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Work, stress, and bodily reactions
Åse Marie HansenNational Research Centre for the
Working Environment
• What is stress?• How to measure stress? • The bodily reaction to workrelated stress?• When is stress unhealthy?• Biological variation
Work, stress, and bodily reactions
Model
Exposure
Biological response
Effect
Concept of biomarkers
Stressor
Acute physiological response
Long term effects
Strain Train
Individual factorsPerceived psykosocialwork environment
What is stress?
Example:Stress is a series of reactions, which may
lead to a chronic individual state characterized by a combination of high arousal, aversion and negative expectation about solving the challenge
What is stress?
Stress is your body's way of responding to any kind of demand. It can be caused by both good and bad experiences.
Stress is the emotional and physical strain causedby our response to pressure from the outside world.
What is workrelated stress?
Stressors at the work place
Physical strain
Job demands,heavy work load
Chemical exposure
Job demands,mental demands
Job control
Physical work placee.g. noise and temperatur
Reactions to stress
• Cognitive and emotional reactions
• Behavioral reactions/symptoms
• Somatic reactions
• Physiological reactions
Cognitive and emotional reactions
Lack of motivation
Tiredness
Difficulty to remember
Difficulty to concentrate
Anxiety
Irritability
Depression
Low self-worth
Lack of appetite
Sleep problems
Reservation
Anger
Behavioral symptoms
Aggression
Low performance
Behavioral reactions to stress
Alcohol
Coffee
Smoking
Abuse
Physical activity
Sick leave
Indecisive
Somatic symptoms of stress
Headache
Sweating
Often infections
Hyperventilation
Stomach problems
Loss of weight
Palpitation/ Pain in the breast
How to measure stress?• Questionnaire, e.g.
– Demand/control– Effort /reward– COPSOQ– Perceived stress and energy
• Observations• Bodily reactions to stress
(physiological reactions), e.g.– cortisol in saliva– adrenaline and noradrenaline in urine
How do you feel after a normal workday?
S: CalmE: PassiveS: PressureE: FocusedS: RelaxedE: IneffectiveE: EnergeticS: StressedE: SadS: TenseE: ActiveS: Refreshed
Very often
OftenSome-times
To some degree
Very littleNot at all
Translated from Kjellberg and Iwanowski 1989
Responses from approx. 600 officeworkers
5 %xE: Passive5 %xE: Ineffective3 %xE: Sad
x5 %E: Focusedx3 %E: Energetic
x2 %E: Active14 %xS: Pressure15 %xS: Stressed15 %xS: Tense
x1,5 %S: Calmx5 %S: Relaxed
x17 %S: Refreshed
Very often
OftenSome-times
To some degree
Very littleNot at all
Stress scale = 2.3 Energy scale = 3.0
0.0
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2.5
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Time
Tuesday Wednesday Thursday Friday Saturday Sunday
Stre
ss In
dex
Scor
eStress index
Ener
gyIn
dex
Scor
e
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Time
Energy index
Tuesday Wednesday Thursday Friday Saturday Sunday
How the body responds to work-related stress
The sympathetic nervous system
• Adrenaline/noradrenaline increase
• Heart frequency increase
• Blood pressure increase
• More blood to the muscles
• Less blood to the skin
• Low digestion
• Increased brain activity
