Cortisol metabolism and the pituitary-adrenal axis in adults with protein-calorie malnutrition

The role of neuroendocrine pathways in prognosis after stroke

A number of neuroendocrine changes have been described after stroke, which may serve adaptive or deleterious functions. The neuroendocrine changes include activation of the hypothalamo-pituitary-adrenal axis, sympathetic nervous system and alterations of several hormonal levels. Alterations of the HPA axis, increased catecholamines, natriuretic peptides and, decreased melatonin and IGF-1 levels are associated with poor post-stroke outcome, although there is no definitive proof of causality. Therefore, it remains to be established whether alteration of neuroendocrine responses could be used as a potential therapeutic target to improve stroke outcome. This article gives an overview of the major neuroendocrine pathways altered by stroke and highlights their potential for clinical use and further neurotherapeutic development by summarizing the evidence for their association with stroke outcome including functional outcome, post-stroke infection, delirium, depression and stroke-related myocardial injury.

Food supplementation and possible mechanisms underlying early breeding in the Florida Scrub-Jay (Aphelocoma coerulescens)

Food supplementation studies demonstrate the importance of resources in the timing of reproduction. Studies of Florida Scrub-Jays (Aphelocoma coerulescens) found that supplemented jays bred earlier than unsupplemented jays and that protein may play a critical role. In this study, free-living scrub-jays were provided with supplemental diets high in fat and protein (HFHP) or high in fat and low in protein (HFLP). Jays in both treatments bred earlier than unsupplemented controls (CNT), but HFHP-supplemented jays bred earlier than HFLP jays. To assess possible mechanisms, we measured testosterone (T) in males, estradiol (E2) in females, and corticosterone (CORT) in both. HFHP males had higher T than HFLP and CNT males, but treatment did not affect E2 levels of females. Pilot studies of scrub-jays in suburban environments suggest that the spatial and temporal predictability of food may influence corticosterone (CORT) levels. Suburban jays have year-round access to human-provided foods and breed earlier than wildland jays; thus, we compared CORT in all treatments in the natural site (wildlands) with those of suburban jays. CORT levels of suburban jays were lower than HFLP, HFHP, and CNT jays. HFHP-supplemented jays had lower CORT levels than those of HFLP and CNT jays. The observed differences in the timing of breeding, both between suburban and wildland populations and between experimental groups in the wildlands, may result from differences in the spatial and temporal predictability of food, and the nutritional differences in diets. Because CORT can negatively affect the reproductive axis, we postulate that nutrient availability, the predictability of food, CORT levels, and initiation of reproduction are inextricably linked.

Neuroendocrine facets of human puberty

The unfolding of pubertal growth and maturation entails multisystem collaboration. Most notably, the outflow of gonadotropins and growth hormone (GH) proceeds both independently and jointly. The current update highlights this unique dependency in the human.

Alternative treatment considerations in anorexia nervosa

Endocrinological factors underlying the etiology of anorexia nervosa are relevant to its treatment. It appears that sufferers of anorexia nervosa perform their weight-limiting behaviors in an attempt to compensate for adrenocortical insufficiency. Hypoglycemia stimulates the secretion of cortisol. In response to severe malnutrition, blood cortisol levels also rise due to increased cortisol half-life and a decrease in its metabolic clearance rate. If an adrenocortical-insufficient individual goes on a severe diet, one effect will be a significant increase in their blood cortisol levels, which will alleviate their adrenocortical insufficiency and its symptoms. This response is a powerful positive reinforcement for continuing their weight-limiting behaviors. Sufferers of anorexia nervosa commonly exhibit two other behaviors that can raise their cortisol levels: excessive exercise and self injury. Treatment of the underlying adrenocortical insufficiency with cortisol supplements has been shown to be effective in five previously published cases of diagnosed anorexia nervosa.

Significance of transthyretin in protein metabolism

Total body nitrogen (TBN) is mainly sequestered within the metabolically active lean body mass, in close relationship with total body potassium (TBK). TBN and TBK of growing children manifest superimposed accretion rates, display a sexual difference at the onset of adolescence and during adulthood, thereafter decreasing in elderly subjects. Plasma transthyretin (TTR) follows a comparable profile from birth to death in healthy individuals. Uncomplicated protein-energy malnutrition primarily affects the activity of nitrogen metabolic pool, reducing protein syntheses to levels compatible with survival. This adaptive response is well identified by declining TTR concentrations. In various stressful conditions, in vivo responses are characterized by upregulation in injured regions and with muscle proteolysis exceeding protein synthesis, resulting in a net body negative nitrogen balance. Again, this evolutionary pattern mirrors that of plasma TTR. Attenuation of stress and/or introduction of nutritional rehabilitation allows restoration to normal of both TBN and TTR values that follow parallel slopes. Despite distinct etiopathogenic mechanisms, TTR concentrations appear to reflect the loss or gain of TBN in body pools and they predict later outcome in malnutrition and in conditions of acute and/or chronic inflammation.

