Need help?

800-5315-2751 Hours: 8am-5pm PST M-Th;  8am-4pm PST Fri
Medicine Lakex


Stressors and stress Stress physiology Stress in relation to the pathogenesis of cardiovascular disease Stress and heart disease - how important is stress according to the patients and according to their doctors? Depression and heart disease Relevant concepts in stress prevention in relation to cardiovascular disease STRESS IN THE WORKPLACE
Two models for describing adverse/benificial work Psychological assessment of working conditions: the subjectivity factor Other factors influencing work conditions Organisational interventions in workplaces aiming at decreased heart disease risk Specific working conditions Long working hours Downsizing and reorganisation in modern working life Marital load and conflict Lack of social support Traumatic experiences and negative life events Individual traits - pesonality and behaviour patterns THE INFLUENCE OF GENDER
Heart rate variability due to job stress Regenerative activity: protection against stress REDUCING RISK CAUSED BY STRESS
Relaxation training Reduction of type A behaviour and hostility Improved social support Improved work environment Report prepared for the European Heart Network (EHN) by: Professor Emeritus Töres Theorell, Karolinska Institutet,Stockholm, Sweden Professor Tage S. Kristensen, Ms.Sc. & Dr.Med.Sci., National Institute of Occupational Health, Copenhagen, Denmark Professor Marcel Kornitzer, MD, PhD.
Professor Sir Michael Marmot, FRCP, Department ofEpidemiology and Public Health, University College London,United Kingdom Professor Kristina Orth-Gomér, Preventive Medicine, Karolinska Institutet, Stockholm, Sweden Professor Andrew Steptoe, MA, DPhil, DSc., British Heart Foundation Professor of Psychology, Deputy Head, Department of Epidemiology and Public Health,University College London, United Kingdom EHN is particularly grateful to Professor Emeritus Theorell for his work as lead author.
Susanne Løgstrup, Cand Jur, MBA. Director, European Heart NetworkBrussels, Belgium Vicki J. Roberts-Gassler, Ph.D.
For coronary heart disease (CHD), these "suspects" are well But this is not the whole story. For people above a certain known: tobacco smoking; dyslipidemia; high blood pressure; threshold of material well-being, another kind of well-being lack of physical activity; obesity. These are usually referred becomes central. Autonomy – how much control we have to as the "causes" of coronary heart disease. Attempts to over our life, self-esteem, and our opportunities for full social decrease CHD morbidity and mortality often include engagement and participation – all are crucial for our health, interventions to decrease smoking; improve eating habits; well-being and longevity.
control hypertension; and decrease overweight. As all these do indeed target important components in CHD pathogenesis, But how do such experiences translate into health and illness? such attempts are usually well founded.
The key lies in that most important organ, our brain.
But why do some people smoke too much, ingest too much It follows that additional targets for interventions intended to fat, sugar and salt, live sedentary lives, and overeat? Genetic promote health and/or prevent or cure disease do exist. Such factors do play a role but do not explain the present variability interventions aim at our cognitive faculties, our emotions and between and within countries in such risk factors and health our coping abilities, but also at our living and working outcomes. There must be some additional "causes behind conditions, in absolute and relative terms. The six authors of the causes". Some of these ultimate causes are social this report review the current evidence and make a convincing determinants of health – a subject chosen by the World Health case for targeting both the "causes", and the "causes behind Organization for its new high-level global Commission, the the causes" of CHD, and some of the mechanisms through Commission on Social Determinants of Health, formed in which they operate.
2005. Social determinants are the conditions in which peoplelive and work. They include, inter alia, poverty, social exclusion, Lennart Levi, M.D., Ph.D.
inappropriate housing, and shortcomings in safeguarding early Emeritus Professor of Psychosocial Medicine childhood development, unsafe employment conditions, and Karolinska institutet a lack of high-quality health systems.
The Chairperson of the WHO Commission is Professor SirMichael Marmot, one of the six distinguished authors of thepresent Report. In his recent comprehensive review, Marmotdemonstrates that health, more often than not, follows a social gradient. The higher our status in the pecking order, the healthier we are likely to be.
For several reasons, the concept of stress has played a much In addition to each individual's subjective assessment of more important role in ideas about cardiovascular disease the stress he or she is experiencing, objective tests confirm (CVD) among laymen than among experts. On a theoretical the body's reaction. For example, a simple saliva test can level, stress is more difficult for health care practitioners to determine cortisol levels; excreted from the adrenal cortex, define and assess than widely accepted coronary risk factors cortisol normally varies throughout the day. Excessive such as physical activity, tobacco smoking, serum cholesterol increases, an inability to inhibit cortisol excretion at night and and blood pressure. It is also believed to be more difficult to and/or an inability to mobilise cortisol with constantly very deal with from a societal point of view.
low levels are indications of a body under stress. High bloodpressure, low testosterone in men or low oestrogen in women However, research has confirmed the importance of stress as (both associated with decreased regenerative activity) are an independent risk factor in the incidence and the course of other verifiable factors that are associated with an increased CVD. In one large international study, for example, a population long-term risk of CVD. attributable risk (PAR) was calculated for all risk factors,including stress. The PAR corresponds to the proportion of Some of the major studies on stress in the workplace and myocardial infarctions that could theoretically be prevented the interventions to alleviate this stress are summarised. Two if the risk factor could be eliminated in the population.
models have influenced studies. The demand/control/support Regardless of country, age, gender and a number of model theorises that the combination of high psychological established risk factors, stress as defined in the study, either demands and low decision latitude (job strain) is dangerous at home or at work, corresponded in men to a PAR of 40% to health, with effects that are worsened by a lack of social before age 55 and 24% above 55. The corresponding support. However, high demands with high decision latitude numbers for women were 53% (before 55) and 31% (active work) may be associated with psychosocial growth and improved coping. Decision latitude involves the possibility ofinfluencing decisions in daily work and the possibility of using Some of the mechanisms by which the body responds to and developing skills. The effort/reward imbalance model posits stress have been clarified, and studies have looked at the that high effort, intrinsic or extrinsic, is associated with health physiology of stress and at particular aspects of working life risk when it is not appropriately recognised with material, social and overall life conditions that act as stressors. And findings and/or psychological rewards. in the literature suggest a number of ways in which stresslevels could be reduced, contributing to a reduction in Studies have produced convincing evidence that job strain is the risk of CVD as well as to general health. a risk factor for cardiovascular disease, independently of otherrisk factors. For example, a group of tax accountants, who This paper surveys the major studies covering several aspects worked as much as 70 hours per week during tax season, of stress and cardiovascular disease. Beginning with a working showed significantly higher cholesterol levels and shorter definition of stress as the non-specific reaction (energy clotting time during the busy periods before deadlines. The mobilisation) that arises in demanding or challenging situations, link between job strain and CVD applies to people still actively it explains how the environment acts on individuals, who working; after retirement the effects are diminished. respond to stressors according to their individual copingprogramme, influenced by their genes and their experience, Compounding the difficulties of designing an appropriate and produce reactions. Stress is necessary and can be workplace intervention are uncontrollable factors such as beneficial, but because the body gives priority to the "fight businesses encountering difficulties, downsizing, reorganising, or flight" reaction, while energy is mobilised to deal with a merging, relocating, etc. Nonetheless, some studies can serve stressor, normal regeneration is neglected. With long-term as examples. A recent study by the Stockholm group (Theorell stress, the stress hormones, which are not harmful over short et al., 2001) in a large company involved giving one group of periods, may act to accelerate coronary atherosclerosis, managers compulsory psychosocial training in sessions over make the heart muscle vulnerable and affect the body's ability a period of one year; a control group did not receive training.
to regulate energy. The paper explains how these and other Tests including one on serum cortisol were performed and physical stress reactions affect the heart. questionnaires administered on both groups. Those whosemanagers received the training reflected its success in theirresponses to the questionnaire, and medical tests confirmed a lower stress level in the intervention group than in the control particularly high risk of belonging to the myocardial infarction group, where tests results remained the same. In the same group even after adjustment for other risk factors. In a further way, a group of bus drivers reacted well to improvements in study, "control at home" and how this relates to risk of new their routes and technological advances with lower systolic episodes of coronary heart disease was addressed. It was blood pressure, diastolic blood pressure, pulse rate, and found that low control predicts coronary heart disease in women but not in men. The risk is higher in women in thelower social classes, perhaps due to a lack of material and One particular workplace stressor, shift work, has been shown psychological resources for coping with excessive household to be less stressful if workers start later each day ("clockwise") and family demands.
instead of earlier ("counterclockwise"). The "clockwise" rotationworks with the human body's circadian rhythm, based on Women and men also differ in respect of social support.
Although a wide circle of friends decreases the risk of CVD for men, evidence indicates that for women a large social In the industrialised countries, low social class is associated network may correspond to a high psychosocial load. both with increased incidence of CVD and with several of theenvironmental risk factors that may give rise to increased The study discusses some of the biological mechanisms prevalence of long-lasting stress. Some stressors, including of stress, including regulation of cortisol levels, heart rate poor working conditions, lack of social support and troubled variability, blood pressure, plasma fibrinogen levels, family life, may contribute to stress reactions that could partly inflammatory responses and other immune system reactions, explain social inequity in cardiovascular health. Extraordinarily and testosterone/oestrogen levels. Regeneration after stress traumatic experiences and a high prevalence of certain is crucial, and sufficient high-quality deep sleep is essential for negative stressful life events also disproportionately affect regeneration. The paper's authors conclude that "changes in people in the lower social classes, according to studies.
energy mobilisation and regenerative activity are two possible Although the Sisyphus syndrome and type A behaviour are mechanisms behind the association between psychosocial not related to social class in the way that would be expected, conditions and cardiovascular disease. The evidence is good hostility, defined as a "cynical" attitude to life and to one's enough at this point to provide biological plausibility for the surroundings, is more common in the lower social classes and relationship between stress and heart disease." also related to the risk of coronary heart disease early in life. Recommendations for dealing with stress on a personal Whilst older literature on stress-related factors was dominated and societal level include: by studies of men, more recent studies are showing a differentpsychological profile for women who develop coronary heart • Relaxation training disease at younger ages. A submissive passive coping pattern • Good sleep hygiene seems to be of greater importance for women than hostility • Healthy lifestyle, including physical activity, a healthy diet, and type A behaviour. Working women report much lower avoiding excessive caffeine and alcohol, not smoking decision latitude at work than working men, mostly because • Reduction of type A behaviour and hostility they are less often promoted to supervisory positions, even • Improved social support, backed by community programmes at comparable education levels. In both managerial and blue • Improved work environment, aiming at an improved collar positions, women and men who have the same jobs relationship between psychological demands and decision with the same level of responsibility report very similar levels latitude/social support, by educating managers or whole of decision authority and skill discretion, so gender differences organisations. Improved relationship between effort and in work stress could result from the different roles the two rewards, and shift work schedules that go "clockwise", genders still play in the workplace. According to a large-scale and for groups with high demands for attention or fear Swedish study, intrinsic effort (overcommitment) in combination avoidance, avoidance of long work weeks.
with job strain (high demand and low control) was a goodpredictor of myocardial infarction in women, while extrinsiceffort/reward imbalance in combination with job strain was a good predictor in men. In a follow-up study, women withovercommitment working in male-dominated jobs were at Scientific research on the relationships between stress, According to Selye (1936) stress is the non-specific reaction psychosocial factors and cardiovascular disease has been (energy mobilisation) that arises in demanding or challenging ongoing for several decades. Physicians, psychologists and situations. Conditions in the environment that induce this psychiatrists and heart patients themselves all agree that stress reaction are labelled stressors. Obviously a crucial element plays a significant role in the incidence and course of heart of stress is the individual´s way of interpreting and coping disease. Determining the precise nature of that role, however, with the stressor, which (according to Kagan and Levi, 1974) is complex as it depends on the interaction of numerous corresponds to the individual programme for dealing with the factors, both personal and societal. This paper summarises situation. If we follow this line of reasoning about stress, there the latest research on several factors that contribute to stress are three levels, namely the environment (stressors),
in both working and private life. which is displayed to the left in the figure below (see Figure 1),
the individual programme, which interacts with stressors
Although there is some overlap between factors studied, in generating stress, in the middle, and the reactions,
research is divided into the broad categories of working life, in this case stress, to the right. The theory underlying the influence of gender, private life including marital situation this publication is that long-lasting stress reactions, and social support networks, results of traumatic experiences, if combined with other conditions, may contribute and the role of personality and behaviour patterns. In each to acceleration/deceleration of processes that lead instance both the evidence for the effects of stress on heart to cardiovascular disease. The pathogenesis of disease risk and the possibilities for reducing the risk are cardiovascular disease and how that may relate discussed. Then we look at research on the biological to stress will be discussed in this paper. mechanisms at play. Finally, recommendations are made for reducing stress.
Figure 1. Basic underlying concepts
in the stress discussion

