Original Research Communications
Cognitive dietary restraint is associated with higher urinary cortisol
excretion in healthy premenopausal women1–3
Judy A McLean, Susan I Barr, and Jerilynn C Prior
ABSTRACT
Background: Cognitive dietary restraint, assessed by the Three-
Factor Eating Questionnaire restraint subscale, is associated with
subclinical menstrual cycle disturbances. This association may
be mediated by stress-activated cortisol release.
Objective: We assessed whether 24-h urinary cortisol excretion
differs between women with high and low restraint scores.
Design: Participants (aged 21.6 ± 2.5 y; n = 62) with normal-
length menstrual cycles and high (n = 33) or low (n = 29) restraint
scores completed a questionnaire describing weight history,
dietary practices, and exercise. Cortisol, calcium, and creatinine
were measured in urine collected over 24 h on a day when all
food and beverages were provided and measured. Previously, 3-d
food records and anthropometric measurements were obtained.
Results: Age, height, weight, body mass index, and length of
menstrual cycle were similar between groups. The reported
amount of exercise was higher (3.4 ± 1.7 compared with
2.2 ± 1.8 h/wk; P < 0.05) and energy intakes (assessed from 3-d
and 24-h food records) were lower in the high- than in the low-
restraint group. Ratios of urinary cortisol (nmol) to creatinine
(mmol) were higher in the high-restraint than in the low-restraint
group (42.9 ± 12.9 compared with 36.3 ± 8.9; P < 0.05), whereas
ratios of urinary calcium (mmol) to creatinine were lower
(0.3 ± 0.1 compared with 0.4 ± 0.2; P < 0.05) in the high-
restraint group. Urinary cortisol was not associated with exer-
cise, nutrient intakes, or anthropometric measurements.
Conclusions: High dietary restraint scores are associated with
urinary cortisol, a biological marker of stress, and high cortisol
excretion may affect bone health. Our results suggest that fur-
ther research is warranted to clarify these associations and to
determine whether they persist over time. Am J Clin Nutr
2001;73:7–12.
KEY WORDS Dietary restraint, urinary cortisol, pre-
menopause, women, Three-Factor Eating Questionnaire
INTRODUCTION
To achieve or maintain a desired body weight, many women
consciously try to limit their food intake. This is referred to as
dietary restraint or cognitive dietary restraint. The concept of
restrained eating was originally introduced to define a type of
eating behavior that was governed by cognitive processes rather
than by physiologic mechanisms such as hunger and satiety (1).
Am J Clin Nutr 2001;73:7–12. Printed in USA. © 2001 American Society for Clinical Nutrition
Of the several scales that have been developed to measure
dietary restraint, the 21-item restraint subscale of the Three-Fac-
tor Eating Questionnaire (TFEQ) (2) is recognized as the most
appropriate tool for the assessment of cognitive dietary restraint
(3). Typically, women with high restraint scores are aware of the
amount and type of food they consume.
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We and others found that women with high restraint scores are
more likely to experience ovulatory disturbances, including a
shortening of luteal phase length or cycle length and an
increased proportion of anovulatory cycles, than are women with
low restraint scores (4–7). Women in these studies (5–7) experi-
enced regular menstrual cycles of normal length and the high-
and low-restraint groups had similar energy intakes and relative
weights. These findings suggest that energy deprivation did not
cause the observed subclinical ovulatory disturbances.
The mediating mechanism between dietary restraint and ovu-
latory disturbances in normal-weight women is not known, but it
could be related to the psychological stress of constantly trying
to monitor and control food intake. Women with high restraint
scores may experience more stress in relation to food consumption
than do women with low restraint scores. At the neuroendocrine
level, high stress can trigger the release of corticotropin-releasing
hormone (CRH) from the hypothalamus, which leads to the
release of cortisol from the adrenal cortex (8). If high stress
occurs in relation to dietary restraint, an elevation in cortisol
concentrations is a likely consequence. High concentrations of
cortisol are associated with increased reproductive disturbances
because of the inhibitory effect of CRH on hypothalamic, and
hence pituitary, hormone secretions required for normal men-
strual cycle function (9, 10). Therefore, if dietary restraint leads
to stress-related increases in serum cortisol and increases in uri-
nary cortisol excretion, women with high restraint scores would
1
From the Division of Food, Nutrition and Health, Faculty of Agricultural
Sciences, and the Division of Endocrinology, Faculty of Medicine, University
of British Columbia, Vancouver, Canada.