Hypothalamic-pituitary-adrenal responses to weight loss in mice following diet restriction, activity or separation stress: effects of tyrosine

We have studied three different types of weight-loss stress caused by Diet restriction, Activity or Separation, for their effects on the hypothalamic-pituitary axis in young female mice and their responses to tyrosine 100 mg/kg/day. Plasma was assayed for ACTH and glucocorticoid determinations, and brain catecholamine concentrations were measured by HPLC/ECD. A similar weight loss of 24-28% was observed in the models despite significant differences in food intake. Diet restriction to 60% and Separation models produced a significant increase in hypothalamic noradrenaline (p < 0.01), while there was a significant decrease (p < 0.05) in the Diet restriction to 40% that was restored after tyrosine. After Activity, noradrenaline levels did not change. ACTH concentrations decreased following Diet restriction (p < 0.05) but were unaffected by Separation or Activity. The peripheral glucocorticoid response increased significantly after Activity and Diet restriction (p < 0.001), but decreased significantly after Separation (p < 0.001). Tyrosine increased glucocorticoid concentrations in the Activity and Separation models (p < 0.05), but not after Diet restriction. Despite similar weight loss in the three models there were no predictable associations between hypothalamic noradrenaline metabolism and plasma ACTH or glucocorticoid concentrations. Tyrosine might alleviate some of the different pathophysiological problems associated with the stress of weight loss.

Impact of maternal undernutrition on hypothalamo-pituitary-adrenal axis and adipocyte functions in male rat offspring

Malnutrition induces profound deleterious effects on several metabolic and neuroendocrine functions. In the present study, we examined the impact of maternal food restriction, during gestation and lactation, on the metabolic-neuroendocrine function of their male offspring at 21 and 60 d of age. Well-nourished (WN) and undernourished (UN) pregnant rats were used, during gestation and lactation, until pups were weaned. Twenty-one-day-old WN and UN male pups were studied in basal and postinsulin conditions. Additional groups of weaned (WN and UN) male rats were fed either ad libitum (WN-WN and UN-WN) or in a restricted fashion (WN-UN and UN-UN) until experimentation at age 60 d. Body weights of mothers and their male offspring were monitored. Basal and postinsulin plasma concentrations of several metabolic fuels were evaluated. Our results indicate that 21-d-old UN male rats exhibited (vs their WN counterparts), decreased body weights, similar basal and postinsulin glycemia, similar basal plasma adrenocorticotropic hormone (ACTH) and corticosterone levels but diminished ACTH response to insulin treatment, and basal hypoleptinemia and significant insulin-induced leptin release. Finally, at 60 d of age, long-term UN (WN-UN and UN-UN) rats showed lower plasma (basal and postinsulin) glucose, and basal triglyceride levels than their counterparts (WN-WN and UN-WN). Sixty-day-old rats submitted to either food restriction protocol also showed a reduced hypothalamo-pituitary-adrenal axis response to insulin-induced hypoglycemia and basal hypoleptinemia, in spite of restoration of normal body weights. These results further indicate a clear metabolic-neuroendocrine dysfunction in male pups of UN mothers, with the abnormality partially present at weaning and deteriorated by adulthood, even after the recovery of normal body weight. Our study strongly supports the importance of the irreversibility of a deleterious allostatic state resulting from fetal and early postnatal undernutrition.

Homeostatic joint amplification of pulsatile and 24-hour rhythmic cortisol secretion by fasting stress in midluteal phase women: concurrent disruption of cortisol-growth hormone, cortisol-luteinizing hormone, and cortisol-leptin synchrony

Short-term fasting as a metabolic stress evokes prominent homeostatic reactions of the reproductive, corticotropic, thyrotropic, somatotropic, and leptinergic axes in men and women. Although reproductive adaptations to fasting are incompletely studied in the female, nutrient deprivation can have major neuroendocrine consequences in the follicular phase. Unexpectedly, a recent clinical study revealed relatively preserved sex steroid and gonadotropin secretion during short-term caloric restriction in the midluteal phase of the menstrual cycle. This observation suggested that female stress-adaptive responses might be muted in this sex steroid-replete milieu. To test this hypothesis, we investigated the impact of fasting on daily cortisol secretion in healthy young women during the midluteal phase of the normal menstrual cycle. Eight volunteers were each studied twice in separate and randomly ordered short-term (2.5-day) fasting and fed sessions. Pulsatile cortisol secretion, 24-h rhythmic cortisol release, and the orderliness of cortisol secretory patterns were quantified. Within-subject statistical comparisons revealed that fasting increased the mean serum cortisol concentration significantly from a baseline value of 8.0+/-0.61 to 12.8+/-0.85 microg/dL (P = 0.0003). (For Systeme International conversion to nanomoles per L, multiply micrograms per dL value by 28.) Pulsatile cortisol secretion rose commensurately, viz. from 101+/-11 to 173+/-16 microg/dL/day (P = 0.0025). Augmented 24-h cortisol production was due to amplification of cortisol secretory burst mass from 8.2+/-1.5 to 12.9+/-2.0 microg/dL (P = 0.017). In contrast, the estimated half-life of endogenous cortisol (104+/-9 min), the calculated duration of underlying cortisol secretory bursts (16+/-7 min) and their mean frequency (14+/-2/day) were not altered by short-term fasting. The quantifiable orderliness of cortisol secretory patterns was also not influenced by caloric restriction. Nutrient deprivation elevated the mean of the 24-h serum cortisol concentration rhythm from 12.4+/-1.3 to 18.4+/-1.9 microg/dL (P = 0.0005), without affecting its diurnal amplitude or timing. Correlation analysis disclosed that fasting reversed the positive relationship between cortisol and LH release evident in the fed state, and abolished the negative association between cortisol and GH as well as between cortisol and leptin observed during nutrient repletion (P < 0.001). Pattern synchrony between cortisol and GH as well as that between cortisol and LH release was also significantly disrupted by fasting stress. In summary, short-term caloric deprivation enhances daily cortisol secretion by 1.7-fold in healthy midluteal phase young women by selectively amplifying cortisol secretory burst mass and elevating the 24-h rhythmic cortisol mean. Augmentation of daily cortisol production occurs without any concomitant changes in cortisol pulse frequency or half-life or any disruption of the timing of the 24-h rhythmicity or orderliness of cortisol release. Fasting degrades the physiological coupling between cortisol and LH, cortisol and GH, and cortisol and leptin secretion otherwise evident in calorie-sufficient women. We conclude that the corticotropic axis in the young adult female is not resistant to the stress-activating effects of short-term nutrient deprivation, but, rather, evinces strong adaptive homeostasis both monohormonally (cortisol) and bihormonally (cortisol paired with GH, LH, and leptin).

