Role of stress in the pathogenesis of the metabolic syndrome

Persistent depressive symptomatology and inflammation: to what extent do health behaviours and weight control mediate this relationship?

We examined if persistent depressive symptoms are associated with markers of inflammation (C-Reactive Protein-CRP) and coagulation (fibrinogen), and if this association can be partly explained by weight control and behavioural risk factors (smoking, alcohol, physical activity). The study sample included 3609 men and women (aged 60.5+/-9.2 years) from The English Longitudinal Study of Ageing, a prospective study of community dwelling older adults. Depressive symptoms (using the 8-item CES-D scale), health behaviours (smoking, alcohol, physical activity), body weight, and central adiposity were assessed at baseline and 2 years follow up. CRP and fibrinogen were assessed at follow up. At baseline 12.7% of the sample reported elevated depressive symptomatology, which persisted in 6.1% of participants at follow up. Baseline CES-D score was associated with CRP (beta=.035, SE=.0066) and fibrinogen (beta=.023, SE=.0060) measured 2 years later. Using simple mediation analysis we observed both a direct association of depressive symptoms on CRP (beta=.013, SE=.0066) and indirect mediating effects through behavioural risk factors (beta for total indirect effect beta=.022, SE=.0023). For fibrinogen there were no direct effects of depression, and the association was entirely explained through indirect mediating effects of health behaviours. The presence of recurrent elevated depressive symptomatology at both time points was more strongly associated with CRP and fibrinogen. In summary, the association between depressive symptoms and low grade inflammation can be partly explained by behavioural risk factors. The presence of persistent depression appears to be associated with the greatest risk of elevated inflammation.

The role of mindfulness in positive reappraisal

Mindfulness meditation is increasingly well known for therapeutic efficacy in a variety of illnesses and conditions, but its mechanism of action is still under debate in scientific circles. In this paper, we propose a hypothetical causal model that argues for the role of mindfulness in positive reappraisal coping. Positive reappraisal is a critical component of meaning-based coping that enables individuals to adapt successfully to stressful life events. Mindfulness, as a metacognitive form of awareness, involves the process of decentering, a shifting of cognitive sets that enables alternate appraisals of life events. We review the concept of positive reappraisal in transactional stress and coping theory, then describe research and traditional literature related to mindfulness and positive reappraisal, and detail the central role of mindfulness in the reappraisal process. With this understanding, we present a causal model explicating the proposed mechanism. The discussion has implications for clinical practice, suggesting how mindfulness-based integrative medicine interventions can be designed to support adaptive coping processes.

Social environmental stressors, psychological factors, and kidney disease

Kidney disease is one of the most striking examples of health disparities in American public health. Disparities in the prevalence and progression of kidney disease are generally thought to be a function of group differences in the prevalence of kidney disease risk factors such as diabetes, hypertension, and obesity. However, the presence of these comorbidities does not completely explain the elevated rate of progression from chronic kidney disease (CKD) to end-stage renal disease among high-risk populations such as African Americans. We believe that the social environment is an important element in the pathway from CKD risk factors to CKD and end-stage renal disease. This review of the literature draws heavily from social science and social epidemiology to present a conceptual frame specifying how social, economic, and psychosocial factors interact to affect the risks for and the progression of kidney disease.

Hypothalamic-pituitary-adrenal axis function: relative contributions of perceived stress and obesity in women

OBJECTIVE

A range of behavioral and psychosocial factors may contribute to a chronically stimulated hypothalamic-pituitary-adrenal (HPA) axis and subsequently altered diurnal patterns. The goal of this cross-sectional study was to examine associations among diurnal cortisol levels, perceived stress, and obesity patterns.

METHODS

Seventy-eight women (aged 24-72 years) employed in a rural public school system completed the perceived stress scale, collected diurnal saliva samples, and underwent anthropometric assessments. Reduced peak-to-nadir cortisol values across the day were considered a sign of impairment in HPA function. A series of linear regression models determined the best predictors of diurnal cortisol variation.

RESULTS

There was a marginal linear trend in stress levels across body mass index (BMI) categories, with obese women reporting the highest levels of stress (p = 0.07). Perceived stress was the only significant predictor of the degree of flattening of the diurnal cortisol curve in the sample as a whole (beta = -0.042, R(2) = 0.11, F = 8.6, p = 0.005), indicating reduction in the normal diurnal pattern. Among overweight women (BMI = 25-29.9 kg/m(2)), stress and waist circumference combined predicted 35% of the variability in diurnal cortisol. In contrast, among obese women (BMI > or = 30 kg/m(2)), BMI predicted 31% of the variability in diurnal cortisol (F = 13.8, p = 0.001), but stress was no longer significantly related to diurnal cortisol.

CONCLUSIONS

Psychological stress predicts a significant portion of HPA axis functioning. In overweight women, perceived stress and waist circumference were of approximately equal importance in predicting adrenal cortisol secretion. However, among obese women, a major portion of the diurnal cortisol variation was predicted by BMI alone, not stress or waist circumference. This may help elucidate the mechanisms linking obesity to increased risk of cardiovascular disease (CVD).

BMI and lipid levels in Mexican American children diagnosed with type 2 diabetes

PURPOSE

The purpose of this study was to determine potential associations between obesity as measured by body mass index (BMI) and lipid values in Mexican American (MA) children diagnosed with type 2 diabetes.

BACKGROUND

Obesity in children is considered to be an emerging epidemic that is accompanied by an increase in prevalence of type 2 diabetes. Literature shows that there is a direct and strong relationship between abnormal lipid levels and obesity in Caucasian and African American children without type 2 diabetes. However, it was unknown whether Mexican American children diagnosed with type 2 diabetes have abnormal lipid levels.

METHOD

A retrospective medical-record review was conducted on paediatric patients who received medical care from a military medical centre in the Southwest region of the United States. A convenience sample of records was used to study the relationship between obesity as measured by BMI and lipid levels in 49 Mexican American children diagnosed with type 2 diabetes. Total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), and BMI were reviewed. Data were analysed using descriptive and logistic regression statistics.

FINDINGS

Ninety percent of the sample was obese and 75% had two or more abnormal lipid values. Abnormal levels of total cholesterol, HDL, and triglycerides were found to be statistically significant.

CONCLUSIONS

The main findings indicate that MA children diagnosed with type 2 diabetes had significant associations between obesity as measured by BMI and abnormal total cholesterol, HDL, and triglyceride levels. As the BMI increased, the probability of abnormal total cholesterol and triglyceride levels increased. Similarly, as the BMI increased, the probability of abnormal HDL values increased. Mexican American children in this study had obesity levels similar to those in a study by the National Center for Health Statistics. In this study a step has been taken toward understanding a physiologic marker for cardiovascular disease in children.