2
Supported by a grant from the British Columbia Medical Services
Foundation.
3
Address reprint requests to SI Barr, Division of Food, Nutrition and
Health, University of British Columbia, 2205 East Mall, Vancouver, Canada
V6T 1Z4. E-mail: sibarr@interchange.ubc.ca.
Received February 29, 2000.
Accepted for publication May 18, 2000.
7
8 MCLEAN ET AL
be more likely to experience reproductive changes such as those
observed in the aforementioned studies (4–7).
We found only one study that explored a possible relation
between cortisol concentrations or excretion and dietary restraint
(11). There was no association between restraint score and serum
cortisol concentrations; however, the overnight protocol used in
that study may not have been appropriate if cortisol is released
with food-related increases in stress. It is unlikely that group dif-
ferences would be observed during a time when food consump-
tion did not occur.
Accordingly, the primary purpose of this cross-sectional study
was to determine whether an association exists between cognitive
dietary restraint and 24-h urinary cortisol excretion in healthy,
normal-weight, regularly menstruating premenopausal women.
SUBJECTS AND METHODS
Overview
Women categorized as having high or low dietary restraint
scores completed 24-h urine collections, which were analyzed
for cortisol, creatinine, and calcium. Urine collections were
conducted within the first 10 d of the menstrual cycle on a day
when all food and beverages were provided at the study center.
This phase was selected to control for variability in energy
intake across the menstrual cycle (12). Power analyses con-
ducted before initiating the study indicated that a sample size
of 32 subjects per group would detect a significant difference
(P < 0.05) in 24-h urinary cortisol concentrations between
groups, with a  of 0.84.
Participants
Participants were recruited for the study from a group of
666 female university students who had completed an instrument
on eating attitudes and behaviors. Among other items, the instru-
ment included the TFEQ (2), which was scored according to the
authors’ instructions. The TFEQ contains subscales for restraint
(possible scores: 0–21), disinhibition (possible scores: 0–16),
and hunger (possible scores: 0–14). The restraint subscale
assesses the intent to control food intake to achieve or maintain
a desired body weight. The disinhibition scale assesses overeat-
ing in response to a variety of situations associated with loss of
control of food intake, and the hunger subscale assesses per-
ceived hunger. The eating attitudes and behaviors instrument
also included items on age, height, weight, dieting history, men-
strual cycle length and history, special diets (eg, vegetarian),
exercise, and vitamin, mineral, and medication use.
Enrollment criteria for the present study included age 20–35 y,
stable body weight with a body mass index (BMI; in kg/m2) of
18–25, nulliparity, self-reported normal menstrual cycle intervals
(21–35 d), ≤ 7 h exercise/wk, and either high (between 13 and
21) or low (between 0 and 5) scores on the TFEQ restraint scale.
Exclusion criteria included cigarette smoking, use of oral con-
traceptives or drugs that can affect bone metabolism (eg, steroid
and thyroid hormones), weight cycling [defined as the loss of
> 2.3 kg (5 lb) more than twice in the past 2 y], consumption of
≥ 2 alcoholic beverages/d, hirsutism, and a previous diagnosis or
treatment of an eating disorder. Participants were also excluded
if they worked night shifts or had other unusual sleep patterns
that may affect stress hormones. Finally, women were excluded
if they were dieting.
Of the 666 women who completed an instrument on eating
attitudes and behaviors, 281 expressed an interest in participat-
ing in the present study. No differences in age or BMI existed
between those who did or did not express interest in participation
(data not shown). Study entry criteria led to the exclusion of
198 women, most of whom (n = 122) were excluded because
their TFEQ scores were between 6 and 12. Of the 83 women eli-
gible for participation, 62 completed the study. The main reason
eligible participants did not participate or complete the study
was because they became unavailable or ineligible before begin-
ning the study (eg, began oral contraceptive use). Most (84%) of
the participants were not enrolled in university nutrition courses.
The study protocol was approved by the University’s Clinical
Screening Committee for Research and Other Studies Involving
Human Subjects, and all subjects provided written consent.
Physical measurements
Height was measured at full inspiration to the nearest 0.1 cm
with a stadiometer while subjects were shoeless. Weight was
measured to the nearest 0.5 kg with an electronic scale while
subjects were wearing a paper examination gown. Waist and hip
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circumferences were measured to the nearest 0.1 cm (13). Dupli-
cate measurements were made; if differences were observed, a
third measurement was made and the 2 most similar measure-
ments were averaged. From these data, BMIs and waist-to-hip
ratios (waist circumference/hip circumference) were calculated.