Biomarkers for catabolicand anabolic metabolism
Catecholamines(adrenaline and noradrenaline)
CortisolGlycated hemoglobin
(HbA1c)
TestosteroneGrowth hormoneDehydroepiandrosterone
(DHEA)
Unwinding after work overload
0
50
100
150
200
250
0 5 10 15 20
Weeks
% o
f pre
-ove
rtim
e va
lue
061218
Evening Daytime Extra working hours
061218
Hours
Frankenhaueser and Johansson. Int.Rev.Appl.Psychol. (1986)
Total serum cholesterol
200205210215220225230235240
31-12
-56
20-01
-57
09-02
-57
01-03
-57
21-03
-57
10-04
-57
30-04
-57
20-05
-57
09-06
-57
29-06
-57
mg/
100
mL
plas
ma
Group A Group B
A A and B BB
Perceived stress Friedman et al. 1958
Noise
0.050
0.060
0.070
0.080
0.090
06:00 08:00 10:00 12:00 14:00
Cor
tisol
(µgr
am/m
g cr
eatin
ine)
Without hearing protectionWith hearing protection
Melamed et al., Psychom.Res.1995
HbA1c
KolesterolDHEA-STestosteronIgAProlaktin
1
AdrenalinNoradrenalinKortisol
Helbredsundersøgelse
Generelt stress niveauOplevet si tuation
Monotonous work
Hansen et al 2003
** p<0.05
Unpublished results
4,50
4,55
4,60
4,65
4,70
4,75
low demand/low control
low demand/high control
high demand/low control
high demand/high control
% o
f tot
al h
emog
lobi
nJob strain and HbA1c
Outsourcing
Outsourcing
-20 0 20 40 60Percent increase
Adrenaline
Noradrenal ine
Cortisol
HbA1c
DHEA-S
**
*
Netterstrøm et al. (2000)
Threat of closing
Erikssen et al. 1990
80
90
100
110
120
130
140
150
160
1982 1983 1984 1985 1986 1987 1988586062646668707274767880BP (mm Hg)
Norwegian metal workers(N = approx. 180) Pulse
SBP
Pulse
DBP
129 129130135
142 145 143
63 63
6970
84 85 8690
94 9691
Organisational downsizing and death
7,5 years follow-up study among 22.430 employeesin the public sector, who kept their jobs
Vahtera et al. BMJ 2004;328:555-558.*Controlled for age, gender, SES og job
0
1
2
1.0
1.5
1.01.2
2.0
1.2
RR*
None Minor Major None Minor Major
Extent of downsizing
2.0
1.0
0
CVD Otherdeaths
When are the physiologicalreactions unhealthy?
Models for health risk
• Cognitive activation theory• Allostasis• Lack of restitution• Shift of rhythms• Stress-disequilibrium theory
(Not included)
Bullying and cortisol in saliva
3.00
7.00
11.00
15.00
19.00
00:00 06:00 12:00 18:00 00:00
Time of day
Cor
tisol
in s
aliv
a(n
mol
/l)
Reference group bullied individuals
AllostasisThe ability to
achieve stabilitythrough change.
McEwen New England Journal of Medicine (1998)
Size of response
Exposure
The wear and tear that result from chronic
overactivity or underactivityof allostatic
systems
Allostatic load
Successful aging
• Systolic blood pressure (>148 mm Hg)• Diastolic blood pressure (>83 mm Hg)• Waist-hip ratio (>0.94)• Total cholesterol-HDL ratio (>5.9)• Total HbA1c (>7.1%)• Urinary cortisol (>25.7 mg/g creatinine)• Urinary norepinephrine (>48 mg/g creatinine)• Urinary epinephrine (>5 mg/g creatinine)• HDL cholesterol (< 1.45 mmol/L)• DHEA-S (<2.5 µmol/L)
T.E. Seeman et al. (1997)
Successful aging
0
5
10
15
0 1-2 >=3
Allostatic load category
New
car
diov
ascu
lar
dise
ase,
%
T.E. Seeman et al. (1997)
Cortisol and memory
0
2
4
6
8
10
12
-10 -5 0 5 10 15 20 25
Cortisol response (nmol/L)
No.
ofc
orre
ctly
reca
lled
wor
ds
Kirschbaum et al. Life Sci. 1996
Cortisol and memory
0
1
2
3
4
5
6
7
8
9
Declarative memory Procedural memory
No.