Effects of obesity on neuroendocrine, cardiovascular, and immune cell responses to acute psychosocial stress in premenopausal women

OBJECTIVE

To analyze the neuroendocrine and immune cell responses to acute psychosocial stress in obese compared to non-obese premenopausal women.

METHODS

N=15 obese (BMI> or =30) and N=24 (BMI<30) non-obese premenopausal women underwent public speaking stress. State anxiety, ACTH, cortisol, and the redistribution of immune cells were measured before, during, and 10 and 45min after public speaking. Serum hsCRP and serum IL-6 levels were analyzed before, and IL-6 additionally 45min after stress.

RESULTS

In response to public speaking stress, both groups showed significant but comparable increases in state anxiety, plasma ACTH, and blood pressure (all p<0.01; time effects). The cortisol stress response was significantly enhanced in obese women (p<0.05; interaction effect). In addition, heart rate and diastolic blood pressure were significantly higher in obese women 10min following stress (p<0.05, t-tests). Public speaking stress led to a significant increase in IL-6 concentrations (p<0.001; time effect), and obese women displayed higher IL-6 levels both pre- and post-stress (p<0.05; group effect; between-group t-tests: pre-stress p<0.05; post-stress p<0.01). Baseline numbers of circulating leukocytes, granulocytes, CD3+ cells and hsCRP concentration were significantly higher in obese women (between-group t-tests: all p<0.05, but the groups did not differ in the stress-induced redistribution of circulating leukocyte subpopulations.

CONCLUSIONS

Our data reveal a strong association of obesity with chronic low-grade inflammation in premenopausal women. This pro-inflammatory state, together with altered neuroendocrine and cardiovascular stress responsiveness, may conceivably constitute one of the mechanisms linking psychological stress and the long-term health risks associated with obesity.

Asthma, environmental risk factors, and hypertension among Arab Americans in metro Detroit

Asthma and obesity-related health problems disproportionately impact low-income ethnic minority communities residing in urban areas. Environmental risk factors, particularly those related to housing and indoor air, may impact the development or exacerbation of asthma. There is increasing evidence to suggest a link between obesity-related health problems and asthma. Previous studies have also reported that immigrant status may influence myriad risk factors and health outcomes among immigrant populations. The Arab American Environmental Health Project (AAEHP) was the first study to explore environmental health problems among Arab Americans. This paper examined whether hypertensive status modified the relationship between environmental risk factors and asthma among Arab Americans in metro Detroit. An environmental risk index (ERI) was used to quantify household environmental risk factors associated with asthma. Physician diagnosed hypertension was self-reported, and asthma status was determined using responses to a validated symptoms checklist and self-reported diagnosis by a physician. Hypertension significantly modified the relationship between ERI and asthma in this study population. The positive association between household environmental risk factors and asthma was stronger among participants diagnosed with hypertension. Effect modification of the relationship between environmental risk factors and asthma could have serious implications among high-risk communities. However, further research is needed to elucidate the relationships between hypertension, environmental risk factors, and asthma.

Secondary hypertension: obesity and the metabolic syndrome

The epidemic of obesity in the United States and around the world is intensifying in severity and scope and has been implicated as an underlying mechanism in systemic hypertension. Obese hypertensive individuals characteristically exhibit volume congestion, relative elevation in heart rate, and high cardiac output with concomitant activation of the renin-angiotensin-aldosterone system. When the metabolic syndrome is present, insulin resistance and hyperinsulinemia may contribute to hypertension through diverse mechanisms. Blood pressure can be lowered when weight control measures are successful, using, for example, caloric restriction, aerobic exercise, weight loss drugs, or bariatric surgery. A major clinical challenge resides in converting short-term weight reduction into a sustained benefit. Pharmacotherapy for the obese hypertensive patient may require multiple agents, with an optimal regimen consisting of inhibitors of the renin-angiotensin-aldosterone system, thiazide diuretics, beta-blockers, and calcium channel blockers if needed to attain contemporary blood pressure treatment goals.

Lack of predictability at work and risk of acute myocardial infarction: an 18-year prospective study of industrial employees

OBJECTIVES

We examined whether the distinctive components of job control-decision authority, skill discretion, and predictability-were related to subsequent acute myocardial infarction (MI) events in a large population of initially heart disease-free industrial employees.

METHODS

We prospectively examined the relation between the components of job control and acute MI among private-sector industrial employees. During an 18-year follow-up, 56 fatal and 316 nonfatal events of acute MI were documented among 7663 employees with no recorded history of cardiovascular disease at baseline (i.e., 1986).

RESULTS

After adjustment for demographics, psychological distress, prevalent medical conditions, lifestyle risk factors, and socioeconomic characteristics, low decision autonomy (P < .53) and skill discretion (P < .10) were not significantly related to subsequent acute MI. By contrast, low predictability at work was associated with elevated risk of acute MI (P = .02). This association was driven by the strong effect of predictability on acute MI among employees aged 45 to 54 years.

CONCLUSIONS

Prospective evidence suggests that low predictability at work is an important component of job control, increasing long-term risk of acute MI among middle-aged employees.

Chronic-intermittent cold stress in rats induces selective ovarian insulin resistance

In rat ovary chronic cold stress increases sympathetic nerve activity, modifies follicular development, and initiates a polycystic condition. To see whether there is a relationship between the previously described changes in follicular development and metabolic changes similar to those in women with polycystic ovary, we have studied the effect of chronic cold stress (4 degrees C for 3 h/day, Monday to Friday, for 4 wk) on insulin sensitivity and the effect of insulin on sympathetic ovarian activity. Although cold-stressed rats ate more than the controls, they did not gain more weight. Insulin sensitivity, determined by hyperinsulinemic-euglycemic clamp, was significantly increased in the stressed animals. Insulin in vitro increased the basal release of norepinephrine from the ovaries of control rats but not from those of stressed rats, suggesting a local neural resistance to insulin in stressed rats. The levels of mRNA and protein for IRS1 and SLC2A4 (also known as GLUT4), molecules involved in insulin signaling, decreased significantly in the ovaries but not in the muscle of stressed rats. This decrease was preferentially located in theca-interstitial cells compared with granulosa cells, indicating that theca cells (the only cells directly innervated by sympathetic nerves) are responsible for the ovarian insulin resistance found in stressed rats. These findings suggest that ovarian insulin resistance produced by chronic stress could be in part responsible for the development of the polycystic condition induced by stress.