Dietary records
To provide an assessment of the usual energy, macronutrient,
and calcium intakes of the 2 groups of women, each subject com-
pleted a 3-d food record (on 2 weekdays and 1 weekend day).
Records were kept during the midfollicular phase (days 4–10 of
the cycle) of a menstrual cycle preceding the cycle in which urine
samples were collected. Participants were individually instructed
about how to complete the food records and were provided with
measuring cups and spoons to assist in quantifying portion sizes.
Any ambiguous entries were clarified with the participant before
data entry. To quantify dietary intakes on the day that urine col-
lections were made, participants consumed only food and bever-
ages supplied at the study center. Participants chose the types and
amounts of foods they wanted to eat during the day from a vari-
ety of foods that were available to them, and were free to con-
sume as much as they wanted. All portions were weighed or
measured before being served; any items remaining after the
meals were consumed were subtracted. Both 3-d and 24-h food
records were analyzed by using FOOD PROCESSOR II (version
7.0, 1997; ESHA Research, Salem, OR).
Urine collection and analyses
Urine samples were collected during a designated 24-h period
within the first 10 d of the subjects’ menstrual cycles. On this
day, the women were instructed to maintain their usual activities
but to avoid intense exercise. After waking, the subjects noted
the time of their first void but discarded this sample; thereafter,
all urine excreted was collected up until and including the first-
voided urine 24 h later on the next day. The volume (mL) of the
24-h sample was measured and aliquots were analyzed for corti-
sol, creatinine, and calcium. Urinary calcium was included in the
analysis to provide information on the relation between calcium
intakes and excretion on the day of collection. Urinary cortisol
was quantitatively determined by using Chiron Diagnostics
 DIETARY RESTRAINT AND CORTISOL EXCRETION 9

TABLE 1 high restraint. Descriptive physical and lifestyle characteristics

Physical and lifestyle characteristics of the participants grouped according of the 2 groups are presented in Table 1. There were no signifi-
to low and high dietary restraint scores cant differences in age, physical characteristics, or menstrual
Low-restraint High-restraint cycle length between groups; however, BMI tended to be higher
group group in the high-restraint group, although not significantly so.
Characteristic (n = 29)1 (n = 33)2 Although subjects who had lost 2.3 kg (5 lb) > 2 times in the past
Age (y) 22.2 ± 3.13 21.2 ± 1.7 2 y were excluded, there was a significant difference in weight
Height (cm) 163.7 ± 8.1 162.7 ± 6.9 fluctuation between the 2 groups. The 2 groups of subjects had
Weight (kg) 55.3 ± 8.3 56.4 ± 5.8 similar intakes of coffee or tea and alcoholic beverages and there
BMI (kg/m2) 20.5 ± 2.0 21.3 ± 1.6 were no significant differences between groups in the propor-
Waist (cm) 66.1 ± 4.7 67.1 ± 4.0 tions who reported following vegetarian diets or using vitamin-
Hip (cm) 89.2 ± 6.3 89.4 ± 5.5 mineral supplements. Reported weekly exercise, however, was
Waist-to-hip ratio 0.74 ± 0.03 0.75 ± 0.05 significantly higher in the high-restraint group.
Weight fluctuation4 0.9 ± 0.9 1.4 ± 0.85
Menstrual cycle length (d)6 28.3 ± 3.4 28.8 ± 3.0 Eating behavior and dietary intakes
Coffee or tea (cups/d) 1.0 ± 1.0 1.1 ± 1.0
Alcohol consumption (drinks/wk) 1.2 ± 1.6 0.8 ± 1.4
By definition, scores on the dietary restraint scale differed
Exercise (h/wk) 2.2 ± 1.8 3.4 ± 1.77 between restraint groups: the women in the high-restraint group
Vegetarian (%) 10.3 12.1 had a score of 15.0 ± 2.2 and the women in the low-restraint group
Vitamin-mineral supplement use (%) 48.3 36.4 had a score of 2.7 ± 1.8 (P < 0.001). Women with high restraint
1
Scores of 0–5 on the Three-Factor Eating Questionnaire (TFEQ) scores also had higher scores on the TFEQ disinhibition scale
(7.6 ± 4.1 compared with 3.5 ± 2.5; P < 0.001), but scores on the

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restraint scale (2).
2
Scores of 13–21 on the TFEQ restraint scale. hunger subscale were similar (6.4 ± 3.7 compared with 5.2 ± 2.2).
