ISMF’s Årsmøde12. november 2004
Eigtveds Pakhus
Hjertekarsygdomme - risikofaktorer i arbejdsmiljøet
Tage Søndergård Kristensen
Arbejdsmiljøinstituttet
General model for the relationship between work environment and cardiovascular diseases
DK-2004-017The significance of work: 1 + 3
CVD risk factors:
Diet, obesity,
blood pressure,
smoking etc.
CARDIO-
VASCULAR
DISEASES.
WORK
ENVIRON-
MENT
1 2
3
Causal network for CVD
DK-2004-010
Job strain
Social isolation
Uemploy-ment
Noise
Physical activity
Tobacco
Diet
Alcohol
Fitness
Obesity
Type A
Stress
Cholesterol
Blood pressure
Fibrinogen
Glucose
Athero-sclerosis
Thrombosis
Arrhythmia
ECG-changes
SES&
Occupa-tion
….
….
….
….
….
Upstream
Downstream
CVD
Social &Environmental
Factors Behavior
Individual
Characteristics Physiology Precursors
The cardiovascular tradition fromFramingham and onwards
DK-2004-012
Cholesterol
Fibrinogen
Triglycerides
Glucose
Blood pressure
Heart rate
Obesity
Risk factors are individual
Smoking
Physical inactivity
Type A
Salt intake
Diet
Alcohol
Physiological: Behavioral:
The occupational medicine tradition from Ramazzini and onwards
DK-2004-011
Physical
Chemical
Psychosocial
Ergonomic
Biological
Risk factors are environmental
Arbejdsmiljøets betydning for hjertekarsygdomme
Etiological fractions of work environment for cardiovascular diseases in Denmark
Olsen & Kristensen. J Epidemiol Community Health 1991;45:4-10 DK-2004-016
Proportion of CVD
Risk factor Men Women
“Sedentary” work 42% 42%
Job strain 6% 14%
Shift & night work 7% 7%
Noise 1% 1%
Chemical exposures 0-1% 0%
Passive smoking 2% 2%
All factors 51% 55%
All factors except sedentary work 16% 22%
The significance of work environment for mortality
Estimates of etiologic fractions in Finland Men Women
Cardiovascular, total 14% 7%
IHD 19% 9%
Cerebrovascular 12% 8%
Cancer, total 13% 2%
Mental disorders 7% 2%
Respiratory diseases 7% 1%
Accidents 4% 0%
Total 10% 2%
Nurminen & Karjalainen. Scand J Work Environ Health 2001;27:161-213.
The significance of work environment for hospitalisations
Estimates of etiologic fractions in Denmark Men Women
Circulatory 16% 18%
Cancer 8% 3%
Nervous system 17% 12%
Respiratory 16% 12%
Accidents 17% 6%
Musculoskeletal 21% 19%
Total 15% 11%
Tüchsen et al. Sci Total Environ 2004
Etiologic fractions of psychosocial factors for acute myocardial infarctions: The INTERHEART STUDY
11,119 cases and 13,648 controls from 52 countriesEtiologic
fractions*
Work stress 9%
Home stress 8%
Financial stress 11%
Life events 10%
Locus of control 16%
Depressive mood 9%
All psychosocial factors 33%
Rosengren et al. www.thelancet.com Sept. 3,2004:1-10
* Adjusted for cardiovascular risk factors
Risikofaktorer i arbejdet
The pioneering studies
Coronary heart disease among London bus drivers and conductors
Morris et al. Lancet 1953;iii:1053-7.DK-2004-004
0
0,5
1
1,5
2
CHD Fatal CHD
Cases/1000 person-years
1.5
0.8 0.8
0.4
2
1.5
1
0.5
0
Bus driversConductors
The effort-reward model in Whitehall II
*Fully adjusted
Bosma et al. Am J Public Health 1998;88:68-74 DK-2004-014
0
1
2
3
4
Ischemic heart disease5.3 years of follow-up
1.0
2.1
3.0
1.0
2.4
3.6
1.0
1.8
2.2
4.0
3.0
2.0
1.0
0.0L.E.H.R.
H.E.or
L.R.
H.E.L.R.
L.E.H.R.
H.E.or
L.R.
H.E.L.R.
L.E.H.R.
H.E.or
L.R.
H.E.L.R.
