Externally validated prediction models for pre-eclampsia: systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the performance of existing externally validated prediction models for pre-eclampsia (PE) (specifically, any-onset, early-onset, late-onset and preterm PE).

METHODS

A systematic search was conducted in five databases (MEDLINE, EMBASE, Emcare, CINAHL and Maternity & Infant Care Database) and using Google Scholar/reference search to identify studies based on the Population, Index prediction model, Comparator, Outcome, Timing and Setting (PICOTS) approach until 20 May 2023. We extracted data using the CHARMS checklist and appraised the risk of bias using the PROBAST tool. A meta-analysis of discrimination and calibration performance was conducted when appropriate.

RESULTS

Twenty-three studies reported 52 externally validated prediction models for PE (one preterm, 20 any-onset, 17 early-onset and 14 late-onset PE models). No model had the same set of predictors. Fifteen any-onset PE models were validated externally once, two were validated twice and three were validated three times, while the Fetal Medicine Foundation (FMF) competing-risks model for preterm PE prediction was validated widely in 16 different settings. The most common predictors were maternal characteristics (prepregnancy body mass index, prior PE, family history of PE, chronic medical conditions and ethnicity) and biomarkers (uterine artery pulsatility index and pregnancy-associated plasma protein-A). The FMF model for preterm PE (triple test plus maternal factors) had the best performance, with a pooled area under the receiver-operating-characteristics curve (AUC) of 0.90 (95% prediction interval (PI), 0.76-0.96), and was well calibrated. The other models generally had poor-to-good discrimination performance (median AUC, 0.66 (range, 0.53-0.77)) and were overfitted on external validation. Apart from the FMF model, only two models that were validated multiple times for any-onset PE prediction, which were based on maternal characteristics only, produced reasonable pooled AUCs of 0.71 (95% PI, 0.66-0.76) and 0.73 (95% PI, 0.55-0.86).

CONCLUSIONS

Existing externally validated prediction models for any-, early- and late-onset PE have limited discrimination and calibration performance, and include inconsistent input variables. The triple-test FMF model had outstanding discrimination performance in predicting preterm PE in numerous settings, but the inclusion of specialized biomarkers may limit feasibility and implementation outside of high-resource settings. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Levels of physical activity and sitting time in women with infants, toddlers and preschoolers: a population-based cross-sectional study

OBJECTIVES

Insufficient physical activity (PA) and prolonged sitting time (ST) increase the risk of chronic disease and mortality. Caring for young children can potentially impact maternal PA and sedentary behaviours. The aims of this study were to explore the levels of PA and ST in women with young children (infants, toddlers and preschoolers) and sociodemographic and behavioural factors associated with these.

STUDY DESIGN

This was a population-based cross-sectional study.

METHODS

Survey 5 data collected in 2009 (n = 4290) of the 1973-1978 birth cohort of the Australian Longitudinal Study on Women's Health were used. Multiple linear and logistic regression models were used to examine associations.

RESULTS

In adjusted models, compared with women with preschoolers, women whose youngest child was an infant aged 0-6 months, aged >6-12 months or toddler had lower PA (-321.3 MET.min/week [95% confidence interval (CI) -416.2, -226.4], -147.9 MET.min/week [95% CI -237.6, -58.1] and -106.4 MET.min/week [95% CI -172.3, -40.5]). ST was higher in women whose youngest child was an infant aged 0-6 months (0.48 h/day; 95% CI 0.19, 0.77) but lower with infants aged >6-12 months (-0.33 h/day; 95% CI -0.60, -0.05) and toddlers (-0.40 h/day; 95% CI -0.60, -0.20) than in those with preschoolers. The findings were similar in the logistic model. Sociodemographic and behavioural factors such as occupation and marital status also influenced PA and ST.

CONCLUSIONS

Women with infants and toddlers have lower PA than women with preschoolers. Women are more likely to sit more in the first 6 months after childbirth. These findings can inform resources and intervention development to improve activity levels in women with young children through consideration of the age of the youngest child, sociodemographic and behavioural factors.

Informing a PCOS Lifestyle Program: Mapping Behavior Change Techniques to Barriers and Enablers to Behavior Change Using the Theoretical Domains Framework

This article aimed to identify the behavior change techniques (BCTs) based on facilitators and barriers to lifestyle management in women with polycystic ovary syndrome (PCOS) according to the behavior change wheel (BCW). This qualitative study design using inductive thematic analysis following semistructured interviews (n = 20) identified barriers and enablers to lifestyle management. These were then mapped to Capability, Opportunity, Motivation-Behavioral Model (COM-B) constructs and the corresponding Theoretical Domains Framework (TDF) domains. This study included women with PCOS residing in Australia. Main outcome measures include intervention functions, policy categories, and BCTs described in the BCW. Twenty-three BCTs were recognized to influence behavior change in women with PCOS. Factors were categorized into the subcomponents of the COM-B: psychological capability (e.g., lack of credible information), physical capability (e.g., managing multiple health conditions), physical opportunity (e.g., limited access to resources), social opportunity (e.g., adequate social support), reflective motivation (e.g., positive health expectancies following behavior change), and automatic motivation (e.g., emotional eating). Future research should use this work to guide PCOS lifestyle intervention development and then test intervention effectiveness through an experimental phase to provide empirical evidence for wider use and implementation of tailored, theory-informed PCOS lifestyle programs as part of evidence-based PCOS management.

Metabolic syndrome in polycystic ovary syndrome: a systematic review, meta-analysis and meta-regression

Women with polycystic ovary syndrome (PCOS) have increased risk of metabolic syndrome. The relative contribution of clinical, demographic or biochemical factors to metabolic syndrome in PCOS is not known. A literature search was conducted in MEDLINE, CINAHL, EMBASE and clinical trial registries. Of 4530 studies reviewed, 59 were included in the systematic review and 27 in the meta-analysis and meta-regression. In good and fair quality studies, women with PCOS had an overall increased prevalence of metabolic syndrome (odds ratio, OR 3.35, 95% confidence interval, CI 2.44, 4.59). Increased prevalence of metabolic syndrome occurred in overweight or obese women with PCOS (OR 1.88, 95% 1.16, 3.04) but not in lean women (OR 1.45, 95% CI 0.35, 6.12). In meta-regression analyses, the markers of metabolic syndrome diagnostic criteria (waist circumference, high-density lipoprotein cholesterol, triglyceride, blood pressure), BMI, glucose tolerance (2-hr oral glucose tolerance test) and surrogate markers of insulin resistance (HOMA-IR) but not markers of reproductive dysfunction (sex hormone binding globulin, testosterone, PCOS phenotypes) contributed significantly to the heterogeneity in the prevalence of metabolic syndrome. Women with PCOS have increased risk of metabolic syndrome which was associated with obesity and metabolic features but not with indices of hyperandrogenism.