Endocrine markers of semistarvation in healthy lean men in a multistressor environment

We tested the hypothesis that key endocrine responses to semistarvation would be attenuated by changing only the food intake in a multistressor environment that also included sustained workload, inadequate sleep, and thermal strain. Serum hormones were compared within and between two groups of healthy young male volunteers participating in the 8-wk US Army Ranger course, with four repeated cycles of restricted energy intakes and refeeding: group 1 (n = 49) and group 2 (n = 48); energy deficits averaged 1,200 and 1,000 kcal/day, respectively. After 8 wk, most of group 1 achieved a minimum body fat, serum 3,5,3'-triiodothyronine (T(3)) was below normal (78 +/- 20 ng/dl), testosterone (T) approached castrate levels (4.5 +/- 3.9 nmol/l), insulin-like growth factor I (IGF-I) declined by one-half (75 +/- 25 microg/l), and cholesterol rose from 158 +/- 31 to 217 +/- 39 mg/dl. Bioavailable T(3) and T were further reduced by increases in their specific binding proteins in response to declining insulin. Refeeding, even with continuation of the other stressors, produced prompt recovery of T(3), T, and IGF-I. Higher energy intakes in group 2 attenuated the subclinical hypothyroidism and hypercholesterolemia, whereas consistent luteinizing hormone suppression indicated centrally mediated threshold effects on gonadal hormone suppression. We conclude that low T, T(3), and IGF-I remained reliable markers of acute energy deficits in the presence of other stressors; elevated cholesterol and cortisol provided information about chronic status, corresponding to diminishing body fat stores.

The role of the central nervous system in the psychoneuroendocrine disturbances of anorexia and bulimia nervosa

It has been well-recognized that starvation in anorexia and bulimia nervosa causes endocrine disturbances. Such disturbances may help understand why many people with eating disorders cannot easily reverse their illness since people with eating disorders often enter a downward spiraling circle with malnutrition sustaining and perpetuating the desire for more weight loss and dieting. Symptoms, such as obsessions and dysphoric mood, and altered appetitive behavior, may be exaggerated by neuropeptide alterations and thus contribute to this downward spiral. While neuropeptide disturbances do not appear to be a permanent feature or cause or anorexia nervosa, these disturbances are strongly entrenched, and are not easily corrected by improved nutrition or short-term weight normalization. This suggests that therapy should be sustained for months after nutritional normalization.

Food aversions in eating disorders

The food aversions of a group of anorexia nervosa patients, bulimia nervosa patients, and no eating disordered individuals (controls) were compared. An open questionnaire was used to obtain data on the eating aversions of each of the three populations. The foodstuffs were placed in categories according to their nutritional value. They were also converted into nutrients, and the average value for each population was calculated. With the exception of the 'legumes' and 'dry fruits' categories, the degree of aversion towards the other food groups detected in the individuals with eating disorders was significantly greater than that detected in controls. Aversion towards food with a high protein content (meat, fish, milk and eggs) was characteristic of patients with eating disorders and is a source of clinical problems, which are discussed in this article.

Food and the circadian activity of the hypothalamic-pituitary-adrenal axis

Temporal organization is an important feature of biological systems and its main function is to facilitate adaptation of the organism to the environment. The daily variation of biological variables arises from an internal time-keeping system. The major action of the environment is to synchronize the internal clock to a period of exactly 24 h. The light-dark cycle, food ingestion, barometric pressure, acoustic stimuli, scents and social cues have been mentioned as synchronizers or "zeitgebers". The circadian rhythmicity of plasma corticosteroids has been well characterized in man and in rats and evidence has been accumulated showing daily rhythmicity at every level of the hypothalamic-pituitary-adrenal (HPA) axis. Studies of restricted feeding in rats are of considerable importance because they reveal feeding as a major synchronizer of rhythms in HPA axis activity. The daily variation of the HPA axis stress response appears to be closely related to food intake as well as to basal activity. In humans, the association of feeding and HPA axis activity has been studied under physiological and pathological conditions such as anorexia nervosa, bulimia, malnutrition, obesity, diabetes mellitus and Cushing's syndrome. Complex neuroanatomical pathways and neurochemical circuitry are involved in feeding-associated HPA axis modulation. In the present review we focus on the interaction among HPA axis rhythmicity, food ingestion, and different nutritional and endocrine states.

Protein malnutrition increases plasma adrenocorticotropin and anterior pituitary proopiomelanocortin messenger ribonucleic acid in the rat

The mechanism by which protein malnutrition increases circulating glucocorticoids is unclear. To determine whether ACTH synthesis and secretion also increase in protein malnutrition, rats were sham adrenalectomized or adrenalectomized and replaced with varying amounts of corticosterone before dietary protein deprivation. Pair-fed rats served as controls for reduced voluntary food intake in protein-deprived rats. Dietary protein deficiency, but not pair-feeding, increased resting plasma corticosterone in sham-adrenalectomized rats. Restraint-induced ACTH secretion was not inhibited by the increased basal corticosterone levels in protein-deficient rats. When increases in corticosterone were eliminated by adrenalectomy or controlled by adrenalectomy with low level corticosterone replacement, increases in resting plasma ACTH and anterior pituitary POMC messenger RNA expression occurred with protein deprivation that could be statistically discriminated by regression analysis from changes due to caloric restriction (pair-feeding) and overt glucocorticoid feedback resistance. We conclude that protein malnutrition increases pituitary-adrenocortical activity at least in part by specifically increasing the drive for ACTH synthesis and secretion.