Stress can be an individual matter, but individuals live in a society over which their control is limited. Policy makers have an opportunity to intervene at various levels. This paperemphasises how important stress is and explains how it can be dealt with in prevention work – which is to a large extent the responsibility of regional governments, communities andpersonnel departments in workplaces. Close collaboration with primary care physicians, occupational physicians andother health care workers is essential.
Environment (stressors) Individual programme Reaction (stress) Source: Kagan and Levi, 1974; Theorell, 1991.
When we discuss possibilities for decreasing the negative Since clinicians are consulted by individuals, it is quite natural effects of stress it is very important that we differentiate for them to be more interested in the individual aspects of between actions that we can take on the environmental stress than in the environment. The environmental level should stressors (for instance improving work organisation so that primarily be addressed by politicians, public health care stress reactions occur less frequently or so that stress workers, personnel administrators and occupational health reactions can be dealt with more effectively in the organisation), care workers, as well as business managers and leaders, on how the individual copes with stress (for instance teaching but all the stress preventive work has to be done in individuals about stress management), and on the individual collaboration between these groups. The reasons for reaction (for instance medication that may reduce the this are depicted in figure 1, as will be discussed below.
physiological consequences of repeated intensive stressreactions) respectively. Sometimes it is possible to act on two Stressors and stress
or three levels at the same time, but it is always important toknow which level an action is addressing. The diagram also Any adverse (negative) or challenging (positive) condition, shows how the three levels are related to one another. physical or psychosocial, in the environment could be labelleda stressor. Selye presented his theory regarding "general Our way of coping with stressors (individual programme) adaptation syndrome" in 1936 and later started using the is a result of our gene interaction with the environment. term "stress" when he popularised his theory. A stressor is The genes never act in isolation, and it is only when a interpreted by the individual programme as a condition that "dangerous" gene is activated by an environmental factor requires energy mobilisation. Energy mobilisation is a basic that it may become dangerous. "Protective" genes may response triggered in all human beings in many situations.
also be activated by favourable conditions. Science is Such a response is sometimes necessary for our survival. only beginning to generate knowledge in this new field. The stress reaction is not dangerous to health per se. In As indicated in the diagram, experiences of "stress" may fact it may be very positive. When it occurs repeatedly influence our coping pattern. This means that coping and intensively without periods of rest and recuperation patterns are always changing. They are modelled in a in between, however, it may become dangerous to health. continuous interaction between our genes and our external The negative stress reaction was labelled "distress" by Selye.
situation. The concept "experience" is used here in a broadsense. Accordingly we are not talking only about conscious Our reactions, however, also influence both our programme experiences. For instance, we are not aware of all the and our environment, as indicated by the arrows. Sometimes stressors that we are exposed to. Despite the lack a reaction may reduce the environmental load, but it could of conscious awareness of some stressors, however, also increase it. And our programme is continuously adapting the body may react to them and record its reactions.
itself to the environment. We are different as individuals bothbecause we have different genes and because we have Clinicians, both health care professionals and psychologists, different experiences. generally focus on the individual programme and the reactions.
The physician can help to strengthen the individual's resistance A crucial element in the intensity and character of our way to stress (which belongs to the individual programme) by giving of coping with stressors is our expectations (Ursin and Eriksen, advice regarding diet, physical activity and sleep habits, for 2004). When we can actively do things that reduce danger and instance. The psychologist or psychiatrist can help the person we are convinced that we can manage our challenges, our to resist adverse conditions through educational procedures stress reactions will be less intensive and of a shorter duration.
(stress management) aiming at improved coping with stress.
However, when the consequences of our coping are The physician can also help the individual to reduce stress, unpredictable (helplessness) the stress reactions will be for instance by prescribing medication such as beta blocking more long lasting. Finally, when our prediction is that there agents that reduce the physiological effects of arousal. The will be negative outcomes regardless of what we do psychiatrist or psychologist, finally, can reduce reactions (hopelessness), the stress reactions will be even more by efforts to teach relaxation and other methods aiming long lasting and damaging.
at reducing one's arousal level in stress situations. THE STRESS CONCEPT
As discussed by Marmot in his recent book Status Syndrome Inhibition of regeneration is accordingly one way in which (2004), associations and preventive actions are quite different long-lasting periods of stress reactions without sufficient on a collective population level than on an individual level. periods of rest may increase the risk of illness. Another way For instance, genetic factors are certainly important on the in which stress could influence the risk of illness is via direct individual level but changes in societies may give rise to effects of the stress hormones. These are not dangerous to pronounced elevation of stress levels. These changes cannot health if they are active during short periods. However, if be explained by sudden changes in genetic factors. energy mobilisation goes on for very long periods withinsufficient rest, the stress hormone effects on serum lipids, Researchers have been interested since the 1960s in all three coagulation and inflammation will result in accelerated coronary levels in Figure 1. On the whole this paper focuses mainly on atherosclerosis. In addition the vulnerability of the heart muscle the environmental aspects and on the individual programme.
will increase. Finally, such periods will result in an inability to Understanding the interplay between these components regulate energy and stimulation/inhibition of stress hormones and how this affects reactions that could increase/decrease in normal ways. Examples include the regulation of cortisol the risk of coronary heart disease is central to any programme excretion from the adrenal cortex. Both excessive increases aiming at stress reduction in society. The development of with an inability to inhibit cortisol excretion at night and with pharmaceutical agents such as beta-blockers has been an inability to mobilise cortisol with constantly very low levels going on since the 1960s, and these kinds of medications have been observed. The metabolic syndrome is associated are becoming more and more sophisticated; they will not with increased cardiovascular risk. It is characterised by be discussed in detail in this paper, however, since the excessive abdominal fat, increased insulin resistance and a pharmaceutical discussion belongs to clinical cardiology.
tendency to diabetes, high blood pressure, high cortisol levels(or inability to regulate cortisol), low testosterone (associated with decreased regenerative activity) in men and low oestrogen (also associated with decreased regenerative When the body mobilises energy for fight or flight, the activity) in women.
provision of fuel for energy production will have the highestpriority. This means that the concentration of glucose and fatty Stress in relation to the pathogenesis
acids will increase. At the same time the body prepares itself of cardiovascular disease
in other ways, such as increased coagulation (if injury arises,bleeding should stop as soon as possible), reduced sensitivity Let us start with a few words about the pathogenesis of to pain (pain from injuries should not stop muscular action) and cardiovascular disease (not including congenital heart disease).
decreased inflammation (swollen tissues should not disturb the Most of the cardiovascular disease that is of importance to person). If the flight or fight reaction continues for some time it public health occurs in middle and old age and can be also becomes evident that the body's regenerative activities regarded as a form of accelerated ageing. The two essential are downplayed. Regeneration is the body's replacement and organs are the heart and the vessels, in particular the arteries.
repairing of injured or worn out cells. This activity goes on in There is a massive amount of documentation showing that the gastrointestinal cells, in the skin, in the muscles (including stiffening/narrowing of the arteries – arterio- or atherosclerosis the heart muscle), in the brain's supportive system (glia cells), – in the heart itself (the coronary arteries) dramatically increases in the skeleton and in the white blood cells, to mention a few the risk of developing cardiovascular disease. Narrowing of the coronary arteries is not the only decisive factor, however. When the regeneration has been inhibited for a long time – There are two manifestations of cardiovascular disease that are weeks, months or years – these tissues become vulnerable. of particular importance. The first one is angina pectoris, which In the circadian rhythm the regenerative activities have their is due to a transient lack of oxygen for the work that the heart peak during sleep, particularly during stage 4 sleep (which muscle is doing. The second one is myocardial infarction, is the deepest sleep stage). So obviously it is very important which arises when the lack of oxygen becomes more long to retain good sleep during periods of long-lasting stress.
lasting and part of the heart muscle is injured due to this Regeneration may also be stimulated actively by physical oxygen shortage. The part of the heart muscle that is injured activity and possibly also by cultural activities such as dancing is replaced by scar tissue, and if the injury is extensive this or listening to music. We have insufficient knowledge regarding will result in persisting reduction of the functioning of the the effects of cultural activities, although some research results indicate that there are such protective effects.
So how does a lack of oxygen arise? The different coronary Secondly, the condition of the heart muscle itself to some arteries supply different parts of the heart muscle with oxygen.
extent seems to determine whether an episode of oxygen When one of the arteries becomes narrowed an insufficient shortage will result in myocardial infarction or not. For instance, amount of oxygenated blood will reach the corresponding after a long period of energy mobilisation with insufficient part of the heart muscle. If the vessel becomes completely periods of rest, the regenerative capacity of the body is low.
and permanently blocked – which occurs if a blood clot is This also affects the heart muscle, which becomes more formed or if debris from an atherosclerotic plaque follows vulnerable to oxygen shortage. the blood from a more proximal to a more distal part of thecoronary arteries – an infarction is inevitable. The artery may How can "stress" influence these different mechanisms? also be only partially blocked by atherosclerosis. If so the heart It can influence cardiovascular disease risk in several ways, muscle may function well at rest and when no extraordinary summarised in Figure 2. demands are made upon it. During heavy physical work oremotionally upsetting conditions, however, the heart starts Coronary atherosclerosis is stimulated by tobacco smoking, beating harder and faster and then the demand for oxygen high blood pressure and high concentrations of certain serum increases. If this situation is long lasting a myocardial infarction lipids (low density lipoprotein). This has been known for a long may arise despite the fact that the artery is not totally blocked.
time. During the last few years it has also been established When the situation is more transient there will be angina that stimulated inflammatory processes as well as increased pectoris and no heart muscle injury will occur. coagulation may accelerate coronary atherosclerosis. Spasms may also arise in the coronary vessels, although Tobacco smoking sometimes increases and sometimes this is not common. Such a spasm may give rise to angina decreases during periods of stress. There are accordingly no pectoris and – although this is very uncommon – even unanimous findings regarding the effects of stress on tobacco myocardial infarction. A coronary artery spasm is triggered smoking. In some cultures tobacco smoking seems to be more by strong emotions and/or physical demands.
associated with stress than in others. The risk of developinghypertension increases during long-lasting stress (see below).
Coronary atherosclerosis is by far the most important With regard to serum lipids the findings in the literature are condition for cardiovascular disease among middle-aged less clear. Some lipids, such as triglycerides, are very sensitive and older people. It should be pointed out, however, that at to stress reactions, and total cholesterol has been shown to any given level of coronary atherosclerosis the risk of manifest rise during periods of long-lasting stress, caused for instance cardiovascular disease varies. This is due mainly to two factors: by unemployment. First of all, massive increases in the demand for oxygenated During the last few years the atherosclerotic process itself blood to the heart muscle may arise during tachyarrhythmias.
has been studied in relation to stress. It has been shown for These are episodes of very fast heart rate that may arise instance that the blood concentration of one of the interleukins unexpectedly. The "speed of the heart" is completely out of (IL-6) which is regarded as a possible important inflammatory proportion to the external demands but enormous demands marker of relevance to the atherosclerotic process increases for oxygen arise in the heart muscle. Some individuals have during experimental stress. This increase is more long-lasting more of a tendency to such arrhythmias than others even and more pronounced in persons from lower socio-economic long before they have developed any coronary atherosclerosis.
strata than in other subjects (Brydon et al., 2004). Another When they are young these episodes are transient and no mechanism related to inflammation, namely the activity of injury occurs to the heart muscle. However, when the person stem cells which can be transformed to endothelial cells develops coronary atherosclerosis this situation changes and (which form the inner surface of the arterial wall and are episodes of oxygen shortage will then give rise to symptoms – therefore of importance to the atherosclerotic process), is angina pectoris or myocardial infarction – during the sensitive to stress (Fischer 2005, personal communication).
tachyarrhythmias. Subjects who have had a myocardial The endothelial activity is in general sensitive to stress, and infarction may have heart muscle scars that by themselves these effects last longer than those recorded with the use increase the risk of such episodes. The likelihood of of more conventional measurements such as heart rate tachyarrhythmia increases during emotionally upsetting or (Ghiadoni et al., 2000). Coagulation (which is closely related physically demanding situations in people with a tendency to inflammation) has also been shown to be of importance to tachyarrhythmia.
to the atherosclerotic process and accordingly the fact that Thus, the factors shown in the figure are interconnected coagulation (for instance plasma fibrinogen) is sensitive to in many different ways. From a research point of view such stress is of great importance to the link between stress and complicated mechanisms are difficult to study, and it is cardiovascular disease (see below).
particularly difficult to evaluate the independent contribution of each single factor. From a prevention point of view the We may thus conclude that there are several ways in interrelatedness of all the factors can be seen as an advantage: which long-lasting periods of stress may influence coronary The reduction of one of the risk factors reduces the overall risk atherosclerosis. It is also important to emphasise that stress of CVD in many different ways. In some cases the reduction reactions could trigger the onset of excessive oxygen demands of one factor even leads to reducing the risk of other diseases in the heart muscle. Emotional reactions resulting in increased such as cancer or diabetes, which should be regarded as an heart activity (the heart muscle beating both harder and faster) "extra bonus" in CVD prevention.
could be important per se, but they may also be importantbecause they increase the risk of uncontrolled excessive Figure 2. Interplay between physiological and behavioural
tachyarrhythmia (uncontrollably fast heart rate) in vulnerable changes in relation to stress and cardiovascular disease
individuals. Sudden physical demands or pronouncedemotional reactions may also increase the risk of forming aclot, which could block a coronary artery completely. Finally,long-lasting episodes of intensive stress reactions could Stress and CVD
increase the vulnerability of the heart muscle itself (viadecreased regenerative activity).
The processes that connect stressors with the risk of cardiovascular diseases follow two different pathways, as shown in figure 2. To the left in the figure a number of physiological mechanisms are indicated. These includeincreased blood pressure, higher levels of lipids such as LDLcholesterol, higher fibrinogen levels in the blood, higher pulse,higher level of obesity, decreased coagulation time of the blood, arrhythmia, and an increased level of stress hormones(e.g. cortisol, adrenalin). Stressors may also change thebehaviour of the people exposed to them (shown to the right in the model). These behavioural changes include increased Physiological changes Behavioural changes tobacco smoking, changes in dietary habits, increased intakeof calories, decreased physical activity, manifestation of type A • Blood pressure personality (hostility and anger), increased alcohol intake, • Dietary habits higher coffee intake, and changes in sleeping habits (poor sleep quality and decreased number of hours of sleep). It should be emphasised that the model presents a simplified • Coagulation time picture of the possible mechanisms leading to increased CVD risk. This is due to the fact that many of the behavioural factors • Stress hormones • Sleeping patterns to the right influence the factors to the left in the model.
• Vascular inflammation • Tobacco increases fibrinogen levels in the blood, which leads to an increased risk of formation of thrombi in the arteries. • Dietary habits influence blood lipids and obesity. • Exercise influences blood pressure, pulse, and obesity. Stress and heart disease – how important is stress
In another very practical approach to the question of stress according to the patients and according to their doctors?
and heart disease, the relevance of the general stress reactionto coronary heart disease risk has been shown indirectly A recent very large international case control study by studies demonstrating that risk factors can be reduced (11 000 patients and 13 000 control subjects) highlighted by regular practice of relaxation over a long period of time.
the connection between stress and heart disease (Rosengren Whether the method for achieving relaxation is transcendental et al., 2004) from the point of view of patients with a recent meditation, biofeedback training or other kinds of relaxation is first myocardial infarction. Subjects (both patients and control probably unimportant. The essential component in success subjects) were asked two single-item questions about stress is a reduced degree of arousal (or stress) in everyday during the past 12 months at home and at work respectively.
life situations. Stress was defined as feeling irritable, filled with anxiety or as having sleeping difficulties as a result of conditions at work The difficulty with this approach for coronary heart disease or at home. This stress definition could of course be criticised risk reduction seems to be the sustainability of the habit of (see above) but the word stress is vaguely defined in common practising relaxation for months and years. Various methods for this have been proposed, for instance Patel et al., 1985. It is probably important to pay attention to the psychosocial A population attributable risk (PAR) was calculated for environment in the family and at work when such programmes all risk factors, including stress. The PAR corresponds to are being planned, and therefore they should generally be the proportion of myocardial infarctions that could theoretically combined with psychosocial interventions. be prevented if the risk factor could be eliminated in thepopulation. Regardless of country, age, gender and a number Depression and heart disease
of established risk factors, stress defined in this way either at home or at work corresponded in men to a PAR of 40% Among cardiologists, opinions about the importance in the ages before 55 and 24% in the ages above 55. The of stress in relation to cardiovascular disease are more corresponding numbers for women were 53% (before 55) divided. During recent years, however, there has been a and 31% respectively. As a comparison it could be mentioned growing consensus that depression is an important risk that in men, smoking corresponds to a PAR of 52% before factor in relation to cardiovascular disease. A comprehensive the age of 55 and 39% after 55. The corresponding numbers meta-analysis recently provided strong evidence for the for women are 21% and 8% respectively. association between depression and the risk of cardiovasculardisease (Rugulies, 2002). There is both evidence showing The conclusion from this study is that for men self-reported that depression is common after the onset of heart disease stress defined in this way and assessed after a heart attack and evidence showing that depression increases the risk of has great importance – as much as the most important developing myocardial infarction and of dying from an accepted risk factors. Its significance is as great as that infarction when heart disease has become apparent. Up to of cigarette smoking. 20% of patients have an episode of major depression within a few weeks of suffering a myocardial infarction, and a According to the same study only one measured risk factor further 25% experience elevated levels of depressive attains greater importance, namely a high apoB/apoA-1 symptoms. Depressive symptoms following acute ratio. This is the ratio between the concentration of proteins myocardial infarction are associated with increased carrying harmful lipids and proteins carrying protective lipids morbidity and impairment in quality of life.
The assessments in the Rosengren study capture a feeling of stress but do not specify what the sources of the stresscould be. In relation to stress, the findings only reflect what the patients consider important – after they have experiencedthe onset of the infarction. This is important in its own right, however. THE STRESS CONCEPT
Relevant concepts in stress prevention
The other groups of stressors mentioned in the table, in relation to cardiovascular disease
extraordinarily traumatic experiences (see Sondergaard, 2002)and a high prevalence of certain negative stressful life events Table 1 shows concepts that have been explored scientifically (see Moller et al., 2005, Rosengren et al., 1993) have been in relation to stress and heart disease. The concepts have been examined in only a few epidemiological studies in relation organised into the three levels described in Figure 1.
to social class (see Dohrenwend and Dohrenwend, 1974;Brown, 1973). These studies have indicated a clear relationship Table 1. Concepts examined scientifically in relation
between low social class and a high prevalence of negative to stress and coronary heart disease
life events. Sisyphus syndrome (a never ending comfortlessextreme struggle, see Wolf, 1969) and type A behaviour, Individual programme Mental reactions
which could be defined as a never-ending "excessive effort to overcome insurmountable obstacles" (see Friedman and Sisyphus syndrome Rosenman, 1959) are not related to social class in the way Bad work environment Chronic fatigue syndrome that would be expected. Hostility on the other hand – perhaps Lack of social support the most basic component of type A behaviour – is a "cynical" Family load and conflict Overcommitment attitude to life and to one's surroundings (Williams, 2003). This attitude is more common in the lower social classes Traumatic experiences* and also related to the risk of coronary heart disease early Stressful life events * Refers to extraordinarily stressful experiences which most people Chronic fatigue syndrome (Cleary, 2000), burnout (Maslach do not ever encounter in their lives, such as rape or natural disaster et al., 2001), vital exhaustion (Appels, 2004) and depressionare examples of disorders to which intensive periods of Social class is a concept that has been discussed extensively "stress" without periods of recuperation may contribute. (see Marmot, 2004) in relation to heart disease risk. From Vital exhaustion has been specifically related in prospective several points of view it could be regarded as an overriding studies to the development of coronary heart disease concept, but it does not cover all aspects of the relevant episodes (Appels, 2004; Prescott et al., 2003). Of these stressors. There is unanimous agreement among researchers disorders, depression is more common in the lower social that in industrialised countries low social class is associated classes (Brown and Harris, 1978; Stansfeld et al., 1999) both with increased prevalence and incidence of coronary heart whereas the relationship between chronic fatigue syndrome, disease and with several of the environmental risk factors that burnout and vital exhaustion on the one hand and social may give rise to increased prevalence of long-lasting stress.
class on the other hand is not clear. Some of the stressors listed in the table are more common in the lower social classes; these stressors may contribute to stress reactions that could partly explain social inequity in cardiovascular health. Examples of such stressors are poorworking conditions (see Marmot et al., 1999), lack of socialsupport (see Berkman and Glass, 2000) and troubled family life (Orth-Gomér et al., 2000).
Two models for describing adverse/beneficial work
The effort/reward imbalance model was introduced by Siegrist (1996). It states that high effort is associated with When we discuss stress with the aim of determining how health risk when it is not rewarded adequately. Reciprocity is to reduce it, is important that we define factors that we can the key concept. Effort has both intrinsic and extrinsic aspects.
influence by means of organisational efforts. The workplace The main component of intrinsic effort is "overcommitment".
is one major area for intervention, so we will begin with a The extrinsic aspect is similar to psychological demands in survey of recent research on the aspects and characteristics the demand/control model. Rewards have three components, of work that can cause stress.
which are referred to as material (monetary), social (for instancepromotion possibility), and psychological (self esteem). When Two models have been particularly influential for describing extrinsic effort is not matched by sufficient reward (sum of the stressors in workplaces, namely the demand/control/support three dimensions) there is an increased risk of illness. Intrinsic and the effort/reward imbalance models. Among the effort serves as an interacting variable (Siegrist et al., 2004). precursors of these models is the person-environment fit model (Kahn et al., 1964). In addition researchers have There is a growing body of research showing that both the constructed practical questionnaires for identifying a large demand/control and effort/reward constructs are related to number of stressors in workplaces (Hurrell et al., 1998; the risk of heart disease. Reviews including both models have Cooper et al., 1976). One of the broadest instruments been published (Schnall et al., 2000; Hemingway and Marmot, (including many factors and properly validated) is the General 1999; Marmot et al., 1999). The evidence for demand/control Nordic questionnaire for psychological and social factors at was summarised more recently by Belkic et al. (2004) who work (Lindström et al, 2000). These are very useful in made a methodological analysis of sources of error and intervention work. Here we focus mainly on the strengths in published studies. The conclusion was that there demand/control/support and effort/reward imbalance models is convincing evidence that job strain is a risk factor because they have been more extensively tested in relation for cardiovascular disease. to cardiovascular outcomes and mechanisms than the other models.
Loss of decision latitude has been shown to be associatedwith an increased risk of developing a myocardial infarction The demand/control/support model was introduced by (Theorell et al., 1998) or new episodes of cardiovascular Karasek (1979) and further developed by Karasek and Theorell disease (Bosma et al., 1997).
(1990). The support dimension was tested and discussed inmore detail for the first time by Johnson and Hall (1990).
There have been prospective studies with negative findings, According to this theory, the combination of high psychological however (Reed, 1989; Eaker et al., 2004). The participants in demands and low decision latitude (job strain) is particularly these studies have been relatively old. This means that a large dangerous to health, and the effects may be worsened by proportion of them have retired during the follow-up period. a lack of social support. On the other hand high demands It has been shown in previous research that the effect with high decision latitude (active work) may be associated of exposure to job strain diminishes after retirement. with psychosocial growth and improved coping. Decision A prospective European study (Kornitzer et al. 2006) with latitude has two components, decision authority (possibility a five-year follow-up on 20 435 middle-aged men previously of influencing decisions in daily work) and skill discretion free from coronary heart disease has recently been performed.
(possibility of using and developing skills). One hundred eighty of these men had myocardial infarctionsduring follow-up. After adjustment for age only there wasclearly an excess risk of myocardial infarction in the job straingroup (Odds ratio 1.53 with 95% confidence limits 1.00 to 2.35) but not in the active or passive groups. Afteradjustment for smoking and systolic blood pressure the odds ratio decreased to 1.47 with 95% confidence limits 0.96 to 2.25. The decision latitude component did notcontribute much to this association however. STRESS IN THE WORKPLACE
There is no evidence from studies in recent years that More detailed observations of working conditions have also the demand/control model shows a decreased ability been tried, and this seems to be a very fruitful area of research.
to predict new heart disease episodes in men.
Greiner et al. (2004), in their studies of bus drivers in SanFrancisco, have been able to show that objectively recorded Two studies of cardiovascular disease, the prospective adverse conditions in the working day of the bus driver are Whitehall II study (Bosma et al., 1998) and the Stockholm much more clearly related to blood pressure elevation than SHEEP study (Peter et al., 2004) used the two models are self-reports. Recent German research by Rau (2001) together, and the findings indicated that they predict coronary has indicated that the relationships between objective heart disease episodes independently of one another. In the working conditions and cardiovascular disease risk may Whitehall II study the decision authority component of the be even clearer than the ones between self-reported demand/control model and the effort/reward imbalance conditions and risk.
model both made independent predictions of new episodes of heart disease among previously healthy state employees. Other factors influencing work conditions
In Stockholm, SHEEP, a large population based case controlstudy of first myocardial infarctions, studied self-rated job Theoretically there is a possibility that adverse material strain as well as the intrinsic and proxy measures of the childhood circumstances (infections, nutrition, drinking water, extrinsic parts of the effort/reward model as separate etc.) could explain the relationship between psychosocial work variables. The results were different for men and women. conditions and coronary heart disease (see for instance For men a combination of job strain and imbalance between Wainwright and Calnan, 2001). Life course research is extrinsic effort and reward was the best predictor of myocardial beginning to address these kinds of questions. Several infarction status. In women the intrinsic part of the effort/reward findings speak against the interpretation that material model (overcommitment) had the same role as the extrinsic childhood conditions could explain it all. First, social class one in men – a combination of overcommitment and job strain in general does not entirely explain away the association was the best predictor of coronary heart disease episodes. between job conditions and ill health. Indeed, in studies inwhich associations have been explored in different social Psychological assessment of working conditions:
strata the relationship between job strain and heart disease, the subjectivity factor
for instance, has been much stronger in blue collar workersthan in white collar workers (Hallqvist et al., 1998). This Critics argue that "subjectivity bias" may explain most indicates that bad job conditions are not simply a "passive" of the associations observed between the psychosocial part of a bad social situation – they probably have effects work environment and coronary heart disease (Wainwright and Calnan, 2002; Mc Leod and Davey Smith, 2003).
A number of psychological dimensions that could possibly Hintsanen et al. (2004) have shown that job strain is influence the subject's description of his/her working associated with increased early signs of atherosclerosis in conditions have been recorded and used in analyses. young adult men and women even after adjustment for other These include hostility, including a cynical and suspicious risk factors. The same group of researchers, in their study of attitude to the environment, and negative affectivity, which a cohort of employees, made similar observations with regard is a propensity to evaluate everything negatively, both the to prospective relationships between work stress and risk of environment and one's own health. Both hostility and negative death from cardiovascular disease later in life. Both job strain affectivity could potentially create spurious relationships. Even and effort/reward imbalance remained significant predictors after controlling for these factors that could falsify the results even after adjustment for a number of childhood factors of the study, there were clearly significant relationships (Brunner et al., 2004).
remaining between working conditions and the risk ofdeveloping new cardiovascular disease episodes (myocardial If low decision latitude and lack of reward constitute parts infarction and angina pectoris) during follow-up (Bosma of the explanation of social inequality in health, they represent conditions that could be the focus of interventions. For severalreasons the health effects of such interventions are difficult to evaluate. One of the main reasons is that in a constantlychanging market, precisely those worksites which are participating in an intervention may be subject to mergers, Employees in another comparable part of the same outsourcing or other major structural changes. Such changes organisation (whose managers were not subjected to the may make it impossible to interpret the process. However, psychosocial training) were followed at the same intervals particularly in the Scandinavian setting, evaluations of the (130 subjects in each group). While cortisol remained health effects of organisational changes aiming at improved unchanged in the comparison group, the employees in the worker participation have been made (for a summary, see intervention group had a substantial significant decrease Wahlstedt, 2001). The effort/reward imbalance model has in serum cortisol during the follow-up year. There was also been the basis of an intervention for bus drivers a more favourable development of the serum concentration (Kompier et al., 2000).