Ethnicity, obesity and the prevalence of impaired glucose tolerance and type 2 diabetes in PCOS: a systematic review and meta-regression

BACKGROUND

Our prior meta-analyses demonstrated an increased prevalence of impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM) with polycystic ovary syndrome (PCOS), but with substantial clinical heterogeneity.

OBJECTIVE AND RATIONALE

We aimed to update our previous review to quantify the prevalence of IGT and T2DM in PCOS with only quality studies (good and fair quality). We also aimed to examine the contribution of parameters including ethnicity, obesity and method of diagnosing T2DM in explaining the observed heterogeneity in IGT and T2DM prevalence in PCOS.

SEARCH METHODS

We conducted a literature search (MEDLINE, CINAHL, EMBASE, clinical trial registries and hand-searching) up to June 2016 to identify studies reporting the prevalence of dysglycemia (IGT and T2DM) in women with and without PCOS. We included studies where women with PCOS (defined according to original National Institute of Health) were compared to women without PCOS for the end-points of the prevalence of IGT or T2DM. We excluded case reports, case series, editorials, and narrative reviews. Studies where PCOS was diagnosed by self-report, or where IGT or T2DM were measured by fasting glucose, only were excluded. We assessed the methodological quality of the included studies using a priori criteria based on the Newcastle-Ottawa Scaling (NOS) for non-randomized studies. Data are presented as odds ratio (OR) (95% CI) with random-effects meta-analysis by Mantel-Haenszel methods. We assessed the contribution of demographic and clinical factors to heterogeneity using subgroup and meta-regression analysis.

OUTCOMES

We reviewed 4530 studies and included 40 eligible studies in the final analysis. On meta-analysis of quality studies, women with PCOS had an increased prevalence of IGT (OR = 3.26, 95% CI: 2.17-4.90) and T2DM (OR = 2.87, 95% CI: 1.44-5.72), which differed by ethnicity (for IGT, Asia: 5-fold, the Americas: 4-fold and Europe: 3-fold), was higher with obesity, and doubled among studies using self-report or administrative data for diagnosing diabetes. The ethnicity-related difference retained its significance for Asia and Europe in BMI-matched subgroups. Clear contributors to heterogeneity did not emerge in meta-regression.

WIDER IMPLICATIONS

Our findings underscore the importance of PCOS as a cause of dysglycemia with a higher prevalence of IGT and T2DM. They support the relevance of ethnicity and obesity and emphasize the need for accurate diagnostic methods for diabetes.

PROSPERO REGISTRATION NUMBER

CRD42017056524.

Cardiometabolic risks in PCOS: a review of the current state of knowledge

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting up to 18% women of reproductive age. It is associated with a range of metabolic, reproductive, and psychological features. Current evidence indicates a role of PCOS in the development of metabolic and increased cardiovascular risk factors (CVRF) with implications for compromised cardiovascular endpoint disease, which may have a considerable impact on health and health care costs.

AREAS COVERED

Existing studies examining long-term cardiometabolic health in PCOS are heterogeneous with inconsistent findings. In the current review, we aim to explore and critically review retrospective, prospective, meta-analysis and review articles relating to PCOS on cardiometabolic risk factors and clinical consequences to summarize the evidence, note evidence gaps, and suggest implications for future research.

EXPERT COMMENTARY

Although there is an established association between PCOS and metabolic health, implications on cardiac health are more uncertain with associations observed for CVRF and subclinical disease, yet limited and conflicting data on actual cardiovascular endpoints. There is a lack of population-based long-term studies examining cardiometabolic morbidity and mortality in PCOS with a need for further research to progress toward a better understanding of the long-term cardiometabolic impacts in women with PCOS.

The characterisation of overweight and obese women who are under reporting energy intake during pregnancy

Background

Misreporting of energy intake is common and can contribute to biased estimates of the relationship between diet and disease. Energy intake misreporting is poorly understood in pregnancy and there is limited research assessing characteristics of women who misreport energy intake or changes in misreporting of energy intake across pregnancy.

Methods

An observational study in n = 945 overweight or obese pregnant women receiving standard antenatal care who participated in the LIMIT randomised trial. Diet, physical activity, psychological factors, body image satisfaction and dieting behaviour were assessed at trial entry (10–20 weeks gestation) and 36 weeks gestation. Energy misreporting status was assessed through the ratio of daily energy intake over basal metabolic rate. Logistic regression analyses were conducted with the dependent variable of under reporting of energy intake at study entry or 36 weeks in separate analysis.

Results

At study entry and 36 weeks, women were classified as under reporters (38 vs 49.4%), adequate reporters (59.7 vs 49.8%) or over reporters of energy intake (2.3 vs 0.8%) respectively. The prevalence of under reporting energy intake at 36 weeks was higher than at study entry (early pregnancy). Body mass index (BMI) at study entry and 36 weeks and socioeconomic status, dieting behaviour and risk of depression at 36 weeks were independent predictors of under reporting of energy intake.

Conclusions

Under reporting of energy intake was present in over a third of overweight and obese pregnant women and was higher in late compared to early pregnancy. Characteristics such as BMI, socioeconomic status, past dieting behaviour and risk of depression may aid in identifying women who either require support in accurate recording of food intake or attention for improving diet quality. Results were unable to distinguish whether under reporting reflects misreporting or a true restriction of dietary intake.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12607000161426, registered 9/3/2007.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1826-x) contains supplementary material, which is available to authorized users.

Systematic review and meta-analysis of the impact of preconception lifestyle interventions on fertility, obstetric, fetal, anthropometric and metabolic outcomes in men and women

STUDY QUESTION

What is the impact of preconception lifestyle interventions on live birth, birth weight and pregnancy rate?

SUMMARY ANSWER

Lifestyle interventions showed benefits for weight loss and increased natural pregnancy rate, but not for live birth or birth weight.