Intrauterine programming of hypertension: nutrient-hormone interactions

Geographic, retrospective, and prospective epidemiologic studies have revealed evidence that the environment in utero is a major determinant of later degenerative disease. Observations from Britain, Sweden, Jamaica, Australia, India, and China support the hypothesis that disproportionate retardation of fetal growth results in increased blood pressure and increased risk of cardiovascular mortality. On the basis of what has been a limited pool of observations linking maternal undernutrition and fetal growth retardation, it has been proposed that hypertension and coronary heart disease are "programmed" by nutrition status.

Neuropeptide abnormalities in anorexia nervosa

Starvation-induced alterations of neuropeptide activity probably contribute to neuroendocrine dysfunctions in anorexia nervosa. For example, CRH alterations contribute to hypercortisolemia and NPY alterations may contribute to amenorrhea. Alterations of these peptides as well as opioids, vasopressin, and oxytocin activity could contribute to other characteristic psychophysiological disturbances, such as reduced feeding, in acutely ill anorexics. Such neuropeptide disturbances could contribute to the vicious cycle that has been hypothesized to occur in anorexia nervosa. That is, the consequences of malnutrition perpetuate pathological behavior.

Energy and protein metabolism in malnutrition due to nonneoplastic gastrointestinal diseases

Although a reduction in both energy expenditure and protein turnover has been demonstrated in starved volunteers, few metabolic data are available for patients in whom malnutrition is due to nonneoplastic gastrointestinal diseases. Chronically malnourished, unstressed adult patients with nonneoplastic gastrointestinal diseases (body mass index, 15.8 +/- 2.5 kg/m2, n = 13) and healthy control subjects (n = 10) were studied in the postabsorptive state using indirect calorimetry, as well as substrate fluxes of L[1-13C]leucine, L-[2-15N]glutamine (seven patients and six controls), and D[6,6-2H2]glucose (seven patients and eight controls). Resting energy expenditure (REE) expressed in kilocalories per 24 hours was significantly lower in patients than in controls; REE expressed per unit of fat-free mass (FFM) was not significantly different in both groups. Whole-body leucine turnover, oxidation, and nonoxidative disposal rates, based on either 13C-leucine or 13C-alpha-ketoisocaproic acid (KIC) enrichments, and glucose turnover rate were not significantly different between malnourished patients and controls. Moreover, glutamine turnover was increased by 28% in malnourished patients as compared with normal volunteers (429.8 +/- 86.8 v 334.9 +/- 15.9 mumol/kg/h, P = .02). These results suggest that hypometabolic adaptation, although previously documented in starved volunteers, is not operative during states of chronic malnutrition due to gastrointestinal disease. The increase in glutamine turnover rate might represent an adaptative mechanism to malnutrition for preservation of visceral mass or function.

The medical complications of anorexia nervosa

The physical complications of anorexia nervosa are common and can be life threatening, but psychiatrists and the increasing number of non-medical therapists involved in treatment programmes often overlook these complications. Cardiovascular complications are the most common, and the most likely to result in fatalities, particularly in those patients who vomit, purge or abuse diuretics, because of the electrolyte abnormalities induced. Osteoporosis is an early and perhaps irreversible consequence of severe weight loss. Further, there are dangers in rapid intravenous hyperalimentation.

Corticotropin-releasing factor modulates dietary preference in nutritionally and physically stressed rats

In order to evaluate the action of central nervous system Corticotropin-Releasing Factor (CRF) in the control of feeding behavior the present studies employed a dietary self-selection task sensitive both to overall appetite as well as preferential intake of familiar versus unfamiliar foods. Prior to the diet selection test, one group of nutritionally stressed animals was fed a protein deficient diet in order to increase the preference for unfamiliar foods relative to nutritionally replete subjects. Both CRF (0.05 and 0.5 micrograms ICV) and physical restraint (30 min) attenuated selectively the consumption of a novel food choice by deficient animals without affecting concurrent intake of familiar food. Further, CRF administration did not alter water intake or consumption of either diet by the replete control group suggesting that the peptide produced a stress dependent, enhanced response to novelty without a general effect on appetite. The CRF antagonist, alpha-helical CRF9-41 (1, 5 and 25 micrograms ICV), increased familiar diet consumption in nutritionally deficient subjects without affecting the self-selection pattern or replete controls. Chlordiazepoxide (5 mg/kg) also increased selectively the intake of familiar food suggesting that this action is the anxiolytic complement of the effect of stress in this paradigm. The CRF antagonist (5 and 25 micrograms) reversed the anorexia produced by CRF (0.5 micrograms) as well as that induced by restraint stress. These results favor a direct role for endogenous CRF systems in coordinating the behavioral responses to dietary stress.