ofr
ecal
led
orco
mpl
eted
wor
ds
10 mg cortisolPlacebo
*
Kirschbaum et al. Life Sci. 1996
Cortisol and memory
45
50
55
60
65
0 2 4 6 8 10Days
Imm
edia
tere
call
bits
placebo40 mg/d160 mg/d
Newcomer et al. Arch.Gen.Psychiatry 1999
Rate of recovery
Exposure
Unwinding after work overload
0 5 10 15 20
Weeks
0
50
100
150
200
250
% o
f pre
-ove
rtim
e va
lue
of e
pine
phrin
e
EveningDaytimeExtra working hours
Frankenhaueser and Johansson. Int.Rev.Appl.Psychol. (1986)
061218
Hours
Reduced reactivity
Stressor
Serum cortisol after stress test
400
450
500
Base 16 20 30 40
Minutes after stress test
Seru
m c
ortis
ol (n
mol
/L)
Vilnius
Linköping
M. Kristensson et al. (1998)
Stress test ***
* ***
Lack of variability
HighFlatNormal
Construction workers
0.00
5.00
10.00
15.00
20.00
25.00
03:00 09:00 15:00 21:00Time (hours)
nmol
cor
tisol
/l sa
liva
Reference group
Construction workers - normal day
Construction workers - long day
Cortisol in saliva during a working day
Significantly higher concentration of saliva cortisol observed in construction workers compared to reference group. No difference was observed between construction workers having long and normal days
Hansen, 2006
Relative variability in salivary cortisol
* Coefficient of variance# 95% Confidence interval
[91-108]
99
[91-108]
99
Reference group
[65-92]CI (%) #
0.00476CV (%) *
0.0437282CV (%) *
[57-95][64-112]CI (%) #
Normal daysLong days
P-valueConstruction workers
Hansen, 2006
Conclusion
• Construction workers had higher concentrations of cortisol in saliva during a work day compared to white collar workers.
• Construction workers had lower relative variability in cortisol compared to whi te collar workers
Restitution
Catabolic metabolismAnabolic metabolism
Demands DemandsRest
Restitution
Catabolic metabolismAnabolic metabolism
Demands DemandsRest
Outsourcing
-20 0 20 40 60Percent increase
Adrenaline
Noradrenal ine
Cortisol
HbA1c
DHEA-S
**
*
Netterstrøm et al. (2000)
Working hours and bloodpressure
Yang et al. 2006
00.20.40.60.8
11.21.41.6
11-39 40 41-51 > 51Weekly working hours
Ris
cof
incr
ease
dbl
ood
pres
sure
Contolled for diabetes, tobacco, physical activty, SES, gender, age(n=24.205, 18-64 år)
Øresundsbron
Building the bridge between Sweden and Denmark
14
16
18
20
22
0 5 10
Test
oste
rone
(nm
ol/L
)
Pylon workersControls
Days
Ørbæk et al. 2000
Øresundsbron
Exhaustion
0
5
10
15
0 5 10 15Dag
% o
f the
day
Pylon workers Track workers
Ørbæk et al. 2000
Typical sleep
Gerlach: Søvn, 2003
Hormones respond to sleep
• Growth hormone, prolactin and testosterone ↑
• Thyroid hormoneand adrenaline ↓
• Cortisol ↑ duringterminal sleep
• CRH reduces sleepquality
• Melatonin stimulatessleep
Sleep → hormones: Hormones → sleep:
Stress and sleep
Stress
Physiologicalarousal
Increased cortisoland adrenaline
Difficultiesfalling asleep
Sleep loss
Need for increased effort
Sleep problems -> illness• Increased risk of heart disease
– Review of 10 studies– High quality studies found increased risk of
coronary events after adjusting for age and otherrisk factors
– The combined risk was 1.7 (range 1.5 -3.9)• Increased risk of diabetes
– 6599 non-diabetic men at baseline, aged 44.5 ±4.0 years
– 281 (4.3%) developed diabetes during follow-up(14.8 years)
– Men with difficulties falling asleep or regular use of hypnotics had increased risk of 1.52 [95% CI: 1.05-2.20] Schwarts S et al., J Psychosom Res, 1999
Nilsson PM et al., Diabetes Care, 2004
Sleep and heart diseaseA study of 71,617 American nurses followed for 10 years
Ayas et al. Arch Intern Med 2003;163:205-9. The Nurses’ Health Study
0.0
0.5
1.0
1.5
2.0
2.5
1.8
1.31.1 1.0
-5
RR
1.61.4
1.2 1.1 1.0
1.4
6 7 8 9+ - 5 6 7 8 9+
Adjusted for 14 factorsAge-adjusted
Psychosocial work and sleep
• High demands• Low control• Keep thinking of
work• Expect difficult
workday
• Unsolved conflicts• Unsolved problems
• Social support
Decreasessleep problems:
Increasessleep problems:
Kalimo et al., Stress Med, 2000Åkerstedt et al., J Psychosom Res 53(1), 2002Åkerstedt et al., J Psychosom Res 53(3), 2002Kecklund et al., Biol Psychol, 2004
Shift of rhytms
Melatonin - workdayMelatonin - day off
KSS - workdayKSS - day off Working hours
Time
Fixed shift day
Very alert
Alert
Neither alert nor sleepy
Sleepy
Extremely sleepy
06:00 12:00 18:00 24:000
2
4
6
8
10
12
14
16
18 Fixed shift night
06:00 12:00 18:00 24:00
Time
0
2
4
6
8
10
12
14
16
18
µmol
aMT6
/mol
creati
nine
Hansen et al., 2006Garde et al., unpublished data
Biological variation
PhysiologicalAge, sex, height, health etc.
