Depression, anxiety, and health-related quality of life in normal weight, overweight and obese individuals with diabetes: a representative study in Germany.

OBJECTIVE: Diabetes in the course of lifetime is related to a higher risk for mental disorders. The present study addresses the comparison of individuals with diabetes and non-diabetic individuals in depressive symptoms, generalized anxiety symptoms, and health-related quality of life. Furthermore, mediator effect of BMI and health-related quality of life (HRQOL) on the association between diabetes, depression, and generalized anxiety was analyzed. METHODS: In this cross-sectional study, the three questionnaires PHQ-9, GAD-7, EQ-5D-5L were measured in a representative sample of the German population (N = 2386). In addition, the presence of diabetes and BMI were assessed via self-report. RESULTS: There were higher values in depressive and anxiety symptoms as well as lower score in HRQOL in individuals with diabetes compared to non-diabetic individuals. Obese individuals with diabetes showed the highest rates in depressive symptoms and generalized anxiety as well as lowest score in HRQOL. With regard to the mediator analyses, association between diabetes, depressive symptoms, and anxiety symptoms is partially mediated by the BMI and fully mediated by the HRQOL. CONCLUSIONS: In conclusion, individuals with diabetes have an increased risk in the development of depressive and anxiety symptoms as well as lower health-related quality of life. Future research and strategies in the public health policies among individuals with diabetes should take into account that the association between diabetes, depression, and anxiety is mediated by BMI and HRQOL.

Kinetics of Plasma Cell-Free DNA under a Highly Standardized and Controlled Stress Induction.

Psychological stress affects the immune system and activates peripheral inflammatory pathways. Circulating cell-free DNA (cfDNA) is associated with systemic inflammation, and recent research indicates that cfDNA is an inflammatory marker that is sensitive to psychological stress in humans. The present study investigated the effects of acute stress on the kinetics of cfDNA in a within-subjects design. Twenty-nine males (mean age: 24.34 ± 4.08 years) underwent both the Trier Social Stress Test (TSST) and a resting condition. Blood samples were collected at two time points before and at 9 time points up to 105 min after both conditions. The cfDNA immediately increased 2-fold after the TSST and returned to baseline levels after 30 min after the test, showing that a brief psychological stressor was sufficient to evoke a robust and rapid increase in cfDNA levels. No associations were detected between perceived stress, whereas subjects with higher basal cfDNA levels showed higher increases. The rapid cfDNA regulation might be attributed to the transient activation of immune cells caused by neuroendocrine-immune activation. Further research is required to evaluate the reliability of cfDNA as a marker of neuroendocrine-immune activation, which could be used for diagnostics purposes or monitoring of treatment progression.

Alterations in heart rate variability and pro-inflammatory cytokine TNF-alpha in individuals with panic disorder.

Based on the autonomic flexibility-neurovisceral integration model, panic disorder (PD) has been associated with a generalized proinflammatory state and lower cardiac vagal tone. The heart rate variability (HRV) provides an index of cardiac autonomic function and reflects the parasympathetic innervation to the heart regulated by the vagus nerve. The aim of this study was to explore the heart rate variability, pro-inflammatory cytokines and their associations in individuals with PD. Short-term HRV with time and frequency domain indices as well as pro-inflammatory cytokines Interleukin-6 (IL-6) and Tumor Necrosis Factor alpha (TNF-alpha) were assessed in seventy individuals with PD (mean age: 35.64 ± 14.21 years) and thirty-three healthy controls (mean age: 38.33 ± 14.14 years). Individuals with PD showed significantly lower HRV in the time and frequency domain parameters during a short-term resting condition. A lower TNF-alpha concentration could be observed in individuals with PD in comparison to healthy controls, but no differences in IL-6. Furthermore, the HRV parameter absolute power in the low-frequency band 0.04-0.15 Hz (LF) predicted TNF-alpha concentrations. In conclusion, a lower cardiac vagal tone, decreased adaptive autonomic nervous system (ANS), and higher pro-inflammatory cytokine state could be observed in individuals with PD compared to healthy controls.