WHAT IS KNOWN ALREADY

Evidence on the practice and content of preconception counseling and interventions is variable and limited.

STUDY DESIGN, SIZE, DURATION

Systematic review and meta-analysis (MA). Main search terms were those related to preconception lifestyle. Database searched were Ovid MEDLINE(R), EBM Reviews, PsycINFO, EMBASE and CINAHL Plus. No language restriction was placed on the published articles. The final search was performed on 10 January 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were non-pregnant women of childbearing age intent on conceiving or their male partners. Exclusion criteria include participants with BMI < 18 kg/m2, animal trials, hereditary disorder in one or both partners and trials focusing solely on alcohol or smoking cessation/reduction, micronutrient supplementation, or diabetes control. Anthropometric, fertility, obstetric and fetal outcomes were assessed. Bias and quality assessments were performed.

MAIN RESULTS AND THE ROLE OF CHANCE

The search returned 1802 articles and eight studies were included for analysis. Populations targeted were primarily overweight or obese subfertile women seeking reproductive assistance, with few community-based studies and none including men. MA showed greater reduction in weight (n = 3, P < 0.00001, mean difference: -3.48 kg, 95% CI: -4.29, -2.67, I2 = 0%) and BMI (n = 2, P < 0.00001, mean difference: -1.40 kg/m2, 95% CI: -1.95, -0.84, I2 = 24%) with intervention. The only significant fertility outcome was an increased natural pregnancy rate (n = 2, P = 0.003, odds ratio: 1.87, CI: 1.24, 2.81, I2 = 0%). No differences were observed for ART adverse events, clinical pregnancy, pregnancy complications, delivery complications, live birth, premature birth, birth weight, neonatal mortality or anxiety. Risk of bias were high for three studies, moderate for three studies and low for two studies, Attrition bias was moderate or high in majority of studies.

LIMITATIONS, REASONS FOR CAUTION

Results were limited to subfertile or infertile women who were overweight or obese undergoing ART with no studies in men. The heterogeneous nature of the interventions in terms of duration and regimen means no conclusions could be made regarding the method or components of optimal lifestyle intervention. Attrition bias itself is an important factor that could affect efficacy of interventions.

WIDER IMPLICATIONS OF THE FINDINGS

Existing preconception lifestyle interventions primarily targeted overweight and obese subfertile women undergoing ART with a focus on weight loss. It is important to note that natural conception increased with lifestyle intervention. This emphasizes the need for further research exploring optimal components of preconception lifestyle interventions in the broader population and on the optimal nature, intensity and timing of interventions.

STUDY FUNDING/COMPETING INTEREST(S)

No conflict of interest declared. C.L.H. is a National Heart Foundation Postdoctoral Research Fellow. B.H. is funded by an Alfred Deakin Postdoctoral Research Fellowship. H.J.T. and B.W.M. hold NHMRC Practitioner fellowships. L.J.M. is supported by a SACVRDP Fellowship; a program collaboratively funded by the NHF, the South Australian Department of Health and the South Australian Health and Medical Research Institute.

PROSPERO REGISTRATION NUMBER

CRD42015023952.

Weight management practices associated with PCOS and their relationships with diet and physical activity

STUDY QUESTION

Do weight management practices differ in women with and without PCOS?

SUMMARY ANSWER

Women in the general population with self-reported PCOS are more likely to be using healthy weight management practices and alternative non-lifestyle measures for weight management than women without PCOS.

WHAT IS KNOWN ALREADY

Lifestyle management is the first-line treatment in PCOS. However, the specific weight management practices used by women with PCOS and their effect on diet and physical activity are unclear.

STUDY DESIGN, SIZE, DURATION

The study was a population-based observational cross-sectional study involving women in the 1973-1978 cohort (n = 7767 total; n = 556 with PCOS, n = 7211 without PCOS).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with and without self-reported PCOS were included. Self-reported outcome measures included healthy lifestyle-related or alternative non-lifestyle-related (e.g. laxatives or smoking) weight management practices, dietary intake and physical activity.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with PCOS were more likely to be following both healthy [reducing meal or snack size (odds ratio (OR) 1.50, 95% CI 1.14, 1.96, P = 0.004) and reducing fat or sugar intake (OR 1.32, 95% CI 1.03, 1.69, P = 0.027) or following a low glycaemic index diet (OR 2.88, 95% CI 2.30, 3.59, P < 0.001)] and alternative [smoking (OR 1.60, 95% CI 1.02, 2.52, P = 0.043) or use of laxative, diet pills, fasting or diuretics (OR 1.45, 95% CI 1.07, 1.97, P = 0.017)] weight management practices than women without PCOS. In PCOS, the use of a range of healthy weight management practices was associated with increases in physical activity (P < 0.001), diet quality (P < 0.001), percentage protein intake (P < 0.001) and decreases in glycaemic index (P < 0.001), and percentages of fat (P = 0.001), saturated fat (P < 0.001) or fibre (P = 0.003). Use of alternative weight management practices was associated with decreases in diet quality.

LIMITATIONS, REASONS FOR CAUTION

Limitations include the use of self-reported data for PCOS, height, weight, diet, physical activity and weight management behaviours.

WIDER IMPLICATIONS OF THE FINDINGS

In PCOS, we should focus on improving healthy weight practices across both diet quality and quantity, and on assessing alternative weight practices and their potential adverse effect on dietary intake.

