The effect of a carbohydrate-rich beverage on mood, appetite, and cognitive function in women with premenstrual syndrome

Changing food preference as a function of mood

The authors investigated the effect of mood on food selection. Participants (N = 98) indicated the likelihood of general eating and the likelihood of eating specific foods after reading and projecting themselves onto the events and emotions described in a sad and a happy vignette. Both men and women believed they were more likely to consume food following a happy versus a sad event, and men believed they were significantly more likely to eat than did women. However, the type of food men and women believed they would consume interacted with the type of event experienced. Vegetarian snack foods were more likely to be consumed following a happy versus a sad event, with men more likely to eat snack foods. Men did not significantly change in likelihood of consuming sweet foods as their mood changed. However, women believed they were more likely to consume sweet foods following a sad event. The authors discuss the results in terms of a self-medication hypothesis and the effect of carbohydrates on central serotonin and endogenous opioids. Overall, results demonstrated that mood influences belief in the likelihood of food selection.

Increased depressive-like traits in an animal model of premenstrual irritability

Women are at higher risk of anxiety and mood disorders, especially at transitions across the reproductive life cycle (premenstruum, postpartum, menopause). Premenstrual dysphoric disorder (PMDD) is one of female mood disorders associated with changing ovarian hormone levels. Because anxiety and depression frequently occur in women with PMDD, premenstrual dysphoria might be a manifestation of certain vulnerability traits increasing the risk of those disorders. The present study was conducted to elucidate a potential association between estrous cycle-dependent aggression, the rodent model of "premenstrual irritability" (resident-intruder test), and anxiety (elevated plus maze), depressive-like traits (forced swim test) as well as carbohydrate craving in female Wistar rats. Some aggressive and nonaggressive females were restraint-stressed before testing to determine their sensitivity to stress at different hormonal stages. The results revealed that females expressing the estrous cycle-dependent aggression but not those not expressing cycle-dependent aggression spent longer time immobile and shorter time swimming in the forced swim test at metestrus compared to proestrus phase of the estrous cycle. There was no difference between aggressive and nonaggressive females in anxiety, locomotor activity and sensitivity to restraint stress and sucrose consumption. The present study suggests a common neurobiological background for the estrous cycle-dependent aggression and depressive-like traits in rodents. This phenomenon could potentially aid the elucidation of premenstrual emotional dysfunctions and might be used as an ethological model to study a biochemical and genetic proneness to depression.

Emotional influences on food choice: sensory, physiological and psychological pathways

Sensory, physiological and psychological mechanisms are reviewed that underlie emotional influences on food choice. Both moods and emotions are considered. Eating a meal will reliably alter mood and emotional predisposition, typically reducing arousal and irritability, and increasing calmness and positive affect. However, this depends on the meal size and composition being close to the eater's habit, expectations and needs. Unusual meals--e.g. too small, unhealthy--may negatively affect mood. Sweetness, and sensory cues to high energy density, such as fatty texture, can improve mood and mitigate effects of stress via brain opioidergic and dopaminergic neurotransmission. However, adaptation in these pathways, perhaps enhanced by inherited sensitivity, with chronic exposure to such sensory qualities, could lead to overeating of energy-dense foods and consequent obesity. Sweet, fatty foods low in protein may also provide alleviation from stress in vulnerable people via enhanced function of the serotonergic system. Moreover, in rats, such foods seem to act as part of a feedback loop, via release of glucocorticoid hormones and insulin, to restrain activity of the hypothalamic pituitary adrenal axis during stress. However, this effect is also associated with abdominal obesity. In humans, a number of psychological characteristics predict the tendency to choose such foods when stressed, such as restrained or emotional eating, neuroticism, depression and premenstrual dysphoria, all of which could indicate neurophysiological sensitivity to reinforcing effects of such foods. Greater understanding of such predictive traits and the underlying mechanisms could lead to tailoring of diet to meet personal emotional needs.