Obesity: Heart Rate Variability during standardized psychosocial stress induction.

Obesity is related to a higher risk of cardiovascular diseases (CVD). An altered stress reactivity of the parasympathetic nervous system (PNS) is a promising predictor of CVD and other negative health outcomes. Therefore, the aim of this study was to compare heart rate (HR) and heart rate variability parameters, root mean square successive differences (RMSSD) and power in the high frequency range 0.15-0.4 Hz (HF-HRV), of individuals with obesity and healthy weight controls during psychosocial stress induction. Thirty-four obese men and women (BMI: 33.80 ± 4.62 kg/m²), and thirty-four age- and gender-matched healthy weight controls (BMI: 22.29 ± 1.81 kg/m²) underwent the Trier Social Stress Test (TSST). Before, during, and after the TSST, their HR, RMSSD, and HF-HRV were measured. The individuals with obesity showed a lower stress reactivity in HR, and less stress recovery in RMSSD, compared to healthy weight controls. Obesity appears related to blunted HR reactivity, which is associated with CVD. In addition, impaired recovery of RMSSD also found in individuals with obesity may reflect health-damaging processes as well.

Effect of a slow-paced breathing with heart rate variability biofeedback intervention on pro-inflammatory cytokines in individuals with panic disorder - A randomized controlled trial.

A generalized proinflammatory state has been observed in individuals with panic disorder (PD). There is evidence that slow-paced breathing (SPB) with heart rate variability-biofeedback (HRV-BF) strengthens the nervus vagus with its anti-inflammatory pathway. Therefore, with this randomized controlled trial we aimed to investigate the effect of a four-week SPB with HRV-BF intervention on pro-inflammatory cytokines in people with PD. Fifty-five individuals with PD (mean age: 37.22 ± 15.13 years) were randomly allocated either to SPB-HRV-BF (intervention group) or to HRV-Sham-BF (active control group). SPB-HRV-BF was performed over four weeks while cytokine concentration and HRV during a short-term resting condition were measured before and after intervention. SPB-HRV-BF decreased concentration of Tumor Necrosis Factor alpha (TNF-alpha) (F(1, 53) = 4.396, p ≤ .05, η2 = 0.077) in individuals with PD. In addition, SPB-HRV-BF demonstrated an increase in the HRV-time and frequency domain parameters SDNN, Total Power and LF during short-term resting condition. There was no intervention effect in HRV-Sham-BF group. In conclusion, SBP-HRV-BF as a non-pharmacological treatment may reduce pro-inflammatory cytokine TNF-alpha via the cholinergic anti-inflammatory pathway in individuals with PD. Based on the generalized proinflammatory state in PD, decreasing TNF-alpha is highly beneficial to reduce risk of cardiovascular diseases and metabolic syndrome.

Mobile Heart Rate Variability Biofeedback Improves Autonomic Activation and Subjective Sleep Quality of Healthy Adults - A Pilot Study.

OBJECTIVE: Restorative sleep is associated with increased autonomous parasympathetic nervous system activity that might be improved by heart rate variability-biofeedback (HRV-BF) training. Hence the aim of this study was to investigate the effect of a four-week mobile HRV-BF intervention on the sleep quality and HRV of healthy adults. METHODS: In a prospective study, 26 healthy participants (11 females; mean age: 26.04 ± 4.52 years; mean body mass index: 23.76 ± 3.91 kg/m2) performed mobile HRV-BF training with 0.1 Hz breathing over four weeks, while sleep quality, actigraphy and HRV were measured before and after the intervention. RESULTS: Mobile HRV-BF training with 0.1 Hz breathing improved the subjective sleep quality in healthy adults [t(24) = 4.9127, p ≤ 0.001, d = 0.99] as measured by the Pittsburgh Sleep Quality Index. In addition, mobile HRV-BF training with 0.1 Hz breathing was associated with an increase in the time and frequency domain parameters SDNN, Total Power and LF after four weeks of intervention. No effect was found on actigraphy metrics. CONCLUSIONS: Mobile HRV-BF intervention with 0.1 Hz breathing increased the reported subjective sleep quality and may enhance the vagal activity in healthy young adults. HRV-BF training emerges as a promising tool for improving sleep quality and sleep-related symptom severity by means of normalizing an impaired autonomic imbalance during sleep.

