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