S A Stansfeld

Adrenocortical, Autonomic, and Inflammatory Causes of the Metabolic Syndrome Nested Case-Control Study

Background—The causes of metabolic syndrome (MS), which may be a precursor of coronary disease, are uncertain. We hypothesize that disturbances in neuroendocrine and cardiac autonomic activity (CAA) contribute to development of MS. We examine reversibility and the power of psychosocial and behavioral factors to explain the neuroendocrine adaptations that accompany MS. Methods and Results—This was a double-blind case-control study of working men aged 45 to 63 years drawn from the Whitehall II cohort. MS cases (n=30) were compared with healthy controls (n=153). Cortisol secretion, sensitivity, and 24-hour cortisol metabolite and catecholamine output were measured over 2 days. CAA was obtained from power spectral analysis of heart rate variability (HRV) recordings. Twenty-four-hour cortisol metabolite and normetanephrine (3-methoxynorepinephrine) outputs were higher among cases than controls (+ 0.49, +0.45 SD, respectively). HRV and total power were lower among cases (both −0.72 SD). Serum interleukin-6, plasma C-reactive protein, and viscosity were higher among cases (+0.89, +0.51, and +0.72 SD). Lower HRV was associated with higher normetanephrine output (r =−0.19;P =0.03). Among former cases (MS 5 years previously, n=23), cortisol output, heart rate, and interleukin-6 were at the level of controls. Psychosocial factors accounted for 37% of the link between MS and normetanephrine output, and 7% to 19% for CAA. Health-related behaviors accounted for 5% to 18% of neuroendocrine differences. Conclusions—Neuroendocrine stress axes are activated in MS. There is relative cardiac sympathetic predominance. The neuroendocrine changes may be reversible. This case-control study provides the first evidence that chronic stress may be a cause of MS. Confirmatory prospective studies are required.

The health effects of major organisational change and job insecurity

Since August 1988 an increasing proportion of the executive functions of government in the United Kingdom have been devolved to executive agencies. Transfer to an executive agency involves a period of uncertainty during which the options of elimination or transfer to the private sector are considered, followed by a marked change in management style and further periods of uncertainty when the agencys function is reconsidered for transfer to the private sector. This paper examines the effects of this major organisational change and consequent job insecurity on the health status of a cohort of 7419 white-collar civil servants by comparing groups either exposed to or anticipating exposure to this stressor, with controls experiencing no change. Compared with controls, men both already working in and anticipating transfer to an executive agency experienced significant increases in health self-rated as average or worse, longstanding illness, adverse sleep patterns, mean number of symptoms in the fortnight before questionnaire completion, and minor psychiatric morbidity. Significant relative increases in body mass index were seen in both exposure groups while exposure to agency status was also associated with significant relative increases in blood pressure. Health-related behaviours, where they differed between exposure and control groups, tended to favour those in the exposure groups. Compared with controls, women in both exposure groups reported small increases in most self-reported morbidity measures and most clinical measurements, accompanied by slight beneficial changes in some health-related behaviours and small adverse changes in others. Significant relative increases were seen in mean number of symptoms, and ischaemia among women anticipating exposure and in body mass index among those exposed to agency status. Policy makers should be aware of the wider consequences of job insecurity when considering the efficiency of changes in employment policy.

Is retirement good or bad for mental and physical health functioning? Whitehall II longitudinal study of civil servants

Background: To determine whether retirement at age 60 is associated with improvement or deterioration in mental and physical health, when analysed by occupational grade and gender. Methods: Longitudinal study of civil servants aged 54 to 59 years at baseline, comparing changes in SF-36 health functioning in retired (n=392) and working (n=618) participants at follow up. Data were collected from self completed questionnaires. Results: Mental health functioning deteriorated among those who continued to work, but improved among the retired. However, improvements in mental health were restricted to those in higher employment grades. Physical functioning declined in both working and retired civil servants. Conclusion: The study found that retirement at age 60 had no effects on physical health functioning and, if anything, was associated with an improvement in mental health, particularly among high socioeconomic status groups.

An uncertain future: the health effects of threats to employment security in white-collar men and women.

OBJECTIVESnThis study examined changes in the health status of civil servants whose employment security was threatened.nnnMETHODSnData were derived from a longitudinal cohort of 10,308 men and women, office staff in 20 British civil service departments. Physiological measurements, self-reported morbidity, and health-related behaviors for 530 members of the department under threat were compared with those of 19 other departments, during the period of uncertainty and during stable employment 5 years earlier.nnnRESULTSnFrom a position of advantage or no difference at baseline, self-reported morbidity and physiological risk factors tended to increase among respondents from the threatened department compared with those from other departments. For both sexes, increases were significant for body mass index (P < .001) and sleeping 9 or more hours (odds ratio [OR] = 1.88; 95% confidence interval [CI] = 1.3, 2.8; P < .01); modest but significant increases were seen in ischemia (OR = 1.45; 95% CI = 1.0, 2.1) and cholesterol concentration (0.08 mmol/L; 95% CI = 0.01, 0.14). Among women only, a significant relative increase in blood pressure (P < .01) was recorded. Over the same period health-related behaviors changed little.nnnCONCLUSIONSnThreats to employment security have adverse consequences for health status that are unexplained by health selection or health-related behaviors.