AKT signaling within the ventral tegmental area regulates cellular and behavioral responses to stressful stimuli

BACKGROUND

The neurobiological mechanisms by which only a minority of stress-exposed individuals develop psychiatric diseases remain largely unknown. Recent evidence suggests that dopaminergic neurons of the ventral tegmental area (VTA) play a key role in the manifestation of stress vulnerability.

METHODS

Using a social defeat paradigm, we segregated susceptible mice (socially avoidant) from unsusceptible mice (socially interactive) and examined VTA punches for changes in neurotrophic signaling. Employing a series of viral vectors, we sought to causally implicate these neurotrophic changes in the development of avoidance behavior.

RESULTS

Susceptibility to social defeat was associated with a significant reduction in levels of active/phosphorylated AKT (thymoma viral proto-oncogene) within the VTA, whereas chronic antidepressant treatment (in mice and humans) increased active AKT levels. This defeat-induced reduction in AKT activation in susceptible mice was both necessary and sufficient to recapitulate depressive behaviors associated with susceptibility. Pharmacologic reductions in AKT activity also significantly raised the firing frequency of VTA dopamine neurons, an important electrophysiologic hallmark of the susceptible phenotype.

CONCLUSIONS

These studies highlight a crucial role for decreases in VTA AKT signaling as a key mediator of the maladaptive cellular and behavioral response to chronic stress.

Sex-dependent role of glucocorticoids and androgens in the pathophysiology of human obesity

Obesity, particularly its abdominal phenotype, a harbinger of the metabolic syndrome, cardiovascular diseases (CVDs) and type 2 diabetes mellitus (T2D), is becoming one of the most significant public health problems worldwide. Among many other potential factors, derangement of multiple hormone systems have increasingly been considered for their potential importance in the pathophysiology of obesity and the metabolic syndrome, with particular reference to glucocorticoids and sex hormones. These systems have a fundamental and coordinating role in the physiology of intermediate metabolism and cardiovascular function, and in the response to acute and chronic stress challenge. Abdominal obesity is associated with a hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis and impaired androgen balance, although these alterations differ according to sex. As there is also increasing evidence that there are many differences between the sexes in the susceptibility and development of obesity, T2D and CVDs, we support the hypothesis that alterations of the HPA axis and androgen balance may have an important function in this context. This is further supported by the fact that there are important differences between males and females in their ability to adapt to both internal and particularly to environmental (external) stressors. In addition, there is also evidence that, in both physiological and pathological conditions, a close cross talk exists between sex hormones and glucocorticoids at both neuroendocrine and peripheral level, again with different specificities according to sex.

Individual and area-based indicators of acculturation and the metabolic syndrome among low-income Mexican American women living in a border region

OBJECTIVES

We sought to examine the relationships between individual and area-based indicators of acculturation and metabolic syndrome (MetS) risk among a sample of Mexican American women living in the California-Baja California border region.

METHODS

We examined data collected between October 2003 and December 2004 from 141 women (mean age = 47.07 years) who completed physical and psychosocial assessments. We reviewed medical records for laboratory values.

RESULTS

Individual-level US acculturation was associated with a greater consumption of fruits, vegetables, and fiber; increased odds of engaging in health-enhancing levels of physical activity; and decreased odds of meeting the clinical criteria for MetS. Moreover, beyond the influence of individual-level factors, US neighborhood acculturation was associated with less fat intake.

CONCLUSIONS

These findings provide preliminary evidence for a relationship between acculturation and the development of MetS in this population. Such information may assist efforts aimed at understanding and eliminating ethnic disparities in MetS risk and related health conditions.

Complications of diabetes in urban Indigenous Australians: the DRUID study

AIMS

To accurately assess the management and complications of type 2 diabetes in urban Indigenous Australians and compare the risk of complications with a general Australian population (AusDiab Study).

METHODS

The Darwin Region Urban Indigenous Diabetes (DRUID) Study included 1004 volunteers aged >/=15 years; diabetes status was classifiable for 866. The assessment of diabetic complications and metabolic control was performed in participants with known diabetes (KDM) and diabetes newly diagnosed by the study (NDM) using an interviewer-administered questionnaire and clinical examination.

RESULTS

Among 172 DRUID participants eligible for complications assessment, 135 were assessed, including 99 KDM (mean age 53 years) and 36 NDM (mean age 47 years). Percentages of KDM participants meeting therapeutic targets were: HbA1c<7%, 29%; blood pressure<130/80mmHg, 45%; total cholesterol<5.5mmol/L, 65%. Among KDM, 39% had albuminuria, 21% retinopathy, 12% peripheral vascular disease (PVD), 9% neuropathy. Factors independently associated with diabetic complications were: albuminuria-HbA1c, systolic blood pressure; retinopathy-diabetes duration; PVD-age. Compared to AusDiab participants after adjusting for other risk factors, DRUID participants had 2-3-fold increased risk of albuminuria and PVD and a non-significant increased risk of neuropathy, but no increased risk of retinopathy.

CONCLUSIONS

Urban Indigenous Australians with diabetes are relatively young and have poor glycaemic control. Compared to the general Australian population with type 2 diabetes, they have greater adjusted risk of albuminuria and PVD but not retinopathy. Urgent action is required to prevent diabetes at a population level and improve diabetes management in this high-risk population.

Fat feeding potentiates the diabetogenic effect of dexamethasone in Wistar rats

Background

The role of cortisol and its increased action/availability is implicated in the pathogenesis of insulin resistance associated with obesity and metabolic syndrome but the mechanism of increased action/availability is not known. Availability of several other lipophilic hormones, drugs and pollutants are also reported to be increased in obesity. Increased lipids in the circulation are reported to alter the fluidity and permeability of membranes. Hyperlipidemia is also reported to alter the pharmacokinetics and pharmacodynamics of lipophilic molecules and also membrane fluidity and permeability. In this context we assumed that the hyperlipidemia associated with human obesity might play a role in the altered action/availability of cortisol and this in turn might have initiated the metabolic complications. To evaluate our assumption we have administered dexamethasone [low [50 μg/kg/day] or high [250 μg/kg/day] dose] to high-fat [coconut oil & vanaspati] fed rats and the results were compared with rats administered with either dexamethasone or high-fat.

Results and Discussion

Within two weeks, the rats co-administered with high-fat and dexamethasone developed severe hyperglycemia, hyperlipidemia and insulin resistance compared to rats treated either of them alone. High-fat fed rats treated with higher dose of dexamethasone were presented with severe hyperglycemia, insulin resistance and also severe glycosuria. The hyperlipidemia caused by high-fat feeding might have altered the transport and distribution of dexamethasone, probably by altering the physical state of membranes and transport proteins.

Conclusion

From the results obtained, it can be speculated that the altered lipid and cortisol metabolism could affect one another, forming a vicious cycle.