Fight or flight: The effect of heart rate reactivity on acute stress-induced food intake.

The 'fight-or-flight-reaction' describes the suppression of all irrelevant functions like food intake during the acute stress response. However, heart rate reactivity and food intake under acute stress has not been investigated. Therefore, the aim of this study was to investigate the effect of high and low heart rate reactivity on food intake following an acute laboratory stress paradigm in individuals with healthy weight. Fifty-six men and women with healthy weight (BMI: M = 21.82 ± 1.53 kg/m²) were categorized into high heart rate reactors (H-HRR) and low heart rate reactors (L-HRR). After the stress paradigm of the Trier Social Stress Test (TSST), total energy intake was measured in a standardized laboratory meal. H-HRR demonstrated a significantly lower appetite (z = -3.133, p≤ 0.01) and food intake (t(49.13) = 2.253, p≤ 0.05, d= 0.68) after the TSST compared to the L-HRR. No differences in the stress perception and cognitive appraisal could be found between the two reactor groups. These results suggest that the stress-induced heart rate reactivity might be a responsible factor in the stress-eating paradox. In view of the divergent results of stress-induced eating studies in laboratory setting with acute stressors, it is highly important to control the effect of the heart rate reactivity on food intake.

Effect of a Biofeedback Intervention on Heart Rate Variability in Individuals With Panic Disorder: A Randomized Controlled Trial.

OBJECTIVE: Some individuals with panic disorder (PD) display reduced heart rate variability (HRV), which may result in an increased risk of cardiovascular mortality. Heart rate variability-biofeedback (HRV-BF) training has been shown to improve the modulation of the autonomic activity. Therefore, this randomized controlled trial was conducted to investigate the effect of a 4-week HRV-BF intervention in individuals with PD. HRV-BF training improved the modulation of the autonomic activity. Therefore, with this randomized controlled trial, we aimed to investigate the effect of a 4-week HRV-BF intervention in people with PD. METHODS: Thirty-six women and 16 men with PD (mean age = 35.85 [15.60] years) were randomly allocated either to HRV-BF with 0.1-Hz breathing as intervention group or to HRV-Sham-BF as active control group. HRV-BF was performed for 4 weeks, whereas HRV was measured both during a short-term resting condition and during a paced breathing condition before and after intervention. RESULTS: HRV-BF with 0.1-Hz breathing increased HRV and reduced panic symptoms in individuals with PD. HRV-BF with 0.1-Hz breathing demonstrated an increase in the time and frequency domain parameters of HRV during the short-term resting condition (ΔPost-Pre root mean square successive differences: 5.87 [14.03] milliseconds; ΔPost-Pre standard deviation of all NN intervals: 11.63 [17.06] milliseconds; ΔPost-Pre total power: 464.88 [1825.47] milliseconds2; ΔPost-Pre power in low-frequency range 0.04-0.15 Hz: 312.73 [592.71] milliseconds2), a decrease in the heart rate during the paced breathing condition (ΔPost-Pre: -5.87 [9.14] beats/min), and a decrease in the Panic and Agoraphobia Scale (ΔPost-Pre: -3.64 [6.30]). There was no intervention effect in the HRV-Sham-BF group. CONCLUSIONS: HRV-BF as a noninvasive and nonpharmacological treatment seems to be an important intervention option to improve reduced HRV and decrease panic symptoms in individuals with PD. Future studies are needed to establish whether these effects translate to reductions in the risk of cardiovascular disease in PD.

How acute physical and psychological stress differentially influence the kynurenine pathway: A randomized cross-over trial.

