The Changing Nature of Work – And its Implications for Cardiovascular Disease

1. The Changing Nature of Work –And its Implications for Cardiovascular Disease Fourth International Conference on Work Environment and Cardiovascular Diseases Southern CaliforniaMarch 9 – 11, 2005 Tage S. KristensenNIOH, Copenhagen

2. Work and CVD • The new challenges • The new fatigue • Family and private life • Problems with methods and design? • Conclusions

3. Work and CVD

4. General model for the relationship between work environment and cardiovascular diseases WORK ENVIRON- MENT CVD risk factors: diet obesity, blood pressure, smoking etc. CARDIO-VASCULAR DISEASES. 2 1 3 The significance of work: 1 + 3

5. Social & Environmental Factors Individual Characteristics Behavior Physiology Precursors Cholesterol Work envi-ronment Physical activity Fitness Athero-sclerosis SES & Occupation CVD Tobacco Blood pressure Social isolation Obesity Thrombosis Unemploy-ment Diet Type A Fibrinogen Arrhythmia Alcohol ECG-changes Noise Stress Glucose …. …. …. …. …. Upstream Downstream Causal network for CVD

6. The cardiovascular tradition fromFramingham and onwards Risk factors are individual Physiological: Behavioral: • Smoking • Physical inactivity • Type A • Salt intake • Diet • Alcohol • Cholesterol • Fibrinogen • Triglycerides • Glucose • Blood pressure • Heart rate • Obesity

7. The occupational medicine tradition from Ramazzini and onwards Risk factors are environmental • Physical • Chemical • Psychosocial • Ergonomic • Biological

8. Etiological fractions of work environment for cardiovascular diseases in Denmark Olsen & Kristensen. J Epidemiol Community Health 1991;45:4-10. DK-2004-016

9. The significance of work environment for mortality Nurminen & Karjalainen. Scand J Work Environ Health 2001;27:161-213.

10. The significance of work environment for hospitalisations Tüchsen et al. Sci Total Environ 2004;328:287-294.

11. Etiologic fractions of psychosocial factors for acute myocardial infarctions: The INTERHEART STUDY * Adjusted for cardiovascular risk factors Rosengren et al. www.thelancet.com Sept. 3,2004:1-10

12. Conclusion • CVD is one of the most important causes of disease, disability, and mortality in the world. • The etiologic fraction of the work environment is higher than for all other major diseases. • CVD is the most common and most serious of all work-related diseases. In spite of this, CVD plays a minor role in occuptional medicine, and work plays a minor role in cardiology and cardiovascular epidemiology.

13. The new challenges Outsourcing, downsizing, privatization,precarious work, job insecurity

14. (N = approx. 180) Threat of closure BP (mm Hg) Pulse 145 143 142 SBP 135 130 129 129 70 69 Pulse 63 63 96 94 91 90 86 85 84 DBP Blood pressure and pulse amongNorwegian metal workers Erikssen et al. Tidsskr Nor Laegeforen. 1990;110:2873-7.

15. 1.8 1.60 1.6 1.4 1.2 1.04 1 0.80 0.8 0.6 0.4 0.2 0 After factory closure (3 years) Before factory closure (2 years) During factory closure (3 years) Hospital admissions for CVD in a group of unemployed men compared with a control group Iversen et al. BMJ 1989;299:1073-6.

16. Threats to employment security among white-collar workers in Whitehall A five-year follow-up studyN=8354 RR New cases of ischemia* 1.60 1.45 1.40 1.0 Men Women Control departments Total Department under privatization *ECG or angina Ferrie et al. AJPH 1998;88:1030-1036.

17. Organisational downsizing and mortality A 7.5 years’ follow-up study of 22.430 public employeeswho kept their jobs. RR* CVD Other deaths 2.0 2.0 1.5 1.2 1.2 1.0 1.0 1.0 0 Minor Minor None Major None Major Extent of downsizing *Controlled for age, gender, SES, occupation Vahtera et al. BMJ 2004;328:555-558.