3–
x ± SD. The mean energy, macronutrient, and calcium intakes from
4
Number of times subjects lost > 2.3 kg (5 lb) during the past 2 y. 3-d and 24-h food records are shown in Table 2. Energy intakes
5,7
Significantly different from the low-restraint group (t test): 5 P < 0.05, were lower in women with high restraint scores, when assessed
7
P < 0.01. by both 3-d and 24-h food records. Carbohydrate as a percent-
6
Self-reported menstrual cycle length. age of energy did not differ significantly between the 2 groups
by either method. On the basis of the 24-h food records, protein
intakes were significantly higher and fat intakes were signifi-
ACS:180R Automated Chemiluminescence Systems (14). The cantly lower in the high-restraint group; similar nonsignificant
reference interval (80.0–600.0 nmol/d) for this method is higher trends were observed on the basis of the 3-d food records. Cal-
than that of other methods (14). Twenty-four–hour urinary crea- cium intakes did not differ significantly between groups by
tinine was measured with the Synchron CX3 module, which either method.
measures the change in absorbance of an alkaline picrate solu-
tion at 41 C after sample addition (14). Twenty-four–hour urinary
calcium was determined by atomic absorption spectrophotome- TABLE 2
try in an air acetylene flame by using the calcium spectral line of Daily energy and macronutrient intakes from 3-d and 24-h food records
422.7 nm (15). Ratios of cortisol (nmol) to creatinine (mmol) of participants grouped according to low and high dietary restraint scores1
and of calcium (mmol) to creatinine were calculated.
Low-restraint High-restraint
Statistical analysis group group
Characteristic (n = 29)2 (n = 33)3
Comparisons were made between women with low restraint
Energy (kJ/d)
scores and women with high restraint scores. Mean values for all
3-d record 9342 ± 2282 8021 ± 14844
physical characteristics, coffee or tea and alcohol intakes, TFEQ 24-h record 10 128 ± 1986 8757 ± 23784
restraint scores, TFEQ disinhibition and hunger scores, energy Carbohydrate (% of energy)
and macronutrient intakes, and urinalysis results were compared 3-d record 55.5 ± 5.8 57.8 ± 11.4
by using unpaired t tests. Associations between all continuous 24-h record 62.5 ± 5.0 64.9 ± 6.8
variables were evaluated by using Pearson’s correlation coeffi- Protein (% of energy)
cients. Comparisons of the prevalence of vegetarianism and use 3-d record 15.0 ± 3.4 16.3 ± 4.5
of vitamin and mineral supplements were conducted by using 24-h record 11.9 ± 1.9 13.9 ± 1.85
chi-square analysis. The statistical analysis was conducted with Fat (% of energy)
SPSS software (version 7.5, 1996; SPSS Inc, Chicago). The level 3-d record 29.2 ± 4.3 25.9 ± 8.7
24-h record 25.5 ± 4.0 21.2 ± 6.45
of significance was set at P < 0.05 and comparisons were two-
Calcium (mg)
tailed. Results are reported as means ± SDs. 3-d record 840.3 ± 440.7 780.1 ± 293.2
24-h record 637.8 ± 328.4 578.3 ± 323.0
1–
x ± SD.
RESULTS 2
Scores of 0–5 on the Three-Factor Eating Questionnaire (TFEQ)
Physical and lifestyle characteristics restraint scale (2).
3
Scores of 13–21 on the TFEQ restraint scale.
Of the 62 women who completed the study, 29 were catego- 4,5
Significantly different from the low-restraint group (t test): 4 P < 0.05,
rized as having low restraint and 33 were categorized as having 5
P < 0.01.
10 MCLEAN ET AL

TABLE 3 urine sample to reflect the influence of various food-related

Analysis of 24-h urine samples of participants grouped according to low stresses throughout the day and to avoid the diurnal variability in
and high dietary restraint scores1 cortisol secretion (18). Although Pirke et al (11) found similar
Low-restraint High-restraint overnight serum cortisol concentrations in women with high and
group group low dietary restraint scores, this finding does not necessarily
Characteristic (n = 28)2 (n = 30)3 contradict our results: presumably, stress in association with
Urine volume (mL) 1391 ± 665 1370 ± 418
food intake or decisions related to food did not occur during the
Creatinine (mmol)4 10.0 ± 1.9 9.8 ± 1.7 overnight protocol used in their study.