Expert Guidelines for the Treatment of Severe PMS, PMDD, and Comorbidities: The Role of SSRIs

The hallmark feature of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) is the predictable, cyclic nature of symptoms or distinct on/offness that begins in the late luteal phase of the menstrual cycle and remits shortly after the onset of menstruation. PMDD is distinguished from PMS by the severity of symptoms, predominance of mood symptoms, and role dysfunction, particularly in personal relationships and marital/family domains. Several treatment modalities are beneficial in PMDD and severe PMS, but the selective serotonin reuptake inhibitors (SSRIs) have emerged as first-line therapy. The SSRIs can be administered continuously throughout the entire month, intermittently from ovulation to the onset of menstruation, or semi-intermittently with dosage increases during the late luteal phase. These guidelines present practical treatment algorithms for the use of SSRIs in women with pure PMDD or severe PMS, PMDD and underlying subsyndromal clinical features of mood or anxiety, or premenstrual exacerbation of a mood/anxiety disorder.

Memory function in women with premenstrual complaints and the effect of serotonergic stimulation by acute administration of an alpha-lactalbumin protein

Serotonergic hypofunction may underlie at least part of the symptoms that are experienced by women with premenstrual complaints, including memory deficits. In the current study we investigated changes in memory functions in the premenstrual phase compared to the early postmenstrual phase in 16 women with premenstrual complaints. In addition, the effect of an acute serotonergic stimulation by administration of an alpha-lactalbumin protein on premenstrual memory performance was assessed using a double-blind placebo-controlled crossover design. It was found that both short-term and long-term memory for words (30-word learning task) and abstract figures (abstract visual learning task) were mildly impaired in the premenstrual phase. Administration of alpha-lactalbumin during the premenstrual phase could only partially attenuate the memory performance decrements that are seen in the premenstrual phase. Specifically, alphalactalbumin improved long-term memory for abstract figures, but not for words. There were no effects of menstrual phase or alpha-lactalbumin on planning functions (computerized Tower of London). The data suggest that serotonergic hypofunction may play a role in premenstrual memory decline, but serotonergic mechanisms cannot fully account for observed cognitive changes in the premenstrual phase.

Premenstrual Syndrome, Premenstrual Dysphoric Disorder, and Beyond: A Clinical Primer for Practitioners

The management of adverse premenstrual symptoms has presented a difficult challenge for clinicians. However, based on numerous well-designed research studies over the last decade, we now have diagnostic criteria for the severe form of the syndrome, premenstrual dysphoric disorder, and a variety of evidence-based therapeutic strategies. This review presents a comprehensive, practical description of what the clinician needs to know to diagnose and treat adverse premenstrual symptoms at all levels of severity. Diagnostic criteria are described in detail, including a discussion of the distinction between premenstrual dysphoric disorder and premenstrual syndrome (PMS). The rationale for including prospective symptom calendars as a routine part of the diagnostic evaluation of severe symptoms is presented. The differential diagnosis of cyclic symptoms, including depression and anxiety disorders, menstrual migraine, and mastalgia, and an approach for the management of each of these problems are presented. A treatment approach is recommended that matches the treatment to the degree of problems the woman is experiencing. Serotonin reuptake inhibitors are the treatment of choice for severe symptoms, and most women with PMS/premenstrual dysphoric disorder will respond to intermittent, luteal phase-only therapy. Ovulation suppression should be reserved for women who do not respond to other forms of therapy. The role of oophorectomy is limited, and guidelines for its use are presented.

Insulin sensitivity and premenstrual syndrome

Maintaining normal blood glucose levels is a constant challenge for women with diabetes. Anecdotal reports reveal that many women question if menstrual cycle phases may affect their blood glucose levels. However, results from studies investigating the effect of the menstrual cycle on insulin sensitivity in diabetic women have been conflicting. One variable that may account for the conflicting results is the presence or absence of premenstrual syndrome (PMS), which may exacerbate menstrual cycle-related effects on insulin sensitivity. Treatment of PMS with serotonin reuptake inhibitors may alleviate the symptoms of PMS, as well as improve insulin sensitivity and help regulate blood glucose levels.

Soy, fat and other dietary factors in relation to premenstrual symptoms in Japanese women

OBJECTIVE

To evaluate the relations of intakes of soy, fat and other dietary components to premenstrual symptoms.

DESIGN

Cross sectional study.

SETTING

Three colleges and two nursing schools.

POPULATION

One hundred and eighty-nine Japanese women aged 19 to 34 years.