STUDY FUNDING/COMPETING INTEREST(S)

L.M. is supported by a South Australian Cardiovascular Research Development Program Fellowship (ID AC11S374); a program collaboratively funded by the National Heart Foundation, the South Australian Department of Health and the South Australian Health and Medical Research Institute. H.T. is supported by the NHMRC. S.A.M. is supported by an NHMRC Career Development Fellowship Level 2, ID1104636 and was previously supported by an ARC Future Fellowship (2011-2015, FT100100581). The authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

The association of the lipidomic profile with features of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) affects up to 18% of reproductive-aged women with reproductive and metabolic complications. While lipidomics can identify associations between lipid species and metabolic diseases, no research has examined the association of lipid species with the pathophysiological features of PCOS. The aim of this study was to examine the lipidomic profile in women with and without PCOS. This study was a cross-sectional study in 156 age-matched pre-menopausal women (18-45 years, BMI >20 kg/m²; n = 92 with PCOS, n = 64 without PCOS). Outcomes included the association between the plasma lipidomic profile (325 lipid species (24 classes) using liquid chromatography mass spectrometry) and PCOS, adiposity, homeostasis assessment of insulin resistance (HOMA), sex hormone-binding globulin (SHBG) and free androgen index (FAI). There were no associations of the lipidomic profile with PCOS or testosterone. HOMA was positively associated with 2 classes (dihydroceramide and triacylglycerol), SHBG was inversely associated with 2 classes (diacylglycerol and triacylglycerol), FAI was positively associated with 8 classes (ceramide, phosphatidylcholine, lysophosphatidylcholine, phosphatidylethanolamine, lysophosphatidylethanolamine, phosphatidylinositol, diacylglycerol and triacylglycerol) and waist circumference was associated with 8 classes (4 positively (dihydroceramide, phosphatidylglycerol, diacylglycerol and triacylglycerol) and 4 inversely (trihexosylceramide, G_M3 ganglioside, alkenylphosphatidylcholine and alkylphosphatidylethanolamine)). The lipidomic profile was primarily related to central adiposity and FAI in women with or without PCOS. This supports prior findings that adiposity is a key driver of dyslipidaemia in PCOS and highlights the need for weight management through lifestyle interventions.

Breastfeeding and obesity in PCOS

Polycystic ovary syndrome (PCOS), a common condition affecting up to 18% of reproductive-aged women, has complications including reproductive, metabolic and psychological dysfunction. There is a strong potentially bidirectional association of obesity with PCOS. Women with PCOS both have a higher risk of obesity and greater longitudinal weight gain and obesity increases the prevalence and severity of the reproductive, metabolic and psychological features of PCOS. In limited observational studies, PCOS is proposed as a potential factor contributing to lower breastfeeding initiation and duration. Areas covered: A narrative review using PubMed was performed covering the areas of the association of obesity and PCOS with breastfeeding success and interventions for improving breastfeeding success. Obesity impacts on breastfeeding success related to factors including impaired lactogenesis, mechanical difficulties, psychological considerations and an increased likelihood of having a caesarean section. The common coexistence of obesity in PCOS is the likely key contributor to the breastfeeding problems observed in PCOS, given the contribution of obesity to reduced breastfeeding initiation and duration. Expert review: Facilitating breastfeeding is crucial for optimising maternal and infant health benefits, highlighting the importance of lactation support for overweight and obese women with or without PCOS.

Vitamin D is independently associated with depression in overweight women with and without PCOS

BACKGROUND

Depression, anxiety, and inflammation are common in polycystic ovary syndrome (PCOS). Inflammation may adversely impact on mood and vitamin D has been associated with both mood disorders and inflammation in the general population, but these relationships have not been studied in PCOS. The aim of this study was to investigate the association among 25 hydroxy-Vitamin D (25OHVD) status, anxiety, depression, and inflammation in women with and without PCOS.

METHODS

Cross-sectional study in overweight or obese premenopausal women with (n = 50) and without (n = 23) PCOS. Primary outcome measures were 25OHVD, mood (Hospital Anxiety and Depression questionnaire), and inflammation (highly sensitive C-reactive protein (hsCRP)).

RESULTS

Vitamin D deficiency (25OHVD<50 nmol/L) (46% versus 39%, p = 0.311) and 25OHVD (50.4 ± 22.2 nmol/L versus 51.6 ± 19.0 nmol/L, p = 0.828) were not significantly different in women with and without PCOS. For all women combined, 25OHVD was the only significant independent predictor of depression (β = -0.063 ± 0.021, p = 0.005) and hsCRP (β = -0.041 ± 0.015, p = 0.010).

CONCLUSIONS

Vitamin D deficiency is common in both women with and without PCOS with no differences between the groups. Vitamin D is independently associated with depression and inflammation in overweight women both with and without PCOS. Further investigation to clarify the interrelationship among vitamin D, inflammation and depression is required to identify optimal prevention and treatment strategies for psychological and metabolic dysfunction in PCOS.

Sleep disturbances in a community-based sample of women with polycystic ovary syndrome

STUDY QUESTION

Is there an excess of sleep disturbances in women with polycystic ovary syndrome (PCOS) in a community-based sample?

STUDY ANSWER

Sleep disturbances are almost twice as common in women with PCOS compared with women of similar age without PCOS, with the association slightly accounted for by body weight and, to a greater extent, by depressive symptoms.

WHAT IS KNOWN ALREADY

There is an excess of sleep-disordered breathing in clinical samples of women with PCOS, after accounting for their profile of body weight. Poor sleep patterns increase insulin resistance and thus may exacerbate PCOS symptoms and longer-term risk of metabolic disease.

STUDY DESIGN, SIZE, DURATION

A cross-sectional study of 724 women, comprising 74% of a cohort study established retrospectively when women were around age 30 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Comparisons were made between 87 women with PCOS, diagnosed using the Rotterdam criteria, and 637 women without this diagnosis in Adelaide, South Australia. Differences in sleep disturbances, assessed using a modified version of the Jenkins questionnaire, were investigated using ordered logistic regression.

MAIN RESULTS AND THE ROLE OF CHANCE

Sleep disturbances were twice as common in women with PCOS compared with those without. Specifically, PCOS was associated with increasing occurrence of difficulty falling asleep (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.28-2.95); this association was attenuated but still statistically significant after accounting for BMI and depressive symptoms. Increasing occurrence of difficulty maintaining sleep (OR 1.92 95% CI 1.12-3.31) was mediated by obesity and depressive symptoms, together. Other factors did not change these findings.

LIMITATIONS, REASONS FOR CAUTION

The cross-sectional nature of the study means that the direction of associations between PCOS and sleep disturbances is unclear, although bi-directionality for the mediators is likely based on data in the wider literature.

WIDER IMPLICATIONS OF THE FINDINGS

Our results indicate that assessment and management of both sleep and mental health problems in women with PCOS should be undertaken. Longitudinal data would be valuable to see how poor sleep affects longer-term health profiles.

Sex hormone binding globulin, but not testosterone, is associated with the metabolic syndrome in overweight and obese women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with hyperandrogenism and an increased risk of Type 2 diabetes and cardiovascular disease. Decreased SHBG and elevated testosterone are associated with metabolic syndrome and glucose intolerance in women.