Abnormal serum lipid profile in Brazilian police officers with post-traumatic stress disorder

BACKGROUND

To measure the serum lipid composition of a sample of Brazilian police officers with and without PTSD regularly exposed to potentially traumatic situations.

METHODS

A cross-sectional survey was conducted with 118 active duty male police officers. Serum concentrations for total cholesterol, LDL-C, HDL-C, and triglycerides were enzymatically determined. Body mass index (BMI) was obtained for each participant.

RESULTS

Officers with PTSD exhibited significantly higher serum total cholesterol, LDL-C and triglycerides levels than those without PTSD. Total cholesterol and triglycerides, but not LDL-C, remained associated with PTSD diagnosis after controlling for confounding influences (i.e. socio-demographics, BMI, and tobacco, alcohol and medication use).

LIMITATIONS

The sample size was small. A nutritional interview was employed instead of established scales to assess alimentary habits, tobacco or alcohol consumption. A self-report screening tool was used to assess the prevalence of PTSD.

CONCLUSIONS

The association between PTSD and abnormal serum lipid profile and a tendency to exhibit higher BMI suggests that individuals with PTSD may be at increased risk for developing metabolic syndrome, a condition that by itself could account for many of the most serious PTSD-related physical health problems.

Inflammation as an intermediate pathway in the association between psychosocial stress and obesity

Psychosocial stress is associated with risk of obesity although little is known about stress-induced biological mechanisms of obesity. We examined the potential mediating role of inflammatory processes. Data were collected from a nationally representative sample of 7540 individuals (54% women, mean age 46.8+/-15.4 years), from the Scottish Health Surveys. We calculated risk estimates of obesity for increasing numbers of psychosocial stressors (based on social position, education, psychological distress and marital/partner discord) using logistic regression analyses. Obesity was assessed using body mass index and central obesity using waist circumference. Potential mediators included inflammatory markers (C-reactive protein and fibrinogen) and health behaviours (physical activity, smoking, alcohol, and dietary intake). The unadjusted odds ratio of obesity for three or more psychosocial stressors was 1.81 (95% CI, 1.39-2.36, p<0.001). In multivariate analyses that adjusted for age, gender, health behaviours and inflammatory markers the association between psychosocial stress and obesity was attenuated but remained significant (1.49, 1.11-2.00, p<0.001). Inflammatory markers independently accounted for approximately 25% of the association between stress and obesity. We found similar associations in separate analyses of psychosocial stress and central obesity, although results were confounded by overall obesity. In summary, inflammatory processes appear to be an important intermediate pathway in the association between psychosocial stress and obesity.

Behavioral Medicine Review: Psychological Risks for Metabolic Syndrome

Despite their ubiquity in primary care, psychological disorders often are overlooked as cues to heightened risk for metabolic syndrome (MetS), potentially leading to the suboptimal management of patients with these comorbid conditions. Accordingly, this review discusses psychological dysfunction as an under-appreciated MetS hazard and the strategic implications for cardiometabolic risk reduction in primary care.

Education, psychosocial resources, and metabolic syndrome variables in Latinas

BACKGROUND

Individuals with low socioeconomic position (SEP) and Latino ethnicity are at high risk for the metabolic syndrome. In part, this may reflect that these populations benefit from fewer resilient resources to manage stressful environments, resulting in accentuated psychological and physiological costs (1).

PURPOSE

We examined the direct effects of educational attainment (an indicator of SEP) and psychosocial resources on metabolic syndrome variables, and tested indirect effects of education, via resources.

METHODS

Participants were 145 middle-aged (M=47.07 years) Latinas recruited from health clinics along the California-Mexico border. Women completed assessments of demographics and resilient resources; metabolic syndrome variables were measured (blood pressure [BP], waist circumference [WC]) or abstracted from medical charts (lipids, glucose).

RESULTS

Women with less education reported fewer psychosocial resources (DeltaR2=.14, p<.0001) and showed a higher risk profile on measures of BP, WC, and plasma glucose (3-7% of variance explained, all ps<.05), relative to those with more education. Resources independently predicted lower WCs (DeltaR2=.07, p<.05). Education exerted an indirect effect (p<.05) through resources on WC, a core factor underlying the metabolic syndrome.

CONCLUSIONS

Additional research is warranted to further explore the roles of resilient resources in relationships among SEP, metabolic risk factors, and chronic disease processes.

Socioeconomic status and diabetes among urban Indigenous Australians aged 15-64 years in the DRUID study

BACKGROUND

Diabetes is associated with lower socioeconomic status (SES) in developed countries, but the reverse is true in developing countries. Little is known about the relationship between SES and diabetes among Indigenous populations in developed countries.

DESIGN

We examined the relationship between measures of SES and the prevalence of diabetes in the DRUID Study, a cross-sectional study of urban Indigenous Australian volunteers in the Darwin region.

RESULTS

Among 777 participants aged 15-64 years included in the analysis, 17.1% had diabetes, ranging from 2.0% among those aged 15-24 years to 50.8% of those aged 55-64 years. After adjusting for age and sex, diabetes was significantly more common among those of lower SES, whether measured by housing tenure, household income, or employment status. For example, compared with those living in a household that was owned/being purchased by its occupants, the relative odds of diabetes was 2.66 (95% confidence interval 1.71-4.15) for those living in rented/other accommodation. The inverse relationship between SES and diabetes was present even among those who had not previously been diagnosed with diabetes. The relationship between disadvantage and diabetes was not mediated to any great degree by obesity.

CONCLUSIONS

The relationship between SES and diabetes among Indigenous Australians in this study is consistent with the patterns observed in developed countries, rather than those in some developing countries.

Stress reactivity and adiposity of youth

OBJECTIVE

The relationship between stress reactivity and total or central adiposity in children has not been widely studied. Data from two studies were combined to determine the relationship between reactivity to interpersonal stress and the adiposity of children.

RESEARCH METHODS AND PROCEDURES

Stress reactivity to an interpersonal stressor (speech) was measured in 36 boys (9.8 +/- 1.3 years of age) and 27 girls (9.3 +/- 1.3 years of age). Total adiposity (percentage body fat) was estimated from skinfolds and central adiposity from the abdominal girth. Multiple regression was used to establish the associations of change in perceived stress and heart rate reactivity with adiposity. Age, sex, ethnicity, and baseline perceived stress and heart rate served as covariates for total adiposity. Fat mass was included as an additional covariate for the prediction of log abdominal girth (central adiposity).

RESULTS

Based on adjusted beta-weights, change in perceived stress (beta = 1.13, p <or= 0.001) and heart rate reactivity (beta = 0.14, p <or= 0.03) independently predicted percentage body fat. Heart rate reactivity (beta = 0.002, p <or= 0.04) independently predicted log abdominal girth.