of the liver enzyme gamma glutamyl transferase, and in femaleparticipants there was also a more favourable development of Organisational interventions in workplaces
serum triglyceride concentration in the experimental group than aiming at decreased heart disease risk
in the control group – both possible consequences of theimproved cortisol concentration. Psychosocial questionnaire It is hard to know what the action should be in preventive data from the same groups of employees indicated that the programmes. There are, however, other research findings development of decision authority was more favourable in the that could help us in this. For instance, in Danish and Swedish intervention group than in the control group, while demands studies (Olsen and Sondergaard-Kristensen, 1988; Karasek and work pace developed in the same way in the two groups.
and Theorell, 1990) it has been shown that a more specific These results indicate that managers could be one target adverse job condition, job strain (see below), which is a group in psychosocial worksite interventions and that combination of high demands and low degree of control, improvement of decision authority for employees may is associated with a population attributable risk (PAR) of be a crucial variable.
approximately 10% for men below 55 years of age and forworking women. If among working men below age 55 those Improved manager knowledge may not necessarily be the 25% who report the worst conditions from the job strain point only possible strategy, however. In a psychosocial intervention of view obtain improved working conditions (so that they have programme in Sweden (Orth-Gomér et al., 1994) a similar at least as good conditions as the remaining 75%) the strategy was used which involved all the employees in incidence of new myocardial infarctions would be reduced workplaces. Compared to the control group the intervention by approximately 10%. This proportion was calculated after group showed improved decision authority and improved adjustment for other risk factors.
lipoprotein patterns (which are associated with decreasedcardiovascular risk). Recently the Stockholm group (Theorell et al., 2001) performed an intervention study aiming at improved It is sometimes claimed that inference on causal mechanisms psychosocial knowledge in managers. The theory behind this has to be built on randomised controlled trials. Such a intervention was built upon both the demand/control/support fundamentalist view of research on causal mechanisms is and the effort/reward imbalance models. The managers in an hardly fruitful. Many established causal mechanisms connecting insurance company had mandatory psychosocial education risk factors and diseases have never been examined with once every second week (half an hour lecture and 90 minutes randomised trials. Examples are the associations between group discussion) for a whole year. The education programme smoking and lung cancer and between sleeping position comprised all relevant aspects of psychosocial working and cot death among babies. Nobody would suggest that conditions, such as the role of demand, decision latitude, we should wait for randomised trials in these fields instead support and effort/reward imbalance. Their employees were of applying our knowledge in practical prevention interventions. examined before, after six months and after a whole year withregard to psychosocial work conditions and serum cortisol(when they arrived at the office in the morning). STRESS IN THE WORKPLACE
When it comes to intervention studies in the field of stress and they also experienced conflicting demands from the at work and CVD there are many obstacles and barriers clients. The study showed significantly higher cholesterol that prevent researcher from applying the ideal randomised levels and shorter clotting time during the busy periods intervention trial. before deadlines. These two factors were seen as indicators of increased risk of CVD during the busy periods. • The researcher does not have the power to reduce or change exposures at the worksite. Orth-Gomér studied the association between shift work and • Randomisation is usually not possible and rarely desirable risk of CVD by following two groups of Stockholm policemen.
from an ethical point of view. One group started to work according to a "clockwise" rotation • The potential number of participants is usually too small system schedule, while the other group worked according to and the follow-up time too short to obtain the necessary the usual "counter-clockwise" system. Under a clockwise statistical power if CVD cases are the endpoints. system the policemen started a bit later every day, which • In most cases many unforeseen factors influence the course is more in accordance with biological rhythms since the of events and tend to overshadow the significance of the spontaneous circadian period has been shown to be factors being studied. approximately 25 hours. After four weeks of work the twogroups switched schedules. The analyses showed that Facing these challenges intervention researchers triglycerides, systolic blood pressure, serum glucose, and have turned to one or more of the following solutions: serum uric acid levels were lower during clockwise rotation.
Self-rated health, length of sleep and quality of sleep were • Use of intermediate endpoints instead of "hard endpoints" also better during the clockwise rotation period. Thus, the such as hospitalisations or mortality. Such intermediate study pointed at the clockwise system as the healthiest endpoints are blood pressure, cholesterol level, CVD risk from a CVD point of view. Furthermore, the study also score, carotid artery wall diameter or other established demonstrated that the system was acceptable and feasible.
CVD risk factors. • Use of non-randomised control groups such as workers In another Swedish intervention study Johansson et al.
at similar workplaces with the same social status. followed CVD risk factors in a group of bus drivers where • Use of "natural experiments" where potential risk factors improvements were introduced concerning work stressors. are changed as a result of company decisions or the Bus drivers from similar routes were studied as the control enforcement of new laws. group. On the intervention bus routes physical changes weremade in the streets and technological improvements were Such intervention studies usually elucidate two important introduced in relation to passenger service. The follow-up study showed that drivers in the intervention groupexperienced fewer hassles at work than before the intervention.
• The causality issue: does the "pill" have the desired effect? In the drivers in the intervention group the systolic blood • The feasibility issue: Does the patient take the "pill"? pressure, the diastolic blood pressure, the pulse rate, and These issues are equally important. It does not help that the stress level went down. The study confirmed that it was the pill has an effect if the patient does not take it. And it possible to reduce the level of job hassles among bus drivers, does not help that the patient takes the pill if it has no effect and that this reduction resulted in reduced CVD risk factor (Kristensen, 2005).
levels. The study is very relevant since bus drivers are known as one of the high risk groups with regard to CVD.
A few examples of CVD intervention studies will be described below.
In a Norwegian study Erikssen et al. followed a group of 225workers at a ferro-alloy plant. During the first years of follow-up In a classical study Friedman et al. studied cholesterol and the blood pressure was constant over time. Then the average blood clotting among tax accountants. This was a natural level of systolic blood pressure increased by approximately 15 experiment where the time before deadline for the accounts mmHg, the diastolic blood pressure by about 10 mmHg, and was considered as the "exposed period". The accountants the pulse rate by 7 bpm. Further analyses showed that the served as their own control group. During the busy periods only likely explanation of this rather dramatic increase in the accountants worked as much as 70 hours per week average blood pressure was the continuous rumours about a possible factory closure. Since the plant was the only large scientific evidence confirming this. Studies (Hinkle et al., 1968) worksite in the geographic area, the closure would have a in the 1960s and 1970s showed that extremely long working dramatic impact on the lives of the employees and their weeks (more than 60 hours per week) were associated with families. This study shows the dramatic impact of an "invisible" an increased risk of developing myocardial infarctions or stressor connected with a low level of control and predictability.
dying of coronary heart disease at a young age. In this natural experiment there was no control group, but theresearchers found it very unlikely that the average increase Few studies concerning long working hours have been in blood pressure in such a large group of workers could published during recent years. However, a Japanese study happen by chance. (Sokejima and Kagamimori, 1998) of white collar workersshowed that both short (below regular work hours per week) In a Danish study of an actual closure of a shipyard, Iversen and long work weeks were associated with elevated risk.
et al. chose the workers in a similar shipyard as the control Another very recent Japanese case-control study (Fukuoka group. The incidence of hospitalisations due to CVD was et al., 2005) showed very clearly that patients reported longer followed for the two groups in the national hospitalisation working hours than control subjects. An epidemiological study registry. The analyses showed that the relative risk among of a large Swedish cohort was based upon imputations: in the workers in the closed shipyard was 0.80 during the two national surveys specified occupations were shown to have years before closure, 1.04 during the period of closure, and a large proportion of subjects with working weeks exceeding 1.60 during the two years after closure. For ischemic heart 50 hours per week. These occupations were compared with disease alone the relative risk was 2.60 during the years other occupations with regard to incidence of hospitalisation after closure. Thus, the study suggests that a factory closure for myocardial infarction. This study (Alfredsson et al., 1985) connected with low control, low predictability and a low level showed different results for women and men. For women the of rewards results in a marked increased risk of CVD. expected relationship was found – a higher incidence of heart disease in the occupations with long working hours. These and other interventions in the field of psychosocial In men the opposite was found, however – those assigned factors at work demonstrate that it is possible to carry out (mainly moderately) long working hours were associated with intervention studies in this field, although it is nearly impossible a lowered incidence. In this study no adjustments were made to apply the strict model of the randomised controlled trial for biological risk factors or for social class. The findings are (Kristensen, 2000). The number of intervention studies is therefore difficult to interpret. Still, they point to the importance increasing steadily and so is the quality of these studies. of context in relation to working hours. In addition there may This is a very promising field of research because it deals be threshold effects. This could mean for instance that in with the two equally important topics of aetiology men a working week of at least 60 hours per week is required and feasibility. before an increased cardiovascular disease risk occurs while in women 50 hours per week may be sufficient. Specific working conditions
Long working hours per se may not increase risk. However, Shift work
in certain occupations – for instance among professionaldrivers, (see Belkic et al., 1994), with a high degree of Shift work defined as constant rotation between day and attention and fear avoidance – long working hours may night work has been shown to be associated with an increased risk of myocardial infarction (for a review see Boggild andKnutsson, 1999). It has also been shown that improved shift In studies published earlier it was difficult to differentiate work schedules (going from "counterclockwise" to "clockwise") the effects of long working hours from the effects of high may decrease the risk of coronary heart disease psychological demands in general. During the 1970s unexpected results were obtained during the long-term follow-up of two Belgian cohorts, both composed of middle- Long working hours
aged males working in Brussels, one in a private bank and the other in a semi-public savings bank. At five and ten years Despite the intuitive idea that long working hours could follow-up respectively – with higher incidence in the private increase coronary heart disease there is relatively sparse bank – a significant difference in the incidence of new hard STRESS IN THE WORKPLACE
coronary events was observed; these differences could not Although the triggers (both week and day preceding) were be explained by differences in classic coronary risk factors potentially important, they did not have great value from (Kornitzer et al., 1975; Kornitzer et al., 1979). A retrospective the public health perspective since despite the statistical ecological study was started in those retired at the ten-year relationship very few myocardial infarctions occur in relation follow-up survey. They were given a specially constructed to such events. Still these relationships point at important questionnaire concerning their job content with questions on theoretical associations – which could be used in perceived psychological demands, decision latitude and social preventive work.
support at work as well as on financial problems. A computedweighted job stress score was significantly higher in those Downsizing and reorganisation in modern working life
retired from the private bank as compared to those from the semi-public savings bank (Kittel et al., 1980).
With the advent of economic globalisation in combination with progress in information technology, competition between This job stress score showed important correlations with companies and pressure towards an increase in the return the type A behaviour pattern and socio-professional level. on investment have been growing over the past two decades.
The same job stress questionnaire was then administered As a consequence, work pressure increased considerably in at the baseline survey of the Belgian Interuniversity Research several private sectors of national economies, but also in on Nutrition and Health Study (BIRNH Study) in 2257 middle- public sectors, due to financial cuts in public expenditures aged working males (Kornitzer and Bara, 1989). After ten (Eurostat 2004). Finnish studies have shown that pronounced years of follow-up the job stress questionnaire was found downsizing among employees in a municipality (follow-up of to be an independent predictor of cardiovascular mortality 7.5 years) is associated with a doubled risk of cardiovascular with a relative risk (RR) of 1.23 adjusted for age, death (Vahtera et al., 2004). Such sweeping changes in systolic blood pressure, smoking, blood cholesterol working life are also associated with privatisation of parts and education level (Kittel et al., 1998).
of the public sector. A study of Whitehall II participants (civil servants in London) during the late 1980s and early In a more recent study, cases of first myocardial infarctions 1990s showed that those who were threatened by or went were compared to matched population control subjects. through privatisation (with resulting threats to job security) In addition the myocardial infarction cases were interviewed had subsequent deterioration in cardiovascular risk patterns in detail about possible triggering factors during the 24 hours with increasing body mass index and increasing blood pressure and the week preceding the myocardial infarction respectively.
(Ferrie et al., 1998). This could not be explained by changes in The disease-free periods preceding the onset were used in health-related behaviours and accordingly physiological these latter comparisons (Moller et al., 2005). It was found reactions related to long-lasting stress could have that increased responsibility and conflicts at work (similar to contributed to this health change. the findings in the prospective study) were more common in the case group than in the control subject group. Governments particularly in Sweden, Norway and The Financial problems were also reported much more often Netherlands have been worried about rising and very in the case group. expensive long-term sick leave rates during the late 1990s and early 2000s. In relation to cardiovascular disease the All these findings were made in both men and women, and consequences of these processes have been of particular adjustment for other risk factors made very little difference.
interest. In the Whitehall II studies civil servants without initial According to these self-reports, triggers during the week signs of heart disease but with other symptoms of ill health at preceding myocardial infarction were "deadlines at work" the start of this period were followed (Kivimäki et al., 2005). In and "praise from boss" (trying to push the patient to work this group, civil servants who had not had sick leave episodes more?), and during the 24 hours before the onset the trigger during follow-up ("sickness presenteeism" or working while ill) was work pressure due to deadline. Accordingly both in had a doubled risk of developing myocardial infarctions prospective and in cross-sectional studies work changes compared to comparably "sick" civil servants with at least related to responsibility, work load and relationships seemed one or several sick leave episodes during this period – after to be important. adjustment for other risk factors. Thus sickness presenteeismmay be associated with increased cardiovascular risk during periods of reorganisation. Sweden is an interesting case in this context. During the 8% increase) and expansion (> 8% increase) were identified.
1990s Sweden went through a pronounced financial crisis Sick leave spells lasting for at least 15 days during the which resulted in markedly increased unemployment rates.
calendar year following the downsizing/expansion were Some economic recovery took place during the latter part identified through individual linkage with the national of the decade, at the expense of increasing demands and insurance register. Interestingly, among women it was decreasing decision authority, most pronounced in the public found that sickness absence during the year following sector of employment (Theorell, 2004). In the period from downsizing was decreased compared to the group of women 1997 to 2001, a sharp increase in long-term sick leave was employed in stable worksites. This may again reflect some observed, particularly among women in the public sector pressure towards "sickness presenteeism", because the trend (Westerlund et al., 2004). The biennial national Swedish Work was particularly pronounced among women with an elevated Environment survey offered an opportunity to analyse the cardiovascular risk score (Theorell et al., 2003). All these impact of expanding and shrinking organisations on sickness findings illustrate the importance of including structural absence and hospital admissions in a prospective design.
changes of labour market and work, in particular downsizing Long-term (≥ 90 days) medically certified sickness absence and continued rapid expansion, in research on work stress and hospital admissions for specified diagnoses during 1997 and health. They also illustrate that cardiovascular disease to 1999 were related to changes in number of staff in the shows a somewhat different pattern than many other health organisations' workforce in previous years (1991 to 1996). changes. Taken together the findings illustrate that excessive As expected, downsizing was associated with elevated long- sickness presenteeism could be particularly dangerous term sick leave. A moderate increase in number of staff was to cardiovascular health, at least among women. associated with an improvement in staff health. Repeated rapid large expansion of the number of staff members That employees with stable working conditions (defined by during several years, on the other hand, was associated managers in the respective worksites) have fewer risk factors with increased long-term sick leave and hospitalisation. for cardiovascular disease than employees with more unstable Such a rapid expansion may cause chaotic conditions conditions was shown in an epidemiological study in Sweden with many stressors. In the public sector such a rapid and (Westerlund et al., 2004).
pronounced increase in number of staff may be due to theclosing of a hospital or a health care centre with the staff in this unit subsequently being placed in adjacent centres.
While the findings on long-term sick leave in relation to rapidexpansion were most pronounced for women in the publicsector, the findings for hospitalisation for cardiovasculardisease were significant only in the private sector women(Westerlund et al., 2005). A further Swedish study analysed the association of expanding or shrinking organisations with"absenteeism" or "presenteeism" in a group of employees who were at risk of developing cardiovascular disease (Theorell et al., 2003). Subjects were 5720 employees aged 18 to 65 in the WOLF study (a prospective study of biologicaland psychosocial cardiovascular risk factors in working menand women in the Stockholm area during the years 1992-1995). From a medical examination a cardiovascular risk score was calculated for each participant. The WOLF study base was linked to national registers of economic and administrative activities in worksites. Worksites withdownsizing (at least 8% decrease from one year to the next),stable number of staff (changes less than 8% decrease or Marital load and conflict
Tsai et al. (2004) recently published a large prospective A few studies have found that a close confiding marital study of the association between involuntary unemployment relationship may protect against coronary heart disease. and cardiovascular mortality in Taiwan in 2001-2002.
The first one was a cohort study in Israel (Medalie et al., Adjustments were made for gender, age, income, firm size 1973). Marital conflicts were studied in relation to the risk and urbanisation that could give rise to spurious associations.
of developing new episodes of cardiovascular disease in a It was shown that involuntarily unemployed men in 2001 had cohort of women who had suffered a myocardial infarction a significantly elevated cardiovascular mortality in 2001 and or severe angina pectoris at the start. Such conflicts predicted 2002. Kim et al. (2004) showed that cardiovascular mortality new episodes of heart disease independently of other risk increased very rapidly after the recent economic crisis in Korea factors (Orth-Gomér et al., 2000). A recent follow-up also with a marked rise in unemployment rates. Henriksson et al.
indicated that the progression of coronary atherosclerosis (2003) published a study from southern Sweden based was more pronounced in this group than in other groups upon an examination of a cohort of 1430 men who were (Orth-Gomér et al., 2005). A combination of marital conflict followed for six years ending in 1997, when the participants and job strain was a particularly strong predictor of were 43 years old. During the beginning of this period the atherosclerosis progression (submitted 2005). unemployment rates rose dramatically. The study showed that risk factors for cardiovascular disease were clearly It is obvious that the quality of the marriage could be increased with unemployment at the start but not in the of great importance to risk and that this could be a target middle or late 1990s when the unemployment rate was high. for interventions. How can these diverging findings be understood? Lack of social support
That the experience of unemployment is a strong stressor has been shown in longitudinal studies (see for instance The importance of social support has been studied for many Brenner and Levi, 1987; Cobb, 1974). Accordingly elevated years in relation to coronary heart disease. In general a large serum cortisol, serum lipids and blood pressure have been social network (many family members, colleagues and friends) observed particularly after job loss. The discussion (see will mean good social support (see Berkman and Glass, 2000).
Janlert 1997) regarding the association between job loss There are different aspects of social support. There is potential and cardiovascular disease risk has dealt with the fact that support at work and outside work, and support may be on the one hand subjects with cardiovascular risk due to emotional as well as instrumental. In the former category excessive tobacco smoking or low physical activity may run there is emotional support in crisis situations but also emotional a greater risk of becoming unemployed than others, and on support in the daily round of life. In the latter category there the other hand the experience of unemployment in itself may are more material aspects of support including access to lead both to long-lasting stress reactions and adverse information that we may need. It has been pointed out that changes in personal habits that may increase risk. Although a large social network may play a different role for men versus these different paths may be difficult to disentangle there is women, however. Among men a large social network is mostly agreement that both processes may exist together. The beneficial, whereas for women a large social network may intensity that the unemployment experience may have correspond to a high psychosocial load. depends upon the time period and upon the societal context.
The two Asian studies may illustrate that in countries with It has been suspected for a long time that social very little societal support to the unemployed the cohesiveness is associated with a low risk of developing unemployment experience may be a very strong stressor.
coronary heart disease (see for instance Marmot, 2004; However, in countries with functioning social protection Berkman and Glass, 2000; Orth-Gomér and Johnson, 1987).
the unemployment experience may be a weaker stressor.
This idea has also been subjected to intervention studies(Schneiderman et al., 2004). These interventions have not been directed so much at the social support itself but rather at the individual's own ability to obtain social support. Inaddition they have been of rather low intensity and the findingshave not been conclusive. In one of them (ENRICHD), a largeAmerican multi-centre study, patients who had suffered a firstmyocardial infarction were approached with a programme for improved social support. Follow-up data did not show any significant effects of the programme on the outcome measures, coronary artery disease. Evidence has emerged from studies and surprisingly the effects were different for men and women.
of the effects of natural disasters such as earthquakes, and Whereas some beneficial effects were observed for white men interviews with survivors of myocardial infarction. Emotional there were no effects for female patients. This may be an stress and emotions such as anger appear to be particularly illustration of possible gender differences in the meaning relevant (Moller et al., 1999). A heightened tendency to of social support.
stress-induced activation of blood platelets may be responsible for emotional triggering in susceptible On a societal level there is an indication that a cohesive society individuals (Strike et al., 2006).
protects against coronary heart disease. In a series of studies,Marmot et al. showed that Japanese men who migrated to Individual traits – personality and behaviour patterns
Hawaii or California were less likely to adopt the highAmerican incidence of coronary heart disease if they Sisyphus syndrome and type A behaviour pattern are two were able to keep the cohesive Japanese social individual traits that have been explored extensively in research patterns (Marmot and Syme, 1976).
on coronary heart disease. Although they are related, the mostextensively studied of the two is the type A behaviour pattern.
Traumatic experiences and negative life events
The central characteristic was initially described as a propensityto manage insurmountable obstacles. Psychological research Although among laypeople there is a common idea that showed that this pattern, which was initially based upon clinical negative life events may play a role in the development of observations of young male victims of myocardial infarction, coronary heart disease, there are relatively few published had three basic components, namely "high drive" (a high studies on this theme. In particular there are very few tempo), "impatience and hostility" and finally "obsession with prospective studies. Li et al. (2002) performed a large scale work". Several questionnaires were constructed but the most study of parents who lost a child. They showed that the effective instrument for predictions was a structured interview loss of a child does increase the risk of developing a (for a review see Matthews and Haynes, 1986). After several myocardial infarction. However, this seems to occur with prospective studies had presented negative findings (Kittel et some delay since the risk did not become obvious al., 1986; Ragland and Brand, 1988) the interest in type A until several years had passed. behaviour was attenuated. Type A behaviour research,however, had introduced programmes for the reduction of type Theorell et al. (1975) performed a prospective study with A behaviour (Thoresen and Powell, 1992; Burell and Granlund, a two-year follow-up of a large cohort of middle-aged building 2002; Sundin et al., 2003) and it was shown that these construction workers. A high life event score (Holmes and programmes were effective in one way or the other in Rahe, 1967) was not associated with risk, but one particular secondary prevention. This means that educational life event related to work, increased responsibility, was programmes were successful in reducing type A behaviour associated with an elevated one-year risk of myocardial in patients with coronary heart disease and that this may infarction. In the two-year follow-up a cluster of events have contributed to a reduced incidence of new coronary that included changes in responsibility and conflicts at heart disease episodes during follow-up.
work was associated with increased risk (Theorell and Floderus Myrhed, 1977).
In the epidemiological studies it was found that the hostility component was more important than the other Most of the prospective studies in this field deal with specific type A components. Several prospective studies showed a events such as death of spouse and retirement as triggers of relationship between a high degree of hostility and subsequent myocardial infarction. The findings in this research have not risk of developing a myocardial infarction, including in been unequivocal. It seems likely that the health risk associated secondary prevention (Boyle et al., 2004). In addition hostility with such events is modified by a number of psychological was shown to be related to social class in the expected and social factors. Lack of control and marked social threats way (more hostility in the lower social classes) and it was in life events may be important aspects. also shown to be related to several physiological parameters of relevance to coronary heart disease (for a review see There is, however, evidence that acute stressors and negative Williams, 2003). In addition it was shown that educational emotional states may act as triggers of myocardial infarction programmes aiming at reducing hostility were successful. (Strike and Steptoe, 2005). In these cases, psychologicalfactors do not ‘cause' heart disease, but instead precipitatemajor cardiac events in individuals who already have underlying THE INFLUENCE OF GENDER
Most of the older literature on stress-related factors and Energy has also been devoted to an improved understanding coronary heart disease was dominated by studies of men. of the role of gender in the associations between the life For instance, type A behaviour and hostility are concepts conditions in working ages in relation to health. For instance, that were constructed mainly on the basis of young male in the example described above the demand/control and the victims of coronary heart disease. It has been shown that effort/reward models were combined in the predictions of the psychological profile of women who develop coronary myocardial infarction cases in the SHEEP study. Intrinsic effort heart disease at younger ages is different from the (overcommitment) in combination with job strain (high demand corresponding profile of men (Hällström et al., 1986; and low control) was a good predictor in women, while Orth-Gomér, 1998). According to these researchers a extrinsic effort/reward imbalance in combination with job submissive passive coping pattern seems to be of greater strain was a good predictor in men (Peter et al., 2003).
importance for women than hostility and type A behaviour.
Although this is very speculative since the number of This study was followed up by a study based upon the published studies in this field is small, more outgoing analytical model proposed by Hall (1990). This model aggressive coping behaviours seem to be relevant for men's addresses the effects of the working climate induced by coronary heart disease while a more inwardly-directed male and female dominance respectively. Subjects working behaviour seems more relevant for coronary heart disease in occupations with male and female dominance, respectively, were examined with regard to the prevalence of myocardialinfarction, and interactions with the components of the It has been known for a long time that working women report effort/reward imbalance were explored. Women with much lower decision latitude at work than working men. Most overcommitment working in male-dominated jobs were at of this difference seems to be due to the fact that women are particularly high risk of belonging to the myocardial infarction less often promoted to become supervisors and managers group even after adjustment for other risk factors (2.7 (1.1- than men (Karasek and Theorell, 1990; Hall, 1990). Women 6.5)). This points to the potential importance of gender and men who have the same jobs with the same level of segregation and the role that female overcommitment responsibility report very similar levels of decision authority and may play in male-dominated jobs (Peter et al., 2005).
skill discretion. This seems to be true both for managers andfor blue collar workers (see Bernin and Theorell, 2001; Theorell, An interesting new line of research has been introduced by 1991). The finding that men in general tend to report higher Chandola et al. (2004), who studied "control at home" and levels of decision latitude at work than women has been how this relates to risk of new episodes of coronary heart repeated in many studies and seems to be as relevant in disease in the Whitehall II study. After adjustments it was found European working life today as it was in the 1980s and that low control predicts coronary heart disease in women but 1990s. The same observation is also relevant for two of the not in men. Furthermore, the results indicated that perceived reward dimensions, material rewards (salaries) and career lack of control at home mediates part of the relationship opportunities: Women have lower salaries and poorer career between low social position and coronary heart disease in opportunities than men even at comparable education levels.
women, and that part of this could be due to a lack of This points to a gender perspective that could be fruitful material and psychological resources for coping with in future intervention efforts.
excessive household and family demands in women belonging to the lower social classes.
Another difference between women and men in relation tocoronary heart disease risk is discussed briefly in the sectionon social support below. Although a wide circle of friendsdecreases risk for men, evidence indicates that the significance of this factor is different for women. BIOLOGICAL MECHANISMS