Psychological stress is associated with the pathogenesis of several neuropsychiatric disorders. In contrast, physical stress, as provoked by exercise, counteracts symptoms and potentially also disease progression. The kynurenine pathway, which is imbalanced in neuropsychiatric disorders, responds to both psychological and physical stress. Here, we compared the acute effects of psychological versus physical stress on the kynurenine pathway and inflammatory mediators. Thirty-five healthy males (mean age: 24.09±3.39 years) underwent both the Trier Social Stress Test (psychological stressor) and the Wingate-Test (physical stressor). The kinetics of tryptophan and its metabolites as well as cytokines IL-6, IFN-γ, TNF-α, and IL-10 were measured before and after the two stress conditions. After both stressors, there was a significant change over time for the kinetics of tryptophan metabolites and for cytokines. Furthermore, the reactivity of kynurenine pathway metabolite ratios and cytokines was statistically greater after physical stress than after psychological stress. The increased metabolic flux towards kynurenic acid following acute physical stress suggests an exercise-induced neuroprotective mechanism. Despite the paradoxical influence of both stressors on neuropsychiatric diseases, the acute kynurenine pathway reactivity appears to be similar, although effects were more pronounced in response to physical stress.

Autonomic Nervous System Response to Psychosocial Stress in Anorexia Nervosa: A Cross-Sectional and Controlled Study.

To foster understanding in the psychopathology of patients with anorexia nervosa (PAN) at the psychological and physiological level, standardized experimental studies on reliable biomarkers are needed, especially due to the lack of disorder-specific samples. To this end, the autonomic nervous system (ANS) response to a psychosocial stressor was investigated in n = 19 PAN (BMI: 18.7 ± 3.3 kg/m2), age, and gender-matched to n = 19 healthy controls (HC; BMI: 24.23 ± 3.0 kg/m2). For this purpose, heart rate (HR) and heart rate variability (HRV) parameters were assessed in a cross-sectional study design under two experimental conditions: (1) rest and (2) stress (Trier Social Stress Test). In addition, psychological indicators of stress were assessed. An 2 × 2 × 8 ANOVA demonstrated similar HR and HRV patterns (except LF-HRV) between PAN and HC at rest. Under stress, PAN (vs. HC) demonstrated a blunted HR [condition*time*group: F (2.91, 104.98) = 9.326, p = 0.000, η2 = 0.206] and an attenuated HRV response (reduced SNS/PNS reactivity). Significant effects of stress appraisal (SA) and BMI on HRV-reactivity were revealed. SA on SDNN = Condition*time*SA = F (4.12, 140.15) = 2.676, p = 0.033, η2 = 0.073. BMI on LF/HF-Ratio = Condition*time*BMI = F (3.53, 60.16) = 3.339, p = 0.019, η2 = 0.164. Psychological indices suggested higher levels of chronic and appraised stress in PAN relative to HC. Additional analyses demonstrated that ED-symptoms are highly correlated with the latter constructs, as well as with psychological burden, but not with weight. Further, it was shown that abnormalities in reactivity persisted despite normalized ANS activity. Overall, we suggested that besides weight recovery, improvement in stress appraisal could be beneficial for cardiac health. In this light, a combination of therapy (e.g., development and activation of coping skills, cognitive reappraisal) and biofeedback training may improve treatment outcomes and regulate stress reactivity.

Effects of stress on chewing and food intake in patients with anorexia nervosa.

OBJECTIVE: The present study investigates the impact of psychosocial stress on chewing and eating behavior in patients with anorexia nervosa (PAN ). METHOD: The eating and chewing behavior of PAN were examined in a standardized setting by means of a chewing sensor. These procedures encompassed n = 19 PAN , age, and gender matched to n = 19 healthy controls (HC). Food intake and chewing frequency were assessed in two experimental conditions: rest versus stress (via Trier Social Stress Test). To verify stress induction, two appraisal scales were employed. In addition, chronic stress, psychological distress and eating disorder symptoms were assessed. RESULTS: In terms of food intake and chewing frequency, the results of the 2x2 ANOVA demonstrated a significant effect of condition and group. During stress, all participants demonstrated a higher chewing frequency and a decreased ingestion. In general, patients ate less at a lower chewing frequency (vs. HC). However, sample specific analyses demonstrated that the eating and chewing behavior of PAN remained unchanged regardless of the condition, except for their drinking. Food choices were comparable between the groups, but appetite values significantly differed. DISCUSSION: The increase in chewing frequency in all participants during stress suggests that chewing might impact affect regulation, however, not specifically in PAN . Future research should clarify to what extent the normalization of chewing behavior could ameliorate ED-symptoms (incl. food intake) in PAN . The application of a chewing sensor could support this aim and future interventions.