DISCUSSION

Reactivity to psychological stress may initiate the antecedents of cardiovascular disease before adolescence by increasing total and central adiposity. Future studies should determine whether stress reactivity increases the adiposity of youth by increasing their consumption of energy-dense snack foods and decreasing their willingness to be physically active.

Oxazolones as potent inhibitors of 11β-hydroxysteroid dehydrogenase type 1

2,5,5-Trisubstituted oxazolones were identified as potent inhibitors of 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1). The synthesis, structure-activity relationship and metabolic stability of these compounds are presented.

Stress, eating and the reward system

An increasing number of people report concerns about the amount of stress in their life. At the same time obesity is an escalating health problem worldwide. Evidence is accumulating rapidly that stress related chronic stimulation of the hypothalamic-pituitary-adrenal (HPA) axis and resulting excess glucocorticoid exposure may play a potential role in the development of visceral obesity. Since adequate regulation of energy and food intake under stress is important for survival, it is not surprising that the HPA axis is not only the 'conductor' of an appropriate stress response, but is also tightly intertwined with the endocrine regulation of appetite. Here we attempt to link animal and human literatures to tease apart how different types of psychological stress affect eating. We propose a theoretical model of Reward Based Stress Eating. This model emphasizes the role of cortisol and reward circuitry on motivating calorically dense food intake, and elucidating potential neuroendocrine mediators in the relationship between stress and eating. The addiction literature suggests that the brain reward circuitry may be a key player in stress-induced food intake. Stress as well as palatable food can stimulate endogenous opioid release. In turn, opioid release appears to be part of an organisms' powerful defense mechanism protecting from the detrimental effects of stress by decreasing activity of the HPA axis and thus attenuating the stress response. Repeated stimulation of the reward pathways through either stress induced HPA stimulation, intake of highly palatable food or both, may lead to neurobiological adaptations that promote the compulsive nature of overeating. Cortisol may influence the reward value of food via neuroendocrine/peptide mediators such as leptin, insulin and neuropeptide Y (NPY). Whereas glucocorticoids are antagonized by insulin and leptin acutely, under chronic stress, that finely balanced system is dysregulated, possibly contributing to increased food intake and visceral fat accumulation. While these mechanisms are only starting to be elucidated in humans, it appears the obesity epidemic may be exacerbated by the preponderance of chronic stress, unsuccessful attempts at food restriction, and their independent and possibly synergistic effects on increasing the reward value of highly palatable food.

Psychiatric and metabolic characteristics of childhood versus adult-onset obesity in patients seeking weight management

The purpose of the study was to examine whether childhood-onset obesity differed from adult-onset obesity in lifetime prevalence of mood and eating disorders, and metabolic abnormalities, in currently obese adults seeking weight loss. A subgroup of childhood-onset obesity participants (N=44) was compared with a subgroup with adult-onset obesity (N=69) on a number of clinical and metabolic features. The results showed high lifetime prevalence rates of mood (78%) and eating (81%) disorders, and metabolic syndrome (45%), in the group as a whole. However, patients with childhood-onset obesity had a significantly higher lifetime prevalence of eating disorders in general, and of bulimia nervosa in particular, than patients with adult-onset obesity. Our results support findings of substantial comorbidity among obesity, mood and eating disorders, and metabolic syndrome in weight loss seeking populations. Early recognition and attention to eating and mood dysregulation, including, but not limited to binge eating disorder and bulimia nervosa, in some persons, might help reduce their lifetime risk for obesity.

Stress in women: metabolic syndrome and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous syndrome that is characterized from oligo- or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries. Clinical expression is determined by genetic as well as environmental factors. Women with PCOS are a specific group of women which have several aspects of metabolic syndrome (MBS). Concomitantly MBS could be part of metabolic abnormalities present in PCOS. Stress has been linked to aggravate the metabolic abnormalities present in MBS. An interaction seems to exist between stress, environmental, as well as genetic factors, starting from the prenatal age and continuing to the adult life. This results in specific endocrinological and metabolic disorders which are shared by women with PCOS and women with MBS.

Hypertension among Polish males during the economic transition

In the late 1980s and early 1990s Polish society experienced deep political, economic and social changes. The aim of the study is to investigate whether changes that occurred in Poland during the transformation significantly influenced the risk of hypertension among adult men. We find that irrespective of age, marital status, education, degree of urbanization, lifestyle variables (smoking, drinking alcohol, and physical activity), and BMI the risk of hypertension after 1989 was higher than before transformation (odds ratio=1.45, p<0.001). Psychosocial factors are proposed as factors which might at least partly explain the higher risk of hypertension during the first years of economic transition in Poland.

Differential effects of oral hypoglycemic agents on glucose control and cardiovascular risk

Cardiovascular disease (CVD) burden remains the predominant cause of mortality and morbidity in the United States and in most of the developed world. The ongoing twin epidemics of obesity and type 2 diabetes mellitus provide a groundswell source for sustaining this trend for the foreseeable future (increasing the prevalence of CVD by 2-4 times), unless radical changes are made in public health policy. Oral hypoglycemic agents (OHAs) remain a mainstay for management of type 2 diabetes in most practice settings. Although these agents are primarily prescribed to achieve better glycemic control, it is important to evaluate what effects they have on cardiovascular risk and whether there are significant differences in effects among the different OHAs. This review presents the available data on the effects of the various OHAs on cardiovascular risk surrogates and actual events in retrospective and prospective study design settings.

Hypercortisolemic depression is associated with the metabolic syndrome in late-life

INTRODUCTION

Depression has been hypothesized to be associated with metabolic abnormalities which increase the risk of cardiovascular disease (CVD) and diabetes. Such a link could be due to increased HPA-axis activity. This study investigates the cross-sectional relationship between depression, urinary cortisol and metabolic syndrome in an older population.

METHODS

Data are from 867 participants of the InChianti Study, aged 65 years. Depressive symptoms were assessed using the CES-D scale; cortisol levels were determined in 24-h urine samples. Metabolic syndrome was defined as three or more of the following: abdominal obesity, high triglycerides, low HDL cholesterol, high blood pressure, and high fasting glucose.

RESULTS

Clinically relevant depressed mood (CES-D20) was present in 20.6% of the sample, and 24.5% had the metabolic syndrome. After adjustment for sociodemographics and health indicators, depression score (per SD increase: OR=1.20, 95% CI=1.02-1.41) and urinary cortisol level (per SD increase: OR=1.23, 95% CI=1.01-1.51) were significantly associated with presence of metabolic syndrome. There was, however, a significant interaction (p=0.003) between depressed mood and urinary cortisol in the probability of having metabolic syndrome. The odds of metabolic syndrome in persons with both depressed mood and urinary cortisol excretion in the highest tertile was 1.84 (95% CI=1.02-3.34) compared to persons with neither condition.