Alterations in serum cortisol, CD4+CD8+ lymphocyte sub-population ration and T cell mediated suppression of immune responses in the malnutrition of anorexia nervosa

Serum cortisol and T lymphocyte sub-populations (CD3+, 4+ and 8+) were studied in 22 consecutively admitted patients with anorexia nervosa (AN) who had a mean weight loss of 30%. In addition Concanavalin A (Con A) mitogen induced T cell suppression of lymphocyte response to PPD (purified protein derivative of tuberculin antigen) was analysed. Increased serum cortisol concentrations were found in the AN-patients compared to the control group, with mean levels 654 and 418 nmol/l respectively. The relative numbers of CD4+ lymphocytes (mean 36.2%) and the CD4+ CD8+ ratio (mean 1.54) were significantly reduced (p < 0.05) in the AN-patients compared to the control group (mean 41.6% and 2.14 respectively). T cell mediated, Con A induced suppression of lymphocyte response to PPD was increased in AN-patients compared to the control group with low (1mug/ml) Con A concentration, but unchanged with high (5 mug/ml) Con A concentration. There was no correlation between serum cortisol concentrations and the numbers of T lymphocyte subpopulations or T cell suppressor activity. In contrast, a highly significant correlation existed between serum cortisol and the duration of AN (p < 0.002), but not with relative weight loss or anthropometric variables: triceps skin-fold (TSF) and arm muscle circumference (AMC). Immunological variables were not correlated with duration of disease. Thus, immunological alterations of the T cell system are detectable in AN, but are subtle and their clinical importance is not well known.

The effects of chronic central administration of corticotropin-releasing factor on food intake, body weight, and hypothalamic-pituitary-adrenocortical hormones

The effects of chronic central administration of corticotropin-releasing factor (CRF) on food intake, body weight, and hypothalamic-pituitary-adrenocortical hormones were investigated in rats. The infusion of ovine CRF at doses of 0.3 and 1.0 microgram/h continuously induced decrease in food intake and a suppression of body-weight gain for 7 days. The inhibition of body weight gain induced by CRF could not be accounted for solely by a decreased food intake since the suppression of body-weight gain in CRF-infused rats was significantly greater than that observed in rats which received the same amount of food as the CRF-infused rats. The content of proopiomelanocortin (POMC) -derived peptides in the anterior lobe of the pituitary as well as the plasma levels of ACTH and corticosterone (B) were significantly elevated in CRF-treated rats, and the CRF content in the hypothalamus was significantly decreased. These results suggest that chronic intracerebroventricular (icv) administration of CRF stimulates the synthesis and secretion of POMC-related peptides in the pituitary and suppresses food intake accompanied by inhibition of body weight gain. The results are similar to clinical and laboratory findings observed in patients with stress-induced anorexia.

Disturbances in the hypothalamo-pituitary-adrenal and other neuroendocrine axes in bulimia

Disturbances in the hypothalamo-pituitary-adrenal (HPA) and other endocrine axes were assessed in 24 women with bulimia and healthy controls. Overnight blood samples for measuring nocturnal plasma cortisol, prolactin (PRL), growth hormone (GH), luteinizing hormone (LH), and follicle stimulating hormone (FSH) were obtained at 30-min intervals. A 1.5 mg dexamethasone suppression test (DST) and a TRH-test were performed. Patients were monitored closely while their nutritional intake was recorded over 21 days. Compared with healthy controls, nocturnal cortisol plasma levels were not elevated in the bulimics. There was a trend toward insufficient cortisol suppression in the DST in patients with bulimia, which was most pronounced in patients with signs of restricted caloric intake. Plasma dexamethasone levels were significantly reduced in bulimics compared with healthy controls. There was a trend for blunted thyrotropin stimulating hormone (TSH) responses to thyrotropin releasing hormone (TRH) in bulimia. The prolactin response to TRH was significantly reduced in bulimics with a history of anorexia nervosa. Plasma LH and plasma FSH were significantly reduced in bulimics with signs of reduced caloric intake [low T3, high levels of beta-hydroxy-butyric acid (BHBA), reduced daily caloric intake, high number of fasting days] as compared with healthy controls. Bulimics with high BHBA levels had significantly reduced nocturnal prolactin plasma levels. Results show that multiple neuroendocrine disturbances exist in bulimia in a milder form than in anorexia nervosa. Evidence for the impact of caloric intake on endocrine functions is presented. Endocrine dysfunctions in our bulimic sample did not show a positive association with the presence of depressive symptoms.

The hypothalamic-pituitary-adrenal axis in infantile malnutrition

We studied the circadian rhythm and the response of the hypothalamic-pituitary-adrenal (HPA) axis to ovine corticotrophin releasing hormone (oCRH) stimulation and dexamethasone suppression in 32 children with grade II-III marasmus. Children were studied prior to and after nutritional rehabilitation. Mean baseline plasma cortisol concentrations were elevated at admission and decreased significantly after nutritional rehabilitation. Mean +/- SEM plasma cortisol response to oCRH increased from a basal of 480 +/- 41 to a peak of 582 +/- 58 nmol/l at the time of admission, and from a basal of 234 +/- 27 to a peak of 532 +/- 41 nmol/l after caloric rehabilitation. Dexamethasone suppression in the malnourished group was associated with a decrease in the mean +/- SEM basal plasma cortisol concentration from 397 +/- 44 to 171 +/- 44 nmol/l. After caloric rehabilitation, basal cortisol levels decreased from 259 +/- 27 to 22 +/- 5 nmol/l following dexamethasone. Our results support the concept that malnutrition is associated with decreased responsiveness to oCRH and incomplete dexamethasone suppression, and that these abnormalities are restored after nutritional rehabilitation.

Are disturbances in opioid and adrenergic systems involved in the hormonal dysfunction of anorexia nervosa?