Cortisol (nmol)5 354.7 ± 83.7 418.8 ± 134.66 We attempted to control for other variables that have been
Cortisol:creatinine 36.3 ± 8.9 42.9 ± 12.96 shown to be associated with elevated cortisol excretion and
Calcium (mmol)7 3.8 ± 2.1 2.7 ± 1.36 could thus have potentially confounded our results. Therefore,
Calcium:creatinine 0.4 ± 0.2 0.3 ± 0.16 we excluded women who reported irregular menstrual cycles
1–
x ± SD. (19) or who had been diagnosed with or treated for eating dis-
2
Scores of 0–5 on the Three-Factor Eating Questionnaire (TFEQ) orders (20). Various physiologic stressors, such as fasting
restraint scale (2). (21–23) and intense exercise (24, 25), can also increase cortisol
3
Scores of 13–21 on the TFEQ restraint scale. release; thus, intense exercise was not allowed on the study day
4
Reference interval: 7.0–16.0 mmol/24 h. and an inclusion criterion was ≤ 7 h exercise/wk. Despite this,
5
Reference interval: 80.0–600.0 nmol/24 h. women with high restraint scores reported higher levels of exer-
6
Significantly different from the low-restraint group, P < 0.05 (t test). cise than did the women with low restraint scores, but hours of
7
Reference interval: 2.5–7.5 mmol/24 h. weekly exercise was not correlated with either urinary cortisol
or cortisol-creatinine ratios. Accordingly, it is unlikely that

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Urinalysis
Results from the analysis of the 24-h urine collections are pre-
sented in Table 3. The number of urine samples analyzed differed
from the number of participants because there were 2 laboratory
errors and 1 incomplete collection. Furthermore, 1 woman was
excluded from the analysis because she had both a very high urine
output (3700 mL) and a high cortisol excretion. A high urine vol-
ume was shown recently to be associated with an increase in uri-
nary cortisol excretion (16). A high urine output was therefore a
potential confounder of free urinary cortisol concentrations.
Cortisol excretion and cortisol-creatinine ratios were both signi-
ficantly higher in the high-restraint group than in the low-restraint
group. Neither cortisol nor cortisol-creatinine ratios correlated with
weight fluctuation, energy or macronutrient intakes, hours of
weekly exercise, or TFEQ disinhibition or hunger scale scores.
Calcium excretion and calcium-creatinine ratios were signifi-
cantly lower in the high- than in the low-restraint group. Twenty-
four–hour calcium excretion correlated with 24-h calcium intake in
the total subject group (r = 0.459, P < 0.001) and in the low-
restraint group (r = 0.677, P < 0.001), but not in the high-restraint
group (r = 0.068, P = 0.727). The calcium-creatinine ratio also cor-
related with calcium intake in the total subject group (r = 0.449,
P < 0.001) and in the low-restraint group (r = 0.650, P < 0.001),
but not in the high-restraint group (r = 0.128, P = 0.507).
DISCUSSION
Our main finding was that women with high dietary restraint
scores had higher 24-h urinary free cortisol concentrations and
cortisol-creatinine ratios than did women with low restraint
scores. Our central hypothesis was contingent on dietary restraint
activating the stress response. We speculated that women with
high restraint scores would experience more stress in relation to
their daily food-related experiences. Stress activates the hypothal-
amic-pituitary-adrenal axis, resulting in a release of cortisol into
the bloodstream (17) and leading to increased urinary excretion.
These results support our hypothesis and are unique among
studies comparing women with different levels of dietary
restraint assessed by the TFEQ. We measured cortisol in a 24-h
exercise was responsible for the higher cortisol concentrations
in women with high restraint scores.
Food intake was carefully monitored on the day urine was col-
lected to ensure that any difference in cortisol excretion was not
the result of very low energy intakes or severely altered macronu-
trient intakes. On the study day, the high-restraint group consumed
less energy and fat than did the low-restraint group; however, nei-
ther energy nor fat intakes correlated with urinary cortisol or cor-
tisol-creatinine ratios. Women in both restraint groups consumed
8–9% more energy on the study day than they reported on their
3-d food records, suggesting that women in both groups responded
similarly to the study conditions. These differences in energy
intake may have been due to underreporting on the 3-d food
records, higher consumption on the study day because of the vari-
ety of food available and lack of cost, or to a combination of both
factors. Finally, there was no evidence from either the 3-d or 24-h
food records to suggest that women with high restraint scores had
higher cortisol excretion because of binge eating or fasting, either
of which could have activated the stress response (26).