Work characteristics and psychiatric disorder in civil servants in London

STUDY OBJECTIVE--To describe the association between self reported and externally assessed work characteristics and psychiatric disorder. DESIGN--Analysis of questionnaire data collected from the first phase of the Whitehall II study, a cohort study of an employed population. SETTING--Twenty civil service departments in London. PARTICIPANTS--Altogether 6900 male and 3414 female civil servants aged 35-55 years. MAIN RESULTS--High levels of subjective social support at work, control at work, job variety, and skill use were associated with greater satisfaction and wellbeing and less psychiatric disorder measured by the 30 item general health questionnaire (GHQ). High levels of subjective work pace and conflicting demands were associated with less satisfaction and wellbeing and greater psychiatric disorder. The combined effects of work characteristics were similar to the effects of the work characteristics considered separately, except that for men there was a small interaction between psychological demands and control on the GHQ. There was little overall support for the two factor job strain model. In contrast, objective indices of work were generally not associated with the psychological indices. Findings in men and women were generally comparable and were not significantly influenced by employment grade. CONCLUSIONS--Negative affectivity and a tendency to report negatively about both work and the psychological indices may partly explain the difference in the findings between subjective and objective work characteristics. However, subjective work characteristics were still associated with psychiatric disorder after adjusting for negative affectivity. The potential confounding effects of employment grade did not explain the association between either subjective or objective work characteristics and the psychological indices. While modifications to the work environment may directly reduce certain adverse physical health effects, the influence of work place design and management on psychological wellbeing, satisfaction, and psychiatric disorder may be mediated through subjective perceptions of the work environment.

Low blood pressure, low mood?

OBJECTIVE--To determine whether a set of physical symptoms is associated with low blood pressure and to investigate the possible role of psychological factors in their occurrence. DESIGN--Analysis of data collected by questionnaire and physical screening from the first phase of the Whitehall II study, a cohort study of an employed population. SETTING--23 civil service departments in London. SUBJECTS--10,314 male and female London based civil servants aged between 35 and 55. MAIN OUTCOME MEASURES--Symptoms of dizziness-giddiness and unexplained tiredness; psychological functioning as measured by the 30 item general health questionnaire in which the response no more than usual to an item about disease was scored as indicating chronic illness. RESULTS--Dizziness-giddiness in men and unexplained tiredness in both men and women were significantly related to low systolic blood pressure. There was a highly significant inverse relation between general health questionnaire score and systolic blood pressure for both men and women, which persisted after controlling for potentially confounding variables, including age, body mass index, drug treatment, physical illness, and exercise. This association of low blood pressure with physical symptoms was no longer significant when general health questionnaire score was controlled for. CONCLUSIONS--There seems a strong relation between low systolic blood pressure and minor psychological dysfunction. Associated physical symptoms seem to be secondary to the primary disturbance in mental state.

Socioeconomic Position, Health, and Possible Explanations: A Tale of Two Cohorts

OBJECTIVESnWe examined whether the social gradient for measures of morbidity is comparable in English and French public employees and investigated risk factors that may explain this gradient.nnnMETHODSnThis longitudinal study of 2 occupational cohorts-5825 London civil servants and 6818 French office-based employees-used 2 health outcomes: long spells of sickness absence during a 4-year follow-up and self-reported health.nnnRESULTSnStrong social gradients in health were observed in both cohorts. Health behaviors showed different relations with socioeconomic position in the 2 samples. Psychosocial work characteristics showed strong gradients in both cohorts. Cohort-specific significant risk factors explained between 12% and 56% of the gradient in sickness absence and self-reported health.nnnCONCLUSIONSnOur cross-cultural comparison suggests that some common susceptibility may underlie the social gradient in health and disease, which explains why inequalities occur in cultures with different patterns of morbidity and mortality.

Sickness absence in the Whitehall II study, London: the role of social support and material problems.