Opioid peptides and catecholamines play an important role in the control of appetite, behaviour and hormonal secretion. To evaluate the role of the opioid and adrenergic systems in the hormonal dysfunction of anorexia nervosa (AN), we investigated the effects of naloxone and clonidine on serum GH, LH, FSH, beta-endorphin, TSH, prolactin and cortisol concentrations in 35 women with AN. Basal plasma beta-endorphin concentrations were significantly lower than those in healthy controls. The response of beta-endorphin to clonidine in the AN patients was increased, whereas the response of beta-endorphin to naloxone was decreased. Basal serum cortisol concentrations were significantly higher in the AN patients than that in the controls. There was a significant increase in the cortisol response to naloxone in the controls but a lack of cortisol response to naloxone in the patients with AN. Naloxone produced a significant increase in LH release in the controls during the luteal phase of the menstrual cycle, as well as in the majority of AN patients. Clonidine caused a diminution of LH in the controls and did not alter LH in the patients. After clonidine injection, a significant increase in GH release was observed in both groups of subjects. If these disturbances persist after normalization of body weight, it might suggest that altered opioid and adrenergic activity is an aetiological factor in the pathogenesis of anorexia nervosa.

Neuroendocrine profile in bulimia nervosa

The neuroendocrinology of bulimia nervosa has only recently been investigated, with initial research suggesting some biological overlap with both anorexia nervosa (AN) and depression. Similarities among AN, depression, and bulimia include a nonsuppressed Dexamethasone Suppression Test and an abnormal growth hormone (GH) response to thyrotropin-releasing hormone (TRH). Bulimics and anorectics both tend to have a delayed thyrotropin (TSH) response to TRH and elevated basal GH levels. Bulimics, however, have a normal GH response to clonidine, a nonblunted TSH response to TRH, low basal prolactin (PRL) levels, and may have an exaggerated PRL response to TRH. Unpublished data suggest bulimics may have a gonadotropin profile distinct from either AN or depression, as well as a variety of other endocrinopathies. Although many of these abnormalities may reflect malnutrition despite normal weight, other factors that are as yet unidentified are likely to be contributing to the neuroendocrine abnormalities seen in bulimia.

Increased urinary excretion of cortisol and catecholami-NES in malnourished cancer patients

Excretion of cortisol and catecholamines were measured from 24-hour urine samples collected over a period of 3 days from hospitalized cancer patients suffering from malnutrition and were compared with those of control patients equally malnourished and having a similar degree of inflammation. Compared with control patients, cancer patients had a higher excretion of cortisol, adrenaline, and noradrenaline, although noradrenaline excretion reached statistical significance only when normalized to creatinine excretion. Plasma glycerol concentrations after an overnight fast were significantly higher in cancer patients as compared with control patients, in keeping with an increased adrenal and adrenergic activity. This study demonstrates evidence of simultaneously elevated catecholamine and cortisol excretion in cancer patients, which could not be ascribed to alteration in body composition. The results may, in part, explain the mechanisms behind ongoing tissue breakdown in progressive cancer disease.

Influences of diet and nutrition on clinical pharmacokinetics

The human diet represents a complex and variable mixture of nutrients, many of which have the potential for altering the disposition of drugs. This review highlights progress from a number of laboratories illustrating nutrient influences on drug dispositions and actions. Emphasis is placed on nutritional effects on hepatic drug metabolism studied in humans. Data from animals have sometimes been difficult to extrapolate to humans, as illustrated by reports on the influences of starvation, dietary lipids, and ascorbic acid. From studies in healthy subjects it is now clear that a number of specific dietary factors can influence drug metabolism by the mixed function oxidase system and conjugating enzymes. These include dietary protein, cruciferous vegetables, charcoal-broiled beef containing polycyclic aromatic hydrocarbons, and methylxanthines. The effects of such dietary components have been demonstrated for only a limited number of drug substrates for these enzyme systems. Effects of food on bioavailability have been more widely studied, and depend greatly upon the type of drug. Malnutrition can be associated with variable but potentially important effects on the bioavailability, binding, hepatic metabolism, and renal clearance of drugs. In malnourished patients it is generally difficult to recognise the roles of individual nutrient deficiencies on drug disposition, and clinical predictors of altered pharmacokinetics for various drugs in such patients are not well defined. It is likely that many important interrelationships between nutrition and new or already marketed drugs remain to be recognised, and therefore warrant further research. Nutritional effects on drug metabolising enzymes also have implications for endogenous substances such as hormones and environmental toxins and carcinogens which are metabolised by the same or related enzyme systems, and for diseases likely to be related to the actions of such chemicals.

Chronic administration of tricyclic antidepressants suppresses hypothalamo-pituitary-adrenocortical activity in male rats

The effect of chronic administration of the clinically effective antidepressants, imipramine, clomipramine and desipramine, on corticosterone (CS) release in male rats was investigated. Chronic administration of imipramine, clomipramine and desipramine at a dose of 20 mg/kg b.w./day, but not at a dose of 2 mg/kg b.w./day, suppressed blood CS concentration at 2000h and abolished its circadian rhythm. The normal circadian rhythm of CS release resumed seven days after the termination of imipramine injection. The acute administration of imipramine (20 mg/kg b.w./day) at 0800h but not at 2000h elevated CS concentrations. Chronic administration of imipramine (20 mg/kg b.w./day) tended to increase the inhibitory effect of dexamethasone on CS release. Adrenocortical sensitivity to exogenous adrenocorticotropic hormone tended to be decreased by chronic administration of imipramine (20 mg/kg b.w./day). These results indicate that antidepressants have effects on the hypothalamo-pituitary-adrenocortical axis which may confound psychoneuroendocrinological tests, such as the dexamethasone suppression test, for the diagnosis of affective disorders.

