)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge group (adult, adolescent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.777\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudy design (case-control, cross-sectional, cohort)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.498\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividual age match (yes, no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.317\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividual BMI match (yes, no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.817\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePCOS definition (Rotterdam, AES, physician-confirmed but criteria not stated)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDietary assessment method (FFQ, food diary/record, food recall)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublication year (2000s, 2010s, 2020s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.221\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCountry (Italy, Spain, Brazil, Canada, USA, Iran, China, Turkey, Poland, Australia)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec13\"\u003e\n \u003ch2\u003eInfluence analysis and publication bias\u003c/h2\u003e\n \u003cp\u003eInfluence analysis showed that the pooled result of association between dietary fiber intake and PCOS was not significantly influenced by a single study (Supplementary Fig.\u0026nbsp;3). Through visual observation, the distribution of all studies on funnel plot appeared to be symmetrical, suggesting no obvious publication bias existed (Supplementary Fig.\u0026nbsp;4). Consistently, Egger\u0026rsquo;s test and Begg\u0026rsquo;s test revealed no evidence of publication bias (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.434 and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.784 respectively, Supplementary Fig.\u0026nbsp;5 and Supplementary Fig.\u0026nbsp;6).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first meta-analysis which investigated the dietary fiber intake in PCOS, and also the first meta-analysis which compare the consumption of specific dietary component in women with and without PCOS.\u003c/p\u003e \u003cp\u003eOn pooling the 12 studies which provided absolute value of fiber intake, we confirmed that, while there was no difference in the total energy intake, PCOS women consumed a significantly lower level of dietary fiber compared with the non-PCOS controls. Influence analysis further confirmed the validity and robustness of the main result. Subgroup analyses were conducted for further interpretation. In the subgroup analysis using geographic location, the difference in dietary fiber intake was found significant in Asia with acceptable between-study heterogeneity, but not found in the other continents. Lower fiber intake was also found in studies that used food diary/records or food recall as dietary assessment method. In addition, studies which had a case-control design or cross-sectional design, or studies which acquired Rotterdam criteria for PCOS definition, also showed a significant difference. When the study on adolescent PCOS was not included, the result was still significant. In the subgroup analysis by whether studies were adjusted or matched by BMI or age, we did not find a meaningful influence on the main results.\u003c/p\u003e \u003cp\u003eOn the other hand, however, no significant difference was found when pooling the two studies which adjusted fiber intake by total fiber intake, although they both reported a significantly lower fiber intake in PCOS women compared with the controls. The high heterogeneity between the study may explain the inconsistency with the main result. Also, when we pooled the data stratified by BMI and subgroup according to BMI classification, no difference was found in the dietary fiber intake or in total energy intake\u003c/p\u003e \u003cp\u003eA few studies have corroborated an association between inadequate dietary fiber intake and metabolic disturbance in PCOS. For instance, research has reported an inverse correlation between dietary fiber intake and body fat accumulation, insulin resistance, fasting insulin and glucose tolerance in PCOS women \u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. A recent randomized controlled trial \u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e which used the resistant dextrin (a soluble dietary fiber) as intervention in PCOS women, showed significant improvements of metabolic parameters and inflammatory markers including decrease in the serum level of LDL-C, triglycerides, total cholesterol and high sensitivity C-reactive protein. Besides, research has also revealed a possible beneficial effect of fiber intake on hormonal regulation in PCOS. A study \u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e from Italy which investigated on 224 women with and without PCOS reported that, following adjustments for BMI and total energy intake, the testosterone level in PCOS women was significantly negative correlated with the adherence to Mediterranean diet (a dietary pattern rich in fiber), or fiber consumption. The clinical trial by Gholizadeh Shamasbi S \u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e also reported an improvement in hyperandrogenism and hirsutism as well as menstrual cycle irregularity in PCOS following dietary fiber intervention. Similar results were also found in another study \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSince lower dietary fiber intake is indicated to be associated the metabolic and hormonal disturbances in PCOS, and our result has confirmed a significantly lower level of dietary fiber intake in PCOS women compared with controls, it brings up an interesting question on how dietary fiber intake may influence with PCOS. One of the most important physiological roles of dietary fiber in human is that through direct interaction with the gut microbes, it can beneficially shape the microbial ecosystem and enhances the production of key microbial metabolites \u003csup\u003e\u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. On the contrary, low dietary fiber intake not only lead to progressive loss of microbial diversity \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e, but also shifts the microbial metabolism towards utilization of less favorable substrates \u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e and degradation of protective mucin \u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e, which are detrimental to the hosts. In PCOS, numerous studies have demonstrated a significant decrease in biodiversity in the gut microbiome \u003csup\u003e\u003cspan additionalcitationids=\"CR59 CR60 CR61\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e. Whether a low dietary fiber intake contribute to the variation in microbial communities remains unclear.