METHODS

Intakes of nutrients and foods, including soy products and isoflavones, were estimated by a semiquantitative food frequency questionnaire. Change in menstrual cycle symptoms were assessed by the Moos Menstrual Distress Questionnaire (MDQ).

MAIN OUTCOME MEASURES

Spearman rank correlation of soy and other dietary factors with changes in MDQ scores between the follicular and the premenstrual phases after controlling for age, marital status, exercise, smoking status, age at menarche and number of days of bleeding.

RESULTS

Neither soy product nor isoflavone intake was significantly associated with change in MDQ score in the premenstrual phase. Intakes of total, saturated and monounsaturated fats were significantly correlated with change in scores for total MDQ and subscale 'pain' in the premenstrual phase after controlling for the covariates. Intake of cereals/potatoes/starches was significantly inversely correlated with a change in total MDQ score in the premenstrual phase.

CONCLUSIONS

High intake of fats and low intake of foods with high concentration of carbohydrate may be associated with premenstrual symptoms.

Chocolate craving and the menstrual cycle

Spanish and American female chocolate cravers reported the usual times when they craved chocolate by answering an open-ended question. They also were asked directly if they craved chocolate perimenstrually. American women (40% open-ended, 60% direct) were more likely than were Spanish women (4% open-ended, 24% direct) to report that their chocolate cravings occurred perimenstrually when responding to both questions. The most frequently reported times (other than perimenstrually) that chocolate was craved were the same for Spanish men and women (after eating, studying) and for American men and women (evening), differing cross-culturally but not across gender. The results suggest a cultural origin rather than a physiological basis for chocolate craving.

A biopsychosocial approach to premenstrual dysphoric disorder

Though epidemiological data is difficult to collect, existing evidence indicates that there is a small but significant population of women in whom premenstrual symptoms, and particularly affective symptoms, severely impair functioning. Although PMDD is predominantly regarded as a biologically based illness, there is strong evidence that variables such as life stress, history of sexual abuse, and cultural socialization are important determinants of premenstrual symptoms. In diagnosing and treating PMDD patients, attention to biological and sociocultural variables is recommended.

A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder

Severe premenstrual syndrome (PMS) and, more recently, premenstrual dysphoric disorder (PMDD) have been studied extensively over the last 20 years. The defining criteria for diagnosis of the disorders according to the American College of Obstetricians and Gynecologists (ACOG) include at least one moderate to severe mood symptom and one physical symptom for the diagnosis of PMS and by DSM IV criteria a total of 5 symptoms with 1 severe mood symptom for the diagnosis of PMDD. There must be functional impairment attributed to the symptoms. The symptoms must be present for one to two weeks premenstrually with relief by day 4 of menses and should be documented prospectively for at least two cycles using a daily rating form. Nonpharmacologic management with some evidence for efficacy include cognitive behavioral relaxation therapy, aerobic exercise, as well as calcium, magnesium, vitamin B(6) L-tryptophan supplementation or a complex carbohydrate drink. Pharmacologic management with at least ten randomized controlled trials to support efficacy include selective serotonin reuptake inhibitors administered daily or premenstrually and serotonergic tricyclic antidepressants. Anxiolytics and potassium sparing diuretics have demonstrated mixed results in the literature. Hormonal therapy is geared towards producing anovulation. There is good clinical evidence for GnRH analogs with addback hormonal therapy, danocrine, and estradiol implants or patches with progestin to protect the endometrium. Oral contraceptive pills prevent ovulation and should be effective for the treatment of PMS/PMDD. However, limited evidence does not support efficacy for oral contraceptive agents containing progestins derived from 19-nortestosterone. The combination of the estrogen and progestin may produce symptoms similar to PMS, such as water retention and irritability. There is preliminary evidence that a new oral contraceptive pill containing low-dose estrogen and the progestin drospirenone, a spironolactone analog, instead of a 19-nortestosterone derivative can reduce symptoms of water retention and other side effects related to estrogen excess. The studies are in progress, however, preliminary evidence suggests that the drospirenone-containing pill called Yasmin may be effective the treatment of PMDD.