These associations were particularly strong in subjects whoreported a high level of "anger out", a tendency to react with How can the two models, the effort/reward imbalance model openly expressed anger in stressful situations. A study of and the demand/control/support model, be linked biologically Japanese female health care workers (Fujiwara et al., 2004) to heart disease risk and other health risks? Long-lasting showed more elevated urinary catecholamine output in those excessive energy mobilisation without periods of relaxation with self-reported job strain than in others. Saliva cortisol has been related to disturbances in the regulation of energy levels, on the other hand, were consistently lower in the mobilisation (Mc Ewen, 1998). Energy mobilisation also job strain group than in the others. inhibits regeneration (Theorell and Hasselhorn, 2002). Studies of cortisol regulation in subjects with job strain and Energy mobilisation is reflected in such parameters as blood imbalance between effort and reward have not shown a pressure elevation and elevation of catecholamine, cortisol and consistent picture. However, disturbed regulation has been thyroid hormone excretion. Both cortisol and catecholamines observed in several studies. Whether elevation or depression can also be assessed in urine. In addition cortisol can be of cortisol levels arises may vary between samples, and assessed in saliva (Kirschbaum and Hellhammer, 1999). Saliva depend on type of job, gender and duration of exposure. cortisol is easily collected, which makes it possible to record In subjects who have retained their capacity to regulate energy, circadian rhythms. In general energy mobilisation corresponds the excretion of cortisol is high particularly in the morning to high serum concentrations of these hormones. During when the job situation is stressful (because of high demands, normal conditions the morning cortisol levels are much higher high commitment or lack of control). Later in the day, however, than the evening levels. The assessment of circadian rhythm these subjects are able to lower their cortisol excretion.
in different states of long-lasting stress has shown that not Patients with long-lasting severe depression are sometimes only repeated peaks reflect responses to demands for arousal.
unable to down-regulate cortisol excretion in the evening – Disturbed regulation of cortisol levels can also arise during they accordingly seem to have "too high" levels at night. long-lasting periods of adverse psychosocial conditions.
Finally, when the stressful conditions have lasted for a long Inability to down-regulate (high levels in the evening and night) time (months) and more severe psychiatric symptoms are as well as inability to respond (low flat curves) have been found (anxiety syndromes, sleep disturbance and mild observed in subjects with stress-related disorders depression) the levels are likely to be lower than average, (Rosmond and Bjorntorp, 2000; Cleary, 2000). particularly in the morning (Alderling et al., 2004). This could be regarded as a form of physiological exhaustion. During There is a rapidly growing literature which relates both such conditions serum lipids are likely to be elevated and the demand/control/support model and the effort/reward anabolism indicators, namely testosterone (in men) and imbalance model to cortisol regulation. Steptoe et al. (2004) oestrogen levels (in women), are likely to be depressed have studied variations in saliva cortisol over the day in relation (Rosmond et al., 2004). Whether or not these different to overcommitment and the external part of the effort/reward kinds of regulatory disturbances are related to one model. The study, which was based upon contrasting samples another sequentially is not known, however.
from the Whitehall II study, showed that men who had highscores on the overcommitment scale had on average 22% Heart rate variability due to job stress
higher saliva cortisol concentrations than men who had lowscores. Heart rate variability is a relatively new concept. It builds upon the fact that the heart rate varies due to many biological Comparisons between these groups also showed that the rise processes that have "rhythms" of their own. For instance in saliva cortisol concentration from awakening to half an hour breathing affects heart rate variations. When we inhale our later was higher in overcommitted than in non-overcommitted heart rate increases, and when we exhale our heart rate men. No such findings were made in women. The external decreases. These variations are less pronounced when we part of the effort/reward score was not related to saliva become old and when we are exposed to a situation that cortisol levels in men or in women. evokes a stress response. For instance the parasympatheticsystem (which is the "slowing-down" system) also has a Steptoe et al. (2000) have also shown that teachers (men or "rhythm" (peaks and troughs in activity) of its own that is women) with job strain have higher saliva cortisol levels at mostly faster than our breathing rate. Advanced computer 8.00 and 8.30 in the morning than other teachers. programmes can sort out such rhythms and this means BIOLOGICAL MECHANISMS OF STRESS
that they can give us information about the level of activity in In the Whitehall II study a relationship was found between the parasympathetic system. In general a high rate of activity low job control and high ambulatory blood pressure, although in all the systems that create such variation is an indicator of demands had no effect (Steptoe and Willemsen, 2004). good health. Collins et al. (2004) have followed spontaneousvariations in job strain and control in subjects with jobs "low" For many years it was believed that there is no relationship and "high" in job strain, respectively. Their dependent variable between blood pressure measured in the conventional way was variations in heart rate. The findings on heart rate (in the doctor's office) and job strain described as a stable variability indicated that there were associations between job characteristic. Two prospective population studies have job strain and/or lack of control on the one hand and recently shown that job strain does predict incident decreased parasympathetic activity on the other hand. hypertension even when other factors have been adjusted. The first one was the CARDIA study in the USA (Markovitz Another "new" principle is to record how fast the heart et al., 2004) which followed 3200 employed initially healthy muscle contracts during a beat. Vrijkotte et al. (2004) found normotensive subjects aged 20 to 32 from 1987-1988 for a significant association between the pre-ejection fraction eight years. Subjects who had had increased job strain (velocity of contraction – an index of sympathetic drive in were more likely than others to have developed hypertension. the heart) and overcommitment in a study of 67 white collar The other study is a Canadian population study workers who were followed during two work days and one (Brisson et al., 2004) with similar findings.
non-work day. In summary there is evidence that job strain,lack of control and overcommitment are associated with high levels of energy mobilisation and inhibition of the "slowing-down" system.
The evidence is growing that psychosocial factors maycontribute to elevated plasma fibrinogen, an indicator of inflammatory activity and increased coagulation (for a review see Theorell, 2002). Accordingly, adverse long-lasting Blood pressure regulation has been studied extensively psychosocial conditions may induce bodily states that increase in relation to decision latitude and job strain. The study of the vulnerability to illness. Enhanced coagulation and increased working men in New York City (Landsbergis et al., 2003) has inflammatory activity could both be regarded as phenomena shown consistent relationships between a high "life exposure" that accompany energy mobilisation. There has been to job strain and high systolic blood pressure during continuous increasing attention during recent years to the immunological blood pressure recordings in prospective analyses. The system and its role in the atherosclerosis process. researchers also found strong cross-sectional associationsbetween job strain and both systolic and diastolic blood The immune system has been studied both in epidemiological pressure (Schnall et al., 2000). and in experimental examinations. Similar results were found in a Swedish study of working Inflammatory responses have become increasingly important men when borderline hypertensives were examined with in atherosclerosis research and in addition there seems to continuous blood pressure recordings and job strain be a strong link between stress and the immune system.
measurements inferred from other sources (Theorell et al., Accordingly the immune system is relevant both to stress 1991) and these findings were later confirmed in more detailed and to coronary heart disease. During recent years both analyses (Rau et al., 2001). Rau (2001) has also studied blood experimental and epidemiological research points to the pressure during work activities in relation to job strain using importance of this link.
very detailed information regarding job conditions; thesestudies have confirmed that in white collar workers there is an independent contribution of more objectively assessed job strain to blood pressure level.
The serum concentration of gamma globulin G (which is a A factor that is of great importance to regeneration is sleep.
crude indicator of immune activity) was followed in employees During deep sleep the growth hormone concentration in the who had spontaneous variations in job strain. The results blood is generally very high as an indication of high anabolic showed that the concentration increased with increasing activity, and the serum testosterone concentration in men is job strain but also that this phenomenon was limited almost lowered after disturbed sleep. Disturbed sleep has been entirely to subjects who had poor social support in their shown to be associated with an elevated risk of developing general life situation (Theorell et al., 1990). coronary heart disease episodes and also with the progression of coronary atherosclerosis (Leineweber et al., Interleukin 6 concentration in serum has been studied 2003; Leineweber et al., 2004). Burnout is associated not in relation to the demand/control model in a Swedish only with marked disturbances of sleep but also with elevated epidemiological study (Theorell et al., 2000). Low decision serum lipids and other components of the metabolic latitude was associated with high serum IL-6 in men syndrome (Söderström et al., 2004, Ekstedt et al., 2004, but not in women. Low job control has also been associated Grossi et al., 2003). Studies have shown that reduction of with impaired vascular endothelial function in the Whitehall II sleep to only four hours per night results in severe (reversible) study (Hemingway et al., 2003). Another analysis from the disturbances in insulin resistance (Gonzalez-Ortiz et al., 2000).
Whitehall study has demonstrated that individuals exposed to Accordingly reduced sleep may result both in excessive work stress (high demands and low decision latitude coupled energy mobilisation and reduced anabolism. There is also with low social support at work) are more than twice as likely a relationship with job strain since a longitudinal study than others to develop the metabolic syndrome over a 14 year (Theorell et al., 1988) showed that increasing job strain follow-up period (Chandola et al., 2006).
was followed by increasing sleep disturbance. Regenerative activity: protection against stress
Accordingly, changes in energy mobilisation and regenerativeactivity are two possible mechanisms behind the association Regenerative activity, one of the most important protective between psychosocial conditions and cardiovascular disease.
forces against stress, is reflected in the serum concentration The evidence is good enough at this point to provide of testosterone (men), oestrogen (women) and their joint biological plausibility for the relationship between stress precursor DHEA-S. A longitudinal study of variations in job and heart disease.
strain in men showed that periods of high job strain wereassociated with lowered serum concentration of testosterone(Theorell et al., 1991). Hansen et al. (2003) studied metabolicand endocrinological concomitants of repetitive work (sewingmachine operators) which were shown to be associated withincreased glycated haemoglobin (HbA1c), which is an indicatorof long-term energy mobilising, and with lowered DHEA-S aswell as free testosterone. A one-year follow-up study in the late 1990s in Sweden (Hertting and Theorell, 2003) showedthat female health care staff members had a lowered serumconcentration of oestradiol (the female counterpart of maletestosterone and also an indicator of anabolic/regenerativeactivity) after having experienced the latest episode ofdownsizing (which occurred after several years of repeatedepisodes of downsizing). The evidence on regeneration is,however, much weaker than that on energy mobilisation.
The concept of stress has played a much more important when the person is under stress. Relatively simple pieces role in ideas about cardiovascular disease among laymen of advice in this field could have quite substantial effects than among experts. There are several reasons for this. on the tolerance to stress. Such advice could be related On a theoretical level, stress is more difficult for health care to room temperature, activities preceding sleep, ingestion practitioners to define and assess than widely accepted coronary risk factors such as physical activity, tobaccosmoking, serum cholesterol and blood pressure. It is also believed to be more difficult to deal with from a societal point of view. Stress is often believed to be difficult to address on A number of pieces of advice relating to lifestyle are important a practical level as well – which is in fact even more important in stress prevention, although these will not be discussed in since preventive work directed towards adverse forms of stress detail here. Physical activity, diet with adequate intake of is not primarily the responsibility of physicians or health care calories and vitamins, avoidance of extensive ingestion of providers. The result is that often physicians feel that they coffee and alcohol etc. are examples. Policies that make it cannot do anything about the patient's stress and therefore easier for individuals to exercise regularly and eat a healthy avoid the subject altogether. In particular the primary care diet are called for. physician cannot easily influence the patient's workingconditions. Reduction of type A behaviour and hostility
In order to tackle stress as a risk factor, health care These are usually programmes that subjects with manifest professionals will need to modify their approach to put coronary heart disease are motivated to follow. The more emphasis on this aspect of treatment. Helping patients programmes are mostly organised in groups at regular recognise the stress they experience, reducing it where intervals – every week or every other week – and could possible and coping better where stress cannot be reduced, last for many months. Such programmes are often difficult is the primary contribution that physicians can make. However, to introduce in groups without illness. But they could since stressors come from the broader environment as well, be introduced in special groups that are motivated effectively dealing with stress also requires the cooperation for other reasons. of human resources managers in companies and policy makers in government. Improved social support
With regard to individual level protective interventions it is Although no controlled intervention studies have shown obvious that the findings in the literature suggest a number clear effects, there is substantial support for the importance of ways in which stress levels could be reduced, contributing of social support in stress prevention (Berkman and Glass, to a reduction in the risk of CVD as well as to general health. 2000). This could be an important goal for communities. It should be borne in mind that the definition and the significance of social support may be different for women than for men.
There are several studies which point to the potential ofrelaxation training in the reduction of coronary heart disease Improved work environment
risk factors (Patel et al., 1985). Methods for achieving relaxation include transcendental meditation, biofeedback Interventions should aim at an improved relationship between training or other kinds of relaxation, but the actual method psychological demands on the one hand and decision latitude used is unimportant; the significant factor is a reduced and social support on the other hand. This could be achieved degree of arousal (or stress) in everyday life situations. in several ways, for instance via education of managers or For the maximum effectiveness, the relaxation method through programmes aiming at the whole organisation (for should become a lifelong habit. It might be most effective instance Participation Activation Research, see Bond and combined with psychosocial intervention. Bunce, 2001 and Kristensen, 2005). They should also aim at an improved relationship between effort and reward (see Sleep hygiene
Kompier et al., 2000). Finally shift work schedules could often be improved (from "counterclockwise" to "clockwise"), Awareness of the importance of sleep is of great potential and for groups with high demands for attention or fear importance. Good health requires both enough sleep and avoidance, long work weeks should be avoided enough deep sleep for the body to regenerate, particularly (Belkic et al., 1994).
Alderling, M., Theorell, T., Bergman, P., Stoetzer, U., de la Torre, B.
Bosma, H., Stansfeld, S.A. and Marmot, M.G. (1998a).
and Lundberg, I. (2004). Saliva cortisol – circadian variation in
"Job control, personal characteristics, and heart disease."
working men and women in relation to the demand/control
J Occup Health Psychol 3(4): 402-9.
model. Manuscript. Dept. of Occupational Health, Karolinska
Hospital and National Institute for Psychosocial Factors and
Bosma, H., Peter, R., Siegrist, J. and Marmot, M. (1998). Health, Stockholm, Sweden. "Two alternative job stress models and the risk of coronary
heart disease."
Am J Public Health 88(1): 68-74.
Alfredsson, L., Spetz, C.L. and Theorell, T. (1985). Type of
occupation and near-future hospitalization for myocardial