DISCUSSION

This study suggests a synergistic relationship between depression, cortisol and metabolic syndrome. Hypercortisolemic depression may constitute a specific risk group for the metabolic syndrome.

The contribution of changes in diet, exercise, and stress management to changes in coronary risk in women and men in the Multisite Cardiac Lifestyle Intervention Program

BACKGROUND

The relative contribution of health behaviors to coronary risk factors in multicomponent secondary coronary heart disease (CHD) prevention programs is largely unknown.

PURPOSE

Our purpose is to evaluate the additive and interactive effects of 3-month changes in health behaviors (dietary fat intake, exercise, and stress management) on 3-month changes in coronary risk and psychosocial factors among 869 nonsmoking CHD patients (34% female) enrolled in the health insurance-based Multisite Cardiac Lifestyle Intervention Program.

METHODS

Analyses of variance for repeated measures were used to analyze health behaviors, coronary risk factors, and psychosocial factors at baseline and 3 months. Multiple regression analyses evaluated changes in dietary fat intake and hours per week of exercise and stress management as predictors of changes in coronary risk and psychosocial factors.

RESULTS

Significant overall improvement in coronary risk was observed. Reductions in dietary fat intake predicted reductions in weight, total cholesterol, low-density lipoprotein cholesterol, and interacted with increased exercise to predict reductions in perceived stress. Increases in exercise predicted improvements in total cholesterol and exercise capacity (for women). Increased stress management was related to reductions in weight, total cholesterol/high-density lipoprotein cholesterol (for men), triglycerides, hemoglobin A1c (in patients with diabetes), and hostility.

CONCLUSIONS

Improvements in dietary fat intake, exercise, and stress management were individually, additively and interactively related to coronary risk and psychosocial factors, suggesting that multicomponent programs focusing on diet, exercise, and stress management may benefit patients with CHD.

The low-dose dexamethasone suppression test in fibromyalgia

OBJECTIVE

Fibromyalgia syndrome (FMS) has been associated with decreased cortisol secretion. Patients with posttraumatic stress disorder (PTSD) exhibit similar hypocortisolism in the context of increased negative feedback sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis. Because trauma and PTSD have been associated with fibromyalgia, we evaluated whether patients with fibromyalgia demonstrate increased HPA feedback sensitivity.

METHOD

Baseline blood samples were obtained at 0800 h, and 0.5 mg of dexamethasone was administered to 15 female patients with FMS and 20 normal controls at 2300 h. Adrenocorticotropin (ACTH), cortisol, and dexamethasone levels were measured at 0800 h after dexamethasone intake.

RESULTS

There were no group differences in mean ACTH or cortisol levels or in ACTH/cortisol ratio at baseline. After dexamethasone intake, patients with FMS exhibited more pronounced suppression of cortisol but not of ACTH, as well as increased ACTH/cortisol ratios compared with controls. Percent cortisol suppression was associated with pain and fatigue, while ACTH/cortisol ratio and dexamethasone availability were associated with stress and anxiety measures.

CONCLUSION

Our results suggest increased sensitivity to glucocorticoid feedback, manifested at the adrenal level, in FMS.

Disruption of glucocorticoid action by environmental chemicals: potential mechanisms and relevance

Glucocorticoids play an essential role in the regulation of key physiological processes, including immunomodulation, brain function, energy metabolism, electrolyte balance and blood pressure. Exposure to naturally occurring compounds or industrial chemicals that impair glucocorticoid action may contribute to the increasing incidence of cognitive deficits, immune disorders and metabolic diseases. Potentially, "glucocorticoid disruptors" can interfere with various steps of hormone action, e.g. hormone synthesis, binding to plasma proteins, delivery to target cells, pre-receptor regulation of the ratio of active versus inactive hormones, glucocorticoid receptor (GR) function, or export and degradation of glucocorticoids. Several recent studies indicate that such chemicals exist and that some of them can cause multiple toxic effects by interfering with different steps of hormone action. For example, increasing evidence suggests that organotins disturb glucocorticoid action by altering the function of factors that regulate the expression of 11beta-hydroxysteroid dehydrogenase (11beta-HSD) pre-receptor enzymes, by direct inhibition of 11beta-HSD2-dependent inactivation of glucocorticoids, and by blocking GR activation. These observations emphasize on the complexity of the toxic effects caused by such compounds and on the need of suitable test systems to assess their effects on each relevant step.

Insulin resistance induced by hydrocortisone is increased in patients with abdominal obesity

Glucocorticoids hypersensitivity may be involved in the development of abdominal obesity and insulin resistance. Eight normal weight and eight obese women received on two occasions a 3-h intravenous infusion of saline or hydrocortisone (HC) (1.5 microg x kg(-1) x min(-1)). Plasma cortisol, insulin, and glucose levels were measured every 30 min from time(-30) (min) (time(-30)) to time(240). Free fatty acids, adiponectin, and plasminogen activator inhibitor-1 (PAI-1) levels were measured at time(-30), time(180), and time(240). At time(240), subjects underwent an insulin tolerance test to obtain an index of insulin sensitivity (K(ITT)). Mean(30-240) cortisol level was similar in control and obese women after saline (74 +/- 16 vs. 75 +/- 20 microg/l) and HC (235 +/- 17 vs. 245 +/- 47 microg/l). The effect of HC on mean(180-240) insulin, mean(180-240) insulin resistance obtained by homeostasis model assessment (HOMA-IR), and K(ITT) was significant in obese (11.4 +/- 2.0 vs. 8.2 +/- 1.3 mU/l, P < 0.05; 2.37 +/- 0.5 vs. 1.64 +/- 0.3, P < 0.05; 2.81 +/- 0.9 vs. 3.32 +/- 1.02%/min, P < 0.05) but not in control women (3.9 +/- 0.6 vs. 2.8 +/- 0.5 mU/l; 0.78 +/- 0.1 vs. 0.49 +/- 0.1; 4.36 +/- 1.1 vs. 4.37 +/- 1.2%/min). In the whole population, the quantity of visceral fat, estimated by computerized tomography scan, was correlated with the increment of plasma insulin and HOMA-IR during HC infusion [Delta mean(30-240) insulin (r = 0.61, P < 0.05), Delta mean(30-240) HOMA-IR (r = 0.66, P < 0.01)]. The increase of PAI-1 between time(180) and time(240) after HC was higher in obese women (+25%) than in controls (+12%) (P < 0.05), whereas no differential effect between groups was observed for free fatty acids or adiponectin. A moderate hypercortisolism, equivalent to that induced by a mild stress, has more pronounced consequences on insulin sensitivity in abdominally obese women than in controls. These deleterious effects are correlated with the amount of visceral fat.