GeneticMetabolism & Genotype
LifestyleSmoking, alcohol, medicine etc.
Biological variation
Individual factorsIndividual factors
Body mass indexBody mass index
AgeAge
GenderGender
Age
Stevens, Wilson, et al. 1997
Age
0
10
20
30
40
19-39 40-49 50-59 >60
Women
Men
DH
EA (n
mol
/L)
Years of age
AR Genazzani (1998)
Age and BMI
30 6020
300
1
2
3
4
5
6
7
8
Age (years)
BMI (kg/m2)
S-DHEA-S (nmol/L)
Hansen et al 2002
Age and smoking
30 60Non-smoker
Smoker
4
5
Age (years)
B-HbA1c (%)
Hansen et al 2002
GenderTe
stos
tero
ne(n
mol
/L)
302520151050
H Olesen et al. (1987)
CoffeeCoffeeCoffee
AlcoholAlcoholAlcohol
SmokingSmokingSmoking
MedicineMedicine
Individual factors related to life style
Individual factors related to life style
Evening coffee steels yoursleep
One cup of coffeecontains enoughcoffein to half theamount of melatonin
Ingeniøren No 22, Maj 2002, (part of a note from New Scientist)
Urinary adrenaline: Smoking and BMI
0
1
2
3
4
5
6
05:45 11:45 17:45 23:45
Hour
µmol
/mol
cre
atin
ine
SmokerNon-smoker
Women BMI 19-20
0123456
05:45 11:45 17:45 23:45
Hour
µmol
/mol
cre
atin
ine Smoker
Non-smokers
Women BMI 28-30
Hansen et al. 2001
Genetic factorsGenetic factors
Ethnic background:20% higher levels of S -testosterone in black subjects% HbA1c lower in Caucasian compared to black subjects
Ethnic background:20% higher levels of S -testosterone in black subjects% HbA1c lower in Caucasian compared to black subjects
Other Interactions
Exercise
Food
Artificiel light
Wake up
Circadian rhytm
Seasonal variation
Circadian variation
Medicinsk Kompendium (1994)
1000
750
500
250
012 16 20 24 4 8 12
Time
Plas
ma
corti
sol (
nmol
/L)
Circadian variation
Medicinsk Kompendium (1994)
Seasonal variation -epinephrine
0
2
4
6
8
10
Hour
µmol
/mol
cre
atin
ine
June and July August to May
0 06.00 12.00 18.00 24.00
Hansen et al 2001
Garde et al, 2000
Seasonal variationof DHEAS
4
5
6
7
8
9
June July Aug Sep Oct Nov Dec Jan Feb Mar Apr May
Pla
sma
DH
EA
S(µ
mol
/L)
WinterSummer
Within and between subjectvariation
02468
1012
0 5 10 15 20
Plasma DHEA-S (µmol/L)
Garde et al, 2000
Within and between subjectvariation
02468
1012
3.0 3.5 4.0 4.5 5.0 5.5
Blood HbA1c (% of total hemoglobin)
Garde et al, 2000
Questions?
• Åse Marie Hansen [email protected]