18. A simple model Job insecurity, downsizing, outsourcing, privatization Loss of control, loss of social support, loss of meaning, loss of predictability, loss of rewards Stress, uncertainty, hopelessness, low self esteem

19. The new fatigue

20. The development of four different symptoms in the adult Swedish population 1986 - 2001 Percent Fatigue Back trouble Sleep trouble Distress Gustafsson & Lundberg, eds. Arbetsliv och hälsa, 2004.

21. Work-related burnout and sleeping problemstwo years later Results from the PUMA baseline and 2 years’ follow-up Karolinska sleep questionnaire (scale) 44.6 34.4 32.6 25.1 Work-related burnout Low High Quartiles N = 1014; Data from NIOH, Denmark

22. Burnout as predictor of ischaemic heart diseas A 4.2 years’ follow-up study of 3,877 Dutch male employees from Rotterdam ”Have you ever been burned out?”No 74% Yes 26% RR* for IHD* 2.13 2 1 1 0 Yes No Burnout * Controlled for age, BP, smoking, cholesterol. 59 cases. Appels & Schouten. Behav Med 1991;Summer:53-59

23. Cases per 1000 50 45 40 30 30 26 20 10 0 None Medium High Degree of exhaustion by the end of the working day. Exhaustion and CHD A 9.5 years’ follow-up study of 3,365 Dutch men. Appels & Otten. Br J Clin Psychol 1992;31:351-356

24. RR* 3 IHD 2.2 1.8 2 1.6 1.6 1 1 1.2 1.1 Mortality Vital exhaustion 0 0 1-4 5-9 10+ Vital exhaustion, IHD and death 6 years of follow-up of 9,563 adults from Copenhagen * Adjusted for 13 biological, behavioural and social factors Prescott et al. Int J Epidemiol 2003;32:990-7

25. Sleep quality and myocardial infarction 3 years of follow-up of 416 middle-aged German blue-collar workers RR 3.8 2.6 1.0 1.0 No Yes No Yes Wake up early Difficulty staying asleep Siegrist. J Chron Dis 1987;40:571-578.

26. RR * 7.8 8 7 6.2 6 5 3.9 4 3 1.0 2 1.0 1.0 1 0 - - - + + + Psychological risk factors for CHD among homemakers from Framingham A 20-year follow-up study of 362 women Trouble falling asleep Tension Symptoms of anxiety *Adjusted for CVD risk factors.Eaker et al. Am J Epidemiol 1992;135:854-864.

27. Sleep and risk of IHD A study of 71,617 American nurses followed for 10 years Adjusted for 14 factors Age-adjusted RR 1.8 1.6 1.4 1.4 1.3 1.2 1.1 1.1 1.0 1.0  5 6  9  5 6  9 7 8 7 8 The Nurses’ Health Study Ayas et al. Arch Intern Med 2003;163:205-9

28. CVD, sleep quality and ”need for recovery” after work Results from 32 months of follow-up of the Maastrict Cohort Study on fatigue RR 3.16 2.82 3 2 1.22 1 1 1 0 Low Poor Good Medium High Need for recovery Sleep quality N=7,944 workers. 18-65 years. 42 cases. Van Amelsvoort et al. Occup Environ Med 2003;60:83-87.

29. Long working hours and short sleep as risk factors for AMI A case control study of working Japanese men 40-79 years of age 260 cases and 445 matched healthy controls RR* 2.1 1.8 1.3 1.1 1 1 41-60 <40 0 61+ 1 2+ Days/week with <5 hours of sleep Working hours/week past year *Adjusted for smoking, alcohol, BMI, BP, DM, cholesterol, heart disease in family, job type and sedentary job Lin er al. Occup Environ Med 2002;59:447-51.

30. Depression and CHD A meta-analysis Relative risk among initially healthy subjects. Analysis of 11 studies Rugulies. Am J Prev Med 2002;23:51-61.

31. The new fatigue Long working hours Fatigue Family/ work conflict Need for recovery Shift work, 24 h society Burnout Stress High emotional demands High work pace Depression Withdrawal Conflicts, bullying Sleep problems Cardiovascular disease

32. Family and private life

33. Is marriage worse than work? (For women) A follow-up study of 292 female heart patients in Stockholm Work stress Marital Stress RR* For new events RR* For new events 2.9 2.8 2 2 1.7 (NS) 1.3 (NS) 1 1 1 1 0 0 Severe Low Moderate Severe Low Moderate * Adjusted for age, diagnosis, SBP, DM, smoking, lipids and estrogen status. Orth-Gomér et al. JAMA 2000;284:3008-14.