Hormonal responsiveness in the Trier Social Stress Test and the dexamethasone-corticotropin releasing hormone test in healthy individuals.

A number of different laboratory procedures investigate the hormonal response in a standardized pharmacological challenge test (dexamethasone-corticotropin releasing hormone; DEX-CRH) or in a psychosocial stress induction on the hypothalamic-pituitary-adrenocortical axis by the Trier Social Stress Test (TSST). However, the magnitude of the response related to the different stressors and the interaction of the responsiveness between the two tests is still unclear. Fifty-two participants underwent both the DEX-CRH test and the TSST on two separate days. The cortisol and the plasma adrenocorticotropic hormone (ACTH) release were assessed before and after the stress tests. For a specification of the cortisol response to both conditions, subgroups of high- and low-cortisol responders to the TSST and the DEX-CRH test were formed. The healthy participants showed a substantial increase in the ACTH and the cortisol concentration after the two tests. This increase was 3 times greater in the TSST than the DEX-CRH test. High responders in both tests demonstrated a higher factor of the cortisol reactivity ratio (TSST/DEX-CRH test). Psychosocial stress as induced by the TSST was associated with a significantly greater increase in cortisol compared to the DEX-CRH test, even though the ACTH response displayed no differences. Our findings indicate an interaction of the hormonal responsiveness between the two tests with regard to the cortisol patterns.

The effect of restrained eating on acute stress-induced food intake in people with obesity.

Restrained eating, defined as a form of intense dieting or restrictive food intake of specific macronutrients or types of food with sporadic episodes of overeating, results in an increased risk of overweight and obesity. Acute stress situations cause irregular eating patterns and are connected to restrained eating. Therefore, the present study investigates the effect of high/low restrained eating on eating behavior in people with obesity after standardized acute stress induction as well as resting condition. Fifty men and women with obesity (BMI: 33.62 ± 3.93 kg/m2) were categorized into high restrained eaters (HRE) and low restrained eaters (LRE). The total energy intake was measured during a standardized laboratory meal after a resting and stress condition (Trier Social Stress Test) on two separate days. HRE and LRE showed differences in the total energy intake in response to acute stress but not after resting condition (F(1, 47) = 9.188, p = .004, η2 = 0.164). Lower total energy intake after stress compared to resting condition could be observed in HRE (t (23) = -2.617, p = .015). LRE showed higher total energy intake after stress than after resting condition (t (25) = 2.155, p = .041). The present data suggest that restrained eating behavior might be an influencing factor for stress-induced eating in obesity. It is highly necessary to understand the association between restrained eating behavior, acute stress and obesity for the improvement of the behavioral intervention of dietary restriction.

Cortisol reactivity in patients with anorexia nervosa after stress induction.