Sugar and fat: cravings and aversions

Food cravings are extremely common, particularly among women. Cravings are frequently reported for specific types of foods, including chocolate and foods high in both sugar and fat. Cravings for specific macronutrients, such as carbohydrate, have been postulated to result from a physiological need to alter neurotransmitters in such states as eating disorders, affective disorders or obesity. However, studies of such cravings are often confounded by differing sensory properties of high and low carbohydrate foods. There is some evidence that sweet, high fat foods are preferred by women with binge-eating disorders and that those preferences are mediated by the endogenous opioid system. Aversion to fat is seen primarily in women with anorexia nervosa. However, it is possible that changes in fat preference may be achieved through behavioral or pharmacological approaches. An understanding of food cravings and aversions may lead to improved methods for the prevention and treatment of obesity and eating disorders.

Effects of normal meals rich in carbohydrates or proteins on plasma tryptophan and tyrosine ratios

BACKGROUND

The delivery of circulating tryptophan to the brain and its conversion to serotonin vary directly with plasma concentrations of tryptophan and inversely with those of other large neutral amino acids (LNAAs). Although carbohydrate-rich, protein-free formula diets have been shown to elevate, and high-protein diets to depress, the tryptophan-LNAA ratio, few data are available about this ratio's responses to actual meals.

OBJECTIVE

We determined whether carbohydrate-rich or protein-rich breakfasts, such as those Americans normally eat, produce substantial differences in the plasma tryptophan-LNAA ratio and in the corresponding ratio for tyrosine, the precursor of brain dopamine and norepinephrine.

DESIGN

Nine overnight-fasted subjects consumed, 3-7 d apart, a carbohydrate-rich (69.9 g carbohydrate and 5.2 g protein) and a protein-rich (15.4 g carbohydrate and 46.8 g protein) breakfast. Blood samples collected at baseline and after 40, 80, 120, and 240 min were assayed for tryptophan, tyrosine, the 5 other LNAAs, and insulin.

RESULTS

The carbohydrate-rich and protein-rich breakfasts had significantly different effects on both the plasma tryptophan-LNAA and tyrosine-LNAA ratios (each P < 0.01). Among the 8 subjects who consumed both breakfasts, the median difference for tryptophan:LNAA was 54% (range: 36-88%) and for tyrosine:LNAA was 28% (range: 10-64%). Insulin concentrations rose significantly after the carbohydrate but not after the protein meal.

CONCLUSIONS

High-carbohydrate and high-protein breakfasts similar to those Americans normally eat can cause substantial differences in the plasma tryptophan ratio and thus, probably, in brain tryptophan concentrations and serotonin synthesis. Such meals also change the plasma tyrosine ratio and may thereby modify catecholamine synthesis.

Selective serotonin reuptake inhibitors for premenstrual dysphoric disorder: the emerging gold standard?

There have been a large number of studies conducted investigating the use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of patients with premenstrual dysphoric disorder (PMDD). The 12 randomised, controlled trials with continuous dose administration of SSRIs and the eight randomised, controlled trials with luteal phase dose administration (from ovulation to menses) are reviewed. All the treatment studies on fluoxetine, sertraline, paroxetine and citalopram have reported positive efficacy. Fluoxetine and sertraline have the largest literature, with a smaller number of studies endorsing paroxetine and citalopram. Mixed efficacy results have been reported with fluvoxamine. In general, adverse effects from the use of SSRIs in women with PMDD are the usual mild and transient adverse effects from SSRIs including anxiety, dizziness, insomnia, sedation, nausea and headache. Sexual dysfunction and weight gain can be problematic long-term adverse effects of SSRIs, but these effects have not been systematically evaluated with long-term SSRI use in women with PMDD. Serotonergic antidepressants have differential superiority over nonserotonergic antidepressants in the treatment of PMDD. Treatments that enhance serotonergic action improve premenstrual irritability and dysphoria with a rapid onset of action, suggesting a different mechanism of action than in the treatment of depression. It is possible that neurosteroids, such as progesterone metabolites, are involved in the rapid action of serotonergic antidepressants in PMDD. Future research needs to address less frequent dose administration regimens, such as 'symptom-onset' dose administration, and the recommended length of treatment.