Boyle, S.H., Williams, R.B., Mark, D.B., Brummett, B.H., Siegler, infarction and some other diagnoses. Int J Epidemiol 14(3):
I.C., Helms, M.J., and Barefoot, J.C. (2004). "Hostility as a
predictor of survival in patients with coronary artery disease."
Psychosom Med 66(5): 629-32.
Appels, A. Exhaustion and coronary heart disease: the history
of a scientific quest.
(2004). Patient Educ Couns 55(2): 223-9.
Brenner, S.O. and Levi, L. (1987). "Long-term unemployment
among women in Sweden."
Soc Sci Med 25(2): 153-61.
Belkic, K., Landsbergis, P., Schnall, P., Baker, D., Theorell,
T., Siegrist, J., Peter, R. and Karasek, R. (2000). "Psychosocial
Brisson, C., Guimont, C., Vézina, M., Moisan, J., Dagenais, G.R., factors: Review of the empirical data among men." In: Schnall,
Milot, A. and Masse, B. (2004). "Psychosocial work environment
P., Belkic, K., Landsbergis, P. and Baker, D. (eds.). The Workplace and evolution of blood pressure: the contribution of job
and Cardiovascular Disease. State of the art review. Occupational control and physical work demands." Abstract at the Eighth
Medicine. pp. 24-57.
International Congress of Behavioral Medicine, Mainz, Germany. Belkic, K., Savic, C., Theorell, T., Rakic, L., Ercegovac, D.
and Djordjevic, M. (1994). "Mechanisms of cardiac risk among
Brown, G.W. (1973). "Life events and the onset of depressive
professional drivers." Scand J Work Environ Health
and schizophrenic conditions." In: Life stress and illness. Eds.
Gunderson, E.K.G. and Rahe, R.H. Springfield, Ill.: CharlesThomas.
Belkic, K.L., Landsbergis, P.A., Schnall, P.L. and Baker, D. (2004).
Brown, G.W. and Harris, T. (1978). Social origins of depression –
"Is job strain a major source of cardiovascular disease risk?"
a study of psychiatric disorders in London. Tavistock: London.
Scand J Work Environ Health 30(2): 85-128.
Brunner, E.J., Kivimäki, M., Siegrist, J., Theorell, T., Luukonen, R., Berkman, L.F. and Glass, T. (2000). "Social integration,
Riihimäki, J., Vahtera, J., Kirjonen, J. and Leino-Arjas, P. (2004).
social network, social support and health." In: Berkman
"Is the effect of work stress confounded by socio-economic
LF and Kawashi I (eds). Social Epidemiology. Oxford Univ. Press.
factors in the Valmet study." J Epidemiol Comm Med 58(12):
Oxford New York, pp. 137-173.
Bernin, P. and Theorell, T. (2001). "Demand-control-support
Brydon, L., Edwards, S., Mohamed-Ali, V. and Steptoe, A. (2004).
among female and male managers in eight Swedish
"Socioeconomic status and stress induced increases in
companies." Stress and Health 17: 231-243,.
interleukin-6." Brain Behav Immun 18(3): 281-90.
Boggild, H. and Knutsson, A. (1999). "Shift work, risk factors
Burell, G. and Granlund, B. (2002). "Women's hearts need
and cardiovascular disease." Scand J Work Environ Health
special treatment." Int J Behav Med 9(3): 228-42.
25(2): 85-99.
Chandola, T., Brunner, E., and Marmot, M. (2006). Bond, F.W. and Bunce D. (2001). "Job control mediates change
"Chronic stress at work and the metabolic syndrome:
in work organization intervention for stress reduction."
prospective study." BMJ 332: 521-5.
J Occup Health Psychology 6: 290-302.
Chandola, T., Kuper, H., Singh-Manoux, A., Bartley, M. Bosma, H., Marmot, M.G., Hemingway, H., Nicholson, A.C., and Marmot, M. (2004). "The effect of control at home
Brunner, E. and Stansfeld, S.A. (1997). "Low job control and risk
on CHD events in the Whitehall II study: Gender differences
of coronary heart disease in Whitehall II (prospective cohort)
in psychosocial domestic pathways to social inequalities
study." BMJ 314: 558-65.
in CHD." Soc Sci Med 58(8): 1501-9.
Cleary, A.J. (2000). "Regulatory disturbance of energy."
Friedman, M., Rosenman, R.H. and Carroll, V. (1958). In Theorell, T. (ed.): "Every-day biological stress mechanisms."
"Changes in the serum cholesterol and blood clotting time in
Adv Psychosom Med 22: 17-34.
men subjected to cyclic variations of occupational stress."
Circulation 17: 852-61.
Cobb, S. (1974). "Physiologic changes in men whose jobs
were abolished."
J Psychosom Res Aug. 18(4): 245-58.
Fujiwara, K., Tsukishima, E., Kasai, S., Masuchi, A., Tsutsumi, A.,
Kawakami, N., Mikaye, H. and Kishi, R. (2004). "Urinary
Collins, S.M., Karasek, R.A. and Costas, K. (2004). catecholamines and salivary cortisol on workdays and days
"Job strain and autonomic indices of cardiovascular disease
off in relation to job strain among female health care
risk." Eighth International Congress of Behavioral Medicine, Mainz,
providers." Scand J Work Env Health 30: 129-38.
Fukuoka, Y., Dracup, K., Froelicher, E.S., Ohno, M., Hirayama, H., Cooper, C.L. and Marshall, J. (1976). "Occupational sources
Shiina, H. and Kobayashi, F. (2005). "Do Japanese workers who
of stress: A review of the literature relating to coronary heart
experience an acute myocardial infarction believe their
disease and mental ill health." J Occup Psychol 49, 11-28
prolonged working hours are a cause?"
Int J Cardiol 100(1): 29-35.
COPSOQ-SJEWH-2003. (2003). Danish Work Environment
Institute, Copenhagen.
Ghiadoni, L., Donald, A.E., Cropley, M., Mullen, M.J., Oakley, G.,Taylor, M., O'Connor, G., Betteridge, J., Klein, N., Steptoe, A. and Dohrenwend, B.S. and Dohrenwend, B.P., eds. (1974). Stressful
Deanfield, J.E. (2000). "Mental stress induces transient
events: Their nature and effects. New York, Wiley.
endothelial dysfunction in humans."
Circulation 102(20): 2473-8.
Eaker, E., Baker, E.D., Sullivan, L.M., Kelly-Hayes, M., D'Agostino,
R.B. Sr. and Benjamin, E.J. (2004). "Does job strain increase the
Gonzalez-Ortiz, M., Martinez-Abundis, E., Balcazar-Munoz, B.R.
risk for coronary heart disease or death in men and women?
and Pascoe-Gonzalez, S. (2000). "Effect of sleep deprivation on
The Framingham Offspring Study." Am J Epidemiol 159: 950-8.
insulin sensitivity and cortisol concentration in healthy
Diabetes Nutr Metab 13(2): 80-3.
Ekstedt, M., Akerstedt, T. and Soderstrom, M. (2004).
"Microarousals during sleep are associated with increased
Greiner, B.A., Krause, N., Ragland, D. and Fisher, J.M. (2004).
levels of lipids, cortisol, and blood pressure." Psychosom Med
"Occupational stressors and hypertension: a multi-method
66(6): 925-31.
study using observer-based job analysis and self-reports in
urban transit operators."
Soc Sci Med 59(5): 1081-94.
Erikssen, J., Knudsen, K., Mowinkel, P., et al. (1990). "Increase
in blood pressure among stress-exposed industrial workers."

