From hypercortisolism to remission: impact of Cushing's disease on eating patterns

Cushing's disease (CD) is characterized by chronic hypercortisolism and is associated with persistent metabolic, psychological, and neurocognitive disturbances. While metabolic consequences are well described, the impact of disease activity and remission on eating behavior remains insufficiently explored.

This study aimed to compare multidimensional eating behavior patterns among patients with active Cushing's disease, patients in biochemical remission, and healthy controls, and to examine their associations with cortisol biomarkers.

In this cross-sectional study, 74 participants were enrolled, including patients with active CD (n = 21), patients in remission (n = 32), and age-, sex-, and BMI-matched healthy controls (n = 21). Eating behavior was assessed using validated questionnaires: the Night Eating Questionnaire (NEQ), Emotional Appetite Questionnaire (EMAQ), Three-Factor Eating Questionnaire-Revised 18 (TFEQ-R18), Mindful Eating Questionnaire (MEQ), and Dutch Eating Behavior Questionnaire (DEBQ). Group differences were analyzed using Kruskal-Wallis tests followed by Dunn's post-hoc comparisons with Bonferroni correction. Associations between eating behavior scores and cortisol parameters were evaluated using Spearman correlation analysis.

Active Cushing's disease was associated with higher night eating (NEQ; p < 0.001) and greater emotional and situational eating compared with remission and healthy controls (EMAQ total; p < 0.001). Positive emotion and situation subscales were higher in active disease (both p = 0.008), whereas negative total scores differed significantly only between active disease and healthy controls (p = 0.014). Mindful eating was reduced in both patient groups versus controls (MEQ total; p < 0.001), with active disease showing higher disinhibition (p = 0.002), greater interference (p < 0.001), and lower conscious nutrition (p = 0.016). Remission patients demonstrated partial but incomplete behavioral recovery. Late-night salivary cortisol correlated with MEQ interference (r = 0.5, p = 0.01), and cortisol levels after the 1-mg DST correlated with DEBQ emotional eating (r = 0.5, p = 0.01).

Cushing's disease is associated with marked alterations in eating behavior, particularly during active disease, including increased night eating, emotional susceptibility, and reduced mindful regulation. Although partial improvement occurs after remission, residual behavioral disturbances persist. These findings underscore the importance of integrating behavioral assessment into the long-term management of Cushing's disease.