Carbohydrate ingestion, blood glucose and mood

A series of studies have reported that a high carbohydrate meal, or diets high in carbohydrate, were associated with feeling less energetic. However, after a drink containing pure sugar most studies report no effect. Meals almost exclusively carbohydrate increase the availability of tryptophan and hence serotonin synthesis in the brain, however, a small amount of protein blocks this mechanism making it an uncommon response. In many individuals, poor mood stimulates the eating of palatable high carbohydrate/high fat foods that stimulate the release of endorphins. There is a tendency for those with lower blood glucose, when performing cognitively demanding tasks, to report poorer mood. In a range of situations an association between a tendency for blood glucose levels to fall rapidly, and irritability, has been found. Differences in the ability to control blood glucose levels influence the association between carbohydrate intake and mood. There is a need in future research to contrast the impact of carbohydrate on mood in those distinguished because of their pre-existing psychological and physiological functioning.

Improving mental health through nutrition: the future

Tell me what you eat, and I will tell you what you are (Anthelme Brillat-Savarin). When I behold a fashionable table set out in all its magnificence, I fancy that I see gouts and dropsies, fever and lethargies, with other innumerable distempers, lying in ambuscade among the dishes. Nature delights in the most plain and simple diet. Every animal, but man, keeps to one dish. Herbs are the food of this species, fish of that, and flesh of a third. Man falls upon everything that comes in his way; not the smallest fruit or excrescence of the earth, scarce a berry or a mushroom can escape him (Joseph Addison). The pleasures of the palate deal with us like the Egyptians thieves, who strangle those whom they embrace (Seneca). Let food be your medicine and medicine be your food (Hippocrates).

Plasma Trp/LNAA ratio increases during chronic ingestion of an alpha-lactalbumin diet in rats

Brain serotonin synthesis depends on the uptake of its precursor, tryptophan (Trp), and is correlated to the plasma ratio of Trp to large neutral amino acids (LNAA) which compete for the same transporter system in the brain. As the plasma Trp/LNAA ratio decreases when the dietary protein content exceeds 5%, we tested whether a diet containing 17% of a Trp-rich protein, namely alpha-lactalbumin (LAC), might increase the plasma Trp/LNAA ratio over a long period. Blood samples were obtained at different days (-1, 3, 6 and 9) from rats receiving either a LAC or casein (CAS) diet, and plasma amino acids and insulin concentrations were determined. The increase in plasma Trp concentration was much higher during the LAC diet (49 vs 26%; P<0.001), while the plasma LNAA concentration remained fairly constant. Consequently, the plasma Trp/LNAA ratio increased by 40% during the LAC diet while it decreased by 15% during the CAS diet (P<0.001). The above results were not related to plasma insulin concentration differences during these diets. These data suggest that a balanced diet containing a natural Trp rich-protein increases the plasma Trp/LNAA ratio over a long period, leading to a probable increase in brain serotonin activity.

Complementary/alternative therapies for premenstrual syndrome: a systematic review of randomized controlled trials

Complementary/alternative therapies are popular with women who have premenstrual syndrome. This systematic review was designed to determine whether use of such therapies is supported by evidence of effectiveness from rigorous clinical trials. Trials were located through searching 7 databases and checking the reference lists of articles. Randomized controlled trials investigating a complementary/alternative therapy in women with premenstrual syndrome published in the peer-reviewed literature were included in the review. Twenty-seven trials were included investigating herbal medicine (7 trials), homeopathy (1), dietary supplements (13), relaxation (1), massage (1), reflexology (1) chiropractic (1), and biofeedback (2). Despite some positive findings, the evidence was not compelling for any of these therapies, with most trials suffering from various methodological limitations. On the basis of current evidence, no complementary/alternative therapy can be recommended as a treatment for premenstrual syndrome.