Depression: a possible complication of orthognathic surgery

Advances in the field of orthognathic surgery as well as increased experience on the part of surgeons have led to successful treatment of greater numbers of patients with maxillofacial deformities. Consequently, greater insight has been gained into not only the technical effects of surgery, but also into the psychological impact on the patients. This paper describes a small pilot study designed to evaluate possible psychiatric effects that may occur during the recuperative period of orthognathic surgery.

Weight loss, cortisol levels, and dexamethasone suppression in major depressive disorder

Appetite and/or weight loss are integral, albeit not necessary, symptoms of depression. We explored the contribution of diminished appetite and/or weight loss ascertained by history to the hypothalamic-pituitary-adrenocortical (HPA) axis dysregulation in 120 patients with primary major depressive disorder. Significant positive relationship for both appetite and weight loss with cortisol levels in plasma and cerebrospinal fluid (CSF) were observed. Plasma cortisol levels were consistently higher in patients who noted both appetite and weight loss as opposed to patients without appetite or weight loss. Depressed patients with weight loss showed higher rates of dexamethasone-nonsuppression. Age and severity of depression influenced but did not eliminate the significance of the findings, suggesting that weight loss accounts in part for the HPA-axis function changes observed in depression.

Use of the dexamethasone suppression test with depressed and demented elderly

Although some researchers have suggested that the dexamethasone suppression test (DST) may be useful in differentiating between major depression and dementia in the elderly, recent reports of abnormal DST results in nondepressed, demented elderly have questioned the validity of the test in this population. This study compared the frequency of abnormal DST results in three groups of elderly inpatients: depressed/not demented; demented/not depressed; and depressed and demented. Two geropsychiatrists independently evaluated 33 patients for symptoms of depression and/or dementia and then assigned each patient to one of the three groups. Subjects in the demented/not depressed group had a significantly larger proportion of abnormal DSTs (P less than .01), and the mean postdexamethasone, 4 PM blood cortisol level of the demented/not depressed group was significantly greater than the means of the other two groups (P less than .005). In this sample, the DST was more likely to identify dementia than depression. Until further investigations clarify the parameters of DST use in the elderly, the diagnosis of depression and dementia should continue to be determined by sensitive interpretation of clinical findings, history, and other diagnostic tests.

Hypothalamic-pituitary-adrenal-cortical activity in anorexia nervosa and bulimia

We studied hypothalamic-pituitary-adrenal-cortical (HPA) activity in nine underweight women with anorexia nervosa, 12 women of normal body weight with bulimia, and nine control subjects. The measures of HPA activity were the pattern of plasma cortisol secretion over 24 hr and the responses of plasma cortisol to dexamethasone suppression and to low dose ACTH stimulation. The patients with anorexia nervosa had significantly elevated 24 hr concentrations of plasma cortisol compared to the controls and showed significantly less cortisol suppression following dexamethasone. There was no difference between patients with anorexia nervosa and controls in the rise in plasma cortisol following ACTH. On most measures of HPA activity, the normal weight patients with bulimia were indistinguishable from the controls. These results suggest that HPA activity is normal in most patients of normal body weight with bulimia and that the psychological and behavioral disturbances common to both anorexia nervosa and bulimia are, in the absence of significant weight loss, insufficient to produce major alterations in HPA activity.

The effects of weight change on the dexamethasone suppression test in depressed and anorexic patients

Prior studies on weight change and hypothalamic-pituitary-adrenal (HPA) axis functioning are reviewed. Data on 58 depressed and eight anorexic patients is presented. No significant difference in the frequency of cortisol non-suppression in the dexamethasone suppression test (DST) was found between depressed patients with a history of weight loss and those without, nor between depressed patients who lost weight during their first week in hospital and those who did not. Mean weight loss of suppressors did not significantly differ from that of non-suppressors. Of 12 patients whose DST normalised during their stay in hospital, only four gained weight. Five anorexics who were non-suppressors were less than 70% of their ideal body weight (IBW), while three suppressor anorexics were greater than or equal to 70% IBW. These results indicate that mild to moderate weight change is not a significant influence on DST response in depression.

Abnormal hypothalamic-pituitary-adrenal function in anorexia nervosa. Pathophysiologic mechanisms in underweight and weight-corrected patients

To study the pathophysiology of hypercortisolism in patients with anorexia nervosa, we examined plasma ACTH and cortisol responses to ovine corticotropin-releasing hormone before and after correction of weight loss. We also studied patients with bulimia whose weight was normal, since this disorder has been suspected to be a variant of anorexia nervosa. Before their weight loss was corrected, the anorexic patients had marked hypercortisolism but normal basal plasma ACTH. The hypercortisolism was associated with a marked reduction in the plasma ACTH response to corticotropin-releasing hormone. When these patients were studied three to four weeks after their body weight had been restored to normal, the hypercortisolism had resolved but the abnormal response to corticotropin-releasing hormone remained unchanged. On the other hand, at least six months after correction of weight loss their responses were normal. The bulimic patients whose weight was normal also had a normal response to corticotropin-releasing hormone. We conclude that in underweight anorexics, the pituitary responds appropriately to corticotropin-releasing hormone, being restrained in its response by the elevated levels of cortisol. This suggests that hypercortisolism in anorexics reflects a defect at or above the hypothalamus. The return to eucortisolism soon after correction of the weight loss indicates resolution of this central defect despite persistence of abnormalities in adrenal function.