AIM

The aim of this study was to assess the relationship between SHBG and testosterone and metabolic syndrome and glucose intolerance in PCOS.

MATERIAL/SUBJECTS AND METHODS

Cross-sectional study in overweight and obese premenopausal non-diabetic women with PCOS (no.=178: no.=55 metabolic syndrome, no.=16 glucose intolerance). Data were analyzed by multiple regression with metabolic syndrome, oral glucose tolerance test (OGTT) glucose or SHBG as dependent variables and reproductive hormones, insulin resistance, glucose tolerance, lipids or C-reactive protein as independent variables.

RESULTS

Metabolic syndrome was independently associated with body mass index [odds ratio (OR) 1.084 95% confidence interval (CI) 1.034-1.170, p=0.015] and SHBG (OR 0.961 95% CI 0.932-0.995, p=0.018). Glucose tolerance was independently associated with OGTT insulin (β=0.418, p<0.001), age (β=0.154, p=0.033) and PRL (β=-0.210, p=0.002). SHBG was independently associated with OGTT insulin (β=-0.216, p=0.014) and PCOS diagnostic criteria (β=0.197, p=0.010).

CONCLUSIONS

SHBG, but not testosterone, is independently associated with metabolic syndrome in overweight women with PCOS and is associated with insulin resistance and PCOS diagnostic criteria.

The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis

While many women with polycystic ovary syndrome (PCOS) are overweight, obese or centrally obese, the effect of excess weight on the outcomes of PCOS is inconsistent. The review aimed to assess the effects of overweight, obesity and central obesity on the reproductive, metabolic and psychological features of PCOS. MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PSYCINFO were searched for studies reporting outcomes according to body mass index categories or body fat distribution. Data were presented as mean difference or risk ratio (95% confidence interval). This review included 30 eligible studies. Overweight or obese women with PCOS had decreased sex hormone-binding globulin (SHBG), increased total testosterone, free androgen index, hirsutism, fasting glucose, fasting insulin, homeostatic model assessment-insulin resistance index and worsened lipid profile. Obesity significantly worsened all metabolic and reproductive outcomes measured except for hirsutism when compared to normal weight women with PCOS. Overweight women had no differences in total testosterone, hirsutism, total-cholesterol and low-density lipoprotein-cholesterol compared to normal weight women and no differences in SHBG and total testosterone compared to obese women. Central obesity was associated with higher fasting insulin levels. These results suggest that prevention and treatment of obesity is important for the management of PCOS.

A decrease in diet quality occurs during pregnancy in overweight and obese women which is maintained post-partum

BACKGROUND

Ensuring adequate dietary intake during pregnancy has important implications for optimising maternal and fetal health. It is not known whether diet quality is altered over pregnancy and the post-partum period.

OBJECTIVE

The aim of this study was to perform a comprehensive assessment of diet quality in overweight and obese women during pregnancy and early post-partum.

DESIGN

In a prospective cohort study, n=301 overweight or obese pregnant women completed a food frequency questionnaire at study entry (10-20 weeks gestation), 28 weeks gestation, 36 weeks gestation and 4 months post-partum for assessment of macronutrient and micronutrient intake and diet quality by the Healthy Eating Index (HEI).

RESULTS

Energy, macronutrient and dietary sources of micronutrients did not alter across pregnancy or post-partum. The HEI was of below average quality in 31.0% of women at baseline. This decreased from week 28 (P<0.001) and was maintained at a lower level post-partum such that HEI levels were lower compared with study entry (53.3±12.7 versus 56.7±10.1, P<0.001). The HEI decrease occurred in association with decreases in the milk, meat and unsaturated oil components, and increases in the proportion of energy from solid fats, alcohol and added sugars (P<0.001), and was independently predicted by the socioeconomic index for areas score (β=-0.011, s.e.=0.011, P=0.031).

CONCLUSION

We report for the first time that dietary quality decreases across pregnancy and is maintained at this reduced level in the early post-partum period in overweight and obese women. Dietary interventions aimed at improving diet quality should be targeted to early pregnancy and post-partum.

Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND Polycystic ovary syndrome (PCOS) is closely associated with obesity but the prevalence of obesity varies between published studies. The objective of this research was to describe the prevalence of overweight, obesity and central obesity in women with and without PCOS and to assess the confounding effect of ethnicity, geographic regions and the diagnostic criteria of PCOS on the prevalence. METHODS MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PSYCINFO were searched for studies reporting the prevalence of overweight, obesity or central obesity in women with and without PCOS. Data were presented as prevalence (%) and risk ratio (RR) [95% confidence interval (CI)]. Random-effect models were used to calculate pooled RR. RESULTS This systematic review included 106 studies while the meta-analysis included 35 studies (15129 women). Women with PCOS had increased prevalence of overweight [RR (95% CI): 1.95 (1.52, 2.50)], obesity [2.77 (1.88, 4.10)] and central obesity [1.73 (1.31, 2.30)] compared with women without PCOS. The Caucasian women with PCOS had a greater increase in obesity prevalence than the Asian women with PCOS compared with women without PCOS [10.79 (5.36, 21.70) versus 2.31 (1.33, 4.00), P < 0.001 between subgroups). CONCLUSIONS Women with PCOS had a greater risk of overweight, obesity and central obesity. Although our findings support a positive association between obesity and PCOS, our conclusions are limited by the significant heterogeneity between studies and further studies are now required to determine the source of this heterogeneity. Clinical management of PCOS should include the prevention and management of overweight and obesity.

Psychological parameters in the reproductive phenotypes of polycystic ovary syndrome

BACKGROUND

The aim of this study was to assess the psychological features in women with different polycystic ovary syndrome (PCOS) phenotypes [National Institute of Health (NIH) and non-NIH diagnostic criteria] and women without PCOS.

METHODS

An observational, cross-sectional study compared overweight (BMI ≥ 25 kg/m(2)) premenopausal women with PCOS (n = 29 NIH and n = 25 non-NIH) and controls (n = 27). Anxiety and depression were compared between women with NIH or non-NIH PCOS and women without PCOS. Health-related quality of life (HRQoL) domains related to emotions, body hair, weight, infertility and menstrual problems were compared between women with NIH and non-NIH PCOS.

