Elsevier

Psychoneuroendocrinology

Volume 39, January 2014, Pages 1-10
Psychoneuroendocrinology

Unhealthy lifestyle in early psychoses: The role of life stress and the hypothalamic–pituitary–adrenal axis

https://doi.org/10.1016/j.psyneuen.2013.09.023Get rights and content

Summary

An unhealthy lifestyle is thought to contribute to the metabolic syndrome in subjects with psychoses. In the present study we aimed to study whether life stress or cortisol measures may influence dietary patterns in subjects with early stages of psychoses. We studied 81 subjects with early psychoses (65 subjects with a psychotic disorder [PD] and <5 years of illness; 16 subjects at risk for psychosis [high-risk, HR]) and a control group of 25 healthy subjects (HS). Dietary habits were examined by a dietician, who registered food intake (24 h recall). Physical activity was assessed by validated questionnaire. Life stress was assessed with Holmes–Rahe Social Readjustment Scale. Fasting morning salivary and plasma cortisol levels were determined. We found that PD and HR reported an unhealthier lifestyle with more smoking, reduced physical activity and poorer dietary habits. HR reported increased intake of calories and saturated fatty acids and reduced protein consumption, when compared to HS. Life stress was a predictor of these adverse behaviours, although we found opposite associations in HR and PD. Life stress was associated with increased intake of refined sugar in PD and decreased intake in HR and HS. Salivary cortisol was related to increased intake of saturated fat only in HR subjects, but cortisol levels in plasma or saliva were not associated with other dietary habits or obesity measures (BMI, waist circumference). Our study suggests that unhealthy diet in early psychoses is influenced by stress, but our data do not support this effect being mediated by hypercortisolism. Future preventive interventions in psychosis may target dietary habits, particularly for those who are at risk for psychosis.

Introduction

Subjects with psychoses are at increased risk of obesity and metabolic complications such as type 2 diabetes, dyslipidaemia and hypertension (Thakore et al., 2002, Ryan et al., 2003, Perez-Iglesias et al., 2008), in the early stages of their illness, that may confer an increased risk of mortality (Hennekens et al., 2005, Saha et al., 2007). Although antipsychotic treatment is thought to be one of the main causes of weight gain in psychosis (Leucht et al., 2009), life style factors including poor dietary habits and reduced physical activity may also play a role (Ratliff et al., 2012, Dipasquale et al., 2013). Moreover, patients may also have an intrinsic vulnerability for metabolic disturbances, as drug-naïve patients with a first psychotic episode show glucose intolerance and visceral fat distribution even before receiving antipsychotic treatment (Thakore et al., 2002, Ryan et al., 2003). In these previous studies, visceral fat was associated with increased cortisol levels in plasma.

Chronic stress is thought to play a role in the pathogenesis of psychosis (Raune et al., 2009) and the metabolic syndrome (Kyrou et al., 2006), and can induce activation of the hypothalamic–pituitary–adrenal (HPA) axis (Tsigos and Chrousos, 2002). The relationship between stress and the metabolic syndrome is bi-directional, because visceral obesity is associated with secretion of inflammatory markers that can also activate the HPA axis (Tsigos and Chrousos, 2002). The relationship between morning cortisol concentrations and the metabolic syndrome is complicated by the impact of obesity on HPA axis activity. Increased cortisol levels, thought to be due to HPA axis activation, have been associated with glucose intolerance, hypertension and hypertriglyceridaemia. In obesity, an increase in the metabolic clearance rate of cortisol results in compensatory activation of the HPA axis but circulating cortisol levels may be normal or lower (Reynolds and Walker, 2007). Stressful life events may have a negative impact on eating behaviour including stress-induced hyperphagia (Wardle et al., 2000). Some studies have reported an unhealthier diet in subjects with schizophrenia and first psychotic episodes, with increased consumption of greater amounts of sugar and saturated fat (Ratliff et al., 2012, Dipasquale et al., 2013). However, to our knowledge there are no studies that have explored whether stressful life events or HPA axis measures are related to dietary habits in subjects with psychoses. In a previous study (Ryan et al., 2003) both hypercortisolaemia and increased intake of saturated fat were described in drug naïve first-episode psychosis subjects, although a correlation between these two variables was not reported. In another study by the same group (Ryan et al., 2004), diet and cortisol levels in plasma were explored in the same patients before and after six months of antipsychotic treatment. Although a decrease in cortisol levels was observed after treatment, no changes were found in dietary habits. This has led some authors (Dipasquale et al., 2013) to suggest that high levels of stress and hypercortisolemia may be more likely to influence dietary pattern in subjects with psychoses only at onset, before the introduction of antipsychotic treatment.

The main aim of our study was to explore the relationship between stress (life stress, HPA axis measures), lifestyle and metabolic parameters in a sample of young subjects with early psychoses. Early intervention in psychosis is a novel approach to mental health care that includes treatment of both psychotic disorders at early stages (usually less than 5 years of illness) as well as subjects with prodromal symptoms who are at risk for psychosis (high-risk, HR). At-risk individuals for psychosis can provide information for intervention prior to development of a full-blown psychosis. However, there is controversy as to whether HR should be considered a diagnostic category (Shrivastava et al., 2011), and only 30% of HR individuals will develop psychosis over a one-year period (Fusar-Poli et al., 2012). An attenuated psychosis syndrome has been included in DSM-V Section 3 along with disorders needing further research. As both HR and psychotic disorders (PD) are attended at Early Intervention Services, these specialized programmes offer a great opportunity to study and compare clinical aspects such as dietary habits in both populations.

The main hypothesis of our study was that dietary habits are altered in both PD and HR subjects. As HR subjects are less frequently treated with antipsychotic drugs, which may induce hyperphagia and have ‘anti-stress’ properties, we also hypothesized that clinical and biological measures of stress are more related to poorer dietary habits in the HR group.

Section snippets

Participants

The study sample included 81 subjects with early psychosis who were attending the Early Psychosis Program from Reus (HPU Institut Pere Mata, Tarragona, Spain). Early psychosis patients were divided into two different clinical populations: (1) PD (n = 65) with less than 5 years from the onset of the illness; (2) HR subjects (n = 16) with prodromal psychotic symptoms fulfilling set criteria for ‘At Risk Mental State’ (Yung and McGorry, 2007). Exclusion criteria were: pregnancy, mental retardation,

Results

Socio-demographic, psychopathological and stress-related variables of the sample are described in Table 1. HR subjects reported more life stress, although there were no differences in plasma or salivary cortisol levels between diagnostic groups. Smoking was more prevalent in PD and HR, when compared to HS. PD subjects were more frequently treated with antipsychotics. We also conducted an exploratory analysis comparing diagnostic subgroups among PD and HR subjects (Table 1 from the Supplementary

Discussion

Our study suggests that both high-risk subjects and psychotic disorders are prone to unhealthy eating behaviours, when compared to healthy individuals. Regarding the potential role of life stress, we found opposite findings for HR and PD. In PD subjects, life stress was associated with increased intake of refined sugar, whereas in HR and HS subjects it was related to a decreased intake of refined sugar. Salivary cortisol levels were related to increased saturated fat only in HR subjects. We did

Role of the funding source

This work was supported by grants from Fundació La Marató de TV3 (092230/0922431) and from Instituto de Salud Carlos III (FIS, PI10/01607). Javier Labad has received an Intensification of Research Activity grant (Programme I3SNS-INT11/323) from the Instituto de Salud Carlos III (Spain) during 2012 and 2013.

Conflict of interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Acknowledgement

We thank Clemens Kirschbaum for analyzing saliva samples.

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