title: Depression, smoking, physical inactivity and season independently associated with midnight salivary cortisol in type 1 diabetes.
abstract: BACKGROUND
  Disturbances of the circadian rhythm of cortisol secretion are associated with depression, coronary calcification, and higher all-cause and cardiovascular mortality.The primary aim of this study was to test the associations between midnight salivary cortisol (MSC), depression and HbA1c, and control for behavioural, environmental and intra individual factors with possible impact on cortisol secretion, like smoking, physical inactivity, season, medication, diabetes duration, severe hypoglycemia episodes, age and gender in patients with type 1 diabetes. Secondary aims were to present MSC levels for a reference group of non-depressed type 1 diabetes patients with a healthy life style (physically active and non-smoking), and to explore seasonal variations.
  
  
  METHODS
  A cross-sectional population based study of 196 patients (54% men and 46% women) aged 18-59 years that participated in a randomized controlled trial targeting depression in type 1 diabetes. Depression was assessed by the Hospital Anxiety and Depression Scale-depression subscale. MSC, HbA1c, serum-lipids, blood pressure, waist circumference and data from medical records and the Swedish National Diabetes Registry were collected.
  
  
  RESULTS
  Thirty four patients (17%) had MSC ≥9.3 nmol/L, which was associated with smoking (AOR 5.5), spring season (AOR 4.3), physical inactivity (AOR 3.9), self-reported depression (AOR 3.1), and older age (per year) (AOR 1.08). HbA1c >70 mmol/mol (>8.6%) (AOR 4.2) and MSC ≥9.3 nmol/L (AOR 4.4) were independently linked to self-reported depression. Season was strongly associated with MSC levels and no other variables studied showed seasonal variations. In a reference group of 137 non-depressed patients with a healthy life style (physically active, non-smoking) the median MSC level was 4.6 nmol/L (range 1.9-23.0).
  
  
  CONCLUSIONS
  In this study of patients with type 1 diabetes high MSC was linked to smoking, physical inactivity, depression, season and older age. Thus a high cortisol value identified three major targets for treatment in type 1 diabetes.
authors.affiliation: Department of Clinical Sciences, Endocrinology and Diabetes, Lund University, Lund, Sweden. eva.melin@ltkronoberg.se.
authors.forename: Eva O
authors.initials: EO
authors.lastname: Melin
authors.forename: Maria
authors.initials: M
authors.lastname: Thunander
authors.forename: Mona
authors.initials: M
authors.lastname: Landin-Olsson
authors.forename: Magnus
authors.initials: M
authors.lastname: Hillman
authors.forename: Hans O
authors.initials: HO
authors.lastname: Thulesius
mesh_terms: D000293:Adolescent; D000328:Adult; D015415:Biomarkers / Q000378:metabolism; D001786:Blood Glucose / Q000378:metabolism*; D001794:Blood Pressure; D002940:Circadian Rhythm; D003430:Cross-Sectional Studies; D003863:Depression / Q000378:metabolism*; D003922:Diabetes Mellitus, Type 1 / Q000453:epidemiology / Q000378:metabolism* / Q000523:psychology; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism*; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism*; D007003:Hypoglycemia / Q000378:metabolism*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D012463:Saliva / Q000737:chemistry* / Q000378:metabolism; D012621:Seasons; D057185:Sedentary Behavior; D057566:Self Report; D012907:Smoking / Q000378:metabolism*; D013548:Sweden / Q000453:epidemiology; D013997:Time Factors; D055105:Waist Circumference
chemical_list: D015415:Biomarkers; D001786:Blood Glucose; D006442:Glycated Hemoglobin; D006854:Hydrocortisone; C517652:hemoglobin A1c protein, human