RESULTS

Overall, women with PCOS had worse anxiety (P = 0.007) and depression (P = 0.048) compared with women without PCOS. Both women with NIH PCOS and non-NIH PCOS presented more often with moderate anxiety (P = 0.005 and P = 0.01, respectively) compared with women without PCOS. Women with NIH PCOS had worse HRQoL related to infertility (P = 0.012), emotions (P = 0.02) and weight (P = 0.016). No significant differences were observed between the two PCOS phenotypes for HRQoL domains related to body hair or menstrual problems. Both NIH (β = 0.30, P = 0.024) and non-NIH (β = 0.32, P = 0.016) PCOS status predicted anxiety, whereas age (β = 0.35, P = 0.008) and free androgen index (β = 0.31, P = 0.027) predicted depression.

CONCLUSIONS

PCOS is associated with anxiety and depression. Non-NIH phenotypes present with similar psychological profiles to NIH PCOS, indicating increased psychological dysfunction in PCOS, even in milder reproductive phenotypes. However, women with NIH PCOS appear to have worse HRQoL in some areas than women with non-NIH PCOS. Psychological function and HRQoL should be considered in all women with PCOS.

Exercise decreases anti-müllerian hormone in anovulatory overweight women with polycystic ovary syndrome: a pilot study

Polycystic ovary syndrome (PCOS) is a common condition in women associated with menstrual irregularity and anovulation. While obesity worsens and weight loss or exercise improves reproduction function in PCOS, the mechanism for this is unclear. The aim of this study was to examine the effect of exercise on ovarian hormones [anti-Müllerian hormone (AMH)] and menstrual and ovulatory function in women with and without PCOS. Overweight women with (n=7) and without (n=8) PCOS of comparable age, weight and BMI undertook a 12-week intensified endurance exercise training program (1 h 3 times/week) with no structured energy restriction. Primary outcomes were AMH, ovulation (weekly urinary pregnanediol) and menstrual regularity. Secondary outcomes were insulin resistance (euglycemic hyperinsulinemic clamp) and body composition (computed tomography and dual X-ray absorptiometry). Exercise decreased BMI, total and android fat mass and improved insulin sensitivity for all women. AMH was significantly higher in women with PCOS compared to controls before (p<0.001) and after exercise (p=0.001). There was a significant interaction between AMH changes with exercise and PCOS status (p=0.007) such that women without PCOS had no change in AMH (+1.4±5.2 pmol/l, p=0.48) while women with PCOS had a decrease in AMH (- 13.2±11.7 pmol/l, p=0.025). Exercise is associated with improvements in ovarian hormones in women with abnormal ovarian function. This suggests that mechanisms associated with ovarian dysfunction can be improved by exercise in PCOS.

Novel inflammatory markers in overweight women with and without polycystic ovary syndrome and following pharmacological intervention

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with reproductive and metabolic abnormalities.

AIM

The aim of this study was to assess novel inflammatory markers [adipokines leptin, adiponectin, and leptinadiponectin ratio (L/A)] in overweight women with and without PCOS and to examine alterations in these markers [aldosterone, leptin, adiponectin, and L/A] with pharmacological interventions modulating insulin resistance (IR) in PCOS.

MATERIALS/SUBJECTS AND METHODS

Overweight age, and body mass index (BMI)-matched women with (no.=80) or without PCOS (no.=27) were assessed cross-sectionally. Subjects with PCOS were then randomised to 6 months metformin (1 g b.d, no.=26) or oral contraceptive pill (OCP) (35 g ethinyl estradiol/2 mg cytoproterone acetate, no.=30). Outcome measures were leptin, adiponectin, L/A, aldosterone, highly sensitive C-reactive protein, lipid profile, IR, and androgen levels.

RESULTS

Leptin levels were lower (156.4+/-85.9 vs 208.5+/-105.2 ng/ml, p=0.015) while adiponectin and L/A were not different between women with and without PCOS. Following intervention, IR increased for the OCP and decreased for metformin, however leptin and aldosterone decreased equivalently with the OCP and metformin with no difference between each treatment (p=0.583 and p=0.801, respectively). There was no change in adiponectin or L/A with the OCP or metformin. On multiple regression, the only baseline predictor of leptin was BMI (r(2)=0.485, p<0.001) and the strongest predictor of change in leptin was change in weight (r(2)=0.402, p<0.001).

CONCLUSIONS

Alterations in leptin between women with and without PCOS and following pharmacological interventions are primarily related to adiposity and not IR. Aldosterone was reduced equivalently with metformin and the OCP despite differential effects on IR.

Comparison of aerobic exercise capacity and muscle strength in overweight women with and without polycystic ovary syndrome

OBJECTIVE

To assess maximal aerobic capacity (VO2max) and muscle strength in overweight and obese women with polycystic ovary syndrome (PCOS) and determine their relationship with metabolic and hormonal factors.

DESIGN

Cross-sectional study.

SETTING

Clinical Research Unit.

POPULATION

Overweight and obese women with PCOS (n = 10) and age-and weight-matched healthy controls (n = 16).

METHODS

VO2max was measured during an incremental treadmill test and maximal isometric (ImS) and isokinetic knee extensor strength (IkS) (120 degrees/second) were assessed by isokinetic dynamometry.

MAIN OUTCOME MEASURES

VO2max, ImS, IkS, waist circumference, blood lipids, glucose, insulin, insulin resistance (homeostatic model assessment [HOMA2]), C-reactive protein (CRP), hormonal profile.

RESULTS

PCOS women had higher levels of testosterone and free testosterone (P < or = 0.05), but there were no significant differences in any cardiovascular disease (CVD) risk markers between the groups. VO2max was similar in women with PCOS and healthy controls (PCOS 26.0 +/- 4.1 ml/kg/minute, controls 25.7 +/- 3.8 ml/kg/minute; P = 0.90), as was ImS (PCOS 1.50 +/- 0.54 Nm/kg, controls 1.50 +/- 0.47 Nm/kg; P = 0.96) and IkS (PCOS 1.04 +/- 0.32 Nm/kg, controls 1.16 +/- 0.23 Nm/kg; P = 0.32). VO2max was inversely related to waist circumference, insulin, HOMA2 and CRP. Waist circumference was inversely associated with ImS and IkS. No significant associations between exercise parameters and hormonal variables were identified.