Grossi, G., Perski, A., Evengard, B., Blomkvist, V. and Tidsskr Nor Laegeforen 110: 2873-7.
Orth-Gomér, K. (2003). "Physiological correlates of burnout
among women."
J Psychosom Res 55(4): 309-16.
European Heart Network. (2005). European Cardiovascular
Disease Statistics.
European Heart Network and British Heart
Hall, E.H. (1990). Women's work: An inquiry into the health
Network, London.
effects of invisible and visible labor. Academic thesis, Karolinska
Institute, Stockholm, Sweden.
Eurostat. (2004). Work and Health in the EU: A statistical
Luxembourg: Office for Official Publications of the
Hallstrom, T., Lapidus, L., Bengtsson, C. and Edstrom, K. (1986).
European Communities. "Psychosocial factors and risk of ischaemic heart disease
and death in women: a twelve-year follow-up of participants

Ferrie, J.E., Shipley, M.J., Marmot, M.G., Stansfeld, S.A. in the population study of women in Gothenburg, Sweden."
and Smith, G.D. (1998). "An uncertain future: the health effects
J Psychosom Res 30(4): 451-9.
of threats to employment security in white-collar men and
Am J Public Health 88(7): 1030-6.
Hansen, A.M., Kaergaard, A., Andersen, J.H. and Netterstrom, B.
(2003). "Associations between repetitive work and
Friedman, M. and Rosenman, R.H. (1969). "Association
endocrinological indicators of stress."
of specific overt behavior pattern with blood and
Work and Stress 17: 264-76.
cardiovascular findings." JAMA 169: 1286.
Hallqvist, J., Diderichsen, F. and Theorell, T. (1998). Hintsanen, M., Kivimäki, M., Elovainio, M., Pulkki-Raback, L., "Is the effect of job strain on myocardial infarction due
Keskivaara, P., Juonala, M. Raitakari, O.T., Keltikangas-Jarvinen, L.
to interaction between high psychological demands
(2005). "Job strain and early atherosclerosis:
and low decision latitude?" Results from the Stockholm Heart
the Cardiovascular Risk in Young Finns Study."
Epidemiology Program (SHEEP)." Social Science and Medicine Psychosom Med 67(5): 740-7.
46: 1405-15.
Hurrell, J.J. Jr., Nelson, D.L. and Simmons, B.L. (1998).
Hasselhorn, H.M., Theorell, T., Hammar, N., Alfredsson, L., "Measuring job stressors and strains: where we have been,
Westerholm, P., the WOLF Study Group. (2004). Occupational
where we are, and where we need to go." J Occup Health
health care team ratings and self reports of demands and
Psychol 3(4): 368-89.
decision latitude. Stress Research Reports, 314, National
Institute for Psychosocial Factors and Health, Stockholm, Sweden.
Hallstrom, T., Lapidus, L., Bengtsson, C. and Edstrom, K. (1986).
"Psychosocial factors and risk of ischaemic heart disease and
Haynes, S.G. (1991). "The effect of job demands, job control,
death in women: a twelve-year follow-up of participants in the
and new technologies on the health of employed women:
population study of women in Gothenburg, Sweden."
A review." In: Frankenhaeuser, M., Lundberg, U. et al. (eds.)
J Psychosom Res 30(4): 451-9.
Women, Work, and Health: Stress and opportunities. The Plenum series on stress and coping. New York, NY, USA: Iversen, L., Sabroe, S. and Damsgaard, M.T. (1989). Plenum Press, 271: 157-69.
"Hospital admissions before and after shipyard closure."
BMJ 299: 1073-6.
Hemingway, H. and Marmot, M. (1999). "Evidence based
cardiology: psychosocial factors in the aetiology and