\u003c/p\u003e \u003cp\u003eAnother mechanism which dietary fiber intake may affect PCOS is the modulation of microbial metabolites. Short-chain fatty acids (SCFAs), which are key microbial metabolites produced in colon through fermentation of dietary fiber by gut microbes \u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e, are famous for possessing functional roles in regulating host metabolism \u003csup\u003e52,64\u0026minus;66\u003c/sup\u003e, immune system \u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e, and cell proliferation \u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e. Decrease in fiber intake could possibly affected with the production of metabolites especially SCFAs, and finally influence with the overall health and well-being. Consider that PCOS women consume less dietary fiber, whether there is a reduction in SCFA production remain unclear. Furthermore, by increasing the SCFA level through modulation of dietary fiber intake, or through dietary supplements, whether there might be beneficial effects on the disorder warrants further investigation.\u003c/p\u003e \u003cp\u003eSeveral limitations of the present meta-analysis should be considered. First, the significant heterogeneity detected could not be sufficiently explained by further meta-regression or subgroup analyses. We attributed the heterogeneity to a number of factors which include: the severity or subtypes of PCOS, inconsistent exclusion criteria, inconsistent nutrient analysis method, measurement or reporting inaccuracy of diet. Second, there were limited number of studies included in the certain subgroups, such as the cohort study or adolescent subgroup, making the results lack certain representation. Third, most of the controls in studies were enrolled from outpatient visitors and may result in a lack of representativeness. Fourth, energy adjustment is advantageous in analyses of diet-disease associations since it mitigates the influence of body size, metabolic efficiency, physical activity etc, and also diminish the measurement errors \u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/sup\u003e. However, only two included studies \u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e conducted energy adjustment. Thus, it was difficult to yield stronger evidence appreciably for result interpretations. In order to diminish the influence of total energy intake and give a more comprehensive interpretations for the results, we also pooled and compared the overall energy intake. Fifth, as only four studies \u003csup\u003e\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e presented information based on BMI classification, it was difficult to confirm the dietary fiber intake level in overweight or obese PCOS women, who are the focus group for dietary or lifestyle interventions. How dietary fiber intake differs in this group remain to be evaluated in future investigations.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe present meta-analysis showed that dietary fiber intake level may be significantly lower in women with PCOS, albeit there was a high heterogeneity of included studies. Decreased dietary fiber intake might play a role in the development of PCOS and warrant attention when considering the dietary intervention strategy for this clinical population. In the future, more studies are needed to further confirm our observations, and to investigate whether and how an increase in dietary fiber intake can be beneficial as a dietary approach to improve PCOS health outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets analyzed in this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the National Natural Science Foundation of China (81771587).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eW.-T.L. and W.Z. conceived this work. W.-T.L. and Z.-J.T. organized and performed the analysis. W.-T.L., Z.-J.T. and W.Z. interpreted the data. Y.-Y.F., H.-Y.G. and Z.-S.H. prepared the figures and tables. W.-T.L. and Z.-J.T. draft the manuscript and W.Z. made the revision. All authors reviewed and approved the final submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGoodarzi, M. O., Dumesic, D. A., Chazenbalk, G. \u0026amp; Azziz, R. Polycystic ovary syndrome: etiology, pathogenesis and diagnosis. \u003cem\u003eNat Rev Endocrinol\u003c/em\u003e \u003cstrong\u003e7\u003c/strong\u003e, 219-231, doi:10.1038/nrendo.2010.217 (2011).\u003c/li\u003e\n \u003cli\u003ePatel, S. 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J., Cho, E. \u0026amp; Willett, W. C. Energy adjustment of nutrient intakes is preferable to adjustment using body weight and physical activity in epidemiological analyses. \u003cem\u003ePublic Health Nutr\u003c/em\u003e \u003cstrong\u003e17\u003c/strong\u003e, 1054-1060, doi:10.1017/S1368980013001390 (2014).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-1458595/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1458595/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePolycystic ovary syndrome is a common endocrine disorder of reproductive women which is associated with metabolic abnormalities and gut microbiota dysbiosis. The deficiency of dietary fiber, a crucial nutrient in daily diet, is also associated with a wide range of metabolic and reproductive abnormalities, and an altered gut microbial ecosystem. This study is a meta-analysis to summarize the available evidence on dietary fiber intake level in PCOS patients.\u003cstrong\u003e \u003c/strong\u003eDatabases of PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov were searched for observational studies and 13 studies were finally included. The pooled standardized mean difference (SMD) with 95% confidence interval (CI) of daily dietary fiber intake and total energy intake were calculated using random-effect model. The pooled result (12 studies) on absolute dietary fiber intake showed that while there was no significant difference in the total energy intake [− 0.17 (− 0.44, − 0.009), \u003cem\u003eP\u003c/em\u003e = 0.208], the dietary fiber intake was significantly lower in PCOS women than those of controls [− 0.32 (− 0.50, − 0.14), \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001]. However, significant heterogeneity was detected across the studies (\u003cem\u003eI\u003c/em\u003e\u003csup\u003e2 \u003c/sup\u003e= 65.6%, \u003cem\u003eP\u003c/em\u003e = 0.001). Meta-regression suggested that geographic region and dietary assessment method may confer borderline significance of influence on the heterogeneity. The pooled result (2 studies) on dietary fiber intake which adjusted for total energy intake, however, showed no significant difference [−2.11 (− 4.77, 0.56), \u003cem\u003eP\u003c/em\u003e = 0.122]. In subgroup analyses based on absolute dietary fiber intake, a lower dietary fiber intake in PCOS was observed in the studies which conducted in Asia, or studies which adopted food diary or records or food recall as dietary assessment method, or studies which had a case-control study design, or used Rotterdam criteria for PCOS definition. The difference of SMD was still significant in adult subgroup or in studies matched or unmatched for age.\u003c/p\u003e","manuscriptTitle":"Lower fiber consumption in women with Polycystic Ovary Syndrome: A Meta-analysis of observational studies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-03-25 18:53:39","doi":"10.21203/rs.3.rs-1458595/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95acecac-5489-4950-8567-9d9c4ef73c8e","owner":[],"postedDate":"March 25th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-09-09T18:14:18+00:00","versionOfRecord":[],"versionCreatedAt":"2022-03-25 18:53:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1458595","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1458595","identity":"rs-1458595","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}