There is a need of experimental studies on biomarkers in patients with anorexia nervosa (PAN), especially in the context of stress, in order to foster understanding in illness maintenance. To this end, the cortisol response to an acute stressor was investigated in n = 26 PAN (BMI: 19.3 ± 3.4 kg/m2), age, and gender matched to n = 26 healthy controls (HC; BMI: 23.08 ± 3.3 kg/m2). For this purpose, salivary cortisol parameters were assessed in two experimental conditions: (1) rest/no intervention and (2) stress intervention (TSST; Trier Social Stress Test). In addition, psychological indicators of stress were assessed (Primary Appraisal Secondary Appraisal, Visual Analogue Scale, and Trier Inventory for the assessment of Chronic Stress), as well as psychological distress, depression, and eating disorder (ED) symptoms. A 2 × 2 × 8 ANOVA demonstrated elevated cortisol levels in PAN in the resting condition. In the stress intervention no significant group effect in terms of cortisol (F (1, 50) = 0.69; p = 0.410; [Formula: see text]). A significant condition (F (1, 50) = 20.50; p = 0.000; [Formula: see text]) and time effect (F(2.71, 135.44) = 11.27; p = 0.000; [Formula: see text]) were revealed, as well as two significant interaction effects. First: Condition × group (F (1, 50) = 4.17, p = 0.046; [Formula: see text]) and second: Condition × time (F (2.71, 135.44) = 16.07, p = 0.000, [Formula: see text]). In terms of AUCG, no significant differences between both groups were exhibited. Regardless, significant results were evinced in terms of an increase (AUCi: F(1, 50) = 20.66, p = 0.015, [Formula: see text]), baseline to peak (+20 min post-TSST: t5 = 16.51 (9.02), p = 0.029) and reactivity (MPAN = 0.73 vs. MHC = 4.25, p = 0.036). In addition, a significant correlation between AUCG and BMI: r (24) = -0.42, p = 0.027 was demonstrated, but not between AUCi and BMI (r (24) = -0.26, p = 0.20). Psychological indices suggested higher levels of chronic and perceived stress in PAN relative to HC. However, stress perception in the stress condition (VAS) was comparable. Additional analyses demonstrated that ED-symptoms are highly correlated with psychological distress and depression, but not with BMI. In addition, it could be demonstrated that reactivity is rather related to ED-symptoms and psychological burden than to BMI. In conclusion, PAN showed elevated basal cortisol levels at rest and exhibited a blunted cortisol reactivity to the TSST as evinced by salivary cortisol parameters. Further, it was shown that weight recovery influences reversibility of hypercortisolemia, i.e., cortisol levels normalize with weight gain. However, HPAA (hypothalamus-pituitary-adrenal axis) irregularities in terms of reactivity persist even at a BMI ≤ 19.3 (±3.4). Our data suggest that pronounced psychological burden in PAN, have a greater impact on the HPAA functionality (secondary to the ED) than BMI itself.

Depression, anxiety and health status across different BMI classes: A representative study in Germany.

BACKGROUND: Changes in body mass index (BMI) over the course of one's lifetime are related to the development of mental disorders. In the current study we compared symptoms of depression, generalized anxiety as well as general health status in the four BMI-classes: underweight, normal weight, overweight and obesity. Furthermore, mediator role of general health status on the relationship between BMI and depression and generalized anxiety was analyzed. METHODS: A representative sample (random-route sampling) of the German population (N = 2350) was investigated in a cross-sectional survey by measuring the three questionnaires PHQ-9, GAD-7 and EQ-5D-5L. RESULTS: The results showed significant differences between the four BMI-classes in all three questionnaires. Individuals with obesity demonstrated higher values in depression, anxiety and general health compared to the three other BMI-classes. However, there was no U-shaped association between BMI and depression, anxiety and health-related quality of life. Regarding to the mediation analysis, general health status fully mediated the association between BMI, depressive symptoms as well as generalized anxiety symptoms. LIMITATIONS: The assessment of the three factors depression, anxiety and general health status were measured by questionnaires, but no clinical diagnoses can be provided. CONCLUSIONS: Evidence supports that individuals with obesity have an increased risk for depression and anxiety as well as lower general health. Further research on potential intervention and strategies in public health policies is needed to be able to target the developing of mental disorders in individuals with obesity. Taking their general health status into account is also of great importance.

High/low cortisol reactivity and food intake in people with obesity and healthy weight.