Evaluation and Management of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

OBJECTIVE

To review premenstrual disorders, their varied symptoms, possible etiology, and treatment options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2001) using the search terms premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) and the additional terms treatment and etiology. Additional references were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

PMS refers to a group of menstrually related disorders that are estimated to affect up to 40% of women of childbearing age. The varied symptoms of PMS include mood swings, tension, anger, irritability, headache, bloating, and increased appetite with food cravings. PMS symptoms occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation or shortly afterward. Approximately 5% of women with PMS suffer from PMDD, a more disabling and severe form of PMS in which mood symptoms predominate. Because no tests can confirm PMS or PMDD, the diagnosis should be made on the basis of a patient-completed daily symptom calendar and the exclusion of other medical disorders. The causes of PMS and PMDD are uncertain, but are likely associated with aberrant responses to normal hormonal fluctuations during the menstrual cycle. For most women, symptoms can be relieved or reduced through lifestyle interventions, such as dietary changes and exercise, and drug therapy with hormonal or psychotropic agents. For PMDD, selective serotonin reuptake inhibitors have recently emerged as first-line therapy. Certain dietary supplements, including calcium, also may be an option for some women.

CONCLUSION

PMS and PMDD are complex but highly treatable disorders. Pharmacists can improve the recognition and management of these common conditions by providing patient education on premenstrual symptoms and counseling women on lifestyle interventions and pharmacotherapy to relieve their discomfort.

Cognitive performance and its relationship with postprandial metabolic changes after ingestion of different macronutrients in the morning

The effect of carbohydrate, protein and fat ingestion on simple as well as complex cognitive functions and the relationship between the respective postprandial metabolic changes and changes in cognitive performance were studied in fifteen healthy male students. Subjects were tested in three sessions, separated by 1 week, for short-term changes in blood variables, indirect calorimetry, subjective performance and different objective performance tasks using a repeated-measures counterbalanced cross-over design. Measurements were made after an overnight fast before and hourly during 3 h after test meal ingestion. Test meals consisted of either pure carbohydrates, protein or fat and were served as isoenergetic (1670 kJ) spoonable creams with similar sensory properties. Most aspects of subjective performance did not differ between test meals. For all objective tasks, however, postprandial cognitive performance was best after fat ingestion concomitant with an almost constant glucose metabolism and constant metabolic activation state measured by glucagon:insulin (G:I). In contrast, carbohydrate as well as protein ingestion resulted in lower overall cognitive performance, both together with partly marked changes in glucose metabolism and metabolic activation. They also differently affected specific cognitive functions in relation to their specific effect on metabolism. Carbohydrate ingestion resulted in relatively better short-term memory and accuracy of tasks concomitant with low metabolic activation, whereas protein ingestion resulted in better attention and efficiency of tasks concomitant with higher metabolic activation. Our findings support the concept that good and stable cognitive performance is related to a balanced glucose metabolism and metabolic activation state.

Premenstrual syndrome. Advances in diagnosis and treatment

Premenstrual syndrome and PMDD are increasingly recognized as medical entities that adversely affect the quality of life of a subset of women. When research criteria or the strict definition of PMDD are used, the prevalence of PMS is thought to range from 3% to 5% among reproductive-aged women. Although the precise pathophysiology is not known, it is increasingly believed that women with PMS have an altered sensitivity of central neurotransmitters, particularly serotoninergic, to normal circulating levels of estradiol and progesterone. Significant advances have been made in pharmacologic therapy for PMDD, with the largest clinical trials demonstrating efficacy of the SSRIs. These studies show relief of distressing mood symptoms and improvements in parameters of social function in most patients.

A pilot study of Hypericum perforatum for the treatment of premenstrual syndrome

OBJECTIVE

To investigate whether Hypericum perforatum could relieve symptoms of premenstrual syndrome in a small group of women in order to establish a hypothesis and to test methods for conducting a future randomised controlled trial.

DESIGN

Prospective, open, uncontrolled, observational study.

SETTING

Department of Complementary Medicine, University of Exeter.

POPULATION

Nineteen women with premenstrual syndrome who were in otherwise good physical and mental health and not taking other treatments for premenstrual syndrome.

METHOD

Volunteers underwent a preliminary screening interview, completed Daily Symptom Ratings for one cycle, and attended a medical screening visit before being diagnosed with premenstrual syndrome. Participants took hypericum tablets for two complete menstrual cycles (1 x 300 mg hypericum extract per day standardised to 900 microg hypericin).

MAIN OUTCOME MEASURES

Symptoms were rated daily throughout the trial using a validated measure. The Hospital Anxiety and Depression scale and modified Social Adjustment Scale were administered at baseline and after one and two cycles of treatment.