Men Women Total*
OR
Job strain and effort-reward imbalance as predictors of CVD mortality
A 26 years’ follow-up of 812 Finnish employees
1
1,64
2,22
0
1
2
3
Low Medium High
RR*
1
1,91
2,42
0
1
2
3
Low Medium High
RR*Job strain Effort-reward imbalance
* Adjusted for smoking, physical activity, SBP, cholesterol, BMI, age and occupation. 73 cases.
Kivimäki et al. BMJ 2002;325:857-60
1
1,38
2,14
1
1,52
2,12
11,19
1,33
11,23
1,48
0
1
2
3RR*
Psychosocial factors and acute myocardial infarction: The INTERHEART STUDY
11,119 cases and 13,648 controls from 52 countries
Work stress Home stress Financial stress Life events
Rosengren et al. www.the lancet.com Sept. 3,2004:1-10
Is marraige worse than work?
(For women)
A follow-up study of 292 female heart patients in Stockholm
1
2,8 2,9
0
1
2
3
Low Moderate Severe
RR*
11,3
1,7
0
1
2
3
Low Moderate Severe
RR*
Marital stress Work stress
* Adjusted for age, diagnosis, SBT, DM, smoking, lipids and estrogen status.
Orth-Gomér et al. JAMA 2000;284:3008-14
For new events* For new events*
(NS)
(NS)
Standardized Hospitalization Ratios (SHR’s) for IHD among Danish men aged 20 – 59 years
Tüchsen. Int J Epidemiol 1993;22:215-21. DK-2004-015
(4 years of follow-up. N = 407,000)
0
50
100
150
200
250
100
193215
168 172
250
200
150
100
50
0
SHR
Day Night Lateevening
24 hourrosters
Otherirregular
Hospital admissions for CVD in a group of unemployed men compared with a control group
Iversen et al. BMJ 1989;299:1073-6. DK-2004-013
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
1,8
0.80
1.04
1.60
Before factoryclosure
(2 years)
During factoryclosure
(3 years)
After factoryclosure
(3 years)
0
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
Passive smoking and IHDThe Nurses’ Health Study
Kawachi et al. Circulation 1997;95:2374-9. DK-2004-019
0
1
2
Never Occational Regular
1.0
1.6
1.9
Adjusted RR
N = 32,046 never smokers
Exposure to passive smoking (work or home)
Carotid artery wall thickness and(passive) smoking
Diez-Roux et al. Prev med 1995;24:48-55.DK-2004-020
0
0,2
0,4
0,6
0,8
1
The ARIC Study
0.67 0.68 0.700.74 0.73
0.78
No P.S.
MenWomen
mm (adjusted)
0.820.90
P.S Ex S.
1.00
0.80
0.60
0.40
0.20
0No P.S. P.S Ex S.
Smoking status
The Seaton – Sjögren hypothesis
Seaton et al. Lancet 1995;345:176-8Sjögren. Occup Environ Med 1997;54:466-9
Air pollution(dust)
Alveolarinflammation(low grade)
Release of mediators
IHD
Increased level of plasma fibrinogen
Den nye træthed
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%
1
2,13
0
1
2
3
No Yes
RR* for IHD*
Burnout
* Controlled for age, BP, smoking, cholesterol. 59 cases.
Appels & Schouten. Behav Med 1991;Summer:53-59
Vital exhaustion, IHD and death
6 years of follow-up of 9,563 adults from Copenhagen
RR*
Vital exhaustion
* Adjusted for 13 biological, behavioural and social factors
Prescott et al. Int J Epidemiol 2003;32:990-7
1 1,1 1,21,6
1
1,61,8
2,2
0
1
2
3
0 1-4 5-9 10+
IHD
Mortality
0
5
10
15
20
25
30
35
40
45
50
Work-relatedburnout
Work-related burnout and sleeping problems two years later
Results from the PUMA baseline and 2 years’ follow-up
N = 1014 DK-2004-007
25.1
32.6 34.4
44.6
Low HighQuartiles
Karolinska sleepquestionnaire (scale)
1
2,82
1,22
3,16
1
0
1
2
3
4
Good Poor Low Medium High
RR
CVD, sleep quality and ”need for recovery” after work
Results from 32 months of follow-up of the Maastrict Cohort Study on fatigue
N=7,944 workers. 18-65 years. 42 cases.