34. Psychosocial factors and acute myocardial infarction: The INTERHEART STUDY 11,119 cases and 13,648 controls from 52 countries RR* 2.14 2.12 2 1.52 1.48 1.38 1.33 1.23 1.19 1 1 1 1 1 0 Work stress Life events Financial stress Home stress Rosengren et al. www.the lancet.com Sept. 3,2004:1-10

35. Problems with methods and design?

36. Job strain and effort-reward imbalance as predictors of CVD mortality A 26 years’ follow-up of 812 Finnish employees Effort-reward imbalance Job strain RR* RR* 2.42 2.22 1.91 2 2 1.64 1 1 1 1 0 0 High Low Medium High Low Medium * Adjusted for smoking, physical activity, SBP, cholesterol, BMI, age and occupation. 73 cases. Kivimäki et al. BMJ 2002;325:857-60.

37. Quantitative demands at work:The two dimensions Basic issue: The (mis)match between the amount of work and the time available to do it. Intensity (pace) Extensity (hours) Kristensen et al. Work & Stress 2004;18:305-322.

38. How should quantitative job demands be measured? JCQ Whitehall II My job requires working very fast. Do you have to work very fast? Intensive demands? Intensive demands? My job requires working very hard. Do you have to work very intensively? Physical demands? Cognitive demands? I am not asked to do an excessive amount of work. Do you have enough time to do everything? Extensive demands? Extensive demands? I have enough time to get the job done. Do different groups at work demand different things from you that you think are hard to combine? Extensive demands? I am free from conflicting demands that others make. Role conflicts? Role conflicts? Each scale seems to measure four different dimensions.

39. We need better measures of job demands “The basic measurement of the demand construct should be improved”(Johnson et al, 1996)“Exposure measurement should be improved, especially for the psychological demand variable”(Steenland et al, 1997)“The measures of psychological job demands need to be refined”(Theorell et al, 1998)“The concept of demands may be too loosely defined”(Hallqvist et al, 1998) Kristensen et al. Work & Stress 2004;18:305-322.

40. Scale for intensive quantitative demands Mismatch between the amount of work to be done and the time available to do it Faster work pace (Intensification) Pressure for increased productivity Basic scale for quantitative demands at work Pressure for Longer working hours (Extensification) Questions on formal and actual working hours How can we measure quantitative demands? Model for the measurement of quantitative job demands. Processes at the workplace and job level. Measures of quantitative job demands. Processes at the (global) labour market. Kristensen et al. Work & Stress 2004;18:305-322.

41. Job strain and CHD in Whitehall II 11 years of follow-up of 10,308 employees Fatal CHD + non-fatal MI. A positive study? RR* N.S. N.S. N.S. N.S. N.S. 1.9 2.0 1.3 1.3 1.3 1.2 1.16 1.14 1.0 1.0 1.0 1.0 1.0 1.0 0.9 1.0 0.71 0.7 0 M L M H M H M L H L L H Low Active High Passive Women Women Men Men Demands Job strain Control * Adjusted for other risk factors. Kuper & Marmot. J Epidemiol Community Health 2003;57:147-153.

42. High Strain Active I I II Demands Women II Men III III Low Strain Passive Control Job strain & Whitehall II Kuper & Marmot. J Epidemiol Community Health 2003;57:147-153.

43. Extending our paradigms Work Demands Control Support Rewards Job insecurity Predictability Meaning of work Rate of change Emotional demands Role conflicts/ambiguities Conflicts/bullying Family/work conflicts Long working hours Irregular working hours Individual (Di)stress Hostility Overcommitment Fatigue Need for recovery Depression Sleep

44. Conclusions • The association between work and CVD is a major – but somewhat neglected – issue. • The new developments in the globalized economy seem to increase CVD risk – at least in the rich countries. • Fatigue, burnout, depression and sleep problems seem to be increasing – and to increase CVD risk. • Our models, methods, and designs should be improved.

45. The End This presentation (and many others) may be found at www.ami.dk/presentations