Cortisol, dehydroepiandrosterone sulphate and dehydroepiandrosterone sulphate/cortisol ratio responses to physical stress in males are influenced by pubertal development

To evaluate the influence of chronological age and pubertal development on the hypothalamus-pituitary-adrenal (HPA) axis response to stress, we studied the possible correlations between male pubertal characteristics and salivary cortisol (C), DHEAS and the DHEAS/C ratio before (pre-stress) and after acute exercise-stress in young male volunteers (no. 87; 13.3+/-2.1 yr). In our overall study population, the mean pre-stress salivary C and DHEAS concentrations, significantly increased after exercise-related stress, whereas the DHEAS/C ratio significantly decreased. Pre-stress salivary C was positively correlated with chronological age, and after-stress salivary C concentration variations were negatively correlated with pubertal stage, mean testis volume and pre-stress salivary DHEAS. Furthermore, salivary DHEAS concentrations and the DHEAS/C ratio, before and after exercise stress, were positively correlated with chronological age, pubertal stage, pre-stress salivary testosterone (T), testis volume and body mass index (BMI). In contrast with late pubertal stages (P4, P5), young individuals at early stages of puberty (P1 to P3) showed higher C increase and lower DHEAS/C ratio after exercise-related stress. In conclusion, since C is also a mediator of stress-related negative effects on health and the DHEAS/C ratio has been hypothesized as an index for the degree to which an individual is buffered against the negative effects of stress, these data might suggest potentially increased stress-related risks at early stages of male puberty.

From Malthus to motive: how the HPA axis engineers the phenotype, yoking needs to wants

The hypothalamo-pituitary-adrenal (HPA) axis is the critical mediator of the vertebrate stress response system, responding to environmental stressors by maintaining internal homeostasis and coupling the needs of the body to the wants of the mind. The HPA axis has numerous complex drivers and highly flexible operating characterisitics. Major drivers include two circadian drivers, two extra-hypothalamic networks controlling top-down (psychogenic) and bottom-up (systemic) threats, and two intra-hypothalamic networks coordinating behavioral, autonomic, and neuroendocrine outflows. These various networks jointly and flexibly control HPA axis output of periodic (oscillatory) functions and a range of adventitious systemic or psychological threats, including predictable daily cycles of energy flow, actual metabolic deficits over many time scales, predicted metabolic deficits, and the state-dependent management of post-prandial responses to feeding. Evidence is provided that reparation of metabolic derangement by either food or glucocorticoids results in a metabolic signal that inhibits HPA activity. In short, the HPA axis is intimately involved in managing and remodeling peripheral energy fluxes, which appear to provide an unidentified metabolic inhibitory feedback signal to the HPA axis via glucocorticoids. In a complementary and perhaps a less appreciated role, adrenocortical hormones also act on brain to provide not only feedback, but feedforward control over the HPA axis itself and its various drivers, as well as coordinating behavioral and autonomic outflows, and mounting central incentive and memorial networks that are adaptive in both appetitive and aversive motivational modes. By centrally remodeling the phenotype, the HPA axis provides ballistic and predictive control over motor outflows relevant to the type of stressor. Evidence is examined concerning the global hypothesis that the HPA axis comprehensively induces integrative phenotypic plasticity, thus remodeling the body and its governor, the brain, to yoke the needs of the body to the wants of the mind. Adverse side effects of this yoking under conditions of glucocorticoid excess are discussed.

The inflammatory response recapitulates phylogeny through trophic mechanisms to the injured tissue

The post-traumatic local acute inflammatory response is described as a succession of three functional phases of possible trophic significance: 1. Nervous or immediate (ischemia-reperfusion); 2. Immune or intermediate (infiltration by inflammatory and bacterial cells) and 3. Endocrine or late (angiogenesis with regeneration and/or cicatrization). Each of these phases emphasizes the trophic role of the mechanisms in the damaged tissue. Hence, the nervous phase is predominated by nutrition by diffusion; in the immune phase trophism is mediated by inflammatory cells and bacteria and, finally, in the endocrine phase, the blood circulation and oxidative metabolism play the most significant nutritive role. Since these trophic mechanisms are of increasing complexity, progressing from anoxia to total specialization in the use of oxygen to obtain usable energy, it could be speculated that they represent the successive reappearance of the stages that take place during the evolution of life on Earth, from ancient times without oxygen. In this sense, the inflammatory response could recapitulate phylogeny through the successive expression of pathophysiologic mechanisms that have a trophic meaning to the injured tissue.

Antihypertensive therapy in the obese hypertensive patient

PURPOSE OF REVIEW

Obesity is becoming recognized as one of the most important risk factors for the development of hypertension. The purpose of the review is to examine the latest evidence linking hypertension to obesity, summarize the benefits of weight reduction and present results of recent clinical trials evaluating antihypertensive treatment in obese patients.

RECENT FINDINGS

Adipose tissue has been directly implicated in the pathogenesis of hypertension. Obesity has been associated with unequivocal changes in cardiovascular structure and function. In contrast to earlier studies, several recent trials included overweight and obese patients. Evidence of potential benefits of angiotensin blockade in the management of obesity hypertension is growing. Hypertension management in obese individuals is complicated by poorer response to treatment, and the increased need for multiple medications. It is important to consider obstructive sleep apnea in obese patients with resistant hypertension.

SUMMARY

Several new lines of evidence suggest that drugs blocking the renin-angiotensin system might be considered as first-line therapy of obesity-related hypertension. Recent progress in understanding the mechanisms of obesity and associated disease processes might lead to development of novel therapeutic strategies. Further research in this area holds great promise for prevention of obesity-related cardiovascular disease.

Hostility and urine norepinephrine interact to predict insulin resistance: the VA Normative Aging Study

OBJECTIVE

Previous research has produced mixed results pertaining to the association between hostility and insulin resistance. These inconsistent findings may be the result of a lack of studies examining potential moderators of this relationship and inconsistent measures of insulin resistance and/or hostility. We hypothesized that hostility may interact with circulating norepinephrine (NEPI) levels, indexed by 24-hour urine concentrations, to affect insulin resistance.

METHODS

Six hundred forty-three men (mean age = 63.1 years) free of diabetic medications completed the Minnesota Multiphasic Personality Inventory and participated in a laboratory assessment. The Cook-Medley Hostility (Ho) and 24-hour urine NEPI were used to predict insulin resistance defined by the homeostatic model assessment (HOMA) index, 2-hour postchallenge glucose (PCGL), and insulin levels (PCIL) after controlling for nine common covariates.

