EUROPEAN HEART NETWORK
TABLE OF CONTENTS
ROUND UP THE USUAL SUSPECTS!
EXECUTIVE SUMMARY AND RECOMMENDATIONS
THE STRESS CONCEPT
Stressors and stress
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
BIOLOGICAL MECHANISMS OF STRESS
Heart rate variability due to job stress
Regenerative activity: protection against stress
REDUCING RISK CAUSED BY STRESS
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.
ROUND UP THE USUAL SUSPECTS!
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
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
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,
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:
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
THE STRESS CONCEPT
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
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.
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
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
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).
STRESS IN THE WORKPLACE
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
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
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
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,
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
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.
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.
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.
REDUCING RISK CAUSED BY STRESS
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
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
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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
A Peer Reviewed Publication of the College of Health Care Sciences at Nova Southeastern University Dedicated to allied health professional practice and education http://ijahsp.nova.edu 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