RESULTS

There were significant reductions in all outcome measures. The degree of improvement in overall premenstrual syndrome scores between baseline and the end of the trial was 51%, with over two-thirds of the sample demonstrating at least a 50% decrease in symptom severity. Tolerance and compliance with the treatment were encouraging.

CONCLUSION

The results of this pilot study suggest that there is scope for conducting a randomised, placebo-controlled, double-blind trial to investigate the value of hypericum as a treatment for premenstrual syndrome.

Can nutrient supplements modify brain function?

Over the past 40 y, several lines of investigation have shown that the chemistry and function of both the developing and the mature brain are influenced by diet. Examples are the effect of folate deficiency on neural tube development during early gestation, the influence of essential fatty acid deficiency during gestation and postnatal life on the development of visual function in infants, and the effects of tryptophan or tyrosine intake (alone or as a constituent of dietary protein) on the production of the brain neurotransmitters derived from them (serotonin and the catecholamines, respectively). Sometimes the functional effects are clear and the underlying biochemical mechanisms are not (as with folate and essential fatty acids); in other cases (such as the amino acids tyrosine and tryptophan), the biochemical effects are well understood, whereas the effect on brain function is not. Despite the incomplete knowledge base on the effects of such nutrients, investigators, physicians, and regulatory bodies have promoted the use of these nutrients in the treatment of disease. Typically, these nutrients have been given in doses above those believed to be required for normal health; after they have been given in pure form, unanticipated adverse effects have occasionally occurred. If this pharmacologic practice is to continue, it is important from a public safety standpoint that each nutrient be examined for potential toxicities so that appropriate purity standards can be developed and the risks weighed against the benefits when considering their use.

Effects of nutrients on brain function

While many of the above examples support a role of these dietary components in modifying the synthesis, storage, release and actions of various neurotransmitter molecules in the central nervous system, most of the responses to eating everyday foods are expected to produce subtle changes in physiological and/or behavioral parameters. However, the observed subtle changes may have significant consequences when present in individuals with altered homeostasis as might be present in various disease states or certain environmental situations (e.g. depression, PMS, stress). Studies in the future should investigate the effects of various diets, e.g., vegetarian, macrobiotic, traditional Eastern, etc. on physiological and psychological functioning. Care should be taken to differentiate between the responses of subgroups of subjects, e.g. male vs. female, old vs. young, and lean vs. obese, as some differences in the rate of neurotransmitter synthesis and receptor dynamics have been reported in some studies. Chronic consumption of these diets may lead to long-term alterations in the neurotransmitter systems' dynamics, or as is often the situation with long-term pharmacological treatments, may result in adaptive changes to minimize the acute effects of such treatments. To date, no such studies have been performed that have systematically addressed many of these issues. Future studies will require careful design so as to enhance the chances of detecting such alterations in function. However, the most significant alterations in function occur when a dietary component is administered in a purified form, separate from the normal diet. In this case the compound should be treated more like a pharmacological agent than a nutrient since adverse (i.e. antinutritive) effects may result. The most difficult studies however will use everyday foods with the aim of detecting changes based on the underlying biochemical changes.

The potential for dietary supplements to reduce premenstrual syndrome (PMS) symptoms

Many types of dietary supplements have been advocated for the reduction of certain symptoms of premenstrual syndrome (PMS). However, only one supplement-calcium-has been demonstrated to be of significant benefit in a large, rigorous, double-blind, placebo-controlled trial. Limited evidence suggests that magnesium, vitamin E and carbohydrate supplements might also be useful, but additional research is needed to confirm these findings. Trials of vitamin B6 supplementation have had conflicting results, and high doses of this vitamin taken for prolonged periods of time can cause neurological symptoms. Trials of evening primrose oil have also had conflicting results; the two most rigorous studies showed no evidence of benefit. A variety of herbal products are suggested to reduce symptoms of PMS. The efficacy of these products is uncertain because of a lack of consistent data from scientific studies. Health professionals should be aware of the possible use of these supplements and ask those with PMS about their use of such products and counsel them based upon the totality of evidence.