RESULTS

Multiple regression showed that the two-way interaction between Ho and NEPI significantly predicted HOMA and PCIL, but not PCGL, after controlling for covariates. Simple regression slopes of Ho on HOMA and PCIL were explored and indicated that, at higher levels of NEPI, higher Ho was associated with higher HOMA (beta = 0.14, p < .05). Ho was not a significant predictor of HOMA at mean and lower levels of NEPI. Similar results were obtained for PCIL, but not PCGL. Cynicism, but not other subscales of Ho, was similarly related to insulin resistance and NEPI.

CONCLUSION

Individuals with high stress and high hostility were more likely to have insulin resistance. It is important to study moderators in the relationship between hostility and insulin resistance.

Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions

Burnout is characterized by emotional exhaustion, physical fatigue, and cognitive weariness, resulting from prolonged exposure to work-related stress. The authors review the accumulated evidence suggesting that burnout and the related concept of vital exhaustion are associated with increased risk of cardiovascular disease and cardiovascular-related events. The authors present evidence supporting several potential mechanisms linking burnout with ill health, including the metabolic syndrome, dysregulation of the hypothalamic-pituitary-adrenal axis along with sympathetic nervous system activation, sleep disturbances, systemic inflammation, impaired immunity functions, blood coagulation and fibrinolysis, and poor health behaviors. The association of burnout and vital exhaustion with these disease mediators suggests that their impact on health may be more extensive than currently indicated.

Coffee inhibits the reactivation of glucocorticoids by 11β-hydroxysteroid dehydrogenase type 1: A glucocorticoid connection in the anti-diabetic action of coffee?

Recent epidemiological studies demonstrated a beneficial effect of coffee consumption for the prevention of type 2 diabetes, however, the underlying mechanisms remained unknown. We demonstrate that coffee extract, corresponding to an Italian Espresso, inhibits recombinant and endogenous 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) activity. The inhibitory component is heat-stable with considerable polarity. Coffee extract blocked 11beta-HSD1-dependent cortisol formation, prevented the subsequent nuclear translocation of the glucocorticoid receptor and abolished glucocorticoid-induced expression of the key gluconeogenic enzyme phosphoenolpyruvate carboxykinase. We suggest that at least part of the anti-diabetic effects of coffee consumption is due to inhibition of 11beta-HSD1-dependent glucocorticoid reactivation.

Psychoneuroendocrine effects of cognitive-behavioral stress management in a naturalistic setting--a randomized controlled trial

It is assumed that chronic or extensive release of cortisol due to stress has deleterious effects on somatic and psychological health, making interventions aiming to reduce and/or normalize cortisol secretion to stress of interest. Cognitive-behavioral stress management (CBSM) has repeatedly been shown to effectively reduce cortisol responses to acute psychosocial stress. However, the effects of CBSM on psychoneuroendocrine responses during "real-life" stress have yet not been examined in healthy subjects. Eight weeks before all subjects took an important academic exam, 28 healthy economics students were randomly assigned to four weekly sessions of cognitive behavioral stress management (CBSM) training or a waiting control condition. Psychological and somatic symptoms were repeatedly assessed throughout the preparation period. Salivary cortisol (cortisol awakening response and short circadian cortisol profile) was repeatedly measured at baseline and on the day of the exam. In addition, cognitive appraisal was assessed on the day of the exam. Subjects in the CBSM group showed significantly lower anxiety and somatic symptom levels throughout the period prior to the exam. On the day of the exam, groups differed in their cortisol awakening stress responses, with significantly attenuated cortisol levels in controls. Short circadian cortisol levels did not differ between groups. Interestingly, groups differed in their associations between cortisol responses before the exam and cognitive stress appraisal, with dissociation in controls but not in the CBSM group. The results show that CBSM reduces psychological and somatic symptoms and influences the ability to show a cortisol response corresponding to subjectively perceived stress. In line with current psychoneuroendocrine models, the inability to mount a cortisol response corresponding to the cognitive appraisal in controls could be a result of a dysregulated HPA axis, probably as a consequence of longlasting stress.

Why is 11beta-hydroxysteroid dehydrogenase type 1 facing the endoplasmic reticulum lumen? Physiological relevance of the membrane topology of 11beta-HSD1

11Beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) is essential for the local activation of glucocorticoid receptors (GR). Unlike unliganded cytoplasmic GR, 11beta-HSD1 is an endoplasmic reticulum (ER)-membrane protein with lumenal orientation. Cortisone might gain direct access to 11beta-HSD1 by free diffusion across membranes, indirectly via intracellular binding proteins or, alternatively, by insertion into membranes. Membranous cortisol, formed by 11beta-HSD1 at the ER-lumenal side, might then activate cytoplasmic GR or bind to ER-lumenal secretory proteins. Compartmentalization of 11beta-HSD1 is important for its regulation by hexose-6-phosphate dehydrogenase (H6PDH), which regenerates cofactor NADPH in the ER lumen and stimulates oxoreductase activity. ER-lumenal orientation of 11beta-HSD1 is also essential for the metabolism of the alternative substrate 7-ketocholesterol (7KC), a major cholesterol oxidation product found in atherosclerotic plaques and taken up from processed cholesterol-rich food. An 11beta-HSD1 mutant adopting cytoplasmic orientation efficiently catalyzed the oxoreduction of cortisone but not 7KC, indicating access to cortisone from both sides of the ER-membrane but to 7KC only from the lumenal side. These aspects may be relevant for understanding the physiological role of 11beta-HSD1 and for developing therapeutic interventions to control glucocorticoid reactivation.

Androgen excess in women--a health hazard?

A significant body of evidence suggests that androgens in women may play a role in the genesis of central adiposity and type 2 diabetes. There are two principal sources of circulating androgens in females: the ovary and the adrenal gland. In hyperandrogenic women, there are elevated serum concentrations of androstenedione and testosterone and, in up to 50% of the women, dehydroepiandrosterone sulfate (DHEAS). The androgen precursor DHEAS is of exclusive adrenal origin, suggesting that hyperandrogenic women have an elevated proportion of adrenal androgen production and secretion. Another cause of androgen excess in reproductive-age women is a decreased conversion of testosterone to estradiol by the aromatase enzyme complex. In this review, we will discuss the hypothesized clinical sequel of elevated androgens in women - an aspect of women's health highly neglected. Furthermore, an attempt is made to appreciate what causes the androgens to initially rise from normal levels, allowing the onset of pathophysiological processes towards diseases.