Van Amelsvoort et al. Occup Environ Med 2003;60:83-87
Sleep quality Need for recovery
Sleep and risk of IHD
A study of 71,617 American nurses followed for 10 years
Ayas et al. Arch Intern Med 2003;163:205-9 DK-2004-008
0,0
0,5
1,0
1,5
2,0
2,5
1.8
1.31.1
1.0
5
RR
1.61.4
1.21.1
1.0
1.4
6 7 8 9 5 6 7 8 9
Adjusted for 14 factorsAge-adjusted
The Nurses’ Health Study
1
1,3
1,8
1 1,1
2,1
0
1
2
3
Under40
41-60 61+ 0 1 2+
RR*
Long working hours and short sleep as risk factors for AMI
*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
Working hours/week past year
Days/week within <5 hours of sleep
A case control study of working Japanese men 40-79 years of age
260 cases and 445 matched healthy controls
1
0,72
2,31
0
1
2
3
At neither time At one time At both times
Bullying at work and CVD
*Adjusted for gender and incomeBullying was associated with obsesity and depression
Kivimäki et al. Occup Environ Med 2003;6:779-83
RR for CVD*
Subjected to bullying
A 2-year follow-up study of 5,432 hospital employees in Finland
The new fatigue
Long workinghours
Shift work,24 h society
High emotionaldemands
Conflicts,bullying
High workpace
Family/work conflict
Fatigue
Burnout
Stress
Withdrawal
Sleep problems
Depression
Need for recovery
Cardiovasculardisease
Danske forskernetværker om arbejde og hjertekarsygdom
Glostrup/Østerbro/HCPB: Eva Prescott, John Barefoot,Bo Netterstrøm, Nanna Eller,Naja Rod Nielsen, Ingelise Andersen
Københavnske mænd (Bispebjerg): Finn Gyntelberg, Hans Ole Hein,Poul Suadicani
Arbejdsmiljøinstituttet: Finn Tüchsen, Reiner Rugulies
Ålborg: Henrik Bøggild
SLUT!!
The pioneering studies
Coronary heart disease in the postal service
Morris et al. Lancet 1953;iii:1053-7.DK-2004-005
Degree of physical activity
Active Medium Sedentary
(Postmen)
(Cases per 1000 person years)
35 – 44 years 0.5 0.6 0.8
45 – 54 years 2.7 2.8 3.4
55 – 59 years 4.6 5.0 5.4
Total, standardized 1.8 2.0 2.4
Hostility and mortality in the Kuopio Study(Relative hazards)
All RHs are controlled for age. N = 2,125 men.
Everson et al. Am J Epidemiol 1997;146:142-52
DK-2004-009
HostilityLow High
1 2 3 4
Total mortality 1.0 1.30 1.33 2.30
Cardiovascular mortality 1.0 1.76 1.85 2.70
Non-CVD mortality 1.0 1.07 1.07 2.09
The most important social and occupational CVD risk factors
DK-2004-018
Social
• Social class• Social network• Life events• Social stressors
• Passive smoking• Noise• Lead
Occupational
• Sedentary work• Work stressors
- Job strain
- Effort reward
imbalance• Shift work• Chemicals
0
1
2
3
Dioxin and CVD
A German study of 1,189 chemical workers and 2,528 controls
Flesch-Janys et al. Am J Epidemiol 1995;142:1165-75 DK-2004-021
1.0 1.0 1.0 1.0
RR (mortality)
1.1
2.7
1.2
1.0 0.9 0.9
Toxic equivalents of PCDD
1.71.5 1.6 1.6
2.1
IHD CVD
Low High Low High
Vinyl chloride and hypertension
Kotseva. Int Arch Occup Environ Health 1996;68:377-9 DK-2004-022
0
1
2
3
4
5
Controls Low Medium High
1.0 1.0
RR (adjusted)
A five-year follow-up study of Bugarian workers105 exposed and 105 non-exposed workers
Exposure
2.0
4.2
CO exposure, CVD and IHD
Koskela. Scand J Work Environ Health 1994;20:286-93 DK-2004-023
0
1
2
3
4
5
6
7
8
Non-smokers
Smokers Non-smokers
Smokers
1.0
2.6
RR (mortality)
A study of Finnish foundry workers
1.01.4 1.4
1.0 1.0
6.9CO exposed
CVD IHD