Janlert, U. (1997). "Unemployment as a disease and diseases
prognosis of coronary heart disease. Systematic review
of the unemployed." Scand J Work Environ Health 23 Suppl 3:
of prospective cohort studies." BMJ 29 (318): 1460-7.
Henriksson, K.M., Lindblad, U., Ågren, B., Nilsson-Ehle, P. Johansson, G., Evans, G.W., Rydstedt, L.W. and Carrere, S.
and Råstam, L. (2003). "Associations between unemployment
(1998). "Job hassles and cardiovascular reaction patterns
and cardiovascular risk factors varies with the unemployment
among urban bus drivers." Int J Behav Med 5: 267-80.
rate: the Cardiovascular Risk Factor Study in Southern
Sweden (CRISS)."
Scand J Public Health 31(4): 305-11.
Johnson, J.V. and Hall, E.M. (1988). "Job strain,
workplace social support and cardiovascular disease:

Hemingway, H., Shipley, M., Mullen, M.J., Kumari, M., Brunner, E., A cross-sectional study of a random sample of the Swedish
Taylor, M., Donald, A. E., Deanfield, J.E., and Marmot, M. (2003).
"Social and psychosocial influences on inflammatory markers
Am J Publ Health 78: 1336-42.
and vascular function in civil servants (the Whitehall II study)."
Am J Cardiol 92: 984-7.
Kagan, A.R. and Levi, L. (1974). "Health and environment-
psychosocial stimuli: a review."
Soc Sci Med 8(5): 225-41.
Hertting, A. and Theorell, T. (2002). "Physiological Changes
Associated with Downsizing of Personnel and Reorganization

Kahn, R., Wolfe, D., Quinn, R., Snoek, J. and Rosenthal, R.
in the Health Care Sector." Psychotherapy and Psychosomatic
(1964). Organizational stress: Studies in role conflict
and ambiquity. New York: Wiley.
Holmes, T.H. and Rahe, R.H. (1967). Karasek, R. (1979). "Job demands, job decision
"The Social Readjustment Rating Scale."
latitude, and mental strain: Implications for job redesign."
J Psychosom Res 11(2): 213-8.
Adm Sci Q 24: 285-307.
Hinkle, L.E. Jr., Whitney, L.H., Lehman, E.W., Dunn, J., Benjamin, Karasek, R.A., Theorell, T., Schwartz, J.E., Schnall, P.L., Pieper, B., King, R., Plakun, A. and Flehinger, B. (1968). "Occupation,
C.F. and Michela, J.L. (1988). "Job characteristics in relation
education, and coronary heart disease. Risk is influenced
to the prevalence of myocardial infarction in the US Health
more by education and background than by occupational
Examination Survey (HES) and the Health and Nutrition
experiences." Bell System Science 161(838): 238-46.
Examination Survey (HANES)." Am J Public Health 78(8):
Karasek, R.A., Brisson, C., Kawakami, N., Houtman, I., Bongers, Kornitzer, M., Dramaix, M. and Gheyssens, H. (1979). "Incidence
P. and Amick, B. (1998). "The job content questionnaire (JCQ):
of ischaemic heart disease in two Belgian cohorts followed
An instrument for internationally comparative assessments of
during 10 years." Eur J Cardiol 6: 455-72.
psychosocial job characteristics." J Occ Health Psychology 3:
Kornitzer, M. and Bara, L. (1989). "Clinical and anthropometric
data, blood chemistry and nutritional patterns in the Belgian

Karasek, R.A. and Theorell, T. Healthy Work. Basic Books, New
population according to age and sex. For the BIRNH study
group." Acta Cardiologica 44: 101-44.
Kim, H., Song, Y.J., Yi J.J., Chung, W.J. and Nam, C.M. (2004).
Kristensen, T.S., Bjorner, J.B., Christensen, K.B. and Borg V.
"Changes in mortality after the recent economic crisis in
(2004). "The distinction between work pace and working
South Korea." Ann Epidemiol July 14(6): 442-6.
hours in the measurement of quantitative demands at work."
Work and Stress 18: 305-22.
Kirschbaum, C. and Hellhammer, D. (1999).
"Noise and stress – salivary cortisol as a non-invasive
Kristensen, T.S. (2000). "Workplace intervention studies."
measure of allostatic load." Noise Health 1: 57-66.
In: Schnall, P.L., Belkic, K, Landsbergis P. and Baker D., eds.
"The workplace and cardiovascular disease."
Kittel, F., Kornitzer, M. and Dramaix, M. (1986). "Evaluation
Occupational Medicine 15: 293-305.
of Type A personality." Postgrad Med 62(730): 781-3.
Kristenson, M., Eriksen, H.R., Sluiter, J.K., Starke, D. Kittel, F., Kornitzer, M. and Dramaix, M. (1980). and Ursin, H. (2004). "Psychobiological mechanisms
"Coronary heart disease and job stress in two cohorts
of socioeconomic differences in health."
of bank clerks." Psychother Psychosom 34: 110-23.
Soc Sci Med 58(8): 1511-22. Review.
Kittel, F., Dramaix, M., Koyuncu, R., De Backer, G. and Kornitzer, Kristensen, T.S. (2005). "Intervention studies
M. (1998). "Socio-professional determinants of CVD, 10 year
in occupational epidemiology." Occup Environ Med 62:
mortality in a Belgian population at work (the BIRNH study)."
Proceedings of the 2nd International Conference on Work,Environment and Cardiovascular Disease, Tel Aviv, Kristensen, T.S., Bjorner, J.B., Christensen, K.B. and Borg, V.
22-25 March 1998.
(2004). "The distinction between work pace and working hours
in the measurement of quantitative demands at work."
Work &
Kivimaki, M., Head, J., Ferrie, J.E., Hemingway, H., Shipley, M.J., Vahtera, J. and Marmot, M.G. (2005). "Working while ill as a
risk factor for serious coronary events: the Whitehall II study."

Kunz-Ebrecht, S.R., Kirschbaum, C. and Steptoe, A. (2004).
Am J Public Health 95(1): 98-102.
"Work stress, socioeconomic status and neuroendocrine
activation over the working day."

Kivimäki, M., Kinnunen, M.L., Pitkanen, T., Vahtera, J., Elovainio, Soc Sci Med 58(8): 1523-30.
M. and Pulkkinen, L. (2004). "Contribution of early and adult
factors to socioeconomic variation in blood pressure: thirty-

Landsbergis, P.A., Schnall, P.L., Pickering, T.G., Warren, K. four-year follow-up study of school children." Psychosom
and Schwartz, J.E. (2003). "Life-course exposure to job strain
Med 66(2): 184-9.
and ambulatory blood pressure in man."
Am J Epidemiology 157: 998-1066.
Kivimäki, M., Elovainio, M., Vahtera J. and Ferrie J.E. (2003).
"Organisational justice and health of employees: prospective
Landsbergis, P.A., Schnall, P. and Deitz, D. (1992). "The
cohort study." Occup Environ Med 60(1): 27-33.
patterning of psychological attributes and distress by
"job strain" and social support in a sample of working men."

Kompier, M.A., Aust, B., van den Berg, A.M. and Siegrist, J.
J Beh Med 15: 379-405.
(2002). "Stress prevention in bus drivers: evaluation
of 13 natural experiments."
J Occ Health Psychol 5: 11-31.
Leineweber, C., Kecklund, G., Janszky, I., Akerstedt, T.
and Orth-Gomér, K. (2003). "Poor sleep increases the
Kornitzer, M., Thilly, C., Vanroux, A. and Balthazar, R. (1975).
prospective risk for recurrent events in middle-aged women
"Incidence of ischaemic heart disease in two cohorts
with coronary disease. The Stockholm Female Coronary Risk
of Belgian clerks." Br J Prev Soc Med 29: 91-7.
Study." J Psychosom Res 54(2): 121-7.
Leineweber, C., Kecklund, G., Janszky, I., Akerstedt, T. Moller, J., Theorell, T., de Faire, U., Ahlbom, A. and Orth-Gomér, K. (2004). "Snoring and progression
and Hallqvist, J. (2005). "Work related stressful life events
of coronary artery disease: The Stockholm Female Coronary
and the risk of myocardial infarction. Case-control and case-
Angiography Study." Sleep 27(7): 1344-9.
crossover analyses within the Stockholm heart epidemiology
programme (SHEEP)."
J Epidemiol Community Health 59(1):
Li, J., Hansen, D., Mortensen, P.B. and Olsen, J. (2002).
"Myocardial infarction in parents who lost a child.
A nationwide prospective cohort study in Denmark".

Moller, J., Hallqvist, J., Diderichsen, F., Theorell, T., Circulation 106: 1634-9.
Reuterwall, C., and Ahlbom, A. (1999). "Do episodes of anger
trigger myocardial infarction? A case-crossover analysis in the

Lindström, K., Elo, A.-L., Skogstad, A., Dallner, M., Gamberale, F.
Stockholm Heart Epidemiology Program (SHEEP)." Psychosom
Hottinen, V., Knardahl, S., Ørhede, E. (2000). QPSNordic:
Med 61: 842-9.
General Nordic Questionnaire for Psychological and Social
Factors at Work: user's guide.
Nordic Council of Ministers,
Netterstrom, B. (2004). "Psychological strain at work increases
Copenhagen, Denmark. the risk of cardiovascular disease." Abstract at the 8th
International Congress of Behavioral Medicine, Mainz, Germany.
Markovitz, J.H., Matthews, K.A., Whooley, M., Lewis, C.E.
and Greenlund, K.J. (2004). "Increases in job strain are
Nirkko, O., Lauroma, M., Siltanen, P., Tuominen, S. and Vanhala, associated with incident hypertension in the CARDIA Study."
K. "Psychological risk factors related to coronary heart
Ann Behav Med. 28(1): 4-9.
disease. Prospective studies among policemen in Helsinki."
Acta Med. Scand (suppl) 1982; 660: 127-54.
Marmot, M.G. and Syme, S.L. (1976). "Acculturation
and coronary heart disease in Japanese-Americans."

Olsen, O. and Sondergaard Kristensen, T. (1988).
Am J Epidemiol 104(3):225-47.
"Hjerte/karsygdomme or arbejdsmiljø. Bind 3, Hvor stor
betydning har arbetsmiljøet for hjerte/karsygdomme i

Marmot, M.G., Siegrist, J., Theorell, T. and Feeney, A. (1999).
Danmark?" (Cardiovascular illnesses and work environment.
"Health and the psychosocial environment at work."
Part 3, What relative importance has the work environment
In: Marmot, M. and Wilkinson, R.G. (eds.). Social Determinants on cardiovascular illnesses in Denmark?)
of Health. Oxford University Press. pp. 105-31.
Copenhagen: Arbejdsmiljøfondet. Marmot, M. (2004). Status syndrome. Bloomsbury. New York.
Orth-Gomér, K. (1983). "Intervention on coronary risk factors
by adapting a shift work schedule to biologic rhythmicity."

Maslach, C., Schaufeli, W.B. and Leiter, M.P. (2001). Psychosom Med 45(5): 407-15.
"Job burnout." Ann Rev Psychol 52: 397-422.
Orth-Gomér, K. and Johnson, J.V. (1987). "Social network
Matthews, K.A. and Haynes, S.G. (1986). "Type A behavior
interaction and mortality. A six year follow-up study
pattern and coronary disease risk. Update and critical
of a random sample of the Swedish population."
evaluation." Am J Epidemiol 123(6): 923-60.
J Chronic Dis 40(10): 949-57.
Mc Ewen, B. (1998). "Protective and damaging effects
Orth-Gomér, K., Eriksson, I., Moser, V., Theorell, T. and Fredlund, of stress mediators." New England J Med 338: 171-79.
P. (1994). "Lipid lowering through work stress reduction."
Int J Behav Med 1(3): 204-14.
Mc Leod, J. and David Smith, G. (2003). "Psychosocial factors
and public health: A suitable case for treatment?"