STUDY OBJECTIVE--To investigate the role of social supports, social networks, and chronic stressors: (i) as predictors of sickness absence; and (ii) as potential explanations for the socioeconomic gradient in sickness absence. DESIGN--A prospective cohort study (Whitehall II study) with sociodemographic factors, health and social support measured at baseline, and spells of sickness absence measured prospectively. SETTING--Twenty London based non-industrial departments of the British civil service. PARTICIPANTS--Participants were civil servants (n = 10,308), aged 35-55 years at baseline, of whom 67% (6895) were men and 33% (3413) were women. The overall response rate for Whitehall II was 73% (74% for men and 71% for women). The analysis is based on 41% of the sample who had data on reasons for sickness absence and were administered all social support questions. Only 4.3% of participants did not complete all necessary questions and were excluded. MEASUREMENTS AND MAIN RESULTS--High levels of confiding/emotional support from the closest person predicted higher levels of both short and long spells of sickness absence. After adjusting for baseline physical and psychological health the effects were increased, suggesting that high levels of confiding/emotional support may encourage illness behaviour rather than generate illness. Social network measures showed a consistent but less striking pattern. Increased levels of negative aspects of social support resulted in higher rates of sickness absence. Material problems strongly predicted sickness absence, but the effect was diminished once adjustment for the covariables was made, suggesting that health status may be functioning as an intervening variable between chronic stressors and sickness absence. In addition, social support may buffer the effects of chronic stressors. Social support did not contribute to explaining the gradient in sickness absence by employment grade beyond that explained by the baseline covariables. CONCLUSIONS--Sickness absence from work is a complex phenomenon, combining illness and coping behaviours. High levels of confiding/emotional support, although not entirely consistent across samples, may either encourage people to stay at home when they are ill or may be accompanied by more social obligations at home prolonging sickness absence. Negative aspects of close relationships may jeopardize health and hence increase sickness absence.

Change in health inequalities among British civil servants: the Whitehall II study

Study objective: Despite an overall decline in mortality rates, the social gradient in mortality has increased over the past two decades. However, evidence on trends in morbidity and cardiovascular risk factors indicates that socioeconomic differences are static or narrowing. The objective of this study was to investigate morbidity and cardiovascular risk factor trends in white collar British civil servants. Design: Self rated health, longstanding illness, minor psychiatric morbidity (General Health Questionnaire (GHQ) 30 score, GHQ caseness and GHQ depression subscale), cholesterol, diastolic and systolic blood pressure, body mass index, alcohol over the recommended limits, and smoking were collected at baseline screening (1985–88) and twice during follow up (mean length of follow up 5.3 and 11.1 years). Employment grade gradients in these measures at each phase were compared. Setting: Whitehall II, prospective cohort study. Participants: White collar women and men aged 35–55, employed in 20 departments at baseline screening. Analyses included 6770 participants who responded to all three phases. Results: Steep employment grade gradients were observed for most measures at second follow up. In general, there was little evidence that employment grade gradients have increased over the 11.1 years of follow up, but marked increases in the gradient were observed for GHQ score (p<0.001) and depression (p=0.05) in both sexes and for cholesterol in men (p=0.01). Conclusions: There is little evidence of an increase in inequality for most measures of morbidity and cardiovascular risk factors in white collar civil servants over the 11.1 years to 1998. Inequalities have increased significantly for minor psychiatric morbidity in both sexes and for cholesterol in men.

Psychological distress, physical illness, and risk of coronary heart disease

Study objective: The aims of this study are to confirm the association between psychological distress and coronary heart disease (CHD) using an epidemiological community study with hospital admissions data and to examine if any association is explained by existing illness. Design: Prospective cohort study modelling the association between psychological distress, measured using the 30 item general health questionnaire (GHQ), and hospital admissions data for CHD (ICD 410–414), using proportional hazards modelling adjusted for sociodemographic, CHD risk factors, and angina, bronchitis, diabetes, ischaemia, and stroke. Setting: Two suburbs of Glasgow, Renfrew and Paisley, in Scotland. Participants: 6575 men and women aged 45–64 years from Paisley. Main:results: Five year CHD risk in distressed men compared with non-distressed men was 1.78 (95% confidence intervals (CI), 1.15 to 2.75) in age adjusted analysis, 1.78 (95% CI, 1.14 to 2.79) with sociodemographic and CHD risk factor adjustment, and 1.61 (95% CI 1.02 to 2.55) with additional adjustment for existing illness. Psychological distress was unrelated to five year CHD risk in women. In further analysis, compared with healthy, non-distressed men, distressed physically ill men had a greater risk of CHD than non-distressed physically ill men, a relative risk of 4.01 (95% CI 2.42 to 6.66) compared with 2.12 (95% CI 1.35 to 3.32). Conclusion: The association of psychological distress with an increased risk of five year CHD risk in men could be a function of baseline physical illness but an effect independent of physical illness cannot be ruled out. Its presence among physically ill men greatly increases CHD risk.