Increased food intake, termed "comfort eating", is a pathologic coping mechanism in chronic stress. Cortisol reactivity under stress is a potent predictor of stress-induced eating behavior affecting the body mass index (BMI). However, cortisol reactivity and food intake under stress in people with obesity has not been evaluated. The aim of this study was to investigate the effect of high/low cortisol reactivity on food intake in people with obesity and healthy weight test controls, following standardized stress induction and a resting condition. Thirty-six men and women with obesity (BMI: 33.00 ± 3.23 kg/m²), as well as 36 age- and gender-matched healthy weight controls (BMI: 21.98 ± 1.81 kg/m²) were categorized into high cortisol reactors (HCR) and low cortisol reactors (LCR) in the Trier Social Stress Test (TSST). Following the TSST and a resting condition, the food intake of all participants was recorded in a standardized laboratory meal. Obese HCR demonstrated a significantly higher food intake than LCR (t (34) = -2.046, p ≤ 0.05). However, there were no significant differences between HCR and LCR in the healthy weight controls (p = 0.26). In addition, HCR of the people with obesity showed lower values in the emotion coping strategy of cognitive reappraisal than obese LCR (t (32) = 2.087, p ≤ 0.05). In conclusion, the magnitude of the cortisol reactivity to stress predicts stress-induced food intake in people with obesity, but not in the healthy weight controls. Limited use of cognitive reappraisal in emotion regulation in the obese HCR may be a marker of vulnerability to stress-induced eating.

Continuous HRV analysis of HEMS emergency physicians to specify the work load over the different working days.

INTRODUCTION: Up to date, there has been little research about the acute stress load of emergency physicians of the Helicopter Emergency Medical Service (HEMS). Therefore, this study investigates the physiological stress level between an air-rescue day, a clinic day, and a day off (control day). Furthermore, phases of activity and resting were compared to assess the activity of the autonomic nervous system (ANS). METHODS: In this field study (within-subjects design), heart rate variability (HRV) and self-perceived stress levels were monitored on an air-rescue day, a clinic day, and a control day of 20 HEMS EPs [three females, 17 males; age: mean (M) = 44.95, standard deviation (SD) = 4.80]. RESULTS: When comparing the activity phases, significant differences were found for HR and HRV. The highest HR was found on the air-rescue day during the phase of landing at the operation site with M = 107.30 bpm (SD = 22.66 bpm), which was significantly higher than during activity phases of the clinic day (M = 88.28 bpm, SD = 11.81 bpm) and the control day (M = 83.28 bpm, SD = 14.83 bpm). The SDNN is significantly higher on the air-rescue day for the phase before the alarm (M = 72.23 ms, SD = 38.60 ms), the phase of the alarm (M = 77.52 ms, SD = 40.52 ms), and the average of all phases (M = 60.04 ms, SD = 34.07 ms) than on the clinic day (M = 38.42 ms, SD = 15.16 ms) and the control day, where the lowest value was reached (M = 39.11 ms, SD = 17.65 ms). The highest LF/HF was found during activity phases of the clinic day with M = 1281.84% (SD = 587.33%), which was significantly higher than the first five phases of the emergency operations and the average of all phases of the emergency operations of the air-rescue day, where a maximum of M = 896.57 ms (SD = 681.79 ms) during the phase before the alarm and a minimum of M = 764.69 ms (SD = 372.28 ms) during the phase of landing at the operation site. The lowest LF/HF for all testing days was found during the activity phases of the control day with M = 693.74% (SD = 404.73%). Overall, 60 observations were analyzed. In the psychological assessment, on average, the EPs shows lower values than the norm sample. DISCUSSION: In the comparison of the activity phases, significant effects were found on the clinic day and during the phases of the emergency operations of the air-rescue day for the HR and HRV. Hereby, a significant activation of the EPs ANS and an outweigh of the sympathetic nervous system could be shown, whereby the subjective stress load was reported mainly as low. For the resting phases, no significant differences were found between all testing days. We interpret this as a good sign for the ability of regeneration between the phases of high stress load.

Stress load of emergency service: effects on the CAR and HRV of HEMS emergency physicians on different working days (N = 20).