CONCLUSIONS

Compared to age- and weight-matched healthy overweight and obese women with similar insulin resistance and CVD risk profiles, women with PCOS had similar aerobic capacity and muscle strength. This suggests PCOS, at least in the absence of an adverse metabolic profile is unlikely to limit physical function. Larger studies examining the effects of PCOS on exercise tolerance in a diverse range of PCOS phenotypes is required.

Comparison of aerobic exercise capacity and muscle strength in overweight women with and without polycystic ovary syndrome

OBJECTIVE

To assess maximal aerobic capacity (VO2max) and muscle strength in overweight and obese women with polycystic ovary syndrome (PCOS) and determine their relationship with metabolic and hormonal factors.

DESIGN

Cross-sectional study.

SETTING

Clinical Research Unit.

POPULATION

Overweight and obese women with PCOS (n = 10) and age-and weight-matched healthy controls (n = 16).

METHODS

VO2max was measured during an incremental treadmill test and maximal isometric (ImS) and isokinetic knee extensor strength (IkS) (120 degrees/second) were assessed by isokinetic dynamometry.

MAIN OUTCOME MEASURES

VO2max, ImS, IkS, waist circumference, blood lipids, glucose, insulin, insulin resistance (homeostatic model assessment [HOMA2]), C-reactive protein (CRP), hormonal profile.

RESULTS

PCOS women had higher levels of testosterone and free testosterone (P < or = 0.05), but there were no significant differences in any cardiovascular disease (CVD) risk markers between the groups. VO2max was similar in women with PCOS and healthy controls (PCOS 26.0 +/- 4.1 ml/kg/minute, controls 25.7 +/- 3.8 ml/kg/minute; P = 0.90), as was ImS (PCOS 1.50 +/- 0.54 Nm/kg, controls 1.50 +/- 0.47 Nm/kg; P = 0.96) and IkS (PCOS 1.04 +/- 0.32 Nm/kg, controls 1.16 +/- 0.23 Nm/kg; P = 0.32). VO2max was inversely related to waist circumference, insulin, HOMA2 and CRP. Waist circumference was inversely associated with ImS and IkS. No significant associations between exercise parameters and hormonal variables were identified.

CONCLUSIONS

Compared to age- and weight-matched healthy overweight and obese women with similar insulin resistance and CVD risk profiles, women with PCOS had similar aerobic capacity and muscle strength. This suggests PCOS, at least in the absence of an adverse metabolic profile is unlikely to limit physical function. Larger studies examining the effects of PCOS on exercise tolerance in a diverse range of PCOS phenotypes is required.

The effect of weight loss on anti-Müllerian hormone levels in overweight and obese women with polycystic ovary syndrome and reproductive impairment

BACKGROUND

Anti-Müllerian hormone (AMH) has been proposed as a clinical predictor of improvements in reproductive function following weight loss in overweight and obese women with polycystic ovary syndrome (PCOS). This study aimed to assess whether baseline and/or change in AMH levels with weight loss predict improvements in reproductive function in overweight and obese women with PCOS.

METHODS

Fifty-two overweight and obese women with PCOS and reproductive impairment (age 29.8 +/- 0.8 years, BMI 36.5 +/- 0.7 kg/m(2)) followed a 20-week weight loss programme. AMH, weight, menstrual cyclicity and ovulatory function were assessed at baseline and post-intervention.

RESULTS

Participants who responded with improvements in reproductive function (n = 26) had lower baseline AMH levels (23.5 +/- 3.7 versus 32.5 +/- 2.9 pmol/l; P = 0.03) and experienced greater weight loss (-11.7 +/- 1.2 versus -6.4 +/- 0.9 kg; P = 0.001) compared with those who did not respond (n = 26). Logistic regression analysis showed that weight loss and baseline AMH were independently related to improvements in reproductive function (P = 0.002 and P = 0.013, respectively). AMH levels did not change with weight loss in both responders and non-responders.

CONCLUSIONS

In overweight and obese women with PCOS and reproductive dysfunction, a 20-week weight loss intervention resulted in improvements in reproductive function but no change in AMH levels.

CLINICAL TRIALS REGISTRATION NUMBER

ACTRN12606000198527.

Flow-mediated dilatation in overweight and obese women with polycystic ovary syndrome

OBJECTIVE

There remains a large degree of disagreement about the association of polycystic ovary syndrome (PCOS) with impaired endothelial dysfunction and cardiovascular disease (CVD) risk. The purpose of this study was to determine whether overweight and obese women with PCOS have impaired endothelial function compared with weight-matched controls without PCOS and whether endothelial function is associated with cardiovascular risk markers and hormonal parameters.

DESIGN

Cross-sectional analysis.

SETTING

An outpatient trial at the Commonwealth Scientific Industrial Research Organisation Clinical Research Unit.

POPULATION

Overweight and obese women with PCOS (n= 12) and weight-matched controls without PCOS (n= 10).

METHODS

Endothelial function, cardiovascular risk markers and hormonal parameters were assessed in the patients.

MAIN OUTCOME MEASURES

Endothelial function was assessed by flow-mediated dilatation (FMD) of the brachial artery using high-resolution ultrasound. Lipid profile, fasting insulin level, glucose level, insulin resistance, C-reactive protein level, folate level, Vitamin B(12) level and hormonal parameters.

RESULTS

Women with PCOS had significantly higher testosterone levels (P < 0.001) and free androgen index (P= 0.006) compared with the controls without PCOS. Both groups were normoinsulinaemic, and there were no significant differences in any of the markers of CVD between women with and without PCOS. Furthermore, FMD was similar in both groups (PCOS 6.1 +/- 1.2% versus control 5.6 +/- 1.0%, P= 0.77).

CONCLUSIONS

Compared with a group of weight-matched women with similar metabolic profiles, normoinsulinemic, overweight and obese women with PCOS did not show any greater impairment in endothelial function assessed by FMD. A normoinsulinemic phenotype of PCOS with low metabolic risk factors may reduce the risk of endothelial dysfunction in overweight and obese women with this syndrome. Further studies are required that directly compare FMD in normoinsulinemic and hyperinsulinaemic women with PCOS.