Weight loss causes neuroendocrine disturbances: experimental study in healthy starving subjects

A variety of endocrine dysfunctions have been reported for anorexia nervosa, protein caloric malnutrition, and depression. The effect of reduced caloric intake and weight loss on endocrine functions was assessed in an experiment with five healthy female subjects during an initial baseline phase, a 3-week phase of complete food abstinence, weight gain to the original level, and a final baseline phase. During fasting, disturbances in hypothalamic-pituitary-adrenal function were observed, with elevated plasma cortisol levels, increase in the number of secretory episodes, increase in cortisol plasma half-life, and insufficient suppression following 1.5 mg dexamethasone. While all dexamethasone suppression tests (DSTs) were normal at baseline, 7 of 14 DSTs showed insufficient suppression in the fasting phase. During fasting, basal thyroid-stimulating hormone (TSH) values were lowered and the TSH response to thyrotropin-releasing hormone (TRH) was blunted. The plasma level of growth hormone (GH) over 24 hours was elevated during fasting and administration of the alpha 2-adrenergic receptor agonist clonidine resulted in a subnormal GH response after restoration of original body weight. One of the five subjects showed increased irritability, distress, anxiety, and depression as measured by various psychological scales. The results show that reduced caloric intake, weight loss, or catabolic state have powerful effects on several endocrine systems. The specificity of measures of endocrine disturbances (DST, TRH tests, and clonidine tests) as biological markers for certain types of depression must be questioned, and the metabolic state should be given more consideration in future studies.

Effect of experimental and pathological weight loss upon the hypothalamo-pituitary-adrenal axis

Five healthy female subjects participated in a starvation experiment. After an initial baseline phase (A) they lost about 8 kg in a 3-week phase of complete food abstinence (B); thereafter they recovered to their original body weight (C) and kept this weight stable over more than 4 weeks (D). While all dexamethasone suppression tests (DST's) during the initial baseline were normal, half of the DST's (7/14) in the fasting phase showed insufficient suppression. In the following weight gain phase, all DST's were sufficiently suppressed. Twenty-four hour plasma cortisol patterns during fasting (B) showed a significant increase, as well as increased cortisol half-life, increased time in secretory activity, and increased number of secretory episodes. Administration of the alpha 2-adrenergic receptor agonist clonidine during fasting did not induce a further decrease in plasma cortisol level, whereas it did during baseline. The results demonstrate that weight loss, reduced caloric intake, and catabolic state have a very powerful influence on the hypothalamo-pituitary-adrenal (HPA) axis and other endocrine systems. The results shed new light on endocrine dysfunctions in mental disorders associated with reduced caloric intake, such as anorexia nervosa and depression, and question the specificity of certain endocrine dysfunctions for depression.

The effect of weight loss and inappropriate plasma dexamethasone levels on the DST

Recent studies from different research groups have raised fundamental questions about the postulated specificity of the dexamethasone suppression test (DST) for endogenous depression. Findings in 116 psychiatric inpatients and 24 semi-starved healthy volunteers underline the importance of weight loss as a factor affecting DST results. A study of 160 DSTs in 93 psychiatric inpatients further revealed a significant negative correlation of plasma cortisol and plasma dexamethasone levels 10 hours after oral administration of 1 mg of dexamethasone. These results suggest a decisive effect of the pharmacokinetics of dexamethasone, at least on the 1-mg DST.

Dexamethasone suppression test as a simple measure of stress?

Non-suppression of cortisol by dexamethasone has been described as a biological marker of a diagnostic subgroup of depressed patients. This paper presents the hypothesis that the degree of non-suppression is a variable that reflects the quantity of stress or distress experienced by the patient rather than relating to a specific diagnosis. Such a quantitative measure of stress would be valuable for research in general medicine as well as in psychiatry. Testing of this postulate should apply a more precise interpretation of endocrine principles than has been applied to the dexamethasone suppression test to date.

Brain tyrosine availability and the depression of central nervous norepinephrine turnover in acute and chronic starvation in adult male rats

Norepinephrine (NE) and 3-methoxy-4-hydroxyphenylglycol (MOPEG) were determined in medio-basal hypothalamus of adult male rats using high-performance liquid chromatography to study nutritional modulation of noradrenergic turnover. Acute starvation, as well as 3 weeks of semistarvation with a low-protein high-carbohydrate or high-protein low-carbohydrate diet decreased NE turnover significantly, as estimated by MOPEG concentration. Low-protein semistarvation resulted in subnormal concentrations of large neutral amino acids (LNAA), high-protein semistarvation in elevated concentrations. Tyrosine/LNAA ratio and calculated tyrosine flow into brain and brain tyrosine levels were reduced in both types of semistarvation. Corticosterone was low in low-protein and high in high-protein diet. These results suggest that tyrosine availability in brain potentially contributes to reduced NE turnover in starvation.

The diagnostic distribution of dexamethasone non-suppressors

Baseline serum cortisols and DSTs were performed on 100 psychiatric inpatients. The rates of non-suppression in selected DSM III diagnostic categories were calculated and the results discussed in the context of recent literature. It was concluded that test specificity may have been frequently overestimated. The suggestion is made that DST non-suppression may have non-specific and relative vector qualities, and thus be of little diagnostic use.

[Dexamethasone suppression test in anorexia nervosa]

In patients suffering from anorexia nervosa (n = 20) a significant correlation was found between pathological DST results and weight loss. In this respect, patients with bulimic symptomatology do not differ from the main anorectic group. In addition, the correlation was unaltered by the length of the disease. These results are interpreted as indicative of secondary regulatory disturbances of the hypothalamic-hypophyseal-adrenal axis, whereas they are inconsistent with a close connection between anorexia nervosa and endogenous depression. As demonstrated by other authors, weight change exerts an influence on DST results in endogenous depression as well.