Effectiveness of professional--peer group treatment: symptom management for women with PMS

The purpose of this intervention study was to determine short- and long-term effectiveness of a symptom management intervention aimed at relieving the distress associated with premenstrual syndrome (PMS). The PMS Symptom Management Program (PMS-SMP), a package of nonpharmacological strategies involving self-monitoring, personal choice, self-regulation, and self/environmental modification, was administered within a group combining peer support and professional guidance to 91 women classified with severe PMS (early treatment groups n = 40; waiting treatment groups n = 51). Repeated behavioral measures (symptom severity and personal resources/demands) were obtained on five occasions: two menstrual cycles prior to treatment and at 3, 6, 12, and 18 months after treatment. A package of symptom management strategies was effective in reducing PMS severity by 75%, premenstrual depression, and general distress by 30-54%, as well as increasing well-being and self-esteem in women experiencing severe PMS. These results compare favorably with antidepressant drug treatment studies that report a 40-52% reduction in PMS severity. The most marked improvement was found in the first 3 months after treatment; however, improvement was maintained or enhanced in the long-term follow-up. Although focused on perimenstrual symptom relief, these strategies are generally health promoting and can be applied to other women's health conditions.

Scientific and regulatory aspects of nutraceutical products in the United States

Within the past decade, the so-called health food industry has experienced a tremendous growth such that these products are commonplace in most community pharmacies within the United States. These products have since been defined, by those in the industry, as nutraceuticals. Passage of the Nutrition Labeling and Education Act of 1990 and the Dietary Supplement Health and Education Act of 1994 has had a significant impact on the information available to the consumers to enable them to make educated decisions when "self-medicating" with this class of products. This paper is an attempt to summarize the current state of scientific and regulatory issues that are relevant to nutraceutical products.

Premenstrual syndromes

Premenstrual syndrome research has made a great deal of progress since 1983 when the criteria for the diagnosis were clearly defined. Confirming the diagnosis prospectively and ruling out other disorders was a major methodologic advance. The DSM-IV criteria for PMDD now help us identify and classify women who have severe psychologic symptoms during the premenstruum. Although we do not have a definitive cause for PMDD, the consensus is that it is the end result of a complex series of events mediated partly by the serotonin system and triggered by ovulation. Women who meet criteria for PMS, do not meet the criteria for PMDD, and do not have a concurrent disorder should be treated conservatively. Women who meet criteria for PMDD can be treated successfully with low-dose clomipramine, SSRIs, or GnRH-as with "add back" estrogen and progestins.

Women, food, and mood

Associations between food intake and mood greatly interest both lay and scientific audiences, although scientific support for many observed associations is sparse. Of particular interest are issues surrounding food intake, food cravings, and mood in women throughout the menstrual cycle. Further research is necessary to support or disprove current hypotheses about the relationship between food intake and mood. Meanwhile, health professionals should be prepared to inform the public about the complexity of factors that influence the relationship between food intake and mood.

The effect of carbohydrates on affect

This report reviews studies addressing the issue of the effect that carbohydrates have on affective behavior. The review begins with an overview of the physiologic and psychological mechanisms that have been proposed to explain a carbohydrate-induced behavioral effect. Attention is then devoted to studies that have investigated the mood-altering effect of carbohydrates on normal individuals, depressed individuals, obese individuals, and individuals with seasonal affective disorder and premenstrual syndrome. Throughout the report it is apparent that carbohydrate consumption is relevant for individuals experiencing symptoms of emotional distress, particularly symptoms indicative of depression, and that the individuals with depressive symptoms show a preference for sweet simple carbohydrates. Enduring questions permeating the diet-behavior field are delineated and future research directions are suggested.

Diagnosis and treatment of premenstrual dysphoric disorder

Premenstrual syndrome (PMS) is a common problem and patients with PMS are encountered by obstetricians, gynecologists, family practitioners, internists (general physicians) and psychiatrists. Despite several decades of biological research, the etiology of the disorder is still elusive. The introduction of a psychiatric category called premenstrual dysphoric disorder (PMDD), describing women with severe emotional premenstrual symptoms, has advanced biological treatment research by identifying a more homogeneous patient population. This paper aims to review our current understanding of the clinical presentation, underlying psycho-biology, and essentials of treatment for premenstrual dysphoric disorder.