Ghrelin and measures of satiety are altered in polycystic ovary syndrome but not differentially affected by diet composition

Polycystic ovary syndrome (PCOS) is a common endocrine condition in women of reproductive age associated with obesity. It may involve dysregulation of ghrelin, a hormone implicated in appetite regulation. The effect of diet composition on ghrelin is unclear. Overweight women with and without PCOS were randomized to a high-protein (40% carbohydrate, 30% protein; 10 PCOS, six non-PCOS) or standard protein diet (55% carbohydrate, 15% protein; 10 PCOS, six non-PCOS) for 12 wk of energy restriction and 4 wk of weight maintenance. Diet composition had no effect on fasting or postprandial ghrelin or measures of satiety. Non-PCOS subjects had a 70% higher fasting baseline ghrelin (P = 0.011), greater increase in fasting ghrelin (57.5 vs. 34.0%, P = 0.033), and greater maximal decrease in postprandial ghrelin after weight loss (-144.1 +/- 58.4 vs. -28.9 +/- 14.2 pg/ml, P = 0.02) than subjects with PCOS. Subjects with PCOS were less satiated (P = 0.001) and more hungry (P = 0.007) after a test meal at wk 0 and 16 than subjects without PCOS. Appetite regulation, as measured by subjective short-term hunger and satiety and ghrelin homeostasis, may be impaired in PCOS.

Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome

Overweight women with polycystic ovary syndrome (PCOS) were randomized to a high protein (HP; 40% carbohydrate and 30% protein; n = 14) or a low protein (LP; 55% carbohydrate and 15% protein) diet (n = 14). The intervention consisted of 12 wk of energy restriction (approximately 6000 kJ/d), followed by 4 wk of weight maintenance. Pregnancies (two HP and one LP); improvements in menstrual cyclicity, lipid profile, and insulin resistance (as measured by the homeostasis model); and decreases in weight (7.5%) and abdominal fat (12.5%) occurred independently of diet composition. Improvements in menstrual cyclicity were associated with greater decreases in insulin resistance and fasting insulin (P = 0.011). On the LP diet, high density lipoprotein cholesterol decreased 10% during energy restriction (P = 0.008), and the free androgen index increased 44% in weight maintenance stages (P = 0.027). Weight loss leads to improvements in cardiovascular and reproductive parameters potentially mediated by improvements in surrogate measures of insulin resistance. An HP weight loss diet may result in minor differential endocrine and metabolic improvements.

The obese patient with infertility: a practical approach to diagnosis and treatment

Overweight and obesity are serious and prevalent conditions in Western countries and carry many health consequences, including reproductive dysfunction. In particular, excess fat in the abdominal area is strongly related to disorders of the reproductive system. Moderate weight loss and reduction of abdominal fat improves menstrual regularity, ovulation, and infertility in women. This may be etiologically related to insulin resistance, particularly in a subset of infertile women with polycystic ovary syndrome. As such, weight loss should be promoted as an initial treatment option for obese women with infertility. However, the most effective method for achieving and maintaining weight loss is unclear. Gradual weight loss is best achieved through a sensible eating plan that can be maintained over long periods of time. The likelihood of maintaining weight loss is increased when diet is combined with regular exercise, cognitive behavior therapy, and a supportive group environment. Adoption of these principles in a primary healthcare setting can therefore aid in treatment of infertility related to obesity.

Community health centre evaluation -- a two year follow up study. The southern memorial hospital

The Community Health Programme has been responsible for the provision of more resources at the primary health care level, and it was forecast that these initiatives would give general practitioners expanded opportunities to develop their skills. An attempt to evaluate this forecast is reported here in a study which surveyed a sample of general practitioners practising in the area now served by the Southern Memorial Hospital Community Care Centre. The results of this study are compared with the results of an earlier study which was completed before the Community Care Centre was established.

Community health centre evaluation. Paper 1: Working patterns of allied health professionals

Community health centres are a new development on the Australian health scene and current indications are that they may play a greater role in the delivery of primary health care of the future. Therefore, information about these centres, what they are doing and who they are affecting, must be forthcoming if more public funds are to be channelled their way. The study reported here and in subsequent papers attempts an in-depth examination of the Southern Memorial Hospital--Community Care Centre for the purpose of establishing a base line from which this centre can measure its progress and with which other centres providing health care can compare. This paper reports the methodology of the evaluation study and the results of a survey of the working patterns of allied health professionals.

Association Structures Of Bright Children At Ages Nine And Twelve

The factor structure of free word associations of children, age 9 and 12, was the same as that for adults. Idiodynamic associative sets of 9-year-old children predicted their commonality scores, but not their reaction times. Both of these variables were predicted by the idiodynamic sets of 12-year-old children. It was speculated that idiodynamic associative sets reflect the organization (independent of culture) of the personal word "dictionary" evolved by children in preschool years, that a "common" (dependent upon culture) association hierarchy evolves independently of the "dictionary," and that variability in free word association dependent variables is a partial function of conflict between these two association hierarchies.

Relationship of association structures to verbal ability

No relationship between verbal ability and idiodynamic associative sets was found in two samples of college freshmen. An earlier finding which related an Object-referent associative set to lower verbal ability was rejected. In the light of Entwistle's recently published results, it was concluded that antecedent conditions related to idiodynamic sets might best be studied in pre-school children or mental retardates.

Objective approximations of idiodynamic associative sets

The differential availability of Perceptual-referent (predication), Object-referent (functional), Concept-referent (synonym or superordinate), and Dimension-referent (contrast or coordinate) associates was determined for a pool of familiar words. From this pool, 28 stimulus words were drawn to construct a multiple-choice form, with one of the four alternate associates appropriate to each of the four sets. One of the four alternates was a “popular” (maximally compatible with one set), with 7 populars representing each set. This multiple-choice form successfully identified Ss with idiodynamic free-association sets. As in free word association, Ss were able to increase their commonality score when instructed to identify the popular associates among the four alternatives.

ASSOCIATION STRUCTURES OF MENTAL RETARDATES

Free word associations of low level retardates (I.Q., 48) and higher level (I.Q., 67) retardates were examined for evidence of normal adult word association structures (idiodynamic associative sets). Such structures were found in both groups. The low level group, however, evidenced a factor structure different from that typical of normal adults. From a semantic point of view, associations of the low level group were more "concrete" than those of the higher level group. From a syntactic point of view, the lower level group lagged well behind the higher level group on the so-called "syntactic-paradigmatic" shift.