PURPOSE: The occupation of the emergency physicians (EPs) of helicopter emergency medical services (HEMS) can be characterized as a high-strain occupation (Karasek in Adm Sci Q 24(2):285-308. https://doi.org/10.2307/2392498 , 1979). Therefore, the aim of this study was to measure and compare the stress load of the EPs of HEMS on duty on air ambulance workdays and on 2 control days. METHODS: In this field study (within-subjects design), hormonal, physiological, and self-perceived stress levels of 20 EPs [3 females, 17 males; mean age (M) = 44.95 years, SD = 4.80, 95% confidence interval (CI) (42.71, 47.19)] of HEMS, were recorded on different test days. Measurements of the cortisol awakening response (CAR) and the heart rate variability (HRV) were performed while on duty on the air ambulance and during workdays at the outpatient clinic as well as at home on days of rest. RESULTS: There were significant differences in the CAR (area under the curve with respect to ground F(2,38) = 12.81, p < 0.001) between the 3 test days with the highest values on the workday at the outpatient clinic [M = 81.24; 98.75% CI (61.24, 101.24)] and not on the air ambulance day [M = 61.82; 98.75% CI (45.18, 78.46)] or on the day of rest [M = 52.96; 98.75% CI (38.17, 67.76)]. In addition, the HRV parameter SDNN [F(2,38) = 6.369; p = 0.004] presented significant differences between the 3 test days with lower levels on the day at the outpatient clinic [M = 101.44; 98.75% CI (83.50, 119.38)] in contrast to the air ambulance day [M = 120.16; 98.75% CI (100.02, 140.30)] and to the resting day [M = 123.79; 98.75% CI (106.49, 141.10)]. Furthermore, there were significant differences in the HRV parameter LF/HF [F(2,38) = 6.215; p = 0.005] between the 3 testing days with the highest values on the workday at the outpatient clinic [M = 8.69; 98.75% CI (6.29, 11.09)] compared to the air ambulance day [M = 6.54; 98.75% CI (4.50, 8.57)] and the day of rest [M = 6.43; 98.75% CI (4.57, 8.29)]. CONCLUSIONS: Compared with the standard values and previous studies, EPs of HEMS have an increase in hormonal reactivity in the morning and a lack of recovery of the ANS. It can be concluded that-with respect to the psychobiological stress model by McEwen and Lasley (The end of stress as we know it, National Academic Press, Washington, 2003)-work-related stressors persist too long or the stress response is exaggerated (allostatic load) due to chronic stress induction and lack of recovery.

Cortisol Stress Reactivity to the Trier Social Stress Test in Obese Adults.

OBJECTIVE: Approximately 600 million adults worldwide suffer from obesity. In addition to individual's eating behavior and lack of physical activity in the development of obesity and overweight, psychosocial stress as well as hormonal stress reactivity must also be considered as important contributing factors. In the current study we compared the cortisol stress response pathway in a psychosocial stress induction (Trier Social Stress Test; TSST) with obese individuals and normal-weight controls. METHOD: 32 obese individuals (17 females; mean age = 33.94 years, SD = 11.31 years) and 32 normal-weight controls (17 females; mean age = 29.09 years, SD = 10.46 years) underwent the TSST. The salivary cortisol responses and three appraisal questionnaires (Primary Appraisal Secondary Appraisal, Visual Analogue Scale, Trier Inventory for Chronic Stress) were measured. RESULTS: After stress induction, there was a significant main group difference between the obese individuals and the normal-weight controls for cortisol, with lower baseline and post-stress cortisol levels in the obese individuals. Nevertheless, the obese individuals as well as the normal-weight controls showed no significant difference in the self-reported assessment of the stress condition but some significant differences in the cognitive appraisal of the TSST. CONCLUSION: In conclusion, the induction of psychosocial stress showed differences in the cortisol patterns between the obese individuals and the normal-weight controls. Furthermore, the present data suggest that obesity leads to lower cortisol activity, which may indicate alterations in the Hypothalamic-pituitary-adrencortical (HPA) axis.