Orth-Gomér, K. (1998). "Psychosocial risk factor profile
J Epidemiol Health 57: 565-70.
in women with coronary heart disease." In Orth-Gomér K. and
Chesney, M. (eds): Women, Stress and Heart Disease, Erlbaum,
Medalie, J.H., Kahn, H.A., Neufeld, H.N., Riss, E. and Goldbourt, M. (1973). "Five-year myocardial infarction incidence." J Chron
Dis 26: 329.
Orth-Gomér, K., Wamala, S.P., Horsten, M., Schenck-Gustafsson,
K., Schneiderman, N. and Mittleman, M.A. (2000). "Marital stress
worsens prognosis in women with coronary heart disease:
The Stockholm Female Coronary Risk Study."
JAMA 284(23):
Orth-Gomér, K., Wang, H.X., Leineweber, C. and Theorell, T.
Rosmond, R. and Bjorntorp, P. (2000). "Occupational status
(2005). "Social determinants and atherosclerosis progression
cortisol secretory pattern and visceral obesity in middle aged
in women." Submitted to the European Society of Cardiology
men." Obesity Res 8: 445-450.
(response May 2005).
Rugulies, R. "Depression as a predictor for coronary heart
Oxenstierna, G., Ferrie, J., Hyde, M., Westerlund, H. and Theorell, disease. a review and meta-analysis." (2002).
T. (2004). "Dual source support and control at work in relation
Am J Prev Med 23(1): 51-61.
to health." Scand J Publ Health. In review.
Schneiderman, N., Saab, P.G., Catellier, D.J., Powell, L.H., Patel, C., Marmot, M.G., Terry, D.J., Carruthers, M., Hunt, B. and DeBusk, R.F., Williams, R.B., Carney, R.M., Raczynski, J.M., Patel, M. (1985). "Trial of relaxation in reducing coronary risk:
Cowan, M.J., Berkman, L.F., Kaufmann, P.G.; ENRICHD Four–year follow-up." Brit Med J 290: 1103-6.
Investigators. (2004). "Psychosocial treatment within sex
by ethnicity subgroups in the Enhancing Recovery in

Peter, R., Siegrist, J., Hallqvist, J., Reuterwall, C., Theorell, T., the Coronary Heart Disease clinical trial." Psychosom Med 66(4):
SHEEP Study Group. (2002). "Psychosocial work environment
and myocardial infarction: improving risk estimation by
combining two complementary job stress models in the

Selye, H. (1936). The stress of life.
SHEEP Study." J Epidemiol Community Health 56: 294-300.
New York: McGraw-Hill, 1976.
Peter, R., Hammarström, A., Hallqvist, J., Siegrist, J., Schnall, P.L., Belkic, K., Landsbergis, P. and Baker D. (2000).
Theorell, T., the SHEEP Study Group. (2005). "Does occupational
"Why the workplace and cardiovascular disease?"
gender segregation influence the association of effort-reward
Occup Med 15: 1-16, III review.
imbalance with myocardial infarction in the SHEEP Study?"
Int J Behav Med. In press.
Siegrist, J., Starke, D., Chandola, T., Godin, I., Marmot, M.,
Niedhammer, I. and Peter, R. (2004). "The measurement of
Prescott, E., Holst, C., Gronbaek, M., Schnohr, P., Jensen, G. effort-reward imbalance at work: European comparisons."
and Barefoot, J. (2003). "Vital exhaustion as a risk factor
Soc Sci Med 58(8): 1483-99.
for ischaemic heart disease and all-cause mortality in
a community sample. A prospective study of 4084 men and

Siegrist, J. and Marmot, M. (2004). "Health inequalities
5479 women in the Copenhagen City Heart Study."
and the psychosocial environment-two scientific challenges."
Int J Epidemiol 32(6): 990-7.
Soc Sci Med 58(8): 1463-73.
Ragland, D.R., Brand, R.J. (1988). "Coronary heart disease
Siegrist, J. (1996). "Adverse health effects of
mortality in the Western Collaborative Group Study. Follow-up
experience of 22 years." Am J Epidemiol 127(3): 462-75.
J Occup Health Psychol 1(1): 27-41.
Rau, R. (2001). Arbeit – Erholung – Gesundheit. Ein Beitrag zur
Soderstrom, M., Ekstedt, M., Akerstedt, T., Nilsson, J. Occupational Health Psychology. Habilitationsschrift. University
and Axelsson, J. (2004). "Sleep and sleepiness in young
individuals with high burnout scores." Sleep 27(7): 1369-77.
Rau, R., Georgiades, A., Fredrikson, M. Lemne, C. and de Faire, Sokejima, S. and Kagamimori, S. (1998). "Working hours
U. (2001). "Psychosocial work characteristics and perceived
as a risk factor for acute myocardial infarction in Japan:
control in relation to cardiovascular rewind at night." J Occ
case-control study." BMJ 317(7161): 775-80.
Health Psychol 6: 171-81. Sondergaard, H.P. and Theorell, T. (2003). "A longitudinal study
Reed, D.M., La Croix, A.Z., Karasek, R.A., Miller, D. of hormonal reactions accompanying life events
and McLean, C.A. (1989). "Occupational strain and the
in recently resettled refugees." Psychother Psychosom
incidence of coronary heart disease." Am J Epidemiol 129:
72(1): 49-58.
Stansfeld, S.A., Fuhrer, R., Shipley, M.J. and Marmot, M.G. (1999).
Rosengren, A., Hawken, S., Ounpuu, S., Sliwa, K., Zubaid, M., "Work characteristics predict psychiatric disorder:
Almahmeed, W.A., Blackett, K.N., Sitthi-amorn, C., Sato, H., prospective results from the Whitehall II Study."
Yusuf, S., for the INTERHEART investigators. (2004). "Association
Occup Environ Med 56(5): 302-7.
of psychosocial risk factors with risk of acute myocardial
infarction in 11 119 cases and 13 648 controls from 52
countries (the INTERHEART study): case-control study 2004."
Lancet http:/image,
Steptoe, A., Wardle, J., Lipsey, Z., Mills, R., Oliver, G., Jarvis, M., Theorell, T., Karasek, R.A. and Eneroth, P. (1990). and Kirschbaum, C. (1998). "A longitudinal study of work load
"Job strain variations in relation to plasma testosterone
and variations in psychological well-being, cortisol, Smoking
fluctuations in working men – a longitudinal study."
and alcohol consumption."
J Internal Med 227: 31-6.
Ann Behav Med 20: 84-91.
Theorell, T., Orth-Gomér, K. and Eneroth, P. (1990). Steptoe, A., Siegrist, J., Kirschbaum, C. and Marmot, M. (2004).
"Slow-reacting immunoglobulin in relation to social support
"Effort-reward imbalance, overcommitment, and measures
and changes in job strain."
of cortisol and blood pressure over the working day."
Psychosom Med 52(5): 511-16.
Psychosom Med 66: 323-9.
Theorell, T. (1991). "Health promotion in the workplace."
Steptoe, A. and Willemsen, G. (2004). "The influence of low job
In B. Badura and I. Kickbusch (eds.). Health promotion research.
control on ambulatory blood pressure and perceived stress
Towards a new social epidemiology, WHO Regional Publications over the working day in men and women from the Whitehall II
European Series No. 37, pp. 251-66,.
cohort." J Hypertens 22(5): 915-20.
Theorell, T. (1991). "Psychosocial cardiovascular risks
Steptoe, A., Cropley, M., Griffith, J. and Kirschbaum, C. (2000).
– on the double loads of women." Psychother Psychosom 55:
"Job strain and anger expression predict early morning
elevations in salivary cortisol." Psychosom Med 62(2):
Theorell, T., de Faire, U., Johnson, J., Hall, E., Perski, A. and
Stewart, W. (1991). "Job strain and ambulatory blood pressure
Strike, P.C., and Steptoe, A. (2005). "Behavioral and emotional
profiles". Scand J Work Environ Health 17: 380-5.
triggers of acute coronary syndromes: a systematic review
and critique."
Psychosom Med 67: 179-86.
Theorell, T., Tsutsumi, A., Hallquist, J., Reuterwall, C., Hogstedt,C., Fredlund, P., Emlund, N., Johnson, J., the Stockholm Heart Strike, P.C., Magid, K., Whitehead, D.L., Brydon, L., Epidemiology Program (SHEEP). (1998). "Decision latitude, job
Bhattacharyya, M.R., and Steptoe, A. (2006).
strain, and myocardial infarction: a study of working men in
"Pathophysiological processes underlying emotional
Stockholm." Am J of Public Health 88: 382-8.
triggering of acute cardiac events." Proc Natl Acad Sci
U S A 103: 4322-7.
Theorell, T., Hasselhorn, H.-M., Vingård, E., Andersson, B.,
the MUSIC-Norrtälje Study Group. (2000). "Interleukin-6 and
Sundin, O., Lisspers, J., Hofman-Bang, C., Nygren, A., Ryden, L.
cortisol in acute musculoskeletal disorders: results from a
and Ohman. A. (2003). "Comparing multifactorial lifestyle
case-referent study in Sweden." Stress Medicine 16: 27-35.
interventions and stress management in coronary risk
Int J Behav Med 10(3): 191-204.
Theorell, T., Emdad, R., Arnetz, B., Weingarten, A.M. (2001).
"Employee effects of an educational program for managers at
Theorell, T., Lind, E., and Flodérus, B. (1975). "The relationship
an insurance company." Psychosomatic Medicine 63: 724-33.
of disturbing life-changes and emotions to the early
development of myocardial infarction and other serious

Theorell, T. (2002). "Job stress and fibrinogen. Editorials."
illnesses." Int J Epidemiology 4(4): 281-93. Also published
European Heart Journal 23: 1799-1801.
in Rev Epidém et Santé Publ 1976; 24: 41-59.
Theorell, T., Hasselhorn, H.M., the MUSIC Norrtälje Study Group.
Theorell, T. and Floderus Myrhed, B. (1977). "Workload and risk
(2002). "Endocrinological and immunological variables
of myocardial infarction: A prospective psychosocial
sensitive to psychosocial factors of possible relevance to
analysis." Int J Epidemiology 6: 17-21.
work-related musculoskeletal disorders." Work & Stress 16 (2):
Theorell, T., Perski, A., Åkerstedt, T., Sigala, F., Ahlberg-Hultén, G.,
Svensson, J. and Eneroth, P. (1988). "Changes in job strain in
relation to changes in physiological state – a longitudinal
Scand J Work Environ Health 14: 189-96.
Theorell, T. (1990). "Family history of hypertension – an
individual trait interacting with spontaneously occurring
job stressors."
Scand J Work Environ Health 16(suppl 1): 74-9.
Theorell, T., Oxenstierna, G., Westerlund, H., Ferrie, J., Hagberg, Wahlstedt, K. (2001). Postal work – work organizational
J. and Alfredsson, L. (2003). "Downsizing of staff
changes as tools to improve health. Acta Universitatis
is associated with lowered medically certified sick leave
in female employees." Occup Environ Med 60(9): E9.
Wainwright, D. and Calnan, M. (2002). Work stress – the making
Theorell, T. (2004). "Democracy at work and its relationship to
of a modern epidemic. Open University Press, Buckingham, UK.
health." In: Perrewé, M.L. and Ganster, D.C. (eds.). Research in
Occupational Stress and Well being. Emotional and Physiological
Westerlund, H., Ferrie, J., Hagberg, J., Jeding, K., Oxenstierna, G.
Processes and positive intervention strategies. Elsevier, 3: 323-57.
and Theorell, T. (2004). "Workplace expansion, long-term
sickness absence, and hospital admission."
Thoresen, C.E. and Powell, L.H. (1992). "Type A behavior
pattern: new perspectives on theory, assessment, and
." J Consult Clin Psychol 60(4): 595-604.
Westerlund, H., Theorell, T. and Alfredsson, L. (2004).
"Organizational instability and cardiovascular risk factors in
Tsai, S.L., Lan, C.F., Lee, C.H., Huang, N. and Chou, Y.J. (2004).
white-collar employees: an analysis of correlates of structural
"Involuntary unemployment and mortality in Taiwan."
instability of workplace organization on risk factors for
J Formos Med Assoc 103(12): 900-7.
coronary heart disease in a sample of 3,904 white collar
employees in the Stockholm region."

Tsutsumi, A. and Kawakami, N. (2004). "A review of empirical
Eur J Public Health 14(1): 37-42.
studies on the model of effort-reward imbalance at work:
reducing occupational stress by implementing a new theory."

Westerlund, H., Ferrie, J., Oxenstierna, G., Hyde, M. and Theorell, Soc Sci Med 59(11): 2335-59.
T. (2005). "Hospitalisation for cardiovascular and other
diseases after periods of staff changes in the Swedish labour

Ursin, H. and Eriksen, H.R. (2004). "The cognitive activation
market." Lecture at the ICOH conference on cardiovascular
theory of stress. Psychoneuroendocrinology."
disease in Newport Beach, CA, March 2005.
Psychoneuroendocrinology 29(5): 567-92.
Williams, R.B. (2003). "Invited commentary: socioeconomic
Vahtera, J., Kivimaki, M., Pentti, J., Linna, A., Virtanen, M., status, hostility, and health behaviors--does it matter which
Virtanen, P. and Ferrie, J.E. (2004). "Organisational downsizing,
comes first?" Am J Epidemiol 158(8): 743-6.
sickness absence, and mortality: 10-town prospective cohort
BMJ Mar 6;328(7439): 555.
Wolf, S. (1969). "Psychosocial forces in myocardial infarction
Epub 2004 Feb 23.
and sudden death." Circulation Suppl 4: 74-82.
Vingård, E., Alfredsson, L., Hagberg, M., Josephson, M., Kilbom,
Å., Theorell, T, Waldenström, M., Wigaeus-Hjelm, E., Wiktorin, C.,
Hogstedt, C. and MUSIC-Norrtälje study group. (2000).
"To what extent do current and past physical and
psychosocial occupational factors explain care-seeking
for low back pain in a working population? Results from
the musculoskeletal intervention centre-Norrtälje study."
SPINE 25(4): 493-500.
Vrijkotte, T.G.M., van Doornen, L.J.P. and de Geus, E.J.C. (2004).
"Overcommitment to work is associated with changes in
cardiac sympathetic regulation."
Psychosom Med 66(5): 656-63.
The European Heart Network is a Brussels-based
List of members:
alliance of heart foundations and other concerned
Austrian Heart Foundation non-governmental organisations throughout Europe
Belgian Heart League committed to the prevention of cardiovascular disease
British Heart Foundation, UK in 26 countries across Europe.
Cyprus Heart FoundationDanish Heart Foundation The European Heart Network plays a leading role in
Estonian Heart Association the prevention and reduction of cardiovascular disease
Finnish Heart Association through advocacy, networking and education so that it
Foundation of Health and Heart, Bosnia and Herzegovina is no longer a major cause of premature death and
French Federation of Cardiology disability throughout Europe.
Georgian Heart FoundationGerman Heart FoundationHeart to Heart League, SlovakiaHellenic Heart Foundation, GreeceHungarian Heart FoundationIcelandic Association of Heart PatientsIcelandic Heart AssociationIrish Heart FoundationItalian Association against Thrombosis (ALT)Italian Heart FoundationLithuanian Heart AssociationNational Heart Forum, UKNetherlands Heart FoundationNorthern Ireland Chest, Heart and Stroke, UKNorwegian Association of Heart and Lung Patients (LHL)Norwegian National Health Association, Council onCardiovascular DiseasesPortuguese Heart FoundationSlovenian Heart FoundationSpanish Heart FoundationSwedish Heart Lung FoundationSwiss Heart FoundationTurkish Heart Foundation


THE 20,000 DAYS CAMPAIGN Health System Improvement Guide Emergency Care/General Surgery /TADU Collaborative The change package SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ THE 20,000 DAYS CAMPAIGN What worked well for our campaign? Health systems worldwide are struggling with rising patient Alignment around a common goal demand and Middlemore Hospital, which serves a growing

Finding employees with undiagnosed diabetes

A Peer Reviewed Publication of the College of Health Care Sciences at Nova Southeastern University Dedicated to allied health professional practice and education Vol. 11 No. 2 ISSN 1540-580X Finding Employees with Undiagnosed Diabetes Thomas Lenz, PharmD1 Nicole Gil espie, PharmD2 Michael Monaghan, PharmD3 1. Associate Professor of Pharmacy Practice, Creighton University, Omaha, Nebraska 2. Assistant Professor of Pharmacy Practice, Creighton University, Omaha, Nebraska