The increase in body weight is the main reason for the increase in the prevalence of both the MBS and T2DM in men (46) and women (47). Apart from a genetic predisposition, the main culprit of this development is the modern, sedentary lifestyle with too little physical activity and constant availability of high energy food.

Worldwide, PCOS patients have higher body weight, body mass index (BMI), waist and/or hip circumference and an elevated intra-abdominal fat mass than age-matched controls (48). The prevalence of affected PCOS patients correlates with the degree of obesity in the general population of their country of residence and thus likely reflects life style factors such as high calorie diet, composition of diet and lack of exercise, as well as ethnic components (2,49). In the U.S. 42% to 50% of PCOS patients are obese, with an average BMI around 35-38 kg/m2 (1,50,51). However, in other countries, women with PCOS tend to be leaner, with mean BMIs of 25 kg/m2 in England (52), 28 kg/m2 in Finland (53), 29 kg/m2 in Italy (54) and 31 kg/m2 in Germany (3). In a study of blood donors in Spain, 30% of the women were overweight, but only 10% were obese (22). In any case, weight gain after adolescence and abdominal obesity are associated with an increased prevalence of PCOS (55).

The importance of obesity in PCOS is also supported by the finding that obesity can profoundly affect quality-of-life (QoL) independent of the presence of other clinical symptoms in otherwise healthy subjects (56). Interestingly, obesity is linked strongly to the physical dimension of QoL, rather than with psychosocial status (57) and social adjustment (58). A variety of studies demonstrated that BMI and hirsutism are the primary mediators in the relationship between PCOS and the reductions in QoL (59-62). In addition, in obese patients the impact of weight reduction on QoL has been well established (58). On the basis of the data documenting the psychological and emotional consequences of changes in outer appearance, clinical interventions in PCOS women that influence obesity, hirsutism, acne, menstrual disturbances or infertility would be expected to improve overall QoL (63).

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