Implicit in our hypothesis that women with high restraint
scores have higher cortisol excretion than do women with low
restraint scores is the supposition that cognitive dietary restraint
is a psychological stressor. In earlier animal research, Selye (27)
documented that psychosocial stressors elicited the same physio-
logic responses as did physical stressors, a finding that was sub-
sequently supported in the literature (28). Others have suggested
that it is the individual’s response to the stressor as opposed to the
stressor itself that determines the extent of the biological
response (29). Although the conditions on the study day differed
from those of normal daily experiences, all efforts were made to
ensure that the experience was comparable for all participants.
For unrestrained eaters it is unlikely that the decisions made
regarding food selections and quantity on the study day would be
stressful. External stresses were assumed to be similar between
groups because all subjects were university students, although it
is possible that the groups differed in this regard.
Ovulatory function was not assessed in the present study;
however, we and others previously observed relations between
dietary restraint and ovulatory disturbances (4–7). The higher
urinary cortisol and cortisol-creatinine ratios in the high-restraint
 DIETARY RESTRAINT AND CORTISOL EXCRETION
group suggest a possible mechanism for these relations. Men-
strual and ovulatory functions are reported to be disturbed when
hypothalamic signals cause increased secretion of cortisol
from the adrenal cortex (8, 10, 30–33). Specifically, high CRH
concentrations interrupt the release of gonadotropin-releasing
hormone, resulting in decreased concentrations of the circulat-
ing pituitary gonadotropins luteinizing hormone and follicle-
stimulating hormone. Decreased pulsatility or lower concentrations
of luteinizing hormone and follicle-stimulating hormone can
lead to ovulatory disturbances (32, 33).
The higher cortisol excretion observed in women with high
restraint scores may thus have long-term implications for bone
health through their effect on ovulatory function. Lower repro-
ductive hormone concentrations are generally associated with
lower bone mass, regardless of the cause (34–39). Furthermore,
cortisol negatively affects bone through its influence on bone
formation, bone resorption, calcium absorption through the
intestine, and calcium excretion through the renal tubule (39).
Therefore, because lifetime bone health and strength are at least
partially dependent on peak bone mass occurring during the first
3 decades of life (40), exposure to high cortisol concentrations
during these years may decrease the potential for achieving max-
imum bone mass. Over the life span, women with high restraint
scores may be at increased risk of fractures. In older adults,
higher baseline overnight urinary cortisol excretion was an inde-
pendent predictor of fracture (41).
Although 24-h urinary calcium excretion was not a primary out-
come variable, it was lower in the high-restraint group than in the
low-restraint group, which may also have implications for bone
health. Calcium intakes assessed by both the 3-d and 24-h food
records were similar between groups, suggesting that differences in
excretion were not related to differences in intakes. Several review
articles of research regarding cortisol and bone health noted an
inverse relation between circulating concentrations of cortisol and
intestinal calcium absorption (30, 39, 42). Calcium malabsorption
is a consistent finding in cortisol-treated patients and is observed
within the first 2 wk of treatment (43). A reduction in calcium
absorption would likely lead to a reduction in urinary losses to pro-
tect the body’s calcium balance (44). Therefore, it is possible that
the lower urinary calcium observed in women with high restraint
scores reflects a cortisol-induced decrease in intestinal calcium
absorption. In support of this postulate is the observation that cal-
cium intake on the study day correlated positively with calcium
excretion in the total study group and in the low-restraint group, but
not in the high-restraint group. Although the women with high
restraint scores may possibly have retained more dietary calcium
than did the women with low restraint scores, it is more plausible
that the women with high restraint scores excreted less calcium
because of reduced absorption. Studies measuring calcium intake
and fecal excretion would clarify this question.
Many women today are aware of their food intake and con-
sciously monitor the quantity and quality of their diet. These
attempts at dietary restraint are generally believed to be innocu-
ous, but this may not be the case for all women. The association
we observed between dietary restraint and cortisol requires fur-
ther investigation because other research has shown associations
between cortisol and increased bone loss, decreased fertility, or
both. Because our cross-sectional study showed an association
rather than causation, our findings must be interpreted with cau-
tion: other unidentified personality factors may be common to women
with high restraint scores and may contribute to, or indeed be
11
better predictors of, the observed association with cortisol excre-
tion. Such possibilities require investigation. Additionally, recent
research has refined the concept of dietary restraint into rigid and
flexible restraint (45); future studies should consider this differ-
entiation. Longitudinal research appears warranted to clarify our
results and to assess whether the observed metabolic and